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Burn disease
Last reviewed: 19.11.2021
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Acute Toxemia
After cupping the burn shock (usually 2-3 days after injury) as a result of resorption of fluid from the lesion in the vascular bed accumulates a large number of toxic substances - the products of tissue decay and bacterial flora. In other words, a burn with necrotic tissues becomes a source of intoxication of the body. The bulk of toxic substances enters the bloodstream during the first week, when an unfolded picture of heavy intoxication is played out. In these terms, the volume of circulating plasma increases, and the number of circulating red blood cells continues to decrease due to their destruction and inhibition of bone marrow hematopoiesis. At 4-6 days after the injury, anemia develops. Transport of oxygen due to anemia is significantly reduced. BP fluctuates within the limits of normal values, in a small part of patients moderate hypotension is observed. In electrocardiographic studies, signs of myocardial hypoxia are revealed, and in elderly and weakened patients, circulatory insufficiency. In connection with the violation of the ventilation function of the lungs, the increase of dyspnea and increased release of carbon dioxide, respiratory alkalosis often develops. There is a violation of the liver. The work of the kidneys is normalized, however, the value of plasma flow and the parameters of glomerular filtration remain low; reveal the failure of renal osmoregulatory function.
Burn disease is characterized by delirium, hallucinations, insomnia, often there is motor excitement. Patients are disoriented in time and space, trying to get out of bed, tearing off bandages. The frequency of mental disorders is directly proportional to the severity of the burn injury: if in case of superficial burns, intoxication delirium is a rarity, then with deep lesions exceeding 20% of the body surface, it occurs in 90% of the affected. The emergence of the most severe and protracted forms of delirium is facilitated by the abuse of alcohol before injury.
Burn disease is often complicated by pneumonia. At the same time, the condition of patients deteriorates sharply, the body temperature rises, cough, dyspnea, cyanosis appears. In the lungs, wet rales are heard. Bilateral pneumonia often leads to the development of respiratory failure, one of the most frequent causes of death. Particularly unfavorable are the combination of severe skin burns with inhalation trauma, when pneumonia develops early in all patients (2-4 days after injury).
Gastrointestinal ulcers are a serious condition that often accompanies a condition such as a burn disease. In this case, the appearance of vomit, reminiscent of "coffee grounds", or dark tar-like stool testifies to acute bleeding that has arisen or taken place from ulcers or erosions of the gastrointestinal tract. Significantly less often they are accompanied by perforation of the stomach or intestine. The general severe condition of the victim neutralizes the symptomatology of the "acute abdomen", as a result of which this complication is often recognized too late.
With extensive burns, toxic myocarditis and hepatitis often occur. This is evidenced by a rise in serum levels of transaminases and bilirubin. The breakdown of protein and the release of nitrogen in the urine increase, there are pronounced disorders of the water-electrolyte balance.
In this period, the appetite is reduced, the motor function of the intestine is broken, there may be inhibition or motor excitement with signs of intoxication delirium, visual and auditory hallucinations, sleep disturbance. The degree of intoxication depends on the nature of tissue damage. The most difficult period of toxemia occurs in the presence of wet necrosis with suppuration of burn wounds. With dry - intoxication is much less pronounced. The duration of this period of burn disease is 7-9 days.
[11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]
Period of purulent-septic complications
This period of burn disease follows after acute toxemia, but often the boundary between them is difficult to conduct. Usually it starts from 10-12 days after receiving a burn and coincides with suppuration of wounds and the beginning of rejection of nonviable tissues. This period is also observed with extensive IIIA degree burns in the case of severe wound suppuration. The duration of this period is either until the healing of burn wounds or their closure by autografts, or until the victim's death.
The purulent process in the wounds is accompanied by severe systemic inflammatory reaction and sepsis. The duration of febrile condition on average is 2-3 weeks, but in the case of complications may be 2-3 months. After rejection of the burned scab, body temperature is usually reduced by 1-1.5 ° C. The general condition of patients remains severe, they complain of constant pain in places of burns, poor sleep, decreased appetite, irritability, capriciousness, often tearfulness. Anemia grows, among which is the destruction of erythrocytes, oppression of erythropoiesis, infectious complications, bleeding from granulating wounds, ulcers and erosions of the gastrointestinal tract. In severe burns, neutrophilia develops with a predominant increase in the number of stab neutrophils (up to 30%) and the appearance of their young forms. An unfavorable sign is eosinogenesis and lymphopenia. The number of white blood cells decreases somewhat after the rejection of nonviable tissues. In severe patients, toxic leukocyte count is found. The loss of tissue and serum proteins, reaching 80 g / day or more, is constantly occurring. Progressing hypoproteinemia serves as a prognostically unfavorable feature. Hypoalbuminemia and an increase in the number of globulin fractions reflect the activity of wound infection and indicate a violation of protein synthesis and resynthesis. Direct confirmation of sepsis is the growth of microorganisms when sowing blood on nutrient media.
In the stage of sepsis, infectious complications are very diverse: the development of pneumonia, bronchitis, phlegmon, abscesses, arthritis. Dyspepsia is common, especially often - paresis of the gastrointestinal tract. Burn disease is complicated by the formation of acute (stressful) Kurling ulcers, which are often accompanied by bleeding and perforation into the abdominal cavity.
With the development of severe sepsis, the condition of the burns significantly worsens: the consciousness is confused, the orientation in the surrounding environment is broken, the skin becomes icteric, hemorrhages and petechial rash are frequent. Burn disease is characterized by the formation of metastatic abscesses in the subcutaneous fat tissue, muscles, internal organs. The fever is hectic in nature, poorly suited to drug therapy and accompanied by chills and profuse sweat.
When sepsis rapidly develops persistent hypochromic anemia, hypoproteinemia, pronounced leukocytosis, increased concentrations of residual nitrogen and bilirubin serum. In the urine, there are erythrocytes, white blood cells, cylinders, protein. High leukocytosis and a shift of the leukocyte formula to the left before the appearance of myelocytes testify to the activity of the infectious-toxic factor with the preserved reactivity of the organism, while eosino- and lymphocytopenia are considered unfavorable signs.
If, within 1.5-2 months, the lost skin is not restored operatively, the burn disease passes to exhaustion, which is accompanied by pronounced dystrophic changes in the internal organs, profound disturbances in metabolic processes, and a sharp inhibition of the body's defenses. In patients, there are bedsores, various complications from the cardiovascular, respiratory, excretory and nervous systems. The loss of body weight reaches 25-30%. With burns exhaustion, reparative processes in the wounds are sharply slowed down or absent. Granulations are pale, vitreous, with a gray coating and a large amount of purulent discharge. Often in the wounds can be seen hematomas, secondary necrosis, extending to areas of healthy skin. From the wounds plague putrefactive anaerobic microflora, Proteus spp., Pseudomonas aeruginosa.
Extensive purulent wounds - the cause of constant intoxication, hypoproteinemia and fever. Patients develop an inactivity, immunity decreases, and exhaustion progresses. Bedsores that are formed reach a large size. Burn disease is often accompanied by the appearance of purulent arthritis, muscle atrophy, stiff joints, contractures. The course of exhaustion is complicated by the defeat of internal organs with the development of severe sepsis, which becomes the immediate cause of death.
The duration of the period of purulent-septic complications is determined by the existence of burn wounds. With the successful restoration of the lost skin, the patient begins to slowly but surely recover: fever gradually improves, sleep and appetite improve, anemia and hypoproteinemia disappear, and the functions of the internal organs are normalized. Patients quickly gain weight, are activated, which indicates the beginning of the last period of burn disease.
Reconvalescence
The duration of the period is 1-1.5 months. However, not everyone who had a burn disease can be considered healthy after that: some suffer from chronic kidney diseases (pyelonephritis, kidney stone disease), others show signs of myocardial dystrophy. The most numerous group of convalescent patients need reconstructive and restorative treatment of cicatricial contractures and deformities that have arisen on the site of deep burns, so the period of convalescence in this category of victims is increased.