Symptoms of clinical burn shock

2021-01-30 12:00 AM

Due to drainage, plasma from the lumen to the intercellular space, caused by damage to capillaries, microcirculation disorders causing vasodilation, increased permeability

Concept

Burn shock is a sudden collapse of the entire body's organ function caused by a burn injury.

Burn shock is a common medical condition immediately after a burn, in the first stage of burn disease.

Burn shock is common in patients with large burn areas, great depth:

If the burned area is less than 10% of body area there is usually no shock.

If the burned area is more than 10% of the body area, shock rate accounts for 40% of the total number of victims.

The wider the burn, the greater the depth, the higher the shock rate, the more severe the shock. 

Relationship between burns and shock:

Rule: 1% superficial burn area: 1 Frank index.

1% of the area of ​​deep burns: 3 Frank's.

If Frank's stats:

Under 30 Rate of shock encountered 5%.

From 30-55 Rate of shock encountered 44%.

56-120 The rate of shock is 80-90%.

Over 120 Rate of shock encountered 100%.

Skin burns combined with respiratory burns: shock incidence is high (over 80%), often severe.

In children and the elderly:

The rate of shock is higher than that of adults.

If Frank's index is above 71 or deep burn area is over 20% => 100% shock rate.

Pathogenesis of burn shock

Excessive pain:

The damage stimulates many nerve endings causing euphoria, after the suppression of the central nervous system, disturbing all organs, shocking system.

Due to circulatory disorders:

In particular, the reduction in circulating blood volume, in which pathological disorders in the affected area play an important role in pathogenesis.

There are many mechanisms in place to reduce the volume of circulating blood:

Due to drainage, plasma from the lumen into the intercellular space. Caused by damage to capillaries, microcirculation disorders causing vasodilation, increased permeability, plasma drainage out in the form of oedema in the burn area, the vicinity and also a systemic phenomenon. Drainage occurs 5 minutes early, highest 3-6 hours, ending 8:30 and lasts until day 3, can reach 2-5l / 24 hours.

Fluid loss through burns due to evaporation: 0.84 ± 0.04 ml / cm2 / 24 hours more than normal skin.

In addition, there is the loss of fluid through the respiratory tract, through vomit.

In patients with severe burns, a reduction in circulating blood volume can be as high as 30-40%.

In addition to reducing circulating blood volume, microcirculation disturbances (due to dilatation, due to plasma drainage, her blood) leads to coagulation of the lumen => obstruction => organizational necrosis. because hc is reduced in many capillaries due to acidosis).

Red blood cell breakdown due to the direct effect of thermal factors play an important role. if the area of ​​deep burns is large, hemolysis may be up to 30-40%.

The consequences of the above disorders lead to lack of organizational oxygen:

Water and electrolyte disturbances.

Disorders of acid-base balance.

Heart failure due to exercise, blood clotting disorders => Circulatory collapse.

Other burn shock trauma

Injury shock:

The factor of action is usually limited in the short term.

Burn shock:

The duration of injury is related to the injury, so the effect is usually prolonged => prolonged shock.

There is a phenomenon of drainage through the vessel wall out

There is blood.

clinical

Erectile shock

Expression of excessive compensation, notably the phenomenon of cyclic centralization.

Meet in patients who come early, in the first hours after burns or in patients with mild and moderate burns (according to Visơnhepski 1967: 12.5% ​​met).

Manifestations: - Stimulating struggles.

Arterial blood pressure increased, central venous pressure increased, tachycardia, bounce. Transient increase in blood pressure due to vasoconstriction center, increased secretion of catecholamine causes vasoconstriction.

Deep rapid breathing due to an excited respiratory center.

Developments:

It is possible to recover (if the burn area is not large, the patient is treated promptly) pure erectile shock

Severe burns => severe shock.

Weak shock

May appear late after a few hours (5-6 jam), in parallel with plasma drainage and decreased circulating blood volume, may also appear after additional trauma during transport, when handling the wound. Soon.

If the burn is extensive, great depth, debilitating shock may appear immediately, often severe.

The symptoms of shock turn signalling: decreased blood pressure, increased pulse (appears earlier than blood pressure)

Manifestations: 

Neuropsychiatric:

May be in an irritated or inhibited mental state in the first place.

Arouse:

Worried, struggled, complained of pain.

Chilling cold, muscle trembling, cold trembling.

Thirsty, demanding to drink.

Consciousness remains.

Lasts 1-2 hours, then gradually turns into a state of inhibition. 

Inhibition: 

Indifference outside.

The sensation of pain is almost reduced, as with any factor: dressing, transport, change of position, increased pain sensation. 

Severe: Coma. 

Nervous plant disorders: Often manifested severe, sweating, cold limbs. 

Cyclic: 

Small fast circuit, sometimes unable to catch weak, circuit = 0. An important symptom of burn shock. Tachycardia due to decreased blood pressure stimulates the heart's heart to beat rapidly. Weak vessels due to a decrease in the volume of circulating blood. 

Arterial blood pressure (hypertension) is usually decreased, may worsen may be fuzzy, or equal zero. BP is strongly associated with other indicators.

In burn shock, blood pressure decreases due to a leading decrease in circulating blood volume, in addition to a decrease in the force of contractility of the heart muscle, vasodilation (acute vascular failure due to inhibited vasomotor centres).

Central venous blood pressure (HATMTW): is an important symptom. It manifests:

The amount of circulating blood.

Muscle contraction force.

Peripheral vascular tone.

Evaluate the efficacy and safety of the infusion method.

HATMTW is normally 8-12 cm H2O. In burn shock, it decreases, usually due to a decreased volume of circulating blood. 

Cyanosis, sometimes cyanosis, is associated with microcirculation disorders and cardiac activity.

Respiratory: 

Usually less disturbing, may experience moist ran due to increased secretion, through the shock phase these symptoms disappear. 

Severe shortness of breath, slow shallow breathing, arrhythmia, may arise cyclical respiratory disorders due to the respiratory centre is inhibited. Poor prognosis, premature respiratory failure, yawning: terminal state.

Urinary excretion disorders:

Play a very important role in assessing shock level and guiding treatment.

Amount:

Intermittent or prolonged oliguria, the amount of urine is 500 ml / 24 hours or 30 ml / h.

Severe: anuria, urine volume <300ml / 24h or complete anuria.

Diuretic disorders are an early symptom (according to Paris 1967: 98%), even when the vessel changes, blood pressure has not appeared. It has diagnostic and prognostic value, is the basis for calculating the amount of infusion.

Colour:

The urine may be clear yellow.

Severe: red, dark brown (manifested Hb urination).

There may be a burning smell, a burning horn.

Digestive: 

Vomiting, nausea, vomiting is constantly vomiting blood, dark brown or fresh blood. 

Bloating, which can cause acute difficulty breathing. Expression of gastrointestinal paralysis.

Acute gastrointestinal tract ulcers can be seen: Curling -quality is usually severe. peptic ulcer due to dysfunction of the system, her blood, congestion of the stomach, intestines. Increased permeability, stasis, embolism, endocrine RL, RL dd.

Body temperature:

The body temperature usually decreases, and in children and some adults, a febrile seizure can occur.

If the body temperature is too high or too low, the prognosis is severe. 

Subclinical:

There may be manifestations of her blood, disorders of water, electrolytes, acid-base balance disturbances, urinary excretion dysfunction.

Blood: 

Her blood: The body's response to increasing red blood cells, drain plasma. 
Red blood cells increased, hematocrit increased, Hb increased (manifested loss of plasma due to exiting the burn and escaping into the intercellular space), increased leukocytes (due to blood concentration, increased reflexes). 

Hemolysis: Her blood condition may be obscured by hemolysis with manifestations:

HC is normal, HC appears small, HC decreases to 1.9-2 / 109 / l.

Hb freely increases.

Hb decreased. usually, when HC is destroyed up to 40%, it affects the hemolysis (hemolysis is mainly due to thermal factors and immune response).

Water and electrolyte disorders:

The most important are Na + and K +.

Mechanism: burn causes stress => activation of the anterior pituitary gland => increased secretion of mineral corticosteroids. Specifically: Characteristics of burn shock are Na + decreased, K + increased. 

Na + decreased due to: Na + retained in the organization => edema.

Lost through the burn.

Na + blood decreased with Cl- blood decreased.

K + increases: due to the drainage and transfer of K + in damaged tissue to the intercellular space (K + blood increases when a large amount of muscle is damaged).

Associated urinary electrolyte disorders:

K + nitrogen increases due to increased K + excretion.

Na +, CL- decreased due to decreased blood.

The K + / Na + coefficient in burn shock can increase by ³ 1.5 (normal 0.5).

Disorders of acid-base balance: due to increased acid formation in the body and acid stagnation (renal failure).

Characteristics of metabolic acidosis: manifestations:

Increased respiration (CO2 emission).

blood pCO2 decreased.

pH decreased.

Reduced HCO3.

Blood clotting disorders:

May increase in early-stage freezing.

Rarely, scattered lumen coagulation syndrome 

Urinary excretion disorders:

Blood nitrogen increased.

Lactic acid increases.

Blood urea increased.

Increased blood creatinine.

Other tests:

Reduced blood protein.

Increased blood glucose causes urinary glucose (+).

Increased blood glucose due to: Reduced secretion of insulin, increased secretion of Glucagon, Adrenaline, ACTH, Glucocorticoid.

Urine:

Proteinuria (+).

There are red blood cells, white blood cells, granulosa cylinders.

Hb urinary (+), urobilin (+).

The proportion of urine increased.

Progress of burn shock

Lasts from a few hours to 2-3 days (severe lasts 3 days).

Patient escaped shock: gradually lost symptoms of shock, appeared symptoms of stage II. Clinical practice when symptoms stabilize for more than 6 hours. However, the relationship between period I and II is not clear (blood pressure increases, pulse decreases, lips and head are redder, urine is clear and quantity increases).

Degree of burn shock

SYMPTOM

LEVELS

SHOCK

Very heavy shock

1. Urinary disorders

Primary oliguria

Primary, anuria

Complete or recurrent anuria

2. Hb

(-)

Late, available in a few hours

appear early, lasting

3. Increased blood nitrogen

Rarely

Usually, at the end of day 1, increase 2-3 days (maybe 70mg%)

appearing in the first hours, increasing from the end of the day1 (100mg%)

4. Vomiting

Rarely

Often met. Reaction to finding red blood cells in the vomit

Persistent vomiting, gross blood vomiting

5. Central venous pressure decreased

Rarely

Regularly

Regularly

6. HAĐM

Not reduced or reduced, but not less than 80mm Hg

Usually less than 80 mm Hg, sometimes zero

Reduce below 80mm Hg

7. Body temperature

37o-38o (mild or normal fever)

36o- 37o (normal or sometimes reduced)

below 36o (down below normal level)

8. Bloating

Not met

Rarely

Meet right in the first hours, increase hour by hour

In addition, Paris also mentioned two common symptoms are chills and her blood. 

Complications in burn shock

Alveolar bleeding

Acute respiratory failure is common after respiratory burns. 

Symptoms: fresh blood cough + wet moaning + respiratory distress + Triangular radiograph blurred. 

Acute gastrointestinal ulceration

Curling Ulcer, manifested by gastrointestinal bleeding or surgical abdominal syndrome due to perforation.

Winter scattered heart vessels

Expression of cyanosis, bleeding time, prolonged blood clotting, Howell increased time, decreased platelets, decreased prothrombin ratio, alcohol therapy (+).

Acute renal failure

Due to excessive pain stimulation cause reflex spasm of blood vessels => kidney anaemia.

Because too much-drained plasma causes pressure coils in the glomerulus
(expanding Bowman envelope filled with plasma causes pressure coils). 

Due to reduced circulating blood volume => decreased renal blood flow => prolonged low arterial blood pressure, 50% slow blood flow => decreased glomerular filtration capacity. 

Due to increased posterior pituitary hormones: Aldosterol and vasopressin, causing increased tubular reabsorption.

These causes can be reversed if treated early and well.

Due to physical damage: acute tubular necrosis (prolonged hypoxia) => acute physical renal failure.

Due to hemolysis, free Hb in the blood increases => urine will have HC, cylindrical shape Hb => oliguria.

If accompanied by metabolic acidosis will be dangerous, because free Hb is not easily expelled from the kidney but turned into Hematin achlorhydria => tubular obstruction => anuria.

Characteristics of burn shock in the elderly and children

Old people

Or have anaemia disorder, cardiovascular disorders.

Or numb, anuria.

Body temperature usually decreases.

Leukocytes are usually not high.

Blood glucose increases blood protein increases.

Children

There may be a shock in a small area: children under 3 years old, there may be a shock in an area of ​​3-5%. When the burn area is more than 10%, there is a risk of shock.

Often high fever with increased arterial blood pressure.

Leukocytes increased.

Her blood was not heavier than adults.

The residue is usually not very high.

Shock inpatient with skin burns and respiratory burns

Shock rate increased 3 times.

The prognosis is heavy.

The disorders were more severe: her blood pressure decreased blood pressure severe electrolyte disorders. 

Common respiratory disorders.