NOTES
dr Claudio
Italiano
When a heat source or a chemical or physical agent is applied to the body without it being able to implement its defense mechanisms (eg sweating, heat dispersion with circulation, etc., defended by the skin layers) a lesion of the integuments is determined.
The depth of the tissue and the extent of the
affected body surface determine the severity of the burn, the more intense the
temperature, the more it deepens and extends to the tissues.
For this reason, depending on the depth, burns are divided into:
• Superficial burns, ie first and second degree not thorough:
• Deep burns, ie deep second and third degree:
• Epidermis or degree I, only affect the epidermis. Macroscopically they are characterized by edema and widespread erythema; at the microscopic level, cellular hypnosis and
• Dermal congestion are observed, which tend to disappear
in a few days, giving peeling of the epidermis.
• Dermal or II degree, affecting the epidermis and the dermis. Burns of the
second degree are characterized by the formation of flittene (collections of
exudate between epidermis and dermis).
They are subdivided in turn into:
Superficial, if they affect the superficial part of the dermis (painful, they
heal without cicatricial results)
Deep, when they affect the deep area of the dermis that contains hair
follicles and sweat glands.
These are not painful and often heal with
hypertrophic scars.
at full thickness or of III and IV degree, they involve the epidermis, the
dermis, the subcutaneous tissue and sometimes the muscular tissue, the tendons
and the bones. The pathological process behind this type of burns is necrosis.
Still the agent that causes the injury may be different, so we will have:
1) thermal, e.g. burn from UV rays from excessive exposure to the sun, radiation
or, conversely, from low temperatures to freezing;
2) chemical, eg caustic soda, sulfuric acid of car batteries
3) electric.
Problems related to burn and practical rules.
To calculate it the 9% rule applies, ie the body is ideally divided into areas that make up a 9% portion, for example each limb is worth 9%, while each leg is worth 18% of the body surface area and thus the front or back of the trunk; the genital part is assigned 1%.
It is also important to take into account the depth of the burn, age, location and type of trauma.
Up to 18% -25% the prognosis is good, but when the burn is more extensive it can take over the problems of infection, loss of fluids and proteins and the pronounced quoad vitam becomes more and more random. In any case over 15% hospitalization is always advisable.
Related issues:
- inhalation of smoke that emanates after burning wood or making synthetic
products; who writes in winter comes across old men with carbomonossiemoglobina,
that is to say, smoke from a wood stove and brazier! With pictures of complete
asphyxia and edema of the first respiratory tract.
- explosion injuries, in these cases the gases are released, the victims can be
projected at a distance and therefore in addition to the damages of the burn
they can report traumas.
The symptomatology can be divided into local and general. The local
symptomatology manifests itself in relation to the degree of burn:
- in the first degree there is the presence of erythema
- in the second degree there are large characteristic bubbles, called flittene,
due to edema, due to the involvement of the subcutaneous tissue
- in the third degree there is the presence of necrotic tissue without blood
circulation
- in the fourth degree there is a real carbonization of the tissues.
The general symptomatology can manifest itself with fever, oliguria, loss of
liquid electrolytes and proteins, substances that if not reintegrated, determine
a picture of relative hypovolemic shock that can lead the subject to death. It
occurs in the first hours after the injury, when the passage of plasma from the
vessels to the interstitium causes dehydration and hypoprotidemia. Following
hypovolemia, compensatory vasoconstriction occurs, especially at the cutaneous
and renal level.
Classically, the infection is the most frequent and is due to severe immunosuppression and defect of skin protection. Gastrointestinal complications: in patients with burns greater than 25% of the total body surface a paralytic ileus always occurs.
Sepsis and /or hypovolemia may produce ischemic changes in
the mucosa or entire wall throughout the gastro-intestinal tract, which result
in outbreaks and mucosal ulcers (which can result in true stress ulcers (Curling
ulcers). ) wall scarring and perforations.
Respiratory complications: bronchopneumonia, pleurisy, etc.
Bronchi and lungs can be involved either directly following the inhalation of toxic vapors or warm air, or indirectly, with the "shock lung" framework, a cause of severe respiratory failure occurring within 24-72 hours after the trauma. Renal complications: oliguria and anuria are justified by the hypovolaemic state, by the shock, by endogenous toxic substances, by the infection, by the drugs administered.
In first and second degree burns, the therapy is essentially local and is based
on two principles:
- cool the affected area to stop inflammation; for this purpose, running water
is sufficient;
-revent the infection by cleaning the burn area and covering it if possible with
sterile gauze.
Only in burns of the first degree it is possible to resort to over-the-counter
ointments, taken in pharmacies, ex. gentamicin and cortisone or benzocaine-based
pain relieving pain. In the burns of the degree, never proceed by removing the
bubbles, since the epidermis that covers them protects the dermis from further
damage. If these open spontaneously, they should be treated with vaseline gauze
containing antibiotics and then covered with non-compressive bandages.
Immediate admission to the hospital is necessary in the burns of III and IV degree. If the
affected body surface is more than 15%, the patient must be referred to a burn
center. Fundamental in these cases is the therapy of complications. In
particular:
- move the victim away from the heat source, turn off the flames, remove
clothing that is burning.
The flames on the victim can be extinguished with water, fire extinguishers or suffocation by blankets. On the burned areas there is ice to soothe pain, do not apply ointments or ointments, wash with sterile solution or simple water, do not break the bubbles, touch the injured areas with dirty hands.
With regard to the general conditions, it is necessary to avoid
making the patient shock, then in the cannula a vein, the vital functions are
monitored and if resuscitation is necessary. evaluate vital functions and, if
necessary, perform cardiorespiratory resuscitation maneuvers;
- perform shock therapy and infuse intravenous fluids or high molecular weight
colloids;
- cover the burned parts with sterile drapes to prevent infections and limit the
loss of plasma;
- immobilize the segments concerned.
- incase of chemical injuries, caustic substances, such as acids (hydrochloric,
sulfuric, nitric) bases (soda, potash, etc.) salts, essences, remove the agent,
thoroughly wash the affected area use a neutralizing substance. In the case of
soda or lime do not use water because it does more damage, but remove the
substance dry.
Furthermore, antitetanic prophylaxis is often necessary, as well as analgesic
therapy in extended burns. After these first urgent treatments, local deep burns
are performed. In particular, small escarts can be treated with substances that
favor their detachment such as silver nitrate, iodine polyvinylpyrrolidone or
silver-sulfadiazine based ointments; in the larger escaras the surgical toilet
is indicated instead. This is important both to combat the development of
infections and to prevent the formation of retracting or hypertrophic scars.