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Complications. Complication of burns: burn disease

Abstract on the topic:

"Complications of thermal And chemically x burns »

In case of deep burns, accompanied by full-thickness necrosis of the skin, after the rejection of necrotic tissues, defects arise, to close which it is often necessary to resort to in various ways skin plastic surgery. Skin grafting for burns speeds up the wound healing process and provides better functional and cosmetic results. For extensive deep burns, skin grafting is the most important element complex therapy injured. It improves the course of burn disease and often (in combination with other measures) saves the life of the burned person.

IN last years Many surgeons, immediately after the boundaries of necrosis are clearly identified, excise dead tissue under anesthesia and immediately close the wound with skin grafts. For small but deep burns (for example, from drops of molten cast iron among foundry workers), it is often possible to excise the entire burned area of skin within healthy tissue and close the surgical wound with interrupted sutures. For more extensive burns, suturing the defect after excision of dead tissue, even with the addition of releasing incisions, is only occasionally possible. Excision of necrotic tissue - necrectomy - can be performed soon after the burn or later. late dates, when sequestration has already begun.

Early necrectomy, usually performed 5-7 days after the burn, has significant advantages. It can be considered as an abortifacient treatment. With this method, it is possible to avoid suppuration of the wound, achieve a relatively quick recovery of the victim and obtain the best functional results. However, complete simultaneous excision of necrotic tissue in extensive burns is a very traumatic intervention, and therefore it should be used mainly in non-weakened patients in whom the dead areas to be removed do not exceed 10-15% of the body surface (Arts and Reise, A.A. Vishnevsky, M.I. Schreiber and M.I. Dolgina). Some surgeons decide to perform early necrectomies even with more extensive lesions (T. Ya. Ariev, N. E. Povstyanoy, etc.).

If early necrectomy is not possible, skin grafting must be postponed until the wound is cleared of necrotic tissue and a granulation cover appears. In these cases, during the next dressings, painless staged necrectomies are performed, accelerating the sequestration process. For the same purpose, attempts are being made to use locally proteolytic enzymes (trypsin, etc.), but the effectiveness of the latter method has not yet been sufficiently tested in the clinic.

During dressings, it is advisable to expose the burned surface to ultraviolet irradiation. When the rejection of necrotic tissue begins, irradiation is used in a small dose and gradually increased. To improve the growth and sanitization of diseased granulations, large doses of radiation (3-5 biodoses) are used. Ultraviolet irradiation is contraindicated in the presence of severe intoxication.

After cleansing the granulating surface, skin autografts are transplanted directly onto the granulations or the latter are first removed. If granulations have healthy looking. then it is better not to touch them, especially with extensive burns, since this is associated with significant trauma. It has been established that with the excision of 100 si 2 of the granulation cover, the patient loses 64 ml blood, when excision of 100 cm 2 of necrotic scab is lost 76 ml blood, and when taking 100 cm 2 skin for transplantation - 40 ml blood (B.S. Vikhrev, M.Ya. Matusevich, F.I. Filatov). The nature of the microflora of a burn wound does not have a significant impact on the outcome of skin grafting (B.A. Petrov, G.D. Vilyavin, M.I. Dolgina, etc.).

For the success of skin autoplasty, good general training the patient and, first of all, the fight against anemia, hypoproteinemia and hypovitaminosis C. It is believed that if the hemoglobin content in the blood is below 50%, skin autoplasty is doomed to failure (B. N. Postnikov). It is also very important to prepare the wound well for transplantation, i.e. to achieve not only complete release of necrotic tissue, but also good condition granulations.

Excision of a skin flap for transplantation is carried out using dermatomes of various designs. Manual dermatomes are used (from the Krasnogvardeets plant, M.V. Kolokoltsev, etc.), electric and pneumodermatomes. Using dermatomes, you can take a uniform thickness (0.3-0.7 mm) large skin flaps. With this method, large donor areas are completely epithelialized under bandages within 10-12 days and, if necessary, can be reused for skin harvesting. To cover limited areas with autografts, some surgeons still use old methods of skin grafting.

Using skin autografts it is often possible to completely close the entire skin defect in one go. With very large defects, sometimes it is necessary to close them in several stages (staged plastic surgery). Some surgeons, with limited resources of skin suitable for autoplasty, in seriously ill patients, in order to save money, cut the excised skin autograft into pieces the size of an ordinary postage stamp (approximately 4 cm 2) and transplant these pieces at some distance from each other [the so-called stamp plastic method] ; The grafts, growing, subsequently form a continuous skin cover. With the branded method of plastic surgery there is no large sizes the grafts adhere well to the granulations, and in this case there is no need for additional fixation with sutures. Large grafts have to be sewn to the edges of the skin, and sometimes stitched together. After the operation, a tiled bandage is applied, which can be easily removed without damaging the grafts, and a light plaster splint is applied to the limbs. In an uncomplicated postoperative course, the first dressing is performed on the 10-12th day after transplantation, when the flaps usually have already taken root.

For extensive burns, along with autoplasty, homoplastic skin grafting is also used. Skin is transplanted from the corpses of people who died from accidental causes, or taken from living donors, including “waste” skin obtained during surgical operations. When transplanting skin obtained from another person, it is necessary, as when taking blood for transfusion, to have reliable data that the donor did not suffer infectious diseases(syphilis, tuberculosis, malaria, etc.), as well as malignant tumors. In particular, in all cases the Wasserman reaction is required. When using cadaveric skin, these sections must be taken into account.

Skin homografts, due to immunological incompatibility, take root only temporarily (including grafts taken from the victim’s closest relatives). They usually reject or resolve within the next few days or weeks after the transplant. However, temporary engraftment of grafts often allows you to gain time to eliminate dangerous hypoproteinemia and better preparation patient for subsequent autoplasty.

Skin homografts can be prepared for future use; for this purpose, they are preserved in various liquid media or by lyophilization. In the latter case, pieces of leather are subjected (in special devices) to freezing to -70° and simultaneous drying in a vacuum. Transplants treated in this way are then stored in special ampoules under vacuum conditions for an unlimited time. Before use, they are immersed for 2 hours to soak in a ¼% novocaine solution.

In some cases, patients with extensive burn surfaces are successfully treated with combined auto- and homoplasty. With this method, small-sized auto- and homografts are placed on the surface of granulations in a checkerboard pattern. With combined plastic surgery, homografts contribute to the revitalization of repair processes and, in particular, faster engraftment and growth of autografts. The latter, growing, can imperceptibly replace homografts before they are rejected. Homoplasty, combined plastic surgery, as well as the branded autoplasty method, are used primarily for burns of the torso and large segments of the limbs (except for the joint area).

To prevent the development of disfiguring scars, joint stiffness and contracture along with the use of skin grafting great importance, especially in the convalescence phase, acquire various methods of physiotherapy and balneotherapy (paraffin, ozokerite applications, mud, hydrogen sulfide and other baths, galvanization, iontophoresis, massage, mechanotherapy, etc.) and therapeutic exercises.

Complications. With extensive thermal burns are often observed various complications. Burn disease itself is the most common complication of extensive lesions. In addition, there are complications from internal organs and local complications. Changes in internal organs that occur during the first two weeks after a burn are very often reversible (I.A. Krivorotoe, A.E. Stepanov).

Changes in the kidneys during a burn are expressed in the first hours and days after injury in oliguria, and sometimes anuria. Transient false albuminuria often occurs. In subsequent periods, pyelitis, nephritis and kephrosonephritis may be observed.

Bronchitis, pneumonia, and pulmonary edema often occur with extensive burns. If the burn was accompanied by inhalation of hot vapors and fumes, then the victims experience hyperemia and pulmonary edema, small infarctions and atelectasis, as well as emphysema of individual segments. In seriously ill patients, especially with chest burns, pneumonia is often not recognized due to the inability to apply physical examination methods. Pulmonary edema occurs mainly during periods of shock and toxemia. Bronchitis and pneumonia can occur throughout the entire period of burn illness. Complications from the digestive system often accompany burn disease. Especially often observed transient disturbances secretory and motor functions of the stomach and intestines. Sometimes there are acute ulcers stomach duodenum, which are a source of gastroduodenal bleeding or cause perforation (A.D. Fedorov). Rarely occur acute pancreatitis. Liver functions are often impaired (N.S. Molchanov, V.I. Semenova, etc.); with extensive burns, necrosis of the liver tissue is possible. Complications from the cardiovascular (toxic myocarditis, cardiovascular failure) and nervous system are also observed. Sometimes thromboembolism is observed (A.V. Zubarev), caused by changes in the dispersion of blood proteins and their composition, blood chemistry, changes in the vascular wall, the presence of infection, etc. The function of the endocrine glands is impaired.

Abstract on the topic:

"Complications of thermal And chemically x burns »

In case of deep burns, accompanied by necrosis of the entire thickness of the skin, after the rejection of necrotic tissues, defects arise, to close which it is often necessary to resort to various methods of skin grafting. Skin grafting for burns speeds up the wound healing process and provides better functional and cosmetic results. In case of extensive deep burns, skin grafting is the most important element in the complex treatment of victims. It improves the course of burn disease and often (in combination with other measures) saves the life of the burned person.

In recent years, many surgeons, immediately after the boundaries of necrosis are clearly identified, excise dead tissue under anesthesia and immediately close the wound with skin grafts. For small but deep burns (for example, from drops of molten cast iron among foundry workers), it is often possible to excise the entire burned area of skin within healthy tissue and close the surgical wound with interrupted sutures. For more extensive burns, suturing the defect after excision of dead tissue, even with the addition of releasing incisions, is only occasionally possible. Excision of necrotic tissue - necrectomy - can be performed soon after the burn or at a later date, when sequestration has already begun.

After cleansing the granulating surface, skin autografts are transplanted directly onto the granulations or the latter are first removed. If the granulations look healthy. then it is better not to touch them, especially with extensive burns, since this is associated with significant trauma. It has been established that with the excision of 100 si 2 of the granulation cover, the patient loses 64 ml blood, when excision of 100 cm 2 of necrotic scab is lost 76 ml blood, and when taking 100 cm 2 skin for transplantation - 40 ml blood (B.S. Vikhrev, M.Ya. Matusevich, F.I. Filatov). The nature of the microflora of a burn wound does not have a significant impact on the outcome of skin grafting (B.A. Petrov, G.D. Vilyavin, M.I. Dolgina, etc.).

For the success of skin autoplasty, good general preparation of the patient and, first of all, the fight against anemia, hypoproteinemia and hypovitaminosis C are extremely important. It is believed that if the hemoglobin content in the blood is below 50%, skin autoplasty is doomed to failure (B. N. Postnikov) . It is also very important to prepare the wound well for transplantation, that is, to achieve not only complete release of necrotic tissue, but also a good state of granulations.

Using skin autografts it is often possible to completely close the entire skin defect in one go. With very large defects, sometimes it is necessary to close them in several stages (staged plastic surgery). Some surgeons, with limited resources of skin suitable for autoplasty, in seriously ill patients, in order to save money, cut the excised skin autograft into pieces the size of an ordinary postage stamp (approximately 4 cm 2) and transplant these pieces at some distance from each other [the so-called stamp plastic method] ; The grafts, growing, subsequently form a continuous skin cover. With the branded plastic method of small sizes, the grafts adhere well to the granulations, and in this case there is no need for additional fixation with sutures. Large grafts have to be sewn to the edges of the skin, and sometimes stitched together. After the operation, a tiled bandage is applied, which can be easily removed without damaging the grafts, and a light plaster splint is applied to the limbs. In an uncomplicated postoperative course, the first dressing is performed on the 10-12th day after transplantation, when the flaps usually have already taken root.

For extensive burns, along with autoplasty, homoplastic skin grafting is also used. Skin is transplanted from the corpses of people who died from accidental causes, or taken from living donors, including “waste” skin obtained during surgical operations. When transplanting skin obtained from another person, it is necessary, as when taking blood for transfusion, to have reliable data that the donor did not suffer from infectious diseases (syphilis, tuberculosis, malaria, etc.), as well as malignant tumors. In particular, in all cases the Wasserman reaction is required. When using cadaveric skin, these sections must be taken into account.

To prevent the development of disfiguring scars, stiffness and contracture of the joints, along with the use of skin plastic surgery, various methods of physiotherapy and balneotherapy (paraffin, ozokerite applications, mud, hydrogen sulfide and other baths, galvanization, iontophoresis, massage, mechanotherapy, etc.) and therapeutic exercises.

Complications. With extensive thermal burns, various complications are often observed. Burn disease itself is the most common complication of extensive lesions. In addition, there are complications from internal organs and local complications. Changes in internal organs that occur during the first two weeks after a burn are very often reversible (I.A. Krivorotoe, A.E. Stepanov).

Bronchitis, pneumonia, and pulmonary edema often occur with extensive burns. If the burn was accompanied by inhalation of hot vapors and fumes, then the victims experience hyperemia and pulmonary edema, small infarctions and atelectasis, as well as emphysema of individual segments. In seriously ill patients, especially with chest burns, pneumonia is often not recognized due to the inability to apply physical examination methods. Pulmonary edema occurs mainly during periods of shock and toxemia. Bronchitis and pneumonia can occur throughout the entire period of burn illness. Complications from the digestive system often accompany burn disease. Transient disturbances in the secretory and motor functions of the stomach and intestines are especially common. Sometimes acute gastric ulcers of the duodenum occur, which are a source of gastroduodenal bleeding or cause perforation (A.D. Fedorov). Acute pancreatitis occurs occasionally. Liver functions are often impaired (N.S. Molchanov, V.I. Semenova, etc.); with extensive burns, necrosis of the liver tissue is possible. Complications from the cardiovascular (toxic myocarditis, cardiovascular failure) and nervous system are also observed. Sometimes thromboembolism is observed (A.V. Zubarev), caused by changes in the dispersion of blood proteins and their composition, blood chemistry, changes in the vascular wall, the presence of infection, etc. The function of the endocrine glands is impaired.

To the number local complications include various purulent diseases skin and subcutaneous tissue, usually developing around the burn (pyoderma, furunculosis, phlegmon). The consequences of deep burns - disfiguring scars and contractures, long-lasting ulcers - often force one to resort to complex methods reconstructive surgery.

Mortality from burns varies widely. It depends on the depth and area of the lesion, on the age of the victims, on the speed of their delivery to a medical facility and on the treatment applied. One of the rather favorable large statistics of mortality from burns is presented by the Institute of Emergency Medicine named after. Yu.Yu. Dzhanelidze. In this institution, for 5 years (1946-1950), for 2088 burned patients, the overall mortality rate was 3.2% (B. N. Postnikov). The main cause of death was acute toxemia (70.3%), the second most common cause was burn shock (20,2%).

In connection with the introduction into practice of such treatments as blood transfusions, antibiotics, etc., it was necessary to reconsider the issue of the dependence of mortality on the area of the burn. If in the past burns of more than 30% of the skin were regarded as absolutely fatal, then with the use of modern therapeutic agents it turns out to be incompatible with life only in the case of a large depth of damage (third and fourth degree), while patients with a predominance of superficial burns can be saved even with a larger area of damage . Complications from the lungs as a cause of death have a relatively small share (5.8%), and sepsis ranks second to last (2.4%). According to the summary statistics of R.V. Bogoslavsky, I.E. Belik and Z.I. Stukalo, for 10,772 burned patients, the mortality rate was 4.7% (27th All-Union Congress of Surgeons, 1960).

The study of the problem of treating burn victims is to a certain extent hampered by the dispersion of a relatively small number of burn victims in peacetime among numerous surgical and trauma departments of hospitals. Therefore, in many countries, specialized departments for burnt victims, the so-called, began to be organized in hospitals and clinics. burn centers. Specialized departments for burnt patients have as their main goal the study of the pathogenesis of burns, the development of the most rational methods of treating burnt victims, as well as pedagogical activity

Chemical burns

Chemical burns arise from the action on tissue of various substances that can cause a local inflammatory reaction, and with significant concentration and exposure - coagulation of cellular proteins and necrosis (strong acids and caustic alkalis, soluble salts of some heavy metals, chemical warfare agents with vesicant action, etc.) . Unlike thermal burns, chemical burns often occur on the mucous membrane of internal organs, especially gastrointestinal tract. Some of the chemicals, especially salts of heavy metals, have a cauterizing effect, mainly on the mucous membranes, while skin burns can only be caused under exceptional conditions (for example, silver nitrate). A feature of chemical burns, compared to thermal burns, is the need for a longer exposure to the damaging agent, which in some cases allows for the successful use of neutralizers that can prevent or reduce the damaging effect of chemical exposure. According to the severity of the changes that occur, chemical burns are classified according to the same old Boyer scheme, i.e., three degrees of their severity are distinguished. But it can also be applied to these burns. modern classification, adopted for thermal burns. With a third-degree chemical burn, necrosis is possible, both dry (mummification) and wet. Mummification is typical for burns caused by strong acids; In case of burns with caustic alkalis, dead tissues undergo liquefaction (liquation necrosis). Severe chemical burns, especially those caused by chemical warfare agents, are characterized by significant changes in the tissues surrounding the necrosis zone and which have not lost vitality. The resulting disturbances in the functioning of these tissues can spread over a long distance and cause very slow healing of burns. Chemical burns with certain substances that have a general toxic effect (mustard gas, lewisite) may also be accompanied by symptoms of general poisoning of the body. First aid for chemical burns skin is reduced to prompt removal chemical substance by rinsing or neutralizing. For burns of internal organs, one or another neutralizer is prescribed as an antidote. .

Treatment for chemical skin burns caused by acids and alkalis is carried out as for thermal burns.

In wartime, the issue of treating burns caused by toxic substances with vesicant action may become of particular importance. . For chemical burns of internal organs, treatment is determined by disorders associated with the location of the burn.

Radiation burns

In everyday life medical practice Most often we encounter radiation burns caused by ultraviolet irradiation. The first degree of this burn occurs when administered with therapeutic purpose erythemal doses of ultraviolet rays. As a nosological form of burn by ultraviolet rays, it usually occurs due to excessive sunbathing - so-called beach burns. These burns, reaching I and only occasionally II degree, can be very extensive. In these cases they cause quite severe but short-lived disorders general condition and excruciating pain.

Treatment comes down to lubricating the reddened skin with indifferent fat; good for severe general disorders healing effect can give a large dose of any laxative, which sometimes has an abortifacient effect and can prevent the formation of blisters in more severe sunburns.

Burns caused by radioactive radiation - penetrating radiation - are more severe. The term “radiation” in its narrow meaning is applied specifically to these burns. Most often, these burns can occur under conditions of local single exposure in doses of 800-1000 rem and more.

The first reports of radiation burns appeared shortly after the discovery of X-rays and the production of radium. They pointed out the high biological effectiveness of penetrating radiation and gave clinical description ulcers that occurred both in the researchers themselves and in persons undergoing research using X-rays. In 1952 L. Hempelman et al. reported severe radiation burns in nuclear industry workers.

The nature and extent of tissue damage in radiation burns, their clinical course and outcome depend on the amount of energy absorbed by the tissues, the type of ionizing radiation, the duration of exposure, and the size and location of the lesion. The most sensitive to irradiation are areas of the skin that are abundantly supplied with nerve endings and rich in sebaceous and sweat glands: palmar surfaces of the hands, plantar surfaces of the feet, internal surfaces thighs, groin and axillary areas. Physical and chemical factors(light, heat, mechanical irritation, acids, alkalis, heavy metals, halogens), causing hyperemia and irritation skin, aggravate the course of radiation burns. Some of them also have an adverse effect on their course. chronic diseases(tuberculosis, malaria, syphilis, nephritis, metabolic diseases, Graves' and Addison's diseases, eczema). The skin of children and women, especially blondes and redheads, is most susceptible to radiation damage. Increased radiosensitivity of the skin is also observed during menstruation. With age, the skin's resistance to ionizing radiation increases. The first morphological changes in irradiated tissues are detected several minutes after irradiation. In the skin and subcutaneous fatty tissue, expansion of the capillary network is detected. The number of functioning capillaries increases significantly (the first wave of hyperemia). Subsequently, for several hours or days, depending on the amount of absorbed energy, the irradiated tissues retain their unchanged structure. Then, gradually, necrobiotic and dystrophic processes begin to appear in them, and primarily in the elements of the nervous system. The myelin sheaths of the cutaneous nerves swell, and the sensitive nerve fibers acquire increased argentophilia. The endings of trophic and sensory nerves disintegrate. Simultaneously with defeat nerve endings changes in the epidermis are detected. The cells of the Malpighian layer are not clearly expressed and swell. They are dying hair follicles, greasy and sweat glands. Collagen fibers swell, split, turn into basophilic fibers and then break down. There is an expansion of the capillaries and blood stasis in them (the second wave of hyperemia). Cells swell in arteries and veins inner shell. These changes are more severe cases Radiation burns end in necrosis of irradiated tissue. In this case, the formation of a leukocyte shaft along the border of the necrotic zone does not occur.

In recent years, many surgeons, immediately after the boundaries of necrosis are clearly identified, excise dead tissue under anesthesia and immediately close the wound with skin grafts. For small but deep burns (for example, from drops of molten cast iron among foundry workers), it is often possible to excise the entire burned area of skin within healthy tissue and close the surgical wound with interrupted sutures. For more extensive burns, suturing the defect after excision of dead tissue, even with the addition of releasing incisions, is only occasionally possible. Excision of necrotic tissue - necrectomy - can be performed soon after the burn is applied or at a later date, when sequestration has already begun.

Early necrectomy, usually performed 5-7 days after the burn, has significant advantages. It can be considered as an abortifacient treatment. With this method, it is possible to avoid suppuration of the wound, achieve a relatively quick recovery of the victim and obtain the best functional results. However, complete simultaneous excision of necrotic tissue in case of extensive burns is a very traumatic intervention, and therefore it should be used mainly in non-weakened patients in whom the dead areas to be removed do not exceed 10-15% of the body surface (Arts and Reise, A.A. Vishnevsky , M.I. Schreiber and M.I. Dolgina). Some surgeons decide to perform early necrectomies even with more extensive lesions (T. Ya. Ariev, N. E. Povstyanoy, etc.).

During dressings, it is advisable to expose the burned surface to ultraviolet irradiation. When the rejection of necrotic tissue begins, irradiation is used in a small dose and gradually increased. To improve the growth and sanitization of diseased granulations, large doses of radiation are used (3-5 biodoses). Ultraviolet irradiation is contraindicated in the presence of severe intoxication.

After cleansing the granulating surface, skin autografts are transplanted directly onto the granulations or the latter are first removed. If the granulations look healthy. then it is better not to touch them, especially with extensive burns, since this is associated with significant trauma. It has been established that with the excision of 100 si 2 of the granulation cover, the patient loses 64 ml blood, when excision of 100 cm 2 of necrotic scab is lost 76 ml blood, and when taking 100 cm 2 skin for grafting -- 40 ml blood (B.S. Vikhrev, M.Ya. Matusevich, F.I. Filatov). The nature of the microflora of a burn wound does not have a significant impact on the outcome of skin grafting (B.A. Petrov, G.D. Vilyavin, M.I. Dolgina, etc.).

Excision of a skin flap for transplantation is carried out using dermatomes of various designs. Manual dermatomes are used (from the Krasnogvardeets plant, M.V. Kolokoltsev, etc.), electric and pneumodermatomes. Using dermatomes, you can take a uniform thickness (0.3--0.7 mm) large skin flaps. With this method, large donor areas are completely epithelialized under bandages within 10-12 days and, if necessary, can be reused for skin harvesting. To cover limited areas with autografts, some surgeons still use old methods of skin grafting.

Using skin autografts it is often possible to completely close the entire skin defect in one go. With very large defects, sometimes it is necessary to close them in several stages (staged plastic surgery). Some surgeons, with limited resources of skin suitable for autoplasty, in seriously ill patients, in order to save money, cut the excised skin autograft into pieces the size of a regular postage stamp (approximately 4 cm 2) and these pieces are transplanted at some distance from each other [the so-called brand plastic method]; The grafts, growing, subsequently form a continuous skin cover. With the branded plastic method of small sizes, the grafts adhere well to the granulations, and in this case there is no need for additional fixation with sutures. Large grafts have to be sewn to the edges of the skin, and sometimes stitched together. After the operation, a tiled bandage is applied, which can be easily removed without damaging the grafts, and a light plaster splint is applied to the limbs. In an uncomplicated postoperative course, the first dressing is performed on the 10th-12th day after transplantation, when the flaps usually have already taken root.

For extensive burns, along with autoplasty, homoplastic skin grafting is also used. Skin is transplanted from the corpses of people who died from accidental causes, or taken from living donors, including “waste” skin obtained during surgical operations. When transplanting skin obtained from another person, it is necessary, as when taking blood for transfusion, to have reliable data that the donor did not suffer from infectious diseases (syphilis, tuberculosis, malaria, etc.), as well as malignant tumors. In particular, in all cases the Wasserman reaction is required. When using cadaveric skin, these sections must be taken into account.

Complications

Bronchitis, pneumonia, and pulmonary edema often occur with extensive burns. If the burn was accompanied by inhalation of hot vapors and fumes, then the victims experience hyperemia and pulmonary edema, small infarctions and atelectasis, as well as emphysema of individual segments. In seriously ill patients, especially with chest burns, pneumonia is often not recognized due to the inability to apply physical examination methods. Pulmonary edema occurs mainly during periods of shock and toxemia. Bronchitis and pneumonia can occur throughout the entire period of burn illness. Complications from the digestive system often accompany burn disease. Transient disturbances in the secretory and motor functions of the stomach and intestines are especially common. Sometimes acute gastric ulcers of the duodenum occur, which are a source of gastroduodenal bleeding or cause perforation (A.D. Fedorov). Acute pancreatitis occurs occasionally. Liver functions are often impaired (N.S. Molchanov, V.I. Semenova, etc.); with extensive burns, necrosis of the liver tissue is possible. Complications from the cardiovascular (toxic myocarditis, cardiovascular failure) and nervous system are also observed. Sometimes thromboembolism is observed (A.V. Zubarev), caused by changes in the dispersion of blood proteins and their composition, blood chemistry, changes in the vascular wall, the presence of infection, etc. The function of the endocrine glands is impaired.

Local complications include various purulent diseases of the skin and subcutaneous tissue, usually developing around the burn (pyoderma, furunculosis, phlegmon). The consequences of deep burns - disfiguring scars and contractures, long-lasting ulcers - often force one to resort to complex methods of reconstructive surgery.

Outcomes burn injury depend on many reasons, the main ones being the depth of the burn, its area, location and age of the patient. Important role An active and targeted treatment program plays a role. As a result, a number of those discharged from medical institution patients experience a complete recovery without any dysfunction of the affected areas of the body. However, this outcome occurs only after spontaneous healing of superficial burns or active surgical treatment for limited deep burns. Victims with extensive burns, as a rule, develop various complications that subsequently cause partial or complete loss disability and often deprive the victim of the opportunity to care for himself.

Patients who have suffered a burn disease and been discharged from the hospital with healed wounds, in most cases cannot be considered fully recovered, since they have a wide variety of disorders of the central nervous system, internal organs, especially the musculoskeletal system, which significantly limits their ability to work.

Burn disease causes a large number of disabled people. According to the All-Union Burn Center, immediately after discharge from the hospital, 6.9% of all those treated were recognized as disabled [Fedorova G. P. et al., 1972]. They were distributed according to disability groups as follows: Group I - 56.5%, Group II - 40.5%, Group III - 3%. The causes of disability were non-healing wounds and ulcers, post-burn scar deformities and contractures (68.6%), 19% of patients had impaired hand function, and 9% had amputation of limbs. Among the disabled, 82% were people of working age (from 20 to 49 years). In the long term (3-10 years), 69% of those who initially had disabilities remained disabled; in most of them (71%), the degree of disability decreased, i.e., they moved from groups I and II to III. This is why burn convalescents need dispensary observation and further rehabilitation treatment aimed at returning them to work.

Post-burn scar deformities are late complications burns and occur quite often [Dolnitsky O.V., 1971; Povstyanoy N. E., 1973; Vikhriev B. S., Burmistrov V. M., 1981]. When scars are localized in the joint area, deformities, contractures and ankylosis develop, leading to various dysfunctions of the limbs. Approximately 75% of convalescents are indicated for scar treatment conservative methods, and 40% of adults and about 35% of children who have suffered deep burns require rehabilitation surgical treatment[Agracheva I.G., 1956; Kazantseva N.D., 1965; Mukhin M.V., 1969; Kolyadenko A.P. et al., 1980; Yudenich V.V., 1981].

The healing of a burn wound goes through certain stages, the duration and nature of which depend on many reasons, mainly on the depth of the burn, its area and the degree of contamination of the burn wound with microbes.

N.I. Krause back in 1942 identified 2 options for wound healing. In option I, as the granulations mature and the wound contracts due to the formation of a scar, its resorption along the periphery simultaneously occurs. Epithelization occurs after the edges of the wound come together to 1 - 1.5 cm. With such healing, a narrow, soft, mobile scar remains, and the wound defect is closed by displacing intact surrounding skin onto it. In option II, the maturation of granulations is not accompanied by resorption of the resulting scar. In a number of patients, the scar becomes pathological, acquiring a keloid or hypertrophic character.

According to the observations of V. S. Dmitrieva (1955), the frequency of keloid formation after burns is 12 - 21%. L.G. Selezneva (1975) observed them in half of those burned who were treated in a hospital, L.A. Bolkhovitinov and M.N. Pavlova (1977) - only in 6 - 8%. Many authors make the formation of keloids dependent on the area of the burn, its depth and duration of treatment [Dmitrieva V.S., 1955; Selezneva L.G. et al., 1963]. It is known that keloids often appear at the site of not very common superficial burns of degree II - 111A (Fig. 1).

Rice. 1. Limited keloid scar after a superficial burn of the neck.

Keloid (Greek kele - tumor and eidos - appearance, similarity) - a kind of dense growth connective tissue, taking on the appearance of a tumor formation. A keloid scar is characterized by lumpiness, density, sharp elevation above the surface of healthy skin, pink and sometimes red with a cyanotic tint. Patients note pain, itching, and a feeling of tension. The scar is wider than its base and hangs over the edges healthy skin y. Keloids in most cases have the appearance of single tumors of bright pink color, dense consistency, rising above the surface of the surrounding skin by 0.5 - 2 cm. Sometimes they occur without visible reasons, which gives reason to think about a predisposition to keloid formation in individuals.

There is an assumption about the more frequent formation of keloids in dark-skinned people and in representatives of races with dark color skin whose melanocytes show a greater response to melanocyte-stimulating hormones. Keloids are most often found in areas of the highest concentration of melanocytes and rarely on the palm and sole. It has been observed that the incidence of keloid formation is higher during periods of increased physiological activity of the pituitary gland, such as during puberty and pregnancy. J. Garb, J. Stone (1942) consider keloid as a proliferation fibrous tissue, emanating from the subpapillary layer of the scar and developing as a result of injury. R. Mancini, J. Quaife (1962) describe keloid as a consequence of benign proliferation of connective tissue and include it in the group of local primary connective tissue lesions of a congenital or acquired nature. A. Policar and A. Collet (1966) believe that the development of keloid is due to a specific “keloid constitution”, manifested not only in the abnormal course of wounds, but also in a hypertrophied fibrotic reaction to all inflammation, as in various organs, and in the skin.

Keloid scars are covered with an even layer of epidermis without outgrowths into the underlying layers of the dermis. The thickened epidermis throughout the scar retains approximately the same structure of all layers. There are no pigment cells in the basal layer; the germinal layer consists of large cells. The keloid itself has 3 layers: subepidermal, “growth zone” and deep. The narrow subepidermal layer consists of differentiated fibroblasts and bundles of collagen fibers, which are 2 times thicker here (40 - 80 nm; 400-800 A) than in healthy skin. The number of fibroblasts in this layer is 23–72 cells per field of view. In actively growing keloid scars, the width of the “growth zone” is 5-10 times greater than the width of the subepidermal layer of the scar. The transition to the deep layers of the scar is gradual, since the lower layers of the “growth zone” are formed by more mature tissue than the upper ones. In the “growth zone” the number of fibroblasts reaches 60–80 and even 120–150 cells per field of view, which is 2–3 times more than in hypertrophied scars, and 3–5 times more than in ordinary scars.

Studying the pathomorphological features of the development of connective tissue in growing post-burn keloid scars, two groups of signs can be distinguished. I include the signs inherent normal tissue: regular sequence of fibroblast differentiation, stability of the molecular and submolecular structure of collagen fibrils; Ko II - pathomorphological features of the connective tissue of keloid scars: larger number functionally active fibroblasts and among them giant cell forms; reduction of functioning capillaries; the presence of polyblasts in connective tissue; mucoid swelling of collagen fibers; absence of plasma cells in perivascular infiltrates; less than in ordinary scars, the number of mast cells and vessels [Yudenich V.V. et al., 1982]. The leading cellular form in the connective tissue of keloid scars are functionally active fibroblasts with a well-developed granular endoplasmic reticulum and lamellar complex.

When examining old keloid scars, a reduction in “growth zones” was discovered. This phenomenon is accompanied by a decrease in the number of fibroblasts and their degenerative changes. Collagen fibers become denser, mature and partially degenerate. In mature connective tissue, the structure of capillaries is normalized, the number of mast cells increases, and plasma cells appear in perivascular infiltrates.

The main sign of a growing keloid scar is the presence of immature connective tissue forming a “growth zone” complete absence elastin fibers in the “growth zones”, which is another evidence of the immaturity of connective tissue [Dzheksenbaev D., 1968].

Yudenich V.V., Grishkevich V.M.

The consequences of burns vary significantly depending on the nature and extent of the injury. A person can receive chemical, thermal, radiation, and electrical injuries of various levels.

Most frequent complications burns are phenomena such as hypovolemia and infectious infections. They occur with a large affected area, which is more than 35% of the total body surface.

The first symptom leads to decreased blood supply, sometimes to the appearance state of shock, the formation of spasms. This is a consequence of vascular damage, dehydration, and bleeding.

The infectious consequences of burns are very dangerous, because they can cause sepsis. In the first few days, gram-negative bacteria, streptococci, staphylococci most often develop; each type is a favorable environment for the growth of pathogenic microflora.

Consequences of injury depending on severity

Any injury has its own characteristics of manifestation, symptoms and possible complications burns.

I degree

Such a wound is often caused by prolonged exposure to the scorching sun or careless handling of boiling water or steam.

This type is characterized by minor injuries, damage to the surface layer occurs, a burning sensation and dryness are felt.

In this case, after the burn, pronounced hyperemia occurs, accompanied by swelling of the skin, pain syndrome, redness appears. With such a wound, complications are practically excluded, superficial damage goes away quite quickly, with proper and timely treatment.

II degree

This type is not considered very serious, but nevertheless affects the upper two layers of the epidermis. Level II burns may cause blisters to form on the skin filled with clear liquid. The injury is accompanied by swelling, red pigmentation, and hyperemia.

In this case, the victim feels a sharp pain and burning sensation. When more than 50% of the body is affected, the effects of burns are potentially life-threatening. If it affects the face, hands, groin area, or blisters appear, you should consult a doctor.

III degree

These thermal injuries are classified into two main types:

“3A” - necrosis of soft tissues develops up to the papillary layer of the epidermis.
“3B” - complete necrosis over the entire thickness of the skin.

This deep damage, in which nerves and muscles die, fatty layers are affected and bone tissue is affected.

Violations of the integrity of the skin have such consequences of burns as sharp pain, the injured area becomes whitish, darkens, and chars.

The surface of the epidermis is dry, with exfoliated areas, the line of limitation of dead tissue is clearly visible already on the 8-9th day.

In this case, it stands out a large number of liquid, therefore, the victim experiences dehydration. After a burn, complications can be prevented by competent drug therapy formulated by your doctor, and you also need to drink plenty of fluids to prevent negative consequences.

Regardless of the quality of therapy, after healing of burn wounds, scars and scars remain on the affected area.

IV degree

Most severe injury deep layers, which is invariably accompanied by necrosis of the skin and underlying soft tissues. The lesion is characterized by complete death of the burned areas, charring, and leads to the formation of a dry scab. To prevent complications of burns and sepsis, the wound is cleaned and dead tissue is removed.

If the injury covers more than 70-80% of the skin, complications from burns can be fatal.

In case of incorrect or untimely therapy, in severe cases the following consequences may occur:

Visually it is very difficult to determine burn lesions and their degree, especially in the first hours. To warn serious consequences burns, such injuries require urgent consultation with a doctor who will prescribe effective method treatment.