How would someone burn spontaneously
Burn wounds: spontaneous healing or surgery?
The primary assessment of the burn depth is difficult even for experienced first responders. However, their correct assessment is crucial for therapy planning.
It is usually not difficult for the first treating physician to estimate the proportion of the body surface burned. The differentiation between the various degrees of combustion, especially between type IIa and IIb, is more difficult. While grade IIa injuries often heal spontaneously after conservative therapy, surgery is usually necessary for grade IIb. At the 17th Federal Surgery Congress in Nuremberg, experts from the Burn Injury Center in the St. Georg Hospital in Leipzig gave an overview of the care for burn injuries.
17 highly specialized centers for burn injuries
While the number of burn injuries is vaguely stated with an incidence of about 600 per 100,000 inhabitants per year, the number of inpatient admissions for burns is well documented at 10,000 cases annually. Of these, around 2,050 patients require treatment in an intensive care unit for those with severe burns, as is provided in the 17 highly specialized centers in Germany - including the Leipzig clinic. In addition, there are 44 children's intensive beds for severely burned children in Germany. They are mediated nationwide via a central contact point, the Hamburg Fire Brigade Operations Center (phone: 040 / 42851- 3998, 24 hours a day).
Anyone who, as a resident doctor or emergency doctor, takes on the primary care of a burn victim should leave the wound alone as far as possible, explained the plastic surgeon Priv.-Doz. Dr. Adrian Dragu. "Please do not clean the injury or moisten it with ointments or antiseptics." Burn blisters should not be removed. It is better to cover the injury with a sterile and dry cover and to get the patient to the clinic as quickly as possible.
“Remember that the body's own thermoregulation does not work in burn injuries. They must therefore be protected from cooling down. ”However, many first aiders believed that they had to cool the wound. "These patients often have a core body temperature of only 35 or 36 degrees when they arrive at the clinic," said Dragu. Even with minor scalds, well-intentioned cooling, for example with cooling units, could lead to frostbite of the affected area.
It is therefore not the task of the first aiders to initiate their own therapeutic measures, but to provide the clinic with all relevant information:
- Age of the patient,
- Location, extent and depth of the burn,
- Concomitant injuries and / or suspected inhalation trauma.
For the actual therapy planning, the depth of the burn is crucial. However, it is usually difficult to assess them at the scene of the accident because clear criteria such as blistering are usually still missing immediately after the trauma. "We have found that the primary assessment of the burn depth, even by experienced surgeons, is correct in just over half of the cases," said Dragu.
It is particularly difficult to distinguish between grade IIa and IIb burns. While a grade IIa burn responds well to conservative therapy and heals within one to two weeks, a grade IIb burn must be operated on. With a low proportion of burned body surface (SCOF), the burned areas can be reconstructed with split-thickness skin grafts or mesh grafts, with a high SCOF proportion one must resort to the skin expansion technique according to Meek.
Intensive medical care is of particular importance in the case of severely burned patients. The anesthetist and intensive care physician Dr. med. Jochen Gille from Leipzig emphasized that, given the small number of cases, there was hardly any scientific evidence in this area. In his clinic, he works according to the Leipzig concept of burn disease, which proceeds from a course in four phases:
- the shock phase (36 to 48 hours after burn trauma),
- the re-absorption phase (days 3 to 7 after the trauma),
- the phase of inflammation and infection (day 7 to wound closure) and
- the recovery and rehabilitation phase.
During the shock phase, fluid therapy is the greatest challenge in intensive care medicine: “How much is enough? And how much is too much? Over-infusion is problematic and can lead to complications including abdominal compartment syndrome, ”Gille pointed out. A whole series of formulas are circulating in Germany for the optimal infusion therapy in the shock phase. In his clinic, the Parkland formula is preferred (4 ml x kg body weight x% VKOF per 24 hours). “But the formula is always just the starting point, after which the fluid therapy has to be adjusted individually depending on the clinical picture. After all, many influencing factors play a role in burn injuries that cannot be represented in formulas. "
Use of high-dose vitamin C is off label
In the shock phase, according to Gille, the administration of high-dose vitamin C (66 mg x kg body weight per hour intravenously in the first 24 hours) has proven to be very effective as an anti-oxidant. "The application is off-label, but is supported by data." However, one must take into account that the high-dose administration of vitamin C significantly reduces the fluid requirement, the patient gains weight and tends to develop edema. "We therefore urgently need larger studies on the use of vitamin C in burn patients," demanded Gille.
It is also advantageous for the course of therapy if the patient is not routinely intubated. "The initial ventilation can unfavorably prolong the shock phase," said Gille. In case of doubt, an emergency doctor should rather intubate the patient, but extubation should be attempted as soon as possible under intensive medical treatment.
After surviving the shock phase, sepsis is the greatest threat to the patient. "Unfortunately, sepsis is a very faithful companion of burn injuries," said Gille. It increases the mortality risk of burn injuries by a factor of eight. Nevertheless, an initial systemic administration of antibiotics in the case of burn injuries in the infection-free early phase is not indicated in order to prevent resistance. In the case of sepsis, both the individual patient and the range of pathogens in your own clinic must be taken into account and high-dose antibiotic therapy initiated.
Pediatric surgeon Dr. med. Christian Geyer says: “Most child burns occur at home, with scalds with hot liquids being the main cause.” Electricity injuries, burns from fireworks or grill deflagrations also played a role in older children. "Child abuse occurs in about one percent of the cases," explained Geyer.
The child's organism has an enormous corrective potential
First aiders should first cool the affected tissue with cold tap water at a temperature of twelve to 15 degrees, because the cooling prevents afterburning and alleviates pain. "However, too long and uncontrolled cooling can lead to cardiac arrhythmias, so only the extremities and not the head or trunk should be cooled," emphasized Geyer. As with adults, cooling with ice or cooling units is prohibited because it would cause additional damage to the wound by frostbite.
In children, too, the therapy depends on the depth of the burn, which in turn depends on the noxious agent, the duration of the exposure, the temperature, the location and the age of the patient. The examiner must note that due to the different body proportions, the proportion of VKOF in children is calculated differently than in adults. Children usually wait longer to see whether spontaneous healing occurs. "Spontaneous healing always leads to better results and fewer scars, and the child's organism also has enormous correction potential," emphasized Geyer.
However, it is difficult to differentiate between grade IIa and IIb burns even in children. An incorrectly applied surgical therapy for an IIa burn leads to scars that would not have developed with conservative therapy. A conservative attempt at therapy for an IIb burn due to a misjudgment of the burn depth would in turn lead to unnecessary loss of time and increase the risk of wound infections and poorer treatment results.
Degrees of combustion
Grade I: A superficial burn at temperatures above 45 ° C, the skin is painful and reddened, but healed after a few days (sunburn).
Grade II: The skin is superficially to deeply burned, and blistering often occurs. Depending on the severity, the burns are divided into types 2a and 2b, whereby it is assumed that the first type heals completely, while the second type can leave scars.
Grade III: A severe burn that can occur at temperatures above 60 ° C. The subcutis is so damaged that the skin has to be replaced with a graft. Since the nerves are also destroyed, the patients usually do not experience any pain.
Grade IV: Often caused by open fire or high voltage. All layers of the skin down to the fatty tissue are destroyed; nerves, muscles and bones can also be damaged. Here you can see a charred wound that requires intensive medical care.
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