Thermal and chemical burns. Sunburns. Respiratory tract burns: Clinical Guidelines

List of Abbreviations

Terms and Definitions

Combustiology is a branch of medicine that studies the etiology, pathogenesis, diagnosis, treatment, and prevention of burns and related pathological conditions.

Pathological condition refers to bodily changes arising from the action of pathogenic and/or physiological factors and requiring medical care.

Syndrome is a set of symptoms sharing a common etiology and pathogenesis.

Conservative treatment is the treatment of diseases without surgery using various chemical, physical, and/or biological agents and methods.

Surgical treatment is a method of treating diseases by dividing and/or joining tissues during a surgical operation.

Dermabrasion - is a surgical wound treatment method (necrectomy) that consists of the layered removal of the affected epidermis and papillary dermis, as well as scar tissue using special devices and/or brushes.

Nutritional support is the provision of nutrition to patients unable to independently consume food in an amount sufficient to supply the body with the required amount of energy and/or nutrients.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Burns (combustio) are injuries resulting from high-temperature, chemical, electrical, or radiation exposure to the body, damaging the skin and underlying tissues. A person who has sustained a burn is referred to as a burn patient (burn casualty).

Inhalation injury is damage to the mucous membrane of the respiratory tract and/or lung tissue resulting from thermal and/or toxic-chemical factors.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Etiological factors of skin burns:

- Thermal (flame, boiling water, contact).

- Electrical.

- Chemical.

- Radiation.

- Mixed.

Comment: Skin burns are caused by a variety of factors.

- Thermal burns are associated with exposure to high temperatures and are the most frequent. Hot liquid and steam burns are most common, followed by flame burns caused by open fire (combustible materials, clothing, campfires, fires), explosions of flammable liquids and incendiary mixtures. Contact burns occur upon contact with hot objects or substances (e.g., hot metal, hot resin, bitumen, asphalt, etc.). Such burns have shapes matching the contours of the hot object that caused the injury. Additional trauma may occur when removing the injuring object. Convection burns caused by hot air and infrared radiation from hot objects or open flame without direct skin contact are less common.

- Chemical burns result from the aggressive action of chemicals on the skin or mucous membranes. Chemical burns account for 2.5-5.1% of all burns. Chemicals cause various skin lesions (not only burns, but also contact dermatitis, eczema), and sometimes the distinction between them can be difficult[1].

- Electrical injury (electrical damage) is an injury resulting from the action of an electric current on the body, causing anatomical and functional disorders accompanied by general and local reactions. The frequency of electrical injuries among all other mechanical injuries does not exceed 1-2.5%. In adults, electrical injuries are mainly associated with occupational risks, while in children they are mostly related to the use of household electrical appliances. Lightning strikes occur with equal frequency across all age groups, more often in rural residents. Electrical injuries are combined with burns in 60-80% of cases, and with other injuries in 30% of cases.

Main types of electrical injury

- Upon direct contact with an electric current conductor. A person's contact with live parts can be single-phase (single-pole) or two-phase (two-pole). Single-phase connection of a person into the circuit between the phase wire and the ground occurs more often than two-phase connection between two phase wires.

- Non-contact, due to exposure to an electric arc arising between the current source and the victim, including lightning (characteristic of high-voltage currents).

- From "step" voltage arising due to the potential difference between different parts of the body in contact with the ground.

Classification of electrical injury depending on current voltage:

- Low-voltage (voltage up to 1000 V);

- High-voltage (1000-10000 V);

- Extra-high-voltage (tens and hundreds of kilovolts).

Electrical injuries can be general and local (electrical burns), and are frequently combined.

General electrical injury is electrical damage manifested solely by general pathological disorders in the human body without any local changes.

General electrical injury [2] is classified by severity into:

- Grade I – short-term spasmodic contraction of skeletal muscles without loss of consciousness;

- Grade II – spasmodic muscle contraction with short-term loss of consciousness, but preserved breathing and cardiac function;

- Grade III – prolonged loss of consciousness, impaired breathing and/or cardiac activity;

- Grade IV – clinical death.

Local electrical injury (electrical burn) is a specific type of local tissue and organ damage caused by a directed flow of electrons, occurring at the sites of exposure and along the path of electric current propagation. Electrical burns can be contact or arc[3].

- Radiation burns may be caused by ultraviolet, infrared, and ionizing radiation. Sunburns are skin injuries caused by excessive exposure to sunlight. Exposure to ionizing radiation leads to both local and systemic changes in the body, known as "radiation sickness".

Etiological factors of inhalation injury

Inhalation of hot air, steam, and/or the action of toxic chemical compounds (combustion products) inhaled with smoke:

- thermal (thermal inhalation injury of the respiratory tract);

- toxic-chemical (acute inhalation poisoning by combustion products);

- thermochemical (mixed).

Comment: Modern building modules consist of polymeric synthetic materials, the combustion of which produces a complex flue gas. Its inhalation causes not only damage to the respiratory tract, but also systemic intoxication of the body. The most hazardous toxic substances inhaled with smoke are: carbon monoxide (CO), hydrocyanic acid and its derivatives (HCN), carbon dioxide (CO₂), chlorine (Cl₂), and phosgene (COCl₂) [1-3].

In young children, upper respiratory tract injuries have been described following head and upper torso burns caused by spilling hot liquids on them.

Pathogenesis of skin burns

The rate of tissue heating (depth of injury) depends on the temperature and physical state of the thermal agent (flame, liquid, heated object, gaseous substance, radiant energy), the heat transfer method (conduction, convection, evaporation), the duration of exposure, the baseline condition of the patient (age, comorbidities), the localization of injuries (skin thickness), and the thermal insulation properties of clothing. The degree of tissue hyperthermia is directly proportional to the duration of heating. Short-term exposure to even very high temperatures may not lead to the development of burns. The higher the degree of tissue overheating, the faster cell death occurs.

Damaging external exposure destroys cells or disrupts their function. At an agent temperature of 42–50°C, the thermal threshold of tissue viability is exceeded, protein coagulation occurs, plasma escapes from the vascular bed, erythrocytes disintegrate, and microcirculation in the tissues is disrupted, leading to profound homeostasis disorders. When tissues overheat above 52⁰C, coagulative protein denaturation becomes irreversible.

Radiation injuries are associated with the biological effects of ionizing radiation due to the formation of organic radicals that have a damaging effect on tissues.

Chemical burns are characterized by the aspect of prolonged destruction: if the damaging substance is not removed in time, chemical agents continue to destroy tissues until they are inactivated in the tissues through neutralization and dilution. They can lead to a systemic toxic effect (poisoning).

Immediately following a burn injury, the burn wound is conventionally divided into three zones, each of which has a different microcirculatory response.

The inner zone of necrosis is characterized by irreversible changes. As a result of the etiological factor, tissue death occurs and a burn eschar forms.

The area adjacent to the necrosis is the zone of paranecrosis, characterized by impaired microcirculation and increased vascular wall permeability. Within the burn wound, a series of processes occurs during the first 48 hours after injury (a transient spasm followed by vasodilation, and increased blood viscosity) that contribute to the development of ischemia and subsequent tissue death. At the same time, during the ischemic stage, the process may be reversible with adequate treatment. The outer zone, with minimal reversible damage, is the hyperemia zone. The cells exhibit reversible changes, and microcirculation is characterized by increased blood flow.

The burn wound serves as a trigger mechanism for the development of a systemic inflammatory response and the entire cascade of pathological changes in the burn patient. The severity of the patients' general condition mainly depends on the area and depth of the burn injury, which ultimately determine the prognosis of the disease. In extensive thermal injuries, a clinically pronounced general reaction of the body (burn disease) develops, and the functions of various organs and systems are impaired.

Pathogenesis of electrical injury

The damaging effect of electricity on the body depends on voltage, current strength, type of current (direct or alternating), current path, duration of contact, tissue resistance, and the condition of the human body. Current with a voltage of 500–1000 V typically leads to deep burns, while a voltage of 110–220 V usually causes muscle spasm during exposure—tetany. High-voltage currents (thousands of volts and more), when an arc discharge (voltaic arc) occurs at the contact site, do not lead to instant death: the skin and underlying tissues char, causing a sharp increase in their resistance and a decrease in current strength. Alternating current up to 500 V is more dangerous than direct current; at about 500 V, alternating and direct currents are equally dangerous; and at voltages exceeding 1000 V, direct current becomes more dangerous [4].

Lightning is an atmospheric electricity discharge of immense voltage (millions of volts) and current strength (over ten thousand amperes).

Electric current acts both locally, damaging tissues along its pathway, and reflexively. In contact or arc injuries, the electric current, having overcome the resistance of the skin and subcutaneous adipose tissue, travels along the path of least resistance—i.e., through tissues with good electrical conductivity from the entry point to the exit point from the body along the electrical circuit formed within the body, creating the so-called current loop. Low-voltage electrical injuries typically feature a single current loop. The most dangerous paths pass through the heart and respiratory organs. The most common pathways in practice are hand-to-hand (up to 40% of all types of injuries) and hand-to-foot (up to 35%). In such situations, 80% of victims die, as this type of exposure almost always affects the heart, leading to ventricular fibrillation [5].

At high voltage, current passes through body tissues from the source (entry wound) to the ground (exit wound) along the shortest path. There is a possibility of multiple electrical channels inside the body, leading to multiple current exits. Spreading fan-like in the body away from the "loop", the current also puts any organ at risk of electrical injury.

Local tissue damage in electrical injury manifests as so-called electrical marks (stigmata), primarily at the sites of current entry and exit. The higher the voltage of the electric current, the more severe the burns. The depth of injury directly depends on the electrical voltage—the higher the voltage, the more severe the injury. Electrical burns are formed as a result of the specific action of electric current by converting electrical energy into heat within the tissues themselves, unlike external tissue heating in thermal injuries. There is a discrepancy between the extent of visible skin damage and the scale of damage to deeper structures, primarily muscles.

Pathogenesis of inhalation injury

Upper respiratory tract injury generally develops as a result of inhaling hot air, steam, or smoke. True burns below the vocal cords practically do not occur because the upper respiratory tract acts as a powerful barrier that prevents high-temperature agents from penetrating into the tracheobronchial tree and lungs for a prolonged period, effectively lowering the temperature of the inhaled mixture. However, with prolonged exposure to flames, inhalation of water vapor, or gas explosions, thermal injury to the respiratory tract can also extend to the tracheobronchial tree.

The most severe respiratory tract injuries develop under the action of toxic chemical compounds inhaled with smoke. It has been experimentally confirmed that the degree of respiratory tract damage depends not only on the composition of the smoke, but also on the duration of exposure [6].

Thermal burns below the vocal cords develop extremely rarely because the upper respiratory tract acts as a barrier that effectively lowers the temperature of the inhaled mixture and prevents high-temperature agents from penetrating the tracheobronchial tree and lungs for a prolonged period. Inhalation injury resulting from the inhalation of combustion products exerts both local and systemic effects on the body. Local damage to the respiratory mucosa and lung parenchyma is caused by thermal and toxic agents, while the systemic effect is a consequence of impaired tissue and organ oxygenation. This occurs due to reduced oxygen delivery and/or utilization when inhaling toxic gases (carbon monoxide — CO, cyanide — CN) and other toxic compounds [602]. It has been experimentally confirmed that the degree of respiratory tract damage depends not only on the composition of the smoke, but also on the duration of its exposure [6].

The solid-disperse phase of smoke performs a transport function in relation to gaseous substances, which penetrate deep into the respiratory tract and cause chemical burns of the respiratory mucosa. As a result of the trauma, neurogenic inflammation develops, which leads to the main pathological changes restricting normal airflow to the alveoli [7].

Causes of airway lumen narrowing: edema of the airway mucosa; airway obstruction (by sloughed epithelial cells, inflammatory cells, mucus, and protein-rich plasma exudate); bronchospasm [8].

Carbon monoxide, binding to hemoglobin and forming carboxyhemoglobin, blocks the transport function of hemoglobin, which leads to impaired tissue respiration [9].

The binding of cyanide to the iron (Fe3+) of cytochrome oxidase leads to impaired cellular respiration [10]. Both processes are reversible [11].

The reduction of the lung barrier function due to impaired ciliary clearance of bronchial epithelial cells, suppression of the cough reflex, and reduced activity of immunocompetent cells leads to secondary infection and the development of purulent respiratory complications as well as generalized infection.

If the use of topical dermatological agents alone is sufficient, the treatment of such dermatitis may be carried out with the involvement of a dermatologist; at the same time, chemical burns requiring the use of wound dressings and/or surgical treatment must be managed in a burn unit.

[2] When signs of general electrical injury are present, hospital admission is indicated regardless of the extent of the lesion and the victim's condition. Victims with general electrical injury should be evacuated in a supine position, as cardiac arrhythmias are possible. Patients with general electrical injury without severe local lesions and in a satisfactory condition are hospitalized for at least 3 days.

[3] In cases where electrical energy converts into thermal energy before contacting the human body, voltaic arc burns occur, which are a type of thermal burn and are not classified as electrical injuries since there is no general electrical injury.

1.3 Epidemiology of the Disease or Condition

Burn trauma is a major medical and social problem in modern society, which is due to its prevalence, high mortality rate, significant rates of temporary disability, and primary permanent disability.

Despite the worldwide trend toward a decrease in burn incidence [603], according to WHO data, 180,000 people die from burns worldwide every year [604].

In Russia, according to official data from 2010, burns ranked sixth (2.4% of cases) in the overall injury structure, accounting for 2.1 cases per 1,000 adult population [12]. According to Rosstat data for 2022 [605], burns accounted for 1.6% of cases in the structure of injuries, poisonings, and certain other consequences of external causes. According to Rosstat data for 2019-2022, between 190.2 and 246.5 thousand adult and child burn victims seek medical help annually in the Russian Federation, which accounts for 139.0 to 166.7 cases per 100,000 population. Furthermore, between 46.0 and 63.2 thousand children sustain burns annually (160.4 to 208.1 per 100,000 children).

At the same time, patients with superficial burns predominate; in 80% of cases, these have small affected areas and require mainly conservative treatment, with 70% of cases managed on an outpatient basis.

About 100,000 victims of thermal injuries (about 30% of all burn cases) are treated in burn inpatient units annually. Among burn patients hospitalized in inpatient units, 60-80% also have superficial and borderline burns.

Burns occur most frequently in children under 5 years of age. The next most frequent group consists of adults aged 21 to 50 years, with men sustaining burns more often than women.

Respiratory tract involvement occurs in 20-30% of adult patients admitted to specialized inpatient units and in 40-45% of patients with flame burns.

1.4 Features of Coding the Disease or Condition

THERMAL AND CHEMICAL BURNS[1]

L55 SUNBURN[6]

T95 SEQUELAE OF THERMAL AND CHEMICAL BURNS AND FROSTBITE

[1] Includes:

burns (thermal) caused by:

- electrical heating appliances

- electric current (with general electrical injury - effects of electric current (T74.5))

- flame

- friction

- hot air and gases

- hot objects

- lightning

- radiation

chemical burns

scalds

Excludes: diseases of the skin and subcutaneous tissue related to radiation (L55 - L59)

[2] Includes: burns classified in more than one of categories T20-T25, T27

[3] Excludes: burns with specified extent of body surface involved (T31)

[4] This category is to be used for primary statistical coding only when the site of the burn is unspecified. If the site is specified, this category may be used as an additional code with categories T20-T25, if necessary.

[5] This category is to be used for primary statistical coding only when the site of the burn is unspecified. If the site is specified, this category may be used as an additional code with categories T20-T25, if necessary.

[6] Excludes:

Other diseases of the skin and subcutaneous tissue related to radiation (L59)

- Other specified acute skin changes due to ultraviolet radiation (L56.8)

- Acute skin change due to ultraviolet radiation, unspecified (L56.9)

Other diseases of the skin and subcutaneous tissue related to radiation (L59)

Erythema ab igne [dermatitis ab igne] (L59.0)

1.5 Classification of the disease or condition

Classification by depth of skin burn injury

- Grade I – burns within the epidermis (epidermal, superficial);

- Grade II – burns extending to the papillary dermis with preservation of skin appendages (dermal, "borderline");

- Grade III – involvement of all layers of the skin down to the deep fascia, in some cases with damage to subfascial structures (deep).

Comment:

In first-degree burns, only the epidermis is affected, presenting with exudative inflammation. Skin hyperemia is typically observed in sunburns and other injuries caused by ultraviolet radiation. Complete restoration of skin structure in these cases occurs 2-3 days after the burn. Local peeling may be observed. Other thermal and chemical burns are characterized, in addition to hyperemia, by skin edema with blister formation containing fluid composition close to plasma. Epithelization in such injuries occurs due to partial preservation of the lower epidermal layers and skin appendages up to 10 days after the trauma. In some cases, pigmentation disorders may occur, resolving over time.

In second-degree burns, the reticular dermis is patchily involved in the injury zone, but many hair follicles, sebaceous and sweat glands—skin appendages—remain undamaged, through which epithelization of burn wounds occurs. Edema spreads throughout the dermis and subcutaneous adipose tissue, which exacerbates microcirculation disorders. Epithelization of second-degree burn wounds is usually observed 18-20 days after the trauma. Skin pigmentation is frequently impaired, and post-burn scars may form, especially when combining second-degree burns with small areas of third-degree burns (so-called "mosaic" burns).

In third-degree burns, skin damage occurs throughout its entire depth (subcutaneous adipose tissue, muscles, fascia, and bones). Only small-area deep burns heal through wound contraction and marginal epithelization. In all other cases, spontaneous healing is impossible, and various types of skin grafting become necessary. After healing, skin pigmentation disorders always persist, post-burn scars form, and scar contractures may develop.

Classification by area of burn injury

The area of burn injury is expressed as a percentage of the total body surface (% of body surface, b.s.) or in square centimeters (cm²). The relative magnitude of the injury zone (relative to the total skin surface taken as 100%) is what matters.

Comment: Accurately determining the injury area is quite difficult due to individual human characteristics—height, weight, limb length, etc. According to calculations, the total body surface area of an adult human averages 17,000-20,000 cm², while the area of a human palm is 170-200 cm², i.e., 1% of the body surface.

Burn disease

The area and depth of the injury determine the nature of the body's reaction, with burn disease developing in victims with a total burn area exceeding 15-20% of the body surface and/or deep burns exceeding 10% of the body surface (in children and elderly patients—with a burn area exceeding 5-10% of the body surface), representing a complex of interrelated pathophysiological reactions and systemic clinical manifestations in response to burn injury of the skin and underlying tissues.

The more extensive the deep lesion, the more severe the burn disease and the longer the recovery process.

Burn disease follows a specific cyclic course. According to the periodization adopted in the Russian Federation, there are four periods of burn disease, each with its own manifestations and requiring specific management.

Comments: With the advent of new and the improvement of traditional treatment methods and means, the course of burn disease can often be modified, reducing the severity of clinical manifestations. For example, primary (early) surgical necrectomy with simultaneous autodermoplasty can reduce the clinical manifestations of the acute burn toxemia period and interrupt the course of burn disease at the onset of the septicotoxemia period.

Classification of burn disease by periods

- Burn shock is the first period of burn disease, which develops immediately after trauma in extensive burns of the skin and underlying tissues due to circulatory disorders against the background of hypovolemia, manifesting as hemoconcentration, hyperlactatemia, metabolic acidosis, and impaired organ functions (kidneys, gastrointestinal tract, and central nervous system). It usually lasts up to 3 days, and in severe cases up to 5 days.

Comment: The clinical picture of burn shock can also develop in burns of limited area: when skin burns are combined with inhalation injury of the respiratory tract, as well as with deep subfascial lesions. In addition to local inflammation in the damage zone, a burn causes the release of inflammatory mediators and the development of systemic inflammatory response syndrome with increased vascular permeability in both damaged and undamaged tissues. This leads to fluid shifting from the intravascular space into the interstitium, resulting in edema, hypovolemia, and hemoconcentration. These changes, together with increased vascular resistance and, in some cases, decreased myocardial contractility, exacerbate circulatory disorders, the severity of which depends on the area and depth of skin damage. Fluid loss from extensive burn surfaces and fluid extravasation from the vascular bed into the interstitial space occur over 12–18 hours or more. A decrease in circulating blood volume and the centralization of circulation lead to microcirculatory disorders, impaired perfusion of internal organs and tissues, decreased oxygen delivery, and the development of hypoxia with subsequent organ dysfunction.

Depending on the total burn area, clinical picture, and examination data, the severity of burn shock is classified into mild, severe, and extremely severe (Table 1).

Table 1

Classification of burn shock by severity

- Acute burn toxemia – the second period of burn disease, characterized by the development of endogenous intoxication syndrome in response to the release of decay products from damaged tissues and other toxic substances of various origins into the body's internal environment. Duration - 3–10 days.

- Septicotoxemia – the third period of burn disease, associated with the development of infection and metabolic changes against the background of the prolonged presence of burn wounds. Duration - from 5–11 days after trauma until complete wound healing.

- Convalescence – the final period of burn disease, which begins after the restoration of the skin and lasts for several weeks and months until the morphological and functional state of various organs and systems is restored following severe burn trauma.

Associated injuries

Associated trauma consists of skin burns combined with eye burns, thermo-inhalation injury, combustion product poisoning, or general overheating (hyperthermia) of the body. Associated injuries should also include burns of various etiologies, such as thermal and chemical skin burns.

Comment: When skin burns are combined with respiratory tract injury, a mutual aggravation syndrome develops, which worsens the course of burn shock and leads to increased mortality compared to patients with isolated thermal skin trauma. At the same time, severe inhalation injury determines the severity of the condition and prognosis; therefore, in the case of localized skin burns, it is indicated prior to them in the diagnosis formulation.

Classification of inhalation injury by localization:

- upper respiratory tract involvement:

- without laryngeal involvement (nasal cavity, pharynx);

- with laryngeal involvement (nasal cavity, pharynx, larynx up to and including the vocal folds);

- upper and lower respiratory tract involvement (trachea and main, lobar, segmental, and subsegmental bronchi).

Endoscopic classification of inhalation injury severity based on tracheobronchial tree involvement [35]:

- mild grade (I) – moderate hyperemia, isolated deposits of easily removable soot in the trachea and bronchi, small amount of mucous secretion;

- moderate grade (II) – mucosal hyperemia and edema, a large amount of soot in the bronchial lumen and isolated deposits of soot fixed to the mucosa, isolated petechial hemorrhages and erosions in the trachea and main bronchi, large amount of soot-admixed bronchial secretion;

- severe grade (III) – pronounced mucosal hyperemia and edema, loose mucosa, total layers of soot fixed to the mucosal membrane down to the segmental bronchi; attempts to wash away the soot reveal an easily vulnerable, bleeding mucosa with multiple erosions or a pale gray "dry" mucosa lacking a vascular pattern, scanty thick bronchial secretion with a large amount of soot or absence of bronchial secretion, desquamated epithelial casts obstructing the bronchial lumen.

Combined injuries

Combined injuries occur as a result of the impact of several different damaging factors of various natures on the body: thermal, chemical, firearm, mechanical, bacteriological, or radiation (e.g., skin burns combined with limb fractures, etc.). The severity of the condition in combined injuries is determined by the "mutual aggravation syndrome".

1.6 Clinical presentation of the disease or condition

The clinical picture of burn injury consists of local and general manifestations.

Burns not accompanied by the development of burn disease (covering an area of less than 10-15% of the body surface) manifest with pronounced local pain syndrome, soft tissue edema in the area of the wounds, and fever.

In extensive burns, a clinically pronounced general reaction of the body develops – burn disease, which begins within the first hours after injury.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria include the identification of skin burns and/or inhalation injury in a patient based on the analysis of complaints, history of the present illness, physical examination, and the exclusion of other pathologies with a similar clinical presentation (Appendix B1).

In most cases, establishing a diagnosis of skin burn and/or inhalation injury does not require laboratory and instrumental diagnostic tests. At the same time, these tests are important for determining the severity of the patient's condition, the extent and depth of tissue damage, identifying complications and comorbid conditions, performing differential diagnosis with other diseases or conditions, determining the need for therapeutic measures, and assessing the dynamics of the patient's condition during treatment.

The principles of laboratory and instrumental diagnostic tests for pediatric patients with burns and/or inhalation injury and an established diagnosis do not differ from the diagnostic principles in adult patients.

Many recommended methods for diagnosing the disease and related conditions have a limited evidence base according to the scales for rating the level of certainty of evidence and the level of recommendation strength due to the lack of clinical studies devoted to them. Despite this, they are necessary elements of patient examination to establish the diagnosis, determine the severity of the condition, identify complications and comorbid conditions, perform differential diagnosis with other diseases or conditions, and select treatment tactics, as more effective and proven methods have not yet been developed.

It should be borne in mind that a patient may present with atypical manifestations of the disease, as well as a combination of a specific disease or condition with other pathologies, which may dictate the need for the attending physician to modify the patient's examination algorithm.

2.1 Complaints and Anamnesis

Comment: The patient's main complaint is the presence of burn wounds and pain and/or burning in their area. Assessment of pain severity in adult patients is recommended using the visual analogue scale (VAS) (Appendix G1). For children, the Wong-Baker FACES Pain Rating Scale (Appendix G2) [18] and the FLACC behavioral pain scale (Appendix G3) [19] are used.

Burn shock is also characterized by complaints of thirst, chills, nausea, and vomiting.

The period of acute burn toxemia is also characterized by weakness, insomnia, loss of appetite, dyspeptic symptoms, febrile fever, and psycho-emotional disorders, including psychomotor agitation or delirious states of consciousness may occur.

The septicotoxemia period is also characterized by fever, decreased appetite, psycho-emotional disorders, and weight loss.

The reconvalescence period is characterized by psycho-emotional disorders, complaints of skin itching, skin depigmentation, post-burn scars, and/or scar deformities.

Inhalation injury is characterized by complaints of difficulty breathing, throat irritation, a sensation of a "lump" in the throat, hoarseness (dysphonia, aphonia), and a cough with soot-containing sputum.

Comment: Special attention is required to identify in the history the time and circumstances of the injury, the type and duration of the damaging agent, prior therapeutic measures, as well as the presence of concomitant acute or chronic diseases in order to determine the force of the damaging factor, the patient's somatic status, and the quality and timeliness of medical care provided, if any.

Inhalation injury can be suspected based on history data when clarifying the circumstances of the injury – being in a fire zone and/or a smoke-filled room, the ignition mechanism (explosion, flash), the composition of the burning material, and the level of consciousness at the time of injury (alcohol intoxication, sleep, loss of consciousness).

Diagnosis of electrical injury may be difficult if the victim is unconscious. In such cases, the presence of current marks or deep electrical burns, as well as eyewitness accounts, are important.

2.2 Physical Examination

Comment: The area and depth of the skin burn determine the severity of the burn injury. The greater the area and depth of tissue damage, the more severe the course of the burn injury.

Determination of burn area

• For a rough estimation of the area of extensive burns that completely cover separate body regions in adults, it is recommended to use the "rule of nines" (Appendix G4) [24, 228].

GoR CLoE 5Grade of Recommendation — C (Level of Evidence — 5).

Comment: For burns with a limited area, as well as burns located in various parts of the body and not completely covering individual body zones, the "rule of palms" is applied. The area of the palm is approximately 1% of the body surface. According to the "rule of palms," the area of the lesion is determined by the number of palms that fit onto the burn surface [25, 228].

• The area of burn injury in children is recommended to be determined using the Lund-Browder chart (Appendix G5) [26, 228, 590].

LeR BLoE 3Level of recommendation strength – B (level of certainty of evidence – 3).

At the pre-hospital stage, absolute accuracy in determining the total area and the area of deep burns is not required. Slight overdiagnosis is acceptable. Modern technologies, such as computer or smartphone applications, are successfully used for accurate and rapid assessment of burn area with a smaller margin of error [21].

Determining Burn Depth

The depth of a burn is determined based on local clinical signs.

- First degree — skin hyperemia, pastosity, or mild skin edema. Epidermal detachment with the formation of thin-walled blisters filled with clear, slightly yellowish fluid may occur. Pain sensitivity is preserved or slightly increased. The base of the burn blister is pink, moist, and shiny.

- Second degree — thick-walled blisters or epidermal desquamation, bright pink and moist dermis, edema of the skin and underlying tissues. Vascular reaction and pain sensitivity are preserved or slightly reduced. Burns caused by high-temperature agents may form a thin, light yellow, or brown eschar through which blood vessels are not visible.

- Third degree — necrotic tissue presented as a thick eschar through which thrombosed subcutaneous veins may be visible, which is a reliable sign of deep lesions. Hemorrhagic contents of remaining burn blisters are noted; the wound base is dull, whitish, with a mottled appearance, sometimes with petechial hemorrhages. Vascular reaction and pain sensitivity are absent; during the hair pull test, hairs are easily removed. Flame burns may cause skin charring with ruptures, with destroyed muscles and tendons showing a complete loss of function. As the wounds are debrided of necrotic tissue, granulation tissue growth is observed.

Diagnosing the depth of a burn injury presents certain difficulties, especially in the first hours after the burn. Burn wounds can change over time. The depth of a burn injury (especially in second- and third-degree burns) can only be definitively determined 7–10 days after the trauma.

It is possible to use additional diagnostic tests to determine burn depth:

• Signs of circulatory impairment are determined using the "capillary" refill test. To do this, the affected area of skin or exposed dermis is pressed with the tip of forceps or a finger, and the change in blood filling is noted. The appearance of a white spot and its refilling with blood indicates a second-degree burn. If a white spot does not form, it indicates dermal vessel damage, which signifies a deep injury.

• The state of pain sensitivity is assessed in various ways: needle pricks, hair pulling, touching the wound surface with gauze (cotton) balls moistened with alcohol, or the bottom of a test tube filled with warm water (thermal test). The examination must take into account the patient's level of consciousness and the possibility of a lowered sensitivity threshold due to pain medications. The deeper the skin lesion, the more pronounced the sensory deficits. Easy painless hair removal, a negative alcohol test, and the absence of a pain reaction when pricking the eschar with a needle are convincing signs of a deep burn.

Comment: Burn shock in the early post-injury period lacks characteristic diagnostic signs. The patient may remain conscious and may not appear severely injured, as compensatory mechanisms stabilize basic homeostatic parameters for a period. Hypotension in burn shock usually does not develop immediately after the injury. Therefore, blood pressure values—which are a primary indicator for assessing traumatic shock severity—do not always correspond to the severity of the burn injury.

To identify signs of burn shock and initiate anti-shock therapy in the early post-injury period, physical examination data reflecting the patient's condition (total area and depth of the burn injury, burn localization, patient age) are sufficient. The earlier anti-shock measures are initiated, the greater the likelihood of a favorable course of burn disease and the lower the frequency of its severe complications.

The main clinical criteria for burn shock 6–8 hours after injury are:

- dry skin and mucous membranes;

- pallor or mottled appearance of the skin;

- capillary refill time greater than 3 seconds;

- hypothermia, an increase in the skin-rectal temperature gradient greater than 5 °C;

- hemodynamic disturbances (tachycardia, decreased blood pressure);

- renal dysfunction (oliguria or anuria);

- mental status alterations (psychomotor agitation, less commonly depressed consciousness);

- gastrointestinal dysfunction (nausea, vomiting, intestinal paresis);

- acute respiratory failure.

Comment: Indirect clinical signs of inhalation injury and smoke inhalation poisoning include:

- localization of burns on the face, neck, anterior chest wall, singed eyelashes, eyebrows, nasal hairs;

- swelling and erythema of the oral and pharyngeal mucosa;

- soot in the oropharyngeal mucosa, nasal passages, and sputum;

- voice changes (dysphonia, aphonia);

- signs of respiratory failure;

- altered mental status not related to central nervous system disease or trauma.

2.3 Laboratory Diagnostics

Comment. There are no laboratory markers specific solely to cutaneous burns and/or inhalation injury.

Laboratory signs characteristic of the burn shock period:

- metabolic acidosis;

- hyperlactatemia;

- hemoconcentration (elevated hemoglobin and hematocrit levels);

- decreased venous blood oxygen saturation, increased arteriovenous oxygen difference.

Laboratory signs characteristic of the acute burn toxemia and septicotoxemia periods:

- anemia;

- leukocytosis with a significant left shift in the leukocyte differential;

- lymphopenia;

- hypokalemia;

- hypoalbuminemia.

Laboratory signs characteristic of inhalation injury and smoke inhalation poisoning:

- elevated carboxyhemoglobin (HbCO) levels above 20%

- acidosis (respiratory and/or metabolic)

Laboratory signs characteristic of skeletal muscle damage (rhabdomyolysis) resulting from deep burn injury:

- Elevated total creatine phosphokinase (CK) with normal troponin I levels, where the CK-MB fraction constitutes no more than 6% of the total CK value [607].

- Elevated myoglobin levels in blood and urine (not always present even with high CK values).

Comment.

The main coagulation parameters in burn patients are: APTT (aPTT); INR, prothrombin index, fibrinogen.

In 50% of cases, based on medical history and physical examination, the diagnosis of deep vein thrombosis (DVT) cannot be established. Determining D-dimer levels has limited value when screening patients with burn trauma for DVT [134].

Comment: Carboxyhemoglobin levels are best measured immediately after injury, but this test is rarely available at the fire scene. Due to the inevitable delay between smoke exposure and carboxyhemoglobin testing, the level measured upon arrival at a medical facility does not reflect the true degree of intoxication [9, 32]. If equipment for determining carboxyhemoglobin levels or blood gas analysis is unavailable, diagnosis is based on clinical data.

Comments: Immunological status testing can serve as an effective tool in identifying damaged key immune markers in burns, determining the severity of immune status disorders in burn disease, and assessing the risk of septic complications [608]. For early diagnosis and prognosis of sepsis in burn patients, the following immune formula is recommended [608]:

- Lymphocytes < 9.3 %

- Band neutrophils > 21%

- Endogenous intoxication index (LII) > 4 UNITS

- Natural killers < 5 %

- CD64+ granulocytes 90 - 100 %

- HLA-DR+ monocytes < 50%

- IgG < 6 g/L

Immunodiagnostics make it possible to identify the most damaged links of the immune system for subsequent timely immunocorrection and prevention of septic complications in the comprehensive treatment of severely burned patients [608].

Comment. Histological diagnostic methods are auxiliary; the long preparation time for analysis samples significantly reduces the value of these methods.

2.4 Instrumental Diagnostics

Comment: Radiological manifestations of inhalation injury are non-specific [395, 468-470]. When toxic products damage the lung parenchyma, a picture characteristic of ARDS is observed.

Duplex scanning of upper and/or lower extremity veins is the primary examination method when venous thrombosis is suspected [123,125].

Comment: Bronchoscopy (BS) - is the most informative method in the diagnosis of inhalation injury. As a rule, initial bronchoscopy only establishes the fact of inhalation injury (presence of soot on the mucous membrane of the respiratory tract), but fails to assess the severity of mucosal damage. Indirect signs of severe inhalation injury include atonia of the respiratory tract walls and tight fixation of soot on the walls of the trachea and bronchi. After 1-2 days, BS can be used to assess the severity of the injury.

BS does not allow assessment of the state of the distal airways and respiratory bronchioles; therefore, damage to this part of the lung explains the discrepancy that sometimes arises between the bronchoscopic and clinical picture. Despite this, the relative simplicity of the method and its accessibility make it possible to establish an initial diagnosis and observe changes dynamically.

Absolute contraindications to emergency BS in patients with suspected inhalation injury include only a terminal state.

Relative contraindications to BS include acute coronary insufficiency, acute myocardial infarction, acute stroke, grade III cardiovascular disease, life-threatening arrhythmias, severe coagulopathy, and extremely severe patient condition with a high risk of complications.

BS Procedure.

Diagnostic BS is performed in a room equipped with respiratory equipment and a centralized medical gas (oxygen) supply. BS is performed under local anesthesia during spontaneous breathing or mechanical ventilation, depending on the severity of respiratory failure phenomena.

Contraindications to emergency bronchoscopy under local anesthesia include alcohol intoxication, absence or impairment of consciousness, respiratory failure, local anesthetic hypersensitivity, status asthmaticus, and aspiration syndrome.

For local anesthesia of the upper and lower respiratory tract mucosa, 10–15 ml of a 2% lidocaine** solution is used (no more than 400 mg per procedure).

The bronchoscope is inserted transnasally (if the nasal passages are wide) or transorally (using a mouthpiece) if passing the endoscope through the nasal passage is not feasible.

When performing bronchoscopy under local anesthesia, humidified oxygen inhalation is administered beforehand for 10–15 minutes. Bronchoscopy is performed under continuous monitoring of blood oxygen saturation (pulse oximetry). If the patient is found to have an upper airway burn with laryngeal involvement, grade III smoke inhalation injury, or signs of respiratory failure (respiratory rate greater than 30 breaths/min, oxygen saturation drop below 90%), the procedure must be terminated. The issue of further bronchoscopy under mechanical ventilation is decided jointly with an anesthesiologist-resuscitologist.

Comment. A distinctive feature of emergency bronchoscopy in a patient with an inhalation injury is also the mandatory assessment of the condition of the nasal passages, nasopharynx, oropharynx, and larynx.

Visual assessment of the upper and lower respiratory tract takes into account:

- assessment of the condition of the nasal passages, nasopharynx, oropharynx, and larynx;

- condition of the airway mucosa (hyperemia and edema, hemorrhages and erosions, their severity and extent);

- presence of combustion products (soot) on the walls and within the lumen of the tracheobronchial tree and the degree of their fixation on the mucosa;

- type and degree of airway obstruction (due to mucosal edema, bronchospasm, obturation by fibrin, combustion products, secretion);

- severity of the cough reflex during local anesthesia.

Comment: Esophagogastroduodenoscopy is the primary diagnostic method for erosive and ulcerative lesions of the gastrointestinal tract in burn patients.

Comment:

Central venous pressure in severely burned patients is not always a sufficiently informative indicator of the adequacy of ongoing infusion therapy, as there is no reliable correlation between right atrial pressure and left ventricular end-diastolic volume. In severe burn shock, even with adequate fluid resuscitation, CVP remains low at 0–5 mm Hg. However, a rapid increase in CVP by 5 mm Hg or more serves as an indication to reduce the rate of infusion therapy and add inotropic support.

In severely burned patients developing shock, a multidisciplinary approach to maintaining mean arterial pressure is necessary to ensure adequate organ and tissue perfusion [609].

Carbon monoxide poisoning cannot be detected using pulse oximetry. The spectra of oxyhemoglobin and carboxyhemoglobin are very similar, and pulse oximeters cannot distinguish between the two forms of hemoglobin [9, 48]. Pulse oximetry can be useful if its data can be compared with the results of blood gas analysis—the difference makes it possible to determine the relative amount of carboxyhemoglobin (or methemoglobin in the case of methemoglobinemia).

The target values of key clinical and laboratory parameters during anti-shock therapy are:

- Maintaining a mean arterial pressure of 65 mm Hg or a systolic BP of at least 90 mm Hg.

- Restoration of diuresis – 0.5–1 ml/kg/h.

- Maintaining optimal oxygen delivery: lactate <2 mmol/l, 70<ScvO₂<80%.

- Reduction of hematocrit ≤35%

- Correction of metabolic acidosis (BE ±2.5)

- Normalization of blood plasma electrolyte composition:

- Potassium level – 3.5–5.1 mmol/l

- Sodium level – within 136–145 mmol/l.

Criteria for the patient's emergence from burn shock are:

- normalization of central hemodynamics parameters (heart rate and blood pressure),

- normalization of hemoglobin, hematocrit, and erythrocyte levels,

- diuresis > 0.5–1 ml/kg/h,

- increase in body temperature above 37⁰C.

Target hemodynamic parameters during advanced non-invasive and/or invasive monitoring are:

- Normalization of heart chamber dimensions according to echocardiography data,

- CI ≥ 2.5 L/^m2/min,

- ITGV 650–800 ml/^m2,

- ITBV ≤10 ml/kg,

- SVV ≤ 13%.

None of the instrumental diagnostic methods for burn-injured tissues provides an objective assessment of the depth of destructive changes and the features of the wound healing process [228, 492, 498]. More accurate data on the viability of burn-injured tissues can be obtained through repeated serial revisions.

Comment: Laser Doppler flowmetry of blood vessels using laser Doppler imagers enables non-contact scanning of a large body area. The method is based on measuring the Doppler component in the spectrum of the reflected laser signal scattered by formed blood elements (mainly erythrocytes) moving in microvessels, allowing for the non-invasive measurement of tissue blood perfusion and the detection of specific microcirculatory disorders. Typically, the laser penetrates to a depth of 1–2 mm. Within 48 hours, the accuracy in assessing indeterminate depth is less than 80%, which is comparable to the 60–70% accuracy of clinical methods. Therefore, this method is recommended to be used from the 2nd to the 5th day after burn injury [21].

2.5 Other Procedures

Other diagnostic tests are performed in accordance with the examination algorithm for burn victims to identify potential complications and concomitant diseases, and to perform differential diagnosis with other diseases or conditions.

In the case of complications and concomitant diseases, a consultation with a relevant medical specialist is conducted along with additional diagnostic tests depending on the nosology [20].

- Primary disease: "burn", etiological factor, burn localization, depth and total surface area of the lesion as a percentage of body surface area (BSA) (indicating the area of deep burns as a percentage of BSA in parentheses, if present), indication of inhalation injury and/or eye burns in polytrauma, as well as other potential injuries in combined trauma. Next, the period of burn disease (if present) is indicated.

- Complications of the primary disease.

- Concomitant diseases.

Comment: Numerous diagrams and calculations have been created to allow an arithmetic or graphical representation of the localization, total burn area, and deep lesion area. In practical application, a graphic schematic representation of the human body—a body map ("sketsa")—can be used, on which conventional symbols are used to mark the localization, area, and depth of the burn. Such a graphic representation can also be used to evaluate scars, donor sites, etc.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Treatment of burn victims is a comprehensive, continuous, sequential, and multi-stage process aimed at restoring the skin, preventing and treating complications. It is carried out at all stages of evacuation and treatment of burned patients in accordance with the established scope of medical care for each stage.

The main link in the pathogenesis of burn disease is the destruction of the skin. In this regard, rational local treatment is essential for preventing and stopping general symptoms. Systemic therapy methods are essentially secondary. Treatment of burn disease is designed to compensate for impaired or lost functions, provide the most favorable background in the pre- and postoperative periods, and prevent or eliminate emerging complications.

The principles of treatment for pediatric patients with burns and/or inhalation injury do not differ from the principles of treatment for adult patients.

Many recommended treatment methods have a limited evidence base according to the scales for assessing the level of reliability of evidence and the level of conviction of recommendations due to the lack of clinical studies devoted to them. Despite this, they are necessary elements of patient treatment, as more effective and proven methods have not yet been developed.

It should be taken into account that a patient may have atypical manifestations of the disease, as well as a combination of a specific disease or condition with other pathologies, which may dictate the need for the attending physician to modify the algorithm for choosing the optimal treatment strategy.

Patients with burns and/or inhalation injury undergo comprehensive general and local treatment, including drugs from various groups in accordance with the Anatomical Therapeutic Chemical (ATC) classification system (Appendix A3). At the same time, most of the drugs used in patients with burns and/or inhalation injury do not have the indication "treatment of burns and/or inhalation injury" according to the instructions for use. All necessary medicinal products for medical use in patients with burns and/or inhalation injury are used for the prevention and treatment of certain conditions or syndromes in accordance with their indications and contraindications, routes of administration, and doses contained in the instructions for medical use. In the case of their use associated with the comorbidity of the listed conditions and syndromes indicated in the "indications" section of the instructions for medical use, there are developed clinical guidelines for these nosologies.

3.1 General (systemic) treatment

3.1.1 Treatment of burn disease

Successful treatment of patients with extensive and deep burns is possible only on the basis of comprehensive therapy of burn disease, timely and adequate to the severity of the trauma and the patient's condition, during all its periods, starting from burn shock.

Comment: Burn shock is the first and most critical period of burn disease for the patient's survival. It is during this period, at any stage of medical evacuation, that all efforts of physicians should be directed toward taking immediate measures to prevent the development and worsening of burn shock, endotoxemia, acute cardiovascular and/or respiratory failure, multiple organ failure, and generalized infectious complications.

Timely treatment of burn shock, adequate to the severity of the injury, aims to reduce microcirculatory disorders and tissue hypoxia in internal organs and body systems of burn victims, decrease the likelihood of burn disease complications, and lower mortality in patients with extensive burns.

- perform pain relief and sedation;

- ensure upper airway patency; in case of acute respiratory failure, provide respiratory support;

- ensure adequate venous access (central or peripheral vein catheterization depending on the severity of the injury) and initiate infusion therapy in accordance with the burn shock infusion-transfusion therapy protocol for adequate replenishment of circulating blood volume (CBV).

Comment: If necessary, venous access can be established through burned tissues [15, 53].

- urinary bladder catheterization (as indicated);

- insertion of a nasogastric tube for decompression, gastric lavage (as indicated);

- application of a burn dressing.

- antithrombotic therapy;

- early initiation of enteral nutrition (if gastrointestinal function is not impaired);

- prevention of erosive and ulcerative lesions of the gastrointestinal tract;

- antibacterial and/or antifungal therapy (as indicated);

- maintaining a comfortable thermal environment (not lower than 24–28 °C);

- maintaining maximally sterile conditions.

- prevention and compensation of protein-energy losses;

- prevention and treatment of anemia (as indicated);

- detoxification therapy;

- normalization of water and electrolyte balance;

- antibacterial and antifungal therapy (as indicated);

- immunotherapy (as indicated);

- organ protection and symptomatic therapy;

- local treatment of burn wounds.

3.1.2 Analgesia and sedation

Comment: For sedation in the anesthesiology, resuscitation, and intensive care unit, including before and/or during diagnostic or surgical interventions in burn patients, it is optimal, if available, to use the medicinal product Dexmedetomidine [21, 56-60, 536, 584-589, 590, 592]. According to the instructions for medical use of the medicinal product, Dexmedetomidine is used for sedation in adult patients and children over 12 years of age within a dosage range of 0.2 to 1.4 mcg/kg/h [57, 584, 586, 588, 589]. In children under 12 years of age with burns, effective use of #Dexmedetomidine within a dosage range of 0.2 to 0.5 mcg/kg/h is also possible [56, 60, 536, 585, 587].

• The recommended level of sedation for a burn patient on the RASS scale is 0 to -1-2 (Appendix G6) [61, 62].

GoR CLoE 5Grade of Recommendation — C (Level of Evidence — 5).

Comment: Pain syndrome, especially pronounced in extensive surface burns, can exacerbate the neurohumoral stress response and significantly affect the course and outcome of burn disease. In patients with thermal trauma, a distinction is made between acute pain syndrome directly associated with the trauma and pain associated with burn wound dressings and surgical procedures. Selecting the optimal anesthesia method, taking into account the need for multiple painful procedures throughout the entire treatment period for burn patients, is extremely important [643]. Analgesia is carried out taking into account the constitutional and age characteristics of the patients and aims to reduce pain severity to less than 3 points on the visual analogue scale (VAS). Deep sedation should be avoided in patients [62].

The use of analgesics from the opioid group or opioid analgesics requires continuous respiratory monitoring in spontaneously breathing patients.

Adequate pain relief is a patient's right. Adequate analgesia has short- and long-term positive effects on the physiological and psychological state of patients and promotes effective wound treatment [64].

At the same time, there is no convincing evidence confirming the advantages of one pain management regimen over another in burn trauma patients [65].

Comment: Non-pharmacological interventions include education, distraction techniques, distraction psychotherapy, meditation, hypnotherapy, acupuncture point stimulation using other physical factors, the use of interactive games during the rehabilitation process, ensuring sleep conditions, early mobilization, etc.

3.1.3 Respiratory support

Comment:

To maintain airway patency, patients are indicated for tracheal intubation [612]. An indication for tracheostomy may be the need for prolonged mechanical ventilation. The optimal timing for performing a tracheostomy remains a subject of debate. At the same time, tracheostomy helps reduce the need for sedation, especially when performed early, allows for enteral feeding, and increases the patient's participation in the weaning process from mechanical ventilation [74, 75].

In burn patients who develop grade I-II acute respiratory failure, non-invasive mechanical ventilation (high-flow nasal cannula oxygen therapy) may be used, as it provides physiological replacement of external respiration functions compared to invasive mechanical ventilation, is better tolerated by patients, reduces the rate of mechanical ventilation initiation, and significantly improves oxygenation parameters [610, 611].

- grade III burns localized to the face and neck with a risk of progressive soft tissue edema;

- impaired consciousness according to the Glasgow Coma Scale <8 points (Appendix G7);

- grade III skin burns >40% of total body surface area (TBSA);

- upper airway burns involving the larynx and a risk of obstruction;

- severe thermochemical airway injury;

- grade III inhalation injury (according to bronchoscopy).

GCR CLEL 4Grade of Recommendation – C (Level of Evidence – 4).

- PaO₂<80 mm Hg;

- SaO₂<93-94%;

- PaCO₂>50 mm Hg;

- impaired normal respiratory mechanics.

GoR CLoE 5Grade of Recommendation — C (Level of Evidence — 5).

Comment:

The main goal of respiratory support in burned patients is to ensure adequate gas exchange.

Rapid progression of edema in head and neck burns as early as 1-3 hours after trauma will make tracheal intubation or tracheostomy extremely difficult to perform.

The choice of ventilation mode and parameters should be based on the safe mechanical ventilation concept, according to which ventilation settings are adjusted so that the plateau pressure does not exceed 35 cm H₂O, FiO₂ 0.5-0.6, to maintain arterial blood oxygen saturation SaO₂ >90%, and arterial pH >7.2 [82]. Due to the risk of lung overdistension, the recommended tidal volume corresponds to 6-8 ml/kg; however, in victims with airway obstruction and increasing PaO₂ and decreasing PaO₂, an increase in tidal volume to 8-10 ml/kg may be required [83-85]. At the same time, consensus regarding optimal mechanical ventilation modes for patients with inhalation injury has not yet been reached [35, 86].

3.1.4 Infusion and transfusion therapy

The main objective of burn shock therapy is the restoration and maintenance of internal organ perfusion, which is achieved through enteral rehydration or intravenous infusion.

Comment: Despite the lack of evidence, the use of oral rehydration is encouraged, especially when infusion therapy is not feasible [88-91].

In the absence of nausea and vomiting, patients can be given non-carbonated mineral water or an alkaline-salt solution (per 1 liter of water, 1/2 teaspoon of baking soda and 1 teaspoon of table salt (1 teaspoon = 5 g)). In more severe cases, additional enteral rehydration should be carried out via a nasogastric tube from the first hours after admission to the hospital, including in combination with infusion therapy.

Comment: Infusion-transfusion therapy in severely burned patients presents certain difficulties caused primarily by the impossibility of accurately estimating fluid losses from extensive burn surfaces and its extravasation into the interstitial space, the need to maintain an optimal oxygen delivery level, and the associated risk of pulmonary edema and compartment syndrome [87].

- in adult patients: V (in ml) = 4 × Body weight (in kg) × Total burn surface area (in % TBSA) [20, 92, 95, 459, 480, 498]. Grade of Recommendations — C (Level of Evidence — 5).

- in children: V (in ml) = 3 ml/kg × Total burn surface area (in % TBSA) (intravenous administration) + Physiological requirement for 24 hours (if enterally feasible 2 hours after admission and subsequently every 3 hours, including nighttime) [96-98, 459].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).

Comment: When calculating the total burn surface area, erythema is not taken into account. The above calculations apply to burns of no more than 50% of the body surface area. For larger burn areas, the infusion volume is calculated based on 50% TBSA. In burned patients older than 50 years, the daily volume of infusion fluids is reduced by 1.5–2 times compared to the calculated value due to the risk of pulmonary circulation overload. In patients with inhalation injury and/or electrical burns, the daily volume must be increased by 15% and 50% of the calculated value, respectively [99, 228, 613].

The daily physiological fluid requirement in children is calculated as follows: at 1 month–1 year − 120 ml/kg/day; 1–2 years − 100 ml/kg/day; 2–5 years − 80 ml/kg/day; 5–10 years − 60 ml/kg/day; 10–18 years − 50 ml/kg/day [98].

Comment: Preference should be given to "balanced solutions" with an electrolyte composition close to that of the blood plasma of a healthy individual, which is associated with a lower risk of acute kidney injury (AKI) and a reduced need for renal replacement therapy [107].

Comment: In severe conditions during the first 24 hours after injury, 2/3 of the calculated volume of intravenous solutions should consist of medicinal products from the electrolyte group (ATX code B05BB and B05BB01) and 1/3 of blood substitutes and plasma protein fractions; in extremely severe conditions and burns exceeding 50% of the body surface area, these products are used in a 1:1 ratio [20, 98, 104].

5% human albumin solution** should be administered at the following rates: for burns covering 20–30% of the body surface area – 12.5 ml/h; 31–44% – 25 ml/h; 45–60% – 37 ml/h; greater than 61% – 50 ml/h.

According to some studies, albumin may improve resuscitation outcomes in burn shock [614]. Other studies do not support the efficacy of early human albumin** use in burn patients [615]. However, the volume and quality of current evidence are limited, and further well-powered, preferably multicenter, clinical trials are needed.

To replace low serum albumin levels, it is advisable to use human albumin** infusions [21].

Fresh frozen plasma (FFP) transfusion in patients with thermal trauma has a favorable clinical effect [104]. FFP is the optimal transfusion medium for patients with extensive burns due to its ability to restore intravascular fluid volume and treat endotheliopathy. FFP has a positive effect on the endothelium, particularly the glycocalyx, mitigating excessive capillary leakage and reducing the required infusion volume during burn shock [616–618].

Comment: There is evidence indicating an increased incidence of renal injury when hydroxyethyl starch**-based blood substitutes and plasma protein fractions are used in burn patients. Furthermore, the use of hydroxyethyl starch** has not been shown to reduce the overall volume requirement of infusion therapy [111]. Additionally, the use of hydroxyethyl starch** is contraindicated in patients with sepsis [619].

Comment. Norepinephrine** is the drug of choice, initiated at a dose of 0.05 mcg/kg/min with subsequent titration until the clinical effect is achieved [558]. When signs of heart failure are present according to hemodynamic monitoring data, the use of dobutamine** or dopamine**, including in combination with norepinephrine**, is effective.

Comment: The volume of ongoing fluid losses in burn patients, especially those with extensive burns, is difficult to determine. The fluid volume received by the patient should not be less than the physiological requirement, which is 1500 ml per 1 m² of body surface area.

The required daily fluid volume can be roughly calculated using the formula: urine output volume for the previous 24 hours + transcutaneous and respiratory water losses (approximately 1000 ml) + losses via stool, vomiting, and/or wounds + 400 ml for every 1⁰C above 37⁰C.

The daily intravenous infusion volume for patients with extensive and deep burns following recovery from burn shock can also be calculated using the formula [112]: Vd + Vv, where Vd = 1.5 ml × deep burn area (% BSA) × body weight (kg); Vv = 0.5 ml × superficial burn area (% BSA) × body weight (kg).

The proposed fluid therapy algorithms should be considered as a general guideline that standardizes and simplifies the calculation of the required intravenous infusion volume, allowing for adequate therapy and avoiding fluid overload complications in patients both during the burn shock period and throughout subsequent treatment. The requirements, composition, and adequacy of ongoing therapy require reassessment based on clinical manifestations, urine output rate, and laboratory test data.

3.1.5 Bronchoscopy

Comment: In severe airway injuries caused by combustion products, therapeutic bronchoscopies for airway clearance should be performed at least once daily.

Irrigation solutions are used for endobronchial administration [28, 30, 45]. For endobronchial lavage during the first 24 hours post-injury, it is advisable to use a warm (37^οC) 2% sodium bicarbonate** solution at 5–10 ml per segmental bronchus [645].

Bronchoscopy is more effective when performed 30 minutes after inhalation of combination solutions of mucolytic agents and beta-agonists.

During prolonged mechanical ventilation, the condition of the tracheal mucosa at the level of the endotracheal or tracheostomy tube cuff must be assessed, along with airway clearance above the tracheostomy. To evaluate potential post-traumatic and post-intubation complications, a control bronchoscopy must be performed after extubation or removal of the tracheostomy tube.

3.1.6 Inhalation (nebulizer) therapy

Comment. Nebulized administration of mucolytic agents and heparin sodium** may be used for up to 7 days following inhalation injury (acetylcysteine** 20% solution – 3 ml every 4 hours alternating with the administration of 5,000 units [in children] or 10,000 units [in adults] of heparin sodium** in 3 ml of 0.9% sodium chloride isotonic solution for infusion, under the monitoring of blood clotting time [for 7 days]) [72, 73, 115–117, 228, 544].

At the same time, the efficacy of nebulized heparin sodium**, as well as the heparin sodium**/acetylcysteine**/salbutamol** protocol, has not been proven [44, 118, 119].

3.1.7 Antithrombotic therapy

The overwhelming majority of patients with burns belong to the moderate risk group (burns up to 20% of the body surface area, grade II thermo-inhalation injury) and high risk group (burns greater than 20% of the body surface area, grade III thermo-inhalation injury, complications of burn disease) for venous thromboembolism (VTE) [121-124, 539, 540].

Comment: Mechanical VTE prophylaxis is also recommended in the presence of contraindications to the use of antithrombotic drugs from the heparin group [620].

3.1.8 Detoxification therapy

Comment: Detoxification therapy essentially encompasses the entire complex of measures for treating burns and burn disease. It is recommended to perform hemodilution via infusion of large fluid volumes (40-80 ml/kg) with forced diuresis, and to use extracorporeal detoxification methods. The decision to initiate or withhold extracorporeal detoxification depends on many factors, including clinical, laboratory, and instrumental data, the feasibility of a surgical solution, comorbid conditions, and risk factors. The use of extracorporeal detoxification methods serves as an additional component of pathogenetic therapy in patients with sepsis, septic shock, and multiple organ dysfunction syndrome, allowing for a sufficiently broad therapeutic strategy and a significant improvement in overall outcomes [136-139].

3.1.9 Prevention of gastrointestinal complications

Comment: Paresis and erosive-ulcerative lesions of the gastrointestinal tract in severe burn trauma develop as a result of hypoperfusion, ischemia, and mucosal damage, typically due to delayed initiation or inadequate anti-shock therapy. Acute erosive-ulcerative lesions of the gastrointestinal tract, including those complicated by gastroduodenal bleeding, worsen the course of burn disease and increase the likelihood of mortality from 20-30% to 70-80% [141, 142, 144].

Prophylpsis should begin immediately upon admission of the injured patients and include targeted infusion and metabolic therapy, the use of proton pump inhibitors or H2-histamine receptor blockers, early enteral support, and early surgical treatment of burn wounds.

The optimal approach for the prevention and treatment of erosive and ulcerative changes in the gastrointestinal tract is the use of proton pump inhibitors [144]. In patients during the burn shock period, the use of parenteral formulations is recommended starting from the first day after sustaining the burn. Subsequently, after patients recover from burn shock and regain the ability to independently take oral nutrition, transitioning from the parenteral route to the oral route is possible.

Drugs for the treatment of acid-related disorders—antacids (Magnesium preparations, Aluminum preparations, Combinations of aluminum, calcium, and magnesium preparations, Antacids combined with antiflatulents, Antacids combined with antispasmodics, Antacids combined with other drugs, Antacids combined with sodium bicarbonate)—are not used for the prevention of stress ulcers of the gastrointestinal tract, but they are used in the complex treatment of ulcers.

3.1.10 Nutritional support

– for the pediatric population [140, 150, 168, 459, 553].

GCR CLOC 4Level of recommendations grading — C (level of evidence certainty - 4).

– for the adult population [145-149, 168, 182, 228, 498, 553].

GCR BLOC 2Level of recommendations grading — B (level of evidence certainty - 2).

Comment: Nutritional support plays one of the primary roles in the treatment of patients with burns and/or inhalation injury, significantly improving treatment outcomes [151-154, 168, 182, 553].

Early initiation of enteral support prevents the development of acute intestinal failure syndrome and the translocation of intestinal microflora into the bloodstream.

In cases of delayed gastric emptying in patients with extensive burns, postpyloric feeding may be performed [159].

Parenteral nutrition (PN) should be used as an adjunct to enteral nutrition when the patient's substrate provision cannot be optimized. Total PN should be prescribed only when enteral nutrition is impossible. When administering total parenteral nutrition, it is recommended to administer the full daily dose of vitamins and trace elements as part of complex preparations [160, 168, 553].

Comment: The use of other parameters in burn victims, such as mid-upper arm circumference, triceps skinfold thickness, and transferrin levels, is frequently difficult. BMI and weight deficit indicators may vary depending on the patient's hydration status.

Comment. In burn disease, the body's energy requirements in burned patients increase by 50% for burns covering 10–20% of the body surface area, by 100% for burns covering 20–40%, and by 150% for burns covering more than 40% of the area. Thus, the body's energy requirements in burn victims can reach 4000–5000 kcal/day.

Several equations have been developed to estimate energy requirements in adults and children with burn trauma. However, these equations are characterized by a certain degree of inaccuracy, likely related to fluctuations in the patient's metabolism caused by surgical interventions or the inflammatory response [162].

When using predictive equations, the daily energy requirement is more frequently overestimated than underestimated. Therefore, the most likely risks associated with strictly following the estimates obtained using equations are overfeeding and the development of associated complications. Conversely, if requirements are determined solely on the basis of individual clinical examination results, the risk increases of failing to provide the patient with sufficient energy substrates, leading to weight loss and wasting due to uncontrolled hypermetabolism.

Comment. Additional enteral administration of #ornithine alpha-ketoglutarate as part of nutritional support significantly reduces protein hypercatabolism and shortens wound healing time in patients with burns [170, 483, 484].

Comment: A target blood glucose level of less than 10.0 mmol/L results in lower mortality than a target of 4.5 to 6.0 mmol/L [621]. When blood glucose levels exceed 12–13 mmol/L, it is advisable to consider intravenous insulin administration up to 7 IU/h, depending on the glycemia level of the specific patient [374, 622]. The advantage of glycemic control using exogenous insulin infusion in burn patients may be associated with a reduction in infectious complications [623-625] and multiple organ failure [626]. Insulin therapy is associated with the attenuation of the hypermetabolic state [627, 628], improved wound healing [629], and preservation of muscle mass [630, 631], which are factors essential for the survival of patients with extensive burns.

Comment: The minimum volume of substrate provision for burn victims after stabilization should correspond to the basal metabolic rate – 20-25 kcal/kg. Calculating energy requirements using formulas carries a risk of overestimating daily needs. Overfeeding can lead to fluid and electrolyte imbalance, hyperglycemia, and hepatic steatosis [168, 178-180]. Aggressive parenteral nutritional support may contribute to increased mortality [168, 180].

The risk of overfeeding is lower when conventional oral diets are used. If the patient is able to consume amounts of food sufficient in nutrients and calories, conventional diets are effective and cheaper than commercial enteral nutrition formulas.

Comment: Plasma micronutrient levels in burn patients, especially those with extensive burns, are significantly decreased for a prolonged period after injury due to increased urinary excretion and significant transcutaneous losses [598-601]. The requirement (average daily dose) for essential micronutrients in burn patients varies according to various studies [21, 168, 553, 555-557, 583] (Table 2).

Table 2

3.1.11 Prevention and treatment of acute kidney injury

Acute kidney injury (AKI) is a syndrome of sharp decline in renal function characterized by decreased urine output down to anuria, accumulation of nitrogenous waste products, and water-electrolyte balance disorders, and is also associated with the development of chronic kidney disease and high mortality.

Comment: The term "acute kidney injury" should be used instead of the notion "acute renal failure" (ARF) [186]. AKI is diagnosed if at least one of the following criteria is met [187]:

- increase in Scr ≥ 0.3 mg/dL (≥ 26.5 µmol/L) within 48 hours;

- increase in Scr ≥ 1.5 times from baseline, known or presumed to have occurred within the prior 7 days;

- urine volume < 0.5 mL/kg/h for 6 hours.

Comment. Measures to prevent or reduce the severity of rhabdomyolysis in electrical injury include adequate infusion therapy and early fasciotomy if compartment syndrome is suspected. Their goal is to limit further muscle tissue damage and the release of myoglobin into the bloodstream. Early adequate infusion therapy is the cornerstone of treating rhabdomyolysis and preventing acute kidney injury.

Mannitol** should be used in patients who do not respond to infusion therapy, whereas its administration is contraindicated in cases of anuria [189, 190].

Comment: The most frequent cause of AKI in severe burn injury is renal hypoperfusion developing as a result of burn shock. The second most frequent is renal AKI in patients with extensive deep or circular burns. Timely adequate infusion therapy for burn shock and active surgical tactics in the treatment of deep burns (necrotomy, surgical necrectomy) reduce the risk of AKI in severe thermal trauma.

3.1.12 Antibacterial therapy

Comment: Burn wound infection is one of the pathological factors that impair wound healing and lead to complications.

The following concepts should be distinguished:

- burn wound contamination with microflora — absence of local and systemic manifestations of the infectious process;

- local signs of infection — pain, unpleasant odor from the wound, purulent discharge, perifocal inflammation, local hyperthermia;

- systemic signs of infection — fever, chills, leukocytosis, development of infectious complications.

Comment: Isolated topical application of antibacterial drugs is significantly inferior in efficacy to their systemic administration, the indications for which are general symptoms of infection [208].

Comment. Measures aimed at the rational use of antibacterial drugs in hospitalized patients help reduce resistance, the incidence of hospital-acquired infections, and improve clinical outcomes [190, 209, 644].

The choice of antibacterial drugs for topical and systemic use must be made strictly in accordance with the susceptibility patterns of the microflora isolated from patients—pathogens of infection—or taking into account epidemiological monitoring data of the therapeutic unit.

When severe infectious complications develop, intravenous administration of maximum doses of antimicrobial drugs covering the entire sensitivity spectrum of suspected pathogens is indicated [201, 644].

3.1.13 Hormone therapy

Comment: Systemic corticosteroids provide symptomatic improvement; the treatment is not etiotropic. Systemic corticosteroids are indicated in the event of ARDS [213, 214] and septic shock [215]. The primary indication for systemic corticosteroids in burn patients is adrenocortical insufficiency associated with burn cachexia. To diagnose adrenal insufficiency, blood cortisol and urinary 17-oxysteroids (17-OHCS) tests are performed. Depending on the patient's severity, various administration routes and dosing regimens for systemic corticosteroids can be used during systemic therapy. For long-term maintenance therapy in burn cachexia, oral administration of "medium" doses of systemic corticosteroids (15–30 mg of #prednisolone** or an equivalent dose of any other drug) with gradual tapering after complete wound healing is recommended [209, 498].

3.1.14 Vitamin therapy

Comment: Patients with burns, especially extensive ones, have vitamin deficiencies [594–596]. Low vitamin levels have been shown to adversely affect wound healing and the functions of the skeletal, neuromuscular, and immune systems [595, 597]. Multivitamin supplementation is indicated for burn patients. However, further studies in adult and pediatric burn patients are needed to determine the effective doses of various vitamins required to achieve plasma levels calculated for healthy individuals [553]. Therefore, the requirement (average daily dose) for essential vitamins in burn patients varies according to various studies [21, 168, 495, 553, 583] (Table 3).

Table 3

The skin of burn patients cannot synthesize vitamin D normally. Supplementation with medicinal products from the group of Vitamin D and analogues (ATX Code: A11CC) is the only way to ensure a sufficient amount of vitamin D for burn victims. At the same time, the requirement of burn patients for medicinal products from the group of Vitamin D and analogues and optimal dosing regimens remain currently unknown [21, 219, 553, 554, 579].

3.1.15 Immunotherapy

Comment: Burn injuries cause numerous defects in the humoral and cellular components of the immune system in victims, leading to secondary immunodeficiency. Timely and comprehensive therapy of burn disease, adequate to the severity of the injury, serves as pathogenetic treatment for secondary immunodeficiency.

Normal human immunoglobulin preparations for intravenous administration are used in a personalized manner depending on the severity of the burn injury, the state of the immune system, and the presence of complications of burn disease [608]. The most pronounced positive changes in clinical, laboratory, and immune parameters were noted when using normal human immunoglobulin preparations for intravenous administration at doses of 0.2–0.4 g/kg with the timely initiation of immune replacement therapy before the development of sepsis [608].

3.1.16 Blood transfusions

Comment: Global practice shows that blood transfusions are not used during the period of burn shock and are not included in standard formulas for calculating anti-shock fluid resuscitation [227].

Comment: Traditional clinical symptoms (tachycardia, tachypnea, dyspnea, fatigue, and weakness) that may indicate the need for blood products (red blood cells) have limited utility in patients with extensive burns, as these signs are detected in the majority of patients with a total body surface area burn greater than 40% and resolve after burn wound healing.

No difference in the incidence of infections and mortality rates was found between groups of burn patients in whom the target hemoglobin level was 70 g/L versus 100 g/L [231].

Although no differences in burn wound healing rates were found[2] depending on liberal versus restrictive blood transfusion strategies, experience indicates a positive effect of blood transfusions on reparative processes in burn wounds [52].

There is evidence that increased oxygen delivery provided by blood product (erythrocyte) transfusion may improve outcomes in patients with sepsis and/or acute coronary ischemia [232].

The risk associated with blood transfusion increases with the number of units transfused. In stable, non-bleeding patients, checking the hemoglobin level 15 minutes after the completion of a blood transfusion adequately reflects the transfusion effect [233, 234].

The efficacy of antianemic agents in reducing the need for blood transfusions in burn patients requires further evidence [235-238].

Comment: Surgical treatment of burn victims can be accompanied by significant blood loss. The estimated blood loss during surgical necrotomy (excision) averages 0.5-1.0 mL per 1 cm² of the excised surface. The greatest blood loss accompanies necrotomy in the scalp, face, and neck regions, where it can reach up to 5.2 mL per 1 cm² of body surface area [241, 242].

Tangential excision is accompanied by greater blood loss and hemostasis difficulties compared to excision with a circumscribing incision.

Active surgical strategy in the treatment of burn injury is a priority, reduces mortality in severely burned patients, significantly shortens treatment time, and allows for optimal functional and aesthetic results; at the same time, patients are at risk of developing severe anemia, requiring a large volume of blood products (erythrocytes) for its correction.

3.1.17. Tetanus prophylaxis

3.1.18. Diet therapy

Prescription of therapeutic nutrition for diseases of the skin, subcutaneous adipose tissue, and skin appendages. Prescription of therapeutic nutrition for upper respiratory tract diseases. Prescription of therapeutic nutrition for lower respiratory tract and lung tissue diseases (see 1.10. Nutritional Support).

3.2 Local conservative treatment

Local conservative treatment of burn patients consists of the complex application of various dressings, antiseptics and disinfectants, topical antibacterial agents, antibiotics combined with antimicrobials, other topical antibacterial agents, and other topical medications, as well as physical methods of exposure to create conditions for burn wound healing and restoration of skin integrity.

When determining the tactics of local conservative treatment for burn patients, one should consider the severity of the patient's condition, the area of superficial and deep burns, their localization, the stage of the wound healing process, the amount of wound exudate, the presence of infection, the experience of the medical staff, and the availability of appropriate equipment, drugs, and dressing materials. In addition, the efficacy of using dressings and various methods of local treatment for the specific clinical situation should be proven.

3.2.1 Local conservative treatment at the pre-hospital stage

Comment. First-aid bandages should not contain substances that could subsequently complicate the assessment of lesion depth and wound toilet. The use of aerosols, ointments, creams, and balms, as well as oils, dyes, and powders as first aid is not recommended. The use of ready-made therapeutic wound dressings, which have a higher cost compared to those mentioned above, is impractical since a dressing change with the removal of these dressings will be performed subsequently. For limited burns, an individual dressing package or sterile medical gauze wipes are used. For burns of the hands and feet, dressings (in the form of sheets, packs, or gloves) based on polyvinyl chloride, polyurethane, or polyethylene film can be used [245-247].

For extensive burns, sterile or clean sheets (preferably disposable cotton sheets) are used as a contour (silhouette) dressing, which are applied without bandaging and without undressing the victim, especially in cold weather, over clothing and shoes if they are not burning or smoldering. The use of damp dressings should be avoided, as heat loss during transport to the hospital can be significant. Conversely, general warming of the victim is necessary.

Comment. Such dressings should be included in first-aid kits, as well as in the medical device supplies of the anti-burn kit for emergency medical care.

3.2.2 Local conservative treatment at the stage of primary health care and specialized medical care

Comment: Burn wound toilet consists of careful, minimally traumatic cleansing of the burn surface from contamination, foreign bodies, epidermal debris, loose necrotic tissue, exudate, and dressing residues, as these are a source of infection.

To date, no systematic reviews have found a reliable correlation between the solution used for wound cleansing and the rate of infection or wound healing characteristics.

Hydrotherapy is performed—the wound and surrounding skin are washed (irrigated) with water, including soapy water [52, 63, 491]. Irrigation is preferable to wiping with sterile medical gauze wipes. Sodium chloride**, 0.9% isotonic solution for infusion is a universal and preferred agent for wound irrigation (cleansing). At the same time, the efficacy of using sterile sodium chloride** solution or regular tap water for wound cleansing during dressing changes has not been proven [249-254]. Tap water can be safely and effectively used for washing wounds [213, 248, 249, 250-253, 256, 260-263, 312-314]. A special antibacterial filter can be used. The water should be at room temperature or warmer to prevent hypothermia. Immersion in a bath, especially for patients with extensive burns, is not used due to the risk of wound contamination, water-electrolyte and heat balance disorders, and hemodynamic decompensation [255, 256].

After washing, the patient's skin must be dried. Before applying therapeutic dressings, the wounds are additionally treated with antiseptic and disinfectant solutions.

Subsequently, hydrotherapy must be continued in the form of wound and intact skin treatment.

Body hair in areas with 2nd–3rd degree burns, as well as at least 2.5 cm from the burn boundary, should be clipped, except for the eyebrows. This subsequently helps reduce bacterial load, makes dressing application and removal simpler and less painful. If facial wounds are present, men should shave daily to also reduce the risk of infection. The necessity of hair removal should be discussed with patients.

Comment: For 1st–2nd degree burns, especially extensive ones, it is optimal to use sterile medical gauze wipes impregnated with topical antibiotics or antibiotics combined with antimicrobial agents in an ointment form on a water-soluble PEG base (e.g., Dioxomethyltetrahydropyrimidine + Chloramphenicol**); for deep 3rd degree burns, sterile medical gauze wipes (moist-drying dressings) impregnated with antiseptic and disinfectant solutions (e.g., povidone-iodine**) are recommended [63, 248, 258, 259]. Additionally, general warming of severely burned patients must be performed along with drying of the burn eschar using appropriate equipment.

Comment: In patients with minor burns who are to be treated on an outpatient basis, small blisters (especially on the palms and soles) may be left intact for the first 2–3 days following the injury. Blisters caused by chemicals must also be removed, as they may contain toxic substances. The use of modern wound dressings requires the removal of blisters and desquamated epidermis.

If burn wound toilet is performed later, wet fibrin and detaching eschar should also be removed. Coagulated dry fibrin (thin eschar) is better left untouched to avoid traumatizing the underlying tissues; treatment in such cases is carried out under a dry eschar.

Following burn wound toilet, the depth and area of the lesion are reassessed more accurately, and further local treatment tactics are determined, including the need for early surgical procedures (necrotomy, surgical debridement, or surgical necrotomy).

Comment: Indications for more frequent dressing changes include soaking through with purulent discharge, edema and hyperemia around the burn, recurrence of pain in the wound, and elevated body temperature. Serous soaking of dressings and mild edema in the first 2–3 days following a burn are natural for the course of a burn wound and should not be confused with suppuration of the burn surface. With the open (dressing-free) method of local treatment, wound toilet (cleansing) is performed 1–2 times a day. At the same time, upon transition to stage 3 of the wound process, the need for frequent dressings disappears, and fixed dressings can be left in place until complete wound epithelialization. It should be noted that, whenever possible, less frequent dressing changes are important for burn patients to reduce additional suffering, pain, and metabolic disorders [16].

When treated on an outpatient basis, a patient's visit to the polyclinic to extend a sick leave certificate is not an indication for a dressing change.

Comment: An integral component of local burn wound treatment is monitoring, assessment of its effectiveness, and standardization of medical documentation. Data obtained during the initial examination determine the required frequency of subsequent revisions. All parameters must be recorded at each dressing change, and a comprehensive wound assessment should be performed weekly or whenever there is a significant change in the patient's condition. Documentation must reflect the dynamic assessment of burn wounds, the course of the wound process, prescribed therapeutic drugs and methods, their tolerability, and adverse effects. Furthermore, the use of standard terminology facilitates interaction between specialists of various fields and enables comparative studies on the efficacy of a particular therapeutic method from an evidence-based medicine perspective. In addition, complete documentation of treatment and care is a mandatory requirement of modern insurance medicine.

Comment: Open (non-dressing) or closed (dressing) methods of local burn wound treatment are used. The closed method is the primary treatment method. The use of antibacterial and other medicinal products is most effective as part of wound dressings. Dressings create optimal conditions for the local prolonged action of medications. Dressings must not be used without reading the manufacturer's instructions. The open method can be used for burns in areas where dressings impede care and physiological functions, mainly on the face and perineal region [266, 491].

In practice, open and dressing methods of local wound treatment can be implemented via dry or moist approaches, respectively [63, 248, 264, 491].

The use of sterile medical gauze wipes impregnated with antiseptic and disinfectant solutions (e.g., povidone-iodine**) or antibiotics combined with antimicrobial agents in ointment form on a water-soluble PEG base, in combination with additional physical methods of eschar drying, allows the wound to be managed using the dry approach. This approach is indicated in the 1st stage of the wound healing process (necrotic and degenerative-inflammatory phases), typically for severely burned patients, in the treatment of extensive 2nd–3rd degree burns and in the presence of wound infection. The open dry approach with wound treatment using antiseptic and disinfectant solutions (optimally, povidone-iodine**) is effective only for eschar conservation on the face. There is no evidence of superiority of any local agents for the treatment of 2nd degree facial burns [267].

The use of atraumatic, hydrogel, hydrocolloid, foam, or film dressings, as well as silver-containing creams that create a moist wound environment, allows the wound to be managed using the moist approach. This approach is more preferable in the absence of infection during the 2nd–3rd stages of the wound healing process (inflammatory-regenerative and regenerative phases) for treating limited superficial and borderline 1st–2nd degree burns, as well as "mosaic" 2nd–3rd degree lesions. Management of wounds via the open moist approach is only possible on the face, whereas for other body areas, the closed moist dressing method is preferred. The moist approach is atraumatic and less painful than the dry approach.

When using the moist approach for local treatment, especially over an area exceeding 10% of the body surface area at once, purulent-resorptive fever is observed, indicating increased intoxication, which necessitates mandatory detoxification therapy and limits the use of this approach in patients with extensive burns. In addition, the use of the moist approach in severely burned patients, particularly in the first days after injury, leads to marked plasma loss. Prolonged use of dressings that create a moist wound environment promotes increased purulent inflammation in the area of wounds with pre-existing signs of infection. Therefore, the use of dressings that create a moist wound environment is not recommended for areas exceeding 10% of the body surface area, in the presence of copious wound discharge, wound suppuration, and perifocal inflammation. Under these conditions, the dry approach of local treatment with additional topical antimicrobial use is more justified.

With the onset of epithelialization—that is, upon transition to the 3rd stage of the wound healing process—it is rational to continue treatment using the dry approach to strengthen the newly formed epidermis (e.g., using atraumatic dressings).

Comment: There is no evidence of the superiority of any specific group of dressings for the treatment of grade I–II burn wounds [271].

In cases of prolonged non-healing of grade II burn wounds (within 3 weeks after trauma), a review of local treatment tactics is necessary, as the wounds may actually be deep burns requiring surgical treatment for plastic closure.

Comment: In deep burns, the primary role is played not by the use of dressings, but by active surgical tactics aimed at removing necrosis and performing plastic wound closure. If immediate early surgery for the entire burn area is not feasible in extensive injuries, local conservative therapy is performed. In the 1st phase of the wound process, treatment aims to dry out the burn eschar. Starting from the 2nd phase of the wound process, including after surgical necrectomy when preparing wounds for delayed autodermoplasty, moist wound management accelerates granulation growth, preserves underlying viable dermis areas (parawound zone), and reduces wound area through epithelialization of grade II burns from surviving viable skin derivatives. Immediately prior to the surgical plastic closure of grade III burns, transitioning to a dry method is indicated, which allows areas of secondary necrosis to be more clearly visualized during surgery and excised radically.

Comment: For grade II–III burns within the first 7 days after trauma, enzymatic necrolysis using the proteolytic enzyme bromelain in a gel base is effective [632, 633]. For enzymatic necrolysis in adults, it is optimal to use freshly prepared gel with bromelain lyophilizate on a burn area of no more than 15% of the body surface, with a gel layer thickness of 1.5–3 mm, and an exposure time of 4 hours under an occlusive film dressing, after which the dissolved eschar is removed mechanically under general or regional anesthesia. Early use of bromelain-based gel within the first 7 days post-trauma leads to rapid, selective, effective, and safe eschar removal with adequate preservation of undamaged dermis compared to standard treatment methods. This also reduces the number of surgical interventions and blood transfusions [632, 633].

For chemical necrolysis of dry burn eschar, it is optimal to use an extemporaneous medicinal product—40% salicylic acid ointment [63, 275-278, 492, 545, 546]. The thickness of the ointment layer should be 1–2 mm. No more than 200 grams of the ointment should be used simultaneously due to the risk of salicylate poisoning. After 48 hours, the burn eschar separates bloodlessly from the underlying tissues. Given this circumstance, chemical necrolysis can be performed simultaneously on an area of up to 10% of the body surface. The use of salicylic acid ointment is contraindicated in the presence of wet burn eschar or if the patient's general condition is severe, including in sepsis.

Comment: The healing time of donor site wounds after harvesting split-thickness skin autografts primarily depends on their thickness (0.2–0.5 mm). A dressing method of treatment is used for managing donor site wounds. To date, there are no optimal methods for treating donor site wounds. One of the main requirements for dressings is simplicity and ease of use.

Donor site wounds typically epithelialize under dressings by the 10th day post-surgery, after which the dressings can be removed. At the same time, the time of complete epithelialization of donor sites after harvesting split-thickness skin grafts is more rationally considered to be the timeframe at which re-harvesting split-thickness skin grafts from these areas becomes possible (i.e., 14–20 days), which is important when conducting comparative studies. If donor site wounds become infected, their treatment is carried out in the same manner as for grade II burns.

The optimal outcome is achieved when complete epithelialization of the donor sites following split-thickness skin graft harvesting has occurred by the time of patient discharge from the hospital (for grade III burns after autodermoplasty).

Comment: The dressing applied to transplanted autografts must be protective and possess anti-adhesive properties, optimize the reparative process, and be easily and painlessly removable. Simplicity and availability in use are also among the requirements for such dressings. When using dressings that create a moist wound environment, they are replaced 3–4 days after surgery at the first dressing change with sterile medical gauze wipes soaked in an antiseptic solution (moist-drying dressings) to support the newly formed epidermis.

The optimal outcome is achieved when complete engraftment of the transplanted autografts over 90% of the wound area has occurred by the time of patient discharge from the hospital (for grade III burns after autodermoplasty).

Comment: Staged treatment of long-standing residual burn wounds is most effective. The first stage involves cleansing the wounds of eschar and purulent crusts, including by washing the wounds with water containing detergents. The second stage consists of controlling infection and the autoimmune component (dressings with antiseptics and disinfectants, topical antibacterial drugs, sulfonamides, antibiotics combined with antimicrobial agents, topical antifungals, and topical glucocorticosteroids). The third stage involves local treatment through alternating dressings that create either a moist or dry wound environment.

The optimal treatment for larger long-standing wounds, following preliminary conservative preparation for 10–14 days, is surgical debridement (excising granulations) with simultaneous autodermoplasty.

3.2.3 Local application of physical methods

Comment: Ultrasonic necrotomy (ultrasonic treatment of granulating wounds) during preoperative preparation provides intensive removal of purulent discharge, fibrin deposits, areas of sloughing scab, necrotic dermis, and pathologically altered hypertrophic granulations [264, 284-287].

Vacuum therapy (vacuum-sealing dressings or vacuum-instillation therapy) following necrotomy of deep burn wounds and during the preparation of long-standing, infected granulating wounds for autodermoplasty reduces tissue edema, improves blood supply, decreases bacterial contamination of wounds, accelerates their cleansing from foci of necrosis, stimulates granulation tissue formation, and shortens the time required to restore skin integrity [288-291].

The efficacy of vacuum therapy for the treatment of borderline burns and following autodermoplasty has not been proven [292,293].

Ultraviolet irradiation of wounds is used when complicated by pyoderma, including erysipelas [495].

Hydrotherapy (therapeutic medicinal baths, local therapeutic baths, or therapeutic showers) is a method of physical impact and treatment for burn wounds involving the immersion of the patient or the affected area in a warm water environment (bath) or exposure to a water stream (shower and specialized units) with the addition of detergents, antiseptics, and/or disinfectants, which reliably correlates with a reduction in wound bacterial contamination and full wound healing [228, 267, 269].

The efficacy of other physical methods of local impact on burn wounds requires evidence.

3.2.4 Local application of antimicrobial drugs

Comment: Topical antimicrobial agents serve as an adjunct to local conservative treatment of burn wounds, and are used both during direct wound care at dressing changes and as part of moist-drying, ointment, and other wound dressings, as well as in combination with physical modalities (ultrasonic treatment, hydrotherapy).

Their use helps reduce the rate of local infectious complications and, consequently, improves conditions for wound regeneration, while also limiting the risk of systemic infectious complications, including infection generalization, especially in extensive burns [323-325, 327, 328, 481].

There is no evidence supporting the efficacy of various topical antimicrobial agents in preventing local infections and/or sepsis in burn patients [329].

Medical and physical methods of local treatment for burn patients are effective only when used comprehensively.

Infection is easier to prevent than to treat. Creating conditions for the rapid healing of burn wounds through optimal local treatment technologies is paramount for preventing wound burn infection.

Strict adherence to the principles of asepsis and antisepsis, infection control (wearing gowns and gloves when contacting the patient, hand hygiene before each patient visit), and treatment in abacterial wards (boxes) also help reduce the risk of wound infection [330-334].

Comment:

- Hydrogen peroxide** 3% solution may be used exclusively for treating burn wounds during dressing changes in the first phase of the wound healing process in the presence of purulent discharge; additionally, hydrogen peroxide** 3% is rationally used for chemical hemostasis of minor capillary bleeding.

- It is advisable to use antiseptic and disinfectant solutions for wound care during dressings, while acid solutions or other alternative agents can be used to combat multiresistant wound microflora [336-340].

- Topical antibiotics and antibiotics combined with antimicrobial agents in the form of water-soluble PEG-based ointments, along with antiseptic and disinfectant solutions (including povidone-iodine**, chlorhexidine**), are rationally applied as part of wound dressings.

- Due to its toxicity, the topical use of dressings containing hydroxymethylquinoxalindioxide must be restricted to small wound areas (no more than 10% of total body surface area) when prior local antimicrobial therapy has failed [341-349].

- Dressings and other topical agents containing silver in any form are used solely for the prevention of wound infection [350-354].

- When using non-antimicrobial dressings (e.g., atraumatic dressings, xenogeneic skin), it is advisable to combine them with antiseptics and disinfectants, or antibiotics combined with antimicrobial agents.

- In the presence of signs of local infection, frequent dressing changes and additional physical methods of wound treatment are recommended.

- Local antiseptics and disinfectants, topical antibacterial agents, antibiotics combined with antimicrobial agents, and other topical antibacterials do not replace surgical debridement of burn wounds and should not be used long-term. If topical antimicrobial therapy yields no effect within two weeks, the local and systemic treatment regimen must be reassessed.

3.3 Surgical Treatment

The main principle in treating deep third-degree burns is the surgical removal of non-viable tissue and the restoration of skin integrity in deep injury zones. The presence of a deep burn is an indication for surgical treatment regardless of the time elapsed since the injury, surface area affected, and other clinical or organizational factors. In 'borderline' second-degree burns, surgical treatment is used to create optimal conditions for epithelialization.

Objectives of surgical treatment:

1. Rapid clearance of the burn wound from non-viable tissue.

2. Prevention of circulatory disorders and restoration of blood supply to tissues adjacent to deep injury zones.

3. Prevention and treatment of wound infection, and reduction of wound intoxication.

4. Restoration of skin integrity through surgical plastic closure of wound defects.

5. Reduction of mortality and shortening of treatment duration.

6. Achievement of optimal functional and aesthetic outcomes, maximizing the recovery of the patient's quality of life.

3.3.1. Surgical treatment methods for burn victims

Surgical debridement of a burn wound is the excision of burn blisters, detached epidermis, and superficial necrotic tissues using mechanical methods (surgical instruments, brushes, sterile medical gauze pads, etc.) for the purpose of wound cleansing and decontamination. Adequate anesthesia is a mandatory requirement for surgical debridement.

Surgical debridement of a burn wound differs from burn wound toilette, which involves cleaning the burn surface from contamination, foreign bodies, detached epidermis, exudate, and dressing residues, opening and/or removing burn blisters, followed by treatment of the wound and surrounding skin with detergent and antiseptic solutions. Burn wound toilette is not classified as a surgical treatment method.

Surgical debridement of a burn wound is subdivided into:

- primary surgical debridement (PSD) of a burn wound – the first burn wound debridement performed. PSD is performed as soon as possible after admission to the hospital, and if necessary, against the background of anti-shock therapy.

- staged surgical debridement of a burn wound – subsequent surgical debridements of the burn wound.

Necrotomy is the incision of the burn eschar and underlying tissues (fasciotomy and myotomy) down to visually viable tissue for the purpose of decompression, restoration of tissue blood supply, chest respiratory excursion, and diagnosis of the depth of the lesion.

Comment. The decision to perform a necrotomy should be based on clinical examination data combined with diagnostic findings. In compartment syndrome, tissue pressure within the fascial space increases, leading to tissue ischemia. When available, direct measurement of compartment pressure aids in decision-making. A pressure value below 25 mmHg indicates adequate tissue perfusion. A pressure value above 40 mmHg is an absolute indication for necrotomy. If the pressure value is in the range of 25 to 40 mmHg, these data must be correlated with other clinical manifestations.

Necrotomy is performed for emergency indications. The golden rule of necrotomy is that in case of doubt, always make a decision in favor of necrotomy [16, 359-362]. In deep circular burns, longitudinal necrotomy incisions are made along the medial and/or lateral sides to the depth of necrosis down to healthy tissues, with wound edges diverging by 1-1.5 cm [361]. In lesions deeper than the muscle fascia (in electrical burns and other subfascial burn injuries), fasciotomy and myotomy are also performed on an emergency basis [190, 363].

Careful hemostasis control is necessary, taking into account potential bleeding in the early postoperative period.

In addition to pressure reduction, necrotomy/fasciotomy allows for clarifying the condition of the extremity and assessing its viability [364, 365].

Surgical necrectomy (SN) is the excision of necrotic tissues using surgical instruments and equipment (skin graft knife (manual, pneumatic, mains-powered, or battery-powered dermatome), hydrotherapy wound debridement system, electrosurgical or ultrasonic devices, etc.) to remove non-viable tissues as early as possible as a preparation for plastic closure of the wound defect in deep burns or to create conditions for epithelization in "borderline" lesions. Surgical necrectomy also includes dermabrasion, in which only the necrotic epidermis and superficial dermis layer are removed.

Surgical necrectomy is subdivided into:

- primary surgical necrectomy (PSN) – performed before the development of clinical signs of inflammation in the wound;

- delayed surgical necrectomy (DSN) – performed against the background of an inflammatory reaction;

- staged surgical necrectomy (SSN) – performed in several stages, not over the entire area in cases of extensive deep lesion zones;

- secondary surgical necrectomy (SSN-sec) – performed when secondary necrosis develops in zones of primary or delayed necrectomy.

According to the surgical technique, wound necrectomies (excisions) are subdivided into:

- tangential excision, including dermabrasion – layered, "tangential" removal of necrotic tissues down to visually viable ones;

- excision with a circumscribing incision – removal of deep lesion zones using a vertical incision to the depth of the lesion along the wound perimeter;

- combined wound excision – using both tangential excision and excision with a circumscribing incision.

According to the depth, wound necrectomies (excisions) are subdivided into:

- within the dermis proper (dermal);

- within the subcutaneous adipose tissue (subcutaneous);

- down to the superficial fascia (fascial);

- within the muscle tissue (muscle);

- within the bone tissue (osteonecrectomy).

When the depth of excision varies across different zones, the entire achieved depth of wound necrectomy (excision) must be indicated.

Surgical necrectomy of a burn wound, as a method of active surgical preparation of deep burn wounds for plastic closure, refers to early surgical treatment of deep burns. In this approach, plastic closure of wound defects is performed immediately or shortly after early surgical preparation of the burn wound, but in a shorter timeframe compared to preparing a granulating wound for skin grafting.

Amputation or disarticulation of the affected limb or its segment is a specific type of surgical necrectomy that differs in its surgical technique.

Surgical debridement of a burn wound is the simultaneous or staged instrumental removal of the burn escar and necrotic tissues as they spontaneously detach [366] or following chemical, including enzymatic, debridement (necrolysis) [275-278], with subsequent preparation of granulating wounds for skin grafting. It is used when primary (delayed) surgical necrectomy cannot be performed due to the patient's condition, refusal of surgery, or lack of proper organizational, personnel, and material-technical support for early surgical treatment.

Excision of granulations is the removal of "immature" and pathologically altered granulation tissue using surgical instruments and equipment in order to prepare the wound surface for plastic closure.

Plastic closure of a wound defect is the surgical restoration of the anatomical integrity of the damaged skin and underlying tissues in areas of deep burn injury.

Methods for the surgical restoration of skin integrity include:

1. Free skin grafting.

a) Using a skin-only autograft (non-vascularized):

- Split-thickness

- Full-thickness.

b) Using a complex composite autograft on microvascular anastomoses (vascularized):

- musculocutaneous;

- fasciocutaneous;

- myocutaneous, including with a bone fragment.

2. Non-free skin grafting.

a) Using local tissues with or without additional incisions, including the method of controlled tissue expansion (dermatension). Dermatension is subdivided into acute and chronic, including the use of expanders.

b) Using a transferred flap (insular, flat, or tubed) on a permanent or temporary vascular pedicle:

- musculocutaneous;

- fasciocutaneous;

- myocutaneous, including with a bone fragment.

Skin grafting can be performed immediately after surgical preparation of the burn wound (immediate skin grafting) or delayed (delayed skin grafting) in case of uncertainty regarding the radicality of surgical preparation, a deficit of donor sites, or the severity of the patient's condition preventing the expansion of the surgical volume.

Skin grafting on a granulating wound is performed when it is ready to serve as a recipient bed for the skin graft (bright, fine-grained granulations with scant wound discharge and optimal preparation timeframes).

The primary method for restoring the anatomical integrity of the skin in deep burns is split-thickness skin autografting (STSA) using a skin-harvesting knife (dermatosome). The optimal thickness of a split-thickness skin autograft is 0.2–0.4 mm.

Skin grafting is primarily performed in functionally and aesthetically important areas (face, hands, joints, neck). The most favorable functional and aesthetic results are provided by transplantation of non-meshed split-thickness skin grafts. Free autografts should be placed on wounds perpendicular to the axis of the operated area.

In localized deep burns, including in functionally and aesthetically important areas of special localization (head, face, hands, genitalia, neck, and large joints), as well as when deep structures are exposed (joints, blood vessels, nerve trunks, bones, tendons), the early use of reconstructive and plastic surgery methods is justified — defect closure using local tissues, including dermotension, full-thickness skin autografts, composite autografts on microvascular anastomoses, or flaps on a permanent or temporary vascular pedicle. The donor site after harvesting such grafts and flaps must be closed by local tissue plastics or split-thickness skin autografting.

In deep burns, especially when donor resources are deficient, the following methods and techniques for plastic closure of wound defects are used:

- Meshed split-thickness skin autograft – orderly creation of incisions on the skin graft using special equipment (skin graft mesher) to increase the surface area of the graft. Meshed split-thickness skin autografts on functionally and aesthetically important areas should only be used in cases of critical donor site shortage.

- Reuse of re-epithelialized donor sites for harvesting split-thickness skin autografts.

- Use of biotechnological treatment methods for extensive burns using minimally manipulated human autologous skin and subcutaneous adipose tissue cells, biological (xenogeneic) or biosynthetic wound dressings, alone or in combination with skin autografting.

3.3.2 Organization and performance of surgical treatment for burn victims (Appendix B5, Appendix B6).

Comment. To provide surgical treatment for burn patients, it is necessary to have:

- an adequate number of surgical teams trained in combustiology through postgraduate education systems and possessing working experience;

- the required number of operating rooms for daily work and/or a 24/7 emergency operating room;

- the necessary quantity of specialized surgical instruments and equipment;

- a 24-hour anesthesia and intensive care service as required;

- an adequate number of nursing and support staff trained in combustiology, including for providing early rehabilitation of burn patients;

- an adequate number of rooms for burn patients complying with sanitary and epidemiological regulations.

Comment. Early surgical treatment is a priority; it reduces mortality in severely burned patients, significantly shortens treatment time, achieves optimal functional and aesthetic treatment outcomes, and improves the quality of life of burn victims [228, 239, 367-380, 492].

Performing early surgical treatment meets modern treatment standards and places high demands on the organizational, staffing, material, technical, and technological support of the department/center where burn victims are treated.

Comment: When planning surgical necrectomy (excision), the specific techniques of the surgical intervention are taken into account [239 382]:

- tangential excision – has advantages in execution time, preservation of undamaged tissue, better functional and aesthetic results, but is accompanied by significant blood loss, hemostasis difficulties, and challenges in objectively assessing the radicality of the excision;

- fascial or subfascial excision using a circumscribing incision – provides greater radicality, lower and controlled blood loss, more reliable hemostasis, but significantly increases the duration of the procedure, leads to the loss of viable tissue, and worsens functional and aesthetic outcomes.

Comment. The area of surgical necrectomy in a single stage should be planned based on 1/3 of the deep lesion area.

Comment: If the operating surgeon is uncertain about the radicality of the necrectomy (excision), skin grafting is delayed by 2-7 days.

Comment: Prolonged conservative preparation of a granulating wound should be preceded by radical excision of pathological granulations followed by simultaneous skin grafting.

- correction of anemia (hemoglobin level not below 90 g/L);

- adequate nutritional support (plasma total protein level not below 50 g/L);

- correction of the blood coagulation system (normalization of coagulogram parameters);

- reduction of a high ("critical") level of microbial colonization of wounds prior to their plastic closure;

- adequate antibiotic therapy;

- proper patient positioning, including the use of fluidized beds.

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).

Comment: Methods for reducing blood loss during surgical treatment include [239, 392, 393, 492]:

- initiating surgical treatment at optimal times after injury;

- proper selection of the excision technique;

- use of antithrombotic agents strictly according to indications, under laboratory monitoring;

- use of antifibrinolytic agents, vitamin K, and other hemostatic agents before performing extensive surgeries;

- maintenance of preoperative hemodilution;

- timely correction of hypotension and hypothermia on the operating table;

- use of a reusable tourniquet on the upper/lower extremity prior to wound excision;

- thorough intraoperative hemostasis, including the use of an electrosurgical system during surgery (an electrosurgical unit for soft tissue cutting and small vessel coagulation);

- use of local hemostatics on the excised wound surface;

- use of medical elastic compression products (elastic bandages) in the area of skin grafting on the extremities in the early postoperative period;

- correct patient positioning;

- timely detection of early postoperative bleeding.

The perioperative period is extremely critical regarding the risk of thrombohemorrhagic complications and requires careful monitoring of the hemostatic system.

3.4 Other treatment

3.4.1 Treatment of complications of burn wounds, burn disease, and/or inhalation injury, as well as comorbidities

[1] Order of the Russian Ministry of Health No. 183n dated April 2, 2013, "On Approval of the Rules for Clinical Use of Donor Blood and (or) Its Components"

[2] Under a restrictive strategy, allogeneic red blood cells are prescribed at a hemoglobin level of 70 g/L (hemoglobin level is maintained between 70 and 90 g/L). Under a liberal strategy, allogeneic red blood cells are prescribed at a hemoglobin level of 100 g/L (hemoglobin level is maintained between 100 and 120 g/L).

[3] Order of the Ministry of Health of the Russian Federation No. 174 dated May 17, 1999, "On Measures to Further Improve Tetanus Prevention."

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comment: Rehabilitation programs for burn survivors encompass a wide range of medical and social measures aimed at the maximum possible restoration of patients' physical and psychological abilities, their successful adaptation in society, and improvement in quality of life.

Stages of medical rehabilitation for burn victims

- Stage 1: early (conservative and surgical) rehabilitation in acute trauma.

- Stage 2: conservative rehabilitation for burn sequelae.

- Stage 3: surgical rehabilitation for burn sequelae.

Principles of medical rehabilitation for burn victims

- Early start (immediately after injury with the initiation of treatment). 

- Comprehensive treatment.

- Continuity and consistency of therapeutic measures.

- Individualized approach.

- Continuity of patient management.

Medical rehabilitation of burn victims is divided into early and late according to the timing of implementation [397-403].

Early rehabilitation of burn victims is carried out during the period when burn wounds are present and includes:

- timely and adequate local and general treatment;

- rational pain management;

- psychological rehabilitation;

- static rehabilitation (correct positioning of affected body parts, functional bed, ensuring pulmonary drainage, etc.);

- immobilization and passive movements in joints;

- active movements (exercise therapy, respiratory gymnastics, early mobilization); 

- physiotherapy.

Late rehabilitation of burn victims is carried out after the healing of burn wounds and includes:

- prevention and treatment of post-burn scars and scar deformities:

- during the scar "maturation" period – a complex of conservative treatment aimed at preventing excessive scar growth;

- after scar "maturation" – scheduled reconstructive surgeries, prevention of postoperative scar growth.

- treatment of somatic consequences of burn disease;

- psychological rehabilitation and employment;

- dispensary follow-up, conservative and surgical treatment in burn departments (centers);

- continuation of rehabilitation on an outpatient basis in local polyclinics;

- implementation of rehabilitation measures in specialized medical and sanatorium-resort organizations (if there are medical indications).

Comment. The choice of treatment tactics for pathological skin scars should be determined in accordance with:

- Scar type (hypo- or atrophic, normotrophic, hypertrophic, or keloid).

- Stage of development and "activity" of scar growth – "immature" or "mature".

- Presence of scar deformity.

The most sound approach to the therapy of hypertrophic and keloid scars is the timely prevention of pathological scar formation. It is much more effective to prevent the appearance of coarse scars than to treat existing ones. The transition from prevention to treatment occurs at the stage when an immature hypertrophic or keloid scar is diagnosed.

The severity of scar erythema is considered an important prognostic sign for determining the nature of scar development and response to treatment.

If erythema does not disappear within 1 month, the risk of developing a hypertrophic scar increases.

There is no single approach to the methods of evaluating the results of scar prevention and treatment. The assessment of the nature and degree of influence of the treatment method for immature post-burn scars can be carried out using the Vancouver Scar Scale (Appendix G9) [405] or its analogues.

Conservative prevention and treatment of post-burn scars and scar deformities.

Comment: The efficacy of various antipruritic drugs in patients with burn sequelae has not been proven [415].

The used dose of #gabapentin for relieving severe post-burn pruritus in adult patients ranges from 100 mg three times daily to a maximum of 300 mg three times daily, and in children — 5 mg/kg body weight, increasing in 5 mg/kg increments up to a maximum of 15 mg/kg [549-552]. 

• The efficacy of scar dermabrasion (laser skin resurfacing, laser skin tissue destruction) for "immature" scars requires evidence, and it is not recommended for keloid scars [430, 431–433].

Leveled Clinical Recommendation (LCR) BLevel of Scientific Evidence (LSE) 2Level of Clinical Recommendations – B (level of scientific evidence – 2).

Comment: Despite the lack of reliable evidence of efficacy as monotherapy for pathological scars in some studies [434], according to other data, onion extract (extractum cepae)-based preparations may be effective in early prevention of post-burn scars, preventing their excessive growth [641, 642].

• Cryotherapy is recommended only for the treatment of very small scars [430, 437].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).

Comment: Conservative prevention and treatment of post-burn scars and scar deformities includes a basic program administered to all patients with burn sequelae, and a special individual program.

Due to the variety of burn injuries and their sequelae, rehabilitation programs are tailored individually. It is extremely crucial that the physician is aware of the various available methods and has the ability to individualize treatment, as some patients may not respond to any single treatment method [438].

Combination anti-scar therapy is more effective than monotherapy.

Developing a long-term prevention and treatment program that includes the sequential use of various methods helps optimize medical care for patients with burn sequelae: a combination of drugs with different mechanisms of action and administration routes, combined with physiotherapeutic and surgical treatments.

Comment. To achieve the maximum effect, it is optimal to maintain a pressure level of 20–32 mmHg at the site of scar-altered skin using medical compression knitwear for 20–23 hours a day for at least 6–12 months [430, 441, 447]. Patient compliance is a key factor in this case, as efficacy directly depends on the duration of treatment [442–444].

Local application of silicone derivatives in the form of gel or sheets is optimally started 2 weeks after the burn wound heals [430, 445, 447]. Optimally, silicone sheets should be used on scars for 20–23 hours a day (removed only for hygiene and moisturization), or any silicone gel should be applied twice a day.

Surgical rehabilitation of patients with post-burn scars and scar deformities.

The timing of reconstructive plastic surgeries depends on the patient's general condition and the nature of the scarring.

Comment: The purpose of reconstructive plastic surgeries in patients with burn injury sequelae is to eliminate functional and aesthetic impairments and restore the damaged skin covering, ideally as close to natural as possible.

Surgical rehabilitation methods for post-burn scar deformities of various localizations [634–637]:

Ectropion.

To eliminate ectropion, the scarring causing it is incised and partially excised, and full-thickness skin grafting is performed. The newly formed eyelid is fixed in a state of overcorrection. Only one eyelid may be operated on per eye at a time.

Microstomia.

To eliminate scarred microstomia, plasty of the scarred oral commissure is performed using a tongue-shaped mucosal flap mobilized from the inner surface of the cheek. Simultaneously, the tightening skin scars forming the narrowing of the mouth angle are incised, and the mobilized mucosal flap is sutured by its free edge to the wound angle on the outer surface of the cheek.

Lip scar ectropion.

Scars causing ectropion are incised and partially excised along the vermilion border of the lip, and the resulting wound is repaired with a full-thickness skin graft harvested from the inner surface of the arm or the inguinal region. If both upper and lower lip ectropion are present, treatment is performed in 2 stages.

Nasal deformity and/or defect.

Limited nasal defects should be repaired with transferred myocutaneous/skin-fat flaps from the buccal and frontal regions. Combined plasty using rotated valve flaps from scar tissues of the lateral surfaces and full-thickness skin grafts is used for alar defects. For defects of the cartilaginous part of the nose, restoration of its shape and framework with autologous cartilage is indicated.

Auricular deformity and/or defect.

For earlobe defects, local tissue plasty of the parotid region is indicated. For limited auricular defects involving cartilage, defect repair with autologous cartilage covered by a vascularized skin flap is required. For subtotal and total auricular defects, combined plasty is recommended: autotransplantation, a rotated superficial temporal fascia flap, and full-thickness skin grafting.

Absence of eyebrows.

The only adequate method for eyebrow reconstruction is plasty using a rotated temporoparietal flap on the vascular pedicle of the superficial temporal artery. In case of burn injury to the temporal region, partial eyebrow reconstruction can be performed by free hair follicle transplantation.

Cheek region and lower third of the face.

In extensive scarring of the lower third of the face, it is advisable to perform plasty using a cervical musculocutaneous/fasciocutaneous flap. Mobilization should be performed strictly along the superficial fascia covering the platysma muscle, 5–6 cm below the clavicles. The flap must include tissues of the parotid region.

Repeat surgeries using a cervical flap should be performed no earlier than 6–8 months later. By this time, the reorganization of blood circulation in the flap is completed, and skin elasticity and its capacity for repeated stretching are restored.

In the surgical rehabilitation of patients with extensive scar defects resulting from combined injuries of the face and adjacent areas, when it is impossible to use a cervical musculocutaneous/fasciocutaneous flap, balloon dermotension of uninjured facial skin as well as adjacent areas (neck, shoulder girdles, chest wall) should be used.

In extensive scar deformities and facial defects with exposure of the mandible bone, it is advisable to use microsurgical autotransplantation of radial or scapular flaps.

If it is impossible to close the wound formed after the excision of scars on the face by transposition of local tissues or tissues from adjacent areas, non-perforated free skin grafting (preferably full-thickness) is used in some cases.

Post-burn cicatricial alopecia.

When eliminating scar lesions of the scalp (alopecia) with an insufficiency of local tissues for these purposes, the method of balloon expansion of hair-bearing layers located adjacent to the scars being removed is used. The method has also proven effective for closing skull bone defects in this area, in some cases over neurocranium implants.

Neck contracture.

In localized scar deformities of the neck, it is advisable to use the method of acute dermotension of local tissues undamaged by burns.

In the treatment of patients with midline deformities and contractures of the neck, the optimal approach is the use of acute dermotension and cervical musculocutaneous/fasciocutaneous flap plasty.

When there is a deficiency of healthy tissues near the defect, balloon dermotension is effective. The best results with this method have been obtained in the treatment of localized midline and lateral neck deformities.

Plasty with cicatricial fasciocutaneous rectangular (tongue-shaped) flaps makes it possible to eliminate neck scar contracture and shorten rehabilitation times in patients with subtotal and total scar deformities of the neck when other methods of reconstructive surgery cannot be applied.

To eliminate subtotal and total deformities and contractures of the neck, it is advisable to use cervicothoracic and scapulothoracic fasciocutaneous flap plasty

Microsurgical autotransplantation of free flaps is the only possible method of plasty in approximately one-third of patients with total and subtotal scar lesions of the neck accompanied by subtotal or total scar deformity of the anterior chest wall.

Sequelae of hand burns.

To eliminate localized scar deformities of the dorsal surface of the hand, acute or balloon dermotension methods are used.

In extensive scar deformities of the dorsal surface of the hand, the optimal approach is simultaneous restoration of the skin cover, creation of interdigital spaces, and elimination of finger extension contractures.

Elimination of hand syndactyly is performed by incision and partial excision of scars down to the metacarpal heads, creation of normal interdigital spaces using skin-fat flaps from the palmar (or dorsal) surface of the hand, and (if necessary) plasty of the lateral surfaces of the fingers with split-thickness or full-thickness skin autografts.

Surgical rehabilitation for tendon flexion contractures of the fingers consists of the following stages: elimination of metacarpophalangeal joint contractures, elimination of finger flexion contractures, elimination of syndactyly, tendon plasty using autografts, and elimination of the skin-fat layer defect of the hand.

In bony ankylosis of the metacarpophalangeal joints (MCPJs) and proximal interphalangeal joints (PIPJs), surgical treatment consists of resection of the affected joints, joint arthroplasty with simultaneous replacement of the soft tissue defect.

Scar deformity of the trunk.

To eliminate scars on the anterior chest wall, we consider the optimal approach to be the use of acute expansion of tissues in adjacent areas undamaged by burns.

Post-burn breast deformities.

The most effective method for restoring the normal skin cover of the breast is plasty using mobilized skin-fat layers from the lateral chest wall, axillary regions, and epigastric region.

With limited reserves of uninjured skin on the lateral chest wall, when it is insufficient to cover the defect via mobilization, skin gain is achieved through the use of expanders followed by plasty with an expanded skin layer.

In extensive scars on the anterior chest wall flattening the breast, a method has been developed to restore the shape, position, and skin cover of a burn-damaged breast using subcapsular circular multilevel shaping sutures.

Scar deformities of the anterior abdominal wall.

In anterolateral unilateral scar deformity, skin-fat layers mobilized on the abdominal wall in areas adjacent to the scar lesion are used. In case of a large scar area, 2-stage surgical treatment with partial excision of scars at each stage is required for complete scar elimination.

To eliminate upper subtotal defects of the abdominal wall, the acute dermotension method also yields good results. With a larger area of scar lesion, repeated transposition of mobilized skin layers is performed.

Deformities of external genitalia and perineum.

Perineal deformities are usually combined with adduction contractures of the hip joints and involvement of the genitalia in the scarring process. Individual scar bands are eliminated using transposition flaps (Z-plasty) or rectangular skin-fat flaps, including those made from scar tissues. Often, local tissue plasty is combined with split-thickness or full-thickness skin autografts.

Contractures of major joints.

In marginal contractures and a sufficient volume of local tissues undamaged by burns, scar excision, contracture elimination, and plasty with transposed skin-fat flaps are performed.

In more extensive scar involvement of the skin in the joint area, contracture elimination is indicated with plasty using rotated skin-fat or fasciocutaneous flaps with axial blood supply or based on perforator vessels. In some cases, this plasty should be supplemented with split-thickness or full-thickness skin autodermoplasty.

In total joint contracture and scar involvement of adjacent areas, contracture elimination with autotransplantation of a fasciocutaneous flap from distant parts of the body on microvascular anastomoses is indicated.

Scar deformities of the foot and ankle joint.

In scar deformity of the dorsal surface of the foot, individual tethering scars are eliminated by opposing skin-fat flap plasty.

In the case of extension scar contracture of toes I–V, combined plasty is performed, including local flap plasty and free autodermoplasty.

In extensive scar deformities of the dorsum and/or plantar surface of the foot, including involvement of the tendinous apparatus, complex composite autotransplants on microvascular anastomoses are used if possible.

Following reconstructive operations, a complex of conservative measures is re-administered to prevent scar growth.

Rehabilitation for complications arising during the course of the disease and treatment is carried out within the framework of the respective nosologies.

5. Prevention and Dispensary Observation

5.1 Prevention

Comment. Prevention of burns at home and in the workplace involves strict compliance with safety regulations when working with sources of high temperatures, electric current, aggressive chemicals, and ionizing radiation. There is no prevention of intentional/criminal burns.

5.2 Dispensary monitoring

Patients discharged from the hospital should be divided into several groups:

- not in need of any treatment;

- in need of conservative treatment only;

- in need of relatively urgent surgery due to rapidly progressing pathological changes;

- patients requiring long-term and systematic conservative and surgical treatment due to the large volume of consequences of burn trauma.

Comment: After the discharge of a burn victim from the hospital, it is extremely important to clearly organize and continue rehabilitation using various therapeutic and preventive methods aimed at the maximum possible physical and psychosocial recovery of patients. Medical rehabilitation at all stages is carried out by a multidisciplinary rehabilitation team led by a physician in physical and rehabilitation medicine. Various specialists must participate in this work, including an orthopedic trauma surgeon, general surgeon, plastic surgeon, general practitioner, neurologist, physical therapy physician, medical psychologist, etc., which requires clear coordination, knowledge of the specifics of modern rehabilitation tools, and adherence to the principles of continuity and succession [228].

The effectiveness of rehabilitation for burn victims is determined by:

- timeliness of initiation and persistence in carrying out the full range of preventive and therapeutic measures;

- qualification and experience of the medical staff;

- perseverance and discipline of the patients themselves.

Only the use of the full range of drug therapy, surgical, and physiotherapeutic treatments, as well as psychosomatic and social rehabilitation, can improve the outcomes of care for patients who have suffered burn trauma [453].

The ultimate outcome of rehabilitation is the social, occupational, and domestic adaptation of burn victims in society, providing for adequate employment, retraining if necessary, acquiring a new profession, and modifying working and living conditions.

6. Organization of Medical Care

Medical care, except for medical care provided as part of clinical trials, in accordance with Federal Law No. 323-FZ dated November 21, 2011 (as amended on May 25, 2019) "On the fundamentals of protecting the health of citizens in the Russian Federation", is organized and provided:

1. in accordance with the regulations on the organization of medical care by types of medical care, approved by the authorized federal executive body;

2. in accordance with the Procedure for the provision of medical care to the population in the profile "Surgery (Combustiology)", approved by the authorized federal executive body and mandatory for implementation on the territory of the Russian Federation by all medical organizations;

3. based on these clinical guidelines;

4. taking into account the standards of medical care approved by the authorized federal executive body.

Procedure for the provision of medical care to the population in the profile "Surgery (Combustiology)"[1]

1. This Procedure establishes the rules for organizing the provision of medical care in the profile "Surgery (Combustiology)" for thermal and chemical burns of the skin of various areas, depths, and localizations, manifesting as an independent nosological form, as well as accompanied by acute and chronic diseases of surgical, therapeutic, obstetrical and gynecological, neurological, pediatric, dental profiles, traumatic injuries, including inhalation injury and eye damage (hereinafter referred to as burns), electrical injury, as well as post-burn scar deformities and tissue defects of various localizations.

2. Medical care in the profile "Surgery (Combustiology)" is provided by medical organizations and other organizations engaged in medical activities and holding a corresponding license for medical activities, in the form of:

· primary health care;

· emergency, including specialized emergency, medical care;

· specialized, including high-tech, medical care.

3. Medical care in the profile "Surgery (Combustiology)" is provided in the following settings:

· outpatient (in settings not providing round-the-clock medical observation and treatment);

· day hospital (in settings providing medical observation and treatment during daytime hours, but not requiring round-the-clock medical observation and treatment);

· inpatient (in settings providing round-the-clock medical observation and treatment);

· outside a medical organization (at the location of the emergency, including specialized emergency, medical care team, as well as in a vehicle during medical evacuation).

4. Care in the profile "Surgery (Combustiology)" is provided in the following forms:

emergency (provided for sudden acute diseases, conditions, exacerbation of chronic diseases posing a threat to the patient's life);

· urgent (provided for sudden acute conditions,

· exacerbation of chronic diseases without obvious signs of a threat to the patient's life, not requiring emergency medical care);

· elective (provided during preventive measures, for diseases and conditions not accompanied by a threat to the patient's life, not requiring emergency and urgent medical care, and the postponement of which for a certain time will not entail a deterioration in the patient's condition, a threat to their life and health).

5. Medical care in the profile "Surgery (Combustiology)" is provided taking into account medical care standards and based on clinical guidelines.

6. Primary health care includes:

· primary pre-medical health care;

· primary general medical health care;

· primary specialized health care.

7. Primary health care in the profile "Surgery (Combustiology)" is provided in outpatient settings and includes measures for the prevention, diagnosis, and treatment of grade I-II burns with a lesion area of up to 10% of the body surface (in children - up to 5% of the body surface) not requiring surgical treatment, as well as medical rehabilitation of patients with post-burn scar deformities and tissue defects of various localizations.

Primary pre-medical health care is provided by paramedics, midwives, and other medical personnel with secondary medical education.

The list of works (services) constituting medical activity in the provision of primary pre-medical health care includes: nursing (pediatric nursing) or general medicine (midwifery).

Primary general medical health care is provided by pediatricians (district pediatricians), general practitioners (district general practitioners), and family physicians.

The list of works (services) constituting medical activity in the provision of primary general medical health care includes: pediatrics, internal medicine, general practice.

Primary specialized health care in the profile "Surgery (Combustiology)" is provided by medical specialists (surgeon, orthopedic trauma surgeon, pediatric surgeon) meeting the qualification requirements for medical and pharmaceutical personnel with higher education in the field of training "Healthcare and Medical Sciences" ^[2] (hereinafter referred to as qualification requirements).

The list of works (services) constituting medical activity in the provision of primary specialized health care includes: surgery, traumatology and orthopedics, pediatric surgery, anesthesiology and intensive care, functional diagnostics, radiology, clinical laboratory diagnostics.

8. In the presence of medical indications for the provision of medical care in the profile "Surgery (Combustiology)" not requiring inpatient conditions, the paramedic, midwife, general practitioner, district general practitioner, family physician, pediatrician (district pediatrician) refer the patient for the provision of primary specialized health care.

9. Primary specialized health care in the profile of "surgery (burn surgery)" is provided when patients apply independently to a medical organization or are referred by a medical professional.

10. The organization of specialized medical care in the profile of "surgery (burn surgery)" is carried out in accordance with the regulations on organizing the provision of specialized, including high-tech, medical care^[3].

Burn units and burn centers are established in medical organizations in numbers sufficient to meet the demand for this profile of specialized, including high-tech, medical care in the constituent entity of the Russian Federation.

11. Medical indications for the provision of specialized medical care in the profile of "surgery (burn surgery)" in a burn unit/center of a medical organization are:

· degree I–II burns with a body surface area involvement of 10% or more (in children, 5% or more of the body surface area);

· degree I–II burns with a body surface area involvement of less than 10% (in children, less than 5% of the body surface area) in special locations: head, face (including combined with eye injuries), hand, foot, perineum, genitalia, neck, and major joints, in the presence of complications or comorbid pathology;

· degree III burns of any area and location;

· skin burns resulting from electrical injury;

· burns combined with inhalation injury;

· post-burn cicatricial deformities and tissue defects in various locations.

12. Medical indications for the provision of high-tech medical care in a burn unit or burn center of a medical organization in the profile of "surgery (burn surgery)" are:

· thermal and chemical burns of degree I–II–III with a body surface area involvement of 30% or more in various locations, including when combined with inhalation injury and the development of severe infectious complications (pneumonia, sepsis);

· post-burn cicatricial deformities and tissue defects in various locations requiring staged reconstructive and plastic surgeries.

In the presence of medical indications for high-tech medical care in the profile of "surgery (burn surgery)", the referral of patients to a medical organization and the provision of high-tech medical care are carried out in accordance with the procedure for organizing high-tech medical care using the Unified State Health Information System[4].

13. Medical indications for the provision of medical care in the profile of "surgery (burn surgery)" in the anesthesiology and resuscitation department of a burn center, or in its absence, in the anesthesiology and resuscitation department within a multidisciplinary medical organization, are:

degree II–III burns exceeding 20% of the body surface area or degree III burns exceeding 10% of the body surface area in adults; degree II–III burns exceeding 10% of the body surface area, or degree III burns exceeding 5% of the body surface area in children, upon the development of burn shock; inhalation injury with the development of respiratory failure; burns resulting from electrical injury with the development of cardiovascular failure; as well as other life-threatening conditions.

Upon the presence of medical indications, after the elimination of the life-threatening condition, the patient is transferred to the burn unit of the medical organization or undergoes medical evacuation to the burn unit or burn center of another medical organization.

14. Specialized, including high-tech, medical care in the profile of "surgery (burn surgery)" is provided in the burn unit or burn center of a medical organization in inpatient settings and day-care settings, and includes measures for the prevention, diagnosis, and treatment of burns, burn disease, and its complications, as well as post-burn cicatricial deformities and tissue defects in various locations requiring the use of special methods and medical technologies, along with medical rehabilitation.

15. Specialized, including high-tech, medical care in the profile of "surgery (burn surgery)" is provided by specialist physicians (surgeons, traumatologists-orthopedists, pediatric surgeons) who meet qualification requirements, in collaboration with other specialist physicians.

16. Emergency, including specialized emergency, medical care in the profile of "surgery (burn surgery)" is provided by paramedic emergency teams, physician emergency teams, and specialized emergency teams in accordance with the procedure for providing emergency, including specialized emergency, medical care^[5].

17. If medical evacuation of a patient for the medical indications specified in clause 11 of this Procedure to a burn unit or burn center of a medical organization is impossible, emergency teams shall perform medical evacuation of the patient to the nearest medical organizations featuring round-the-clock operation of:

· admission department;

· operating room(s) or operating suite;

· anesthesiology and resuscitation department or anesthesiology and resuscitation department with intensive care units;

· X-ray department (room) equipped with a stationary X-ray diagnostic machine (excluding dental) and/or a stationary X-ray computed tomography scanner (excluding dental) and/or a magnetic resonance imaging scanner;

· transfusiology room (blood transfusion room);

· clinical diagnostic laboratory;

· surgical department.

18. Consultation of an adult patient with a burn exceeding 10% of the body surface area or a pediatric patient with a burn exceeding 5% of the body surface area is performed by a combustiologist specialist of the burn unit/center within the first 24 hours after admission to the inpatient facility. Following the consultation by the specialist of the burn unit/center, in the absence of medical contraindications for transportation, a patient located in a medical organization lacking a burn unit or burn center shall be transferred within a period not exceeding 72 hours from the time of injury to a burn unit or burn center of another medical organization for the provision of specialized, including high-tech, medical care.

19. In constituent entities of the Russian Federation whose medical organizations lack a burn unit or burn center, specialized medical care in the profile of "surgery (burn surgery)" is provided in burn beds (adult and pediatric) allocated within the surgical departments of multidisciplinary medical organizations, followed by medical evacuation for the provision of specialized, including high-tech, medical care to a burn unit or burn center of another constituent entity of the Russian Federation or a federal medical organization.

20. To ensure the principle of continuity in the provision of medical care in the profile of "surgery (burn surgery)", upon referral to the stage of specialized, including high-tech, medical care, the patient is provided with an extract from medical records certified by the signature of the attending physician and the signature of the head (authorized person) of the referring medical organization, containing the disease diagnosis, the code according to the International Statistical Classification of Diseases and Related Health Problems, data on the severity of the patient's condition, diagnostic tests performed, and treatment confirming the need for medical care in the profile of "surgery (burn surgery)".

21. After the provision of specialized, including high-tech, medical care in inpatient settings in the profile of "surgery (burn surgery)", the patient is issued a discharge epicrisis containing the results of examinations and treatment, recommendations on further tactics for monitoring, examination, treatment, and medical rehabilitation, including a referral to a medical organization providing primary health care to continue treatment and medical rehabilitation in outpatient settings under the supervision of a specialist physician (surgeon, pediatric surgeon, or traumatologist-orthopedist).

When medical indications are present, the patient is referred for rehabilitation measures to a specialized medical organization, including a sanatorium-resort organization.

22. Medical care in the profile of "surgery (burn surgery)" may be provided using telemedicine technologies through organizing and conducting consultations and/or participating in medical boards in accordance with the procedure for organizing and providing medical care using telemedicine technologies^[6].

23. Medical organizations providing specialized, including high-tech, medical care to the population in the profile «surgery (combustiology)» carry out their activities in accordance with the appendices to the Procedure for the Provision of Medical Care to the Population in the Profile «Surgery (Combustiology)».

[1] Order of the Russian Ministry of Health No. 559n dated June 9, 2020, «On Approval of the Procedure for the Provision of Medical Care to the Population in the Profile „Surgery (Combustiology)“.

[2] Clause 5.2.2 of the Regulations on the Ministry of Health of the Russian Federation, approved by Decree of the Government of the Russian Federation No. 608 of June 19, 2012 (Collected Legislation of the Russian Federation, 2012, No. 26, art. 3526).

[3] Part 2 of Article 34 of Federal Law No. 323-FZ of November 21, 2011, «On the Fundamentals of Protecting the Health of Citizens in the Russian Federation» (hereinafter referred to as Federal Law No. 323-FZ of November 21, 2011) (Collected Legislation of the Russian Federation, 2011, No. 48, art. 6724; 2017, No. 31, art. 4791).

[4] Part 8 of Article 34 of Federal Law No. 323-FZ of November 21, 2011 (Collected Legislation of the Russian Federation, 2011, No. 48, art. 6724; 2017, No. 31, art. 4791).

[5] Part 2 of Article 37 of Federal Law No. 323-FZ of November 21, 2011 (Collected Legislation of the Russian Federation, 2011, No. 48, art. 6724; 2018, No. 53, art. 8415).

[6] Part 1 of Article 36.2 of Federal Law No. 323-FZ (Collected Legislation of the Russian Federation, 2011, No. 48, art. 6724; 2018, No. 53, art. 8415).

7. Additional Information

7.1 Assessment of the severity prognosis of burn injury.

Prognostic factors affecting the outcome include age, area and depth of burns, presence of concomitant and/or combined injuries, underlying diseases, and adequacy of prior treatment.

Comment: Traditionally used formulas for determining the severity and prognosis of burn injury (Appendix G10-12) may be important during medical triage and indications for medical evacuation, allowing casualties to be prioritized based on their need for medical care. At the same time, formulas for predicting mortality deserve attention and can be used in clinical practice and research only for a comparative assessment of patient severity, since there are currently no treatment algorithms based on them [638-640].

7.2 Features of the course of burn disease in patients under 18 and over 60 years of age

The age of patients affects the course and outcome of a burn injury.

Comment: Anatomical and physiological characteristics, imperfection of defense reactions and regulatory mechanisms, and the undifferentiated state of the nervous and other systems in children prevent them from adequately responding to burn injury, which significantly affects its course and treatment outcomes. Frequent concomitant diseases, instability of metabolic processes, weakened resistance, and low compensatory capabilities of the pediatric body determine the specific features of the course of burn disease in them.

The specific clinical course of burn disease in elderly and senile patients is also due to pronounced age-related changes and comorbid conditions (generalized atherosclerosis, hypertension, diabetes mellitus, etc.). On the other hand, the characteristics of the aging body include a decrease in all types of metabolism. Significant difficulties in treating this patient cohort are posed not only by extensive but also by limited burns, which are accompanied by marked disorders of internal organs and hemodynamic parameters. Within the first few hours after burn injury, mutually aggravating syndrome develops, wherein existing premorbid conditions adversely affect the wound healing process, while the resulting burn in turn exacerbates the severity of their condition. In elderly patients with burns, improved outcomes can be achieved only through early surgical treatment [460].

7.3 Complications of burn wounds, burn disease, and inhalation injury

In an unfavorable course of burn wounds and burn disease, complications develop involving virtually any organs and systems of the body; these can occur during any period and significantly impair the patient's condition, the wound healing process, prolong treatment time, and may lead to a fatal outcome. The prognosis for survival in burn victims is largely associated precisely with the developed complications.

Comment. Complications are divided into local and general, as well as primary (occurring directly at the time of injury), secondary (arising during treatment), and late (after healing or surgical closure of burn wounds).

Primary complications of burns due to thermal factors include carbonization and tissue mummification, coagulation and vascular thrombosis; due to mechanical factors – soft tissue rupture, hematoma, contusion, fracture, amputation of a limb segment.

Secondary complications of burns and burn disease occur with damage at the level of various organs and systems of the body:

Skin – dermatitis, eczema, erysipelas.

Subcutaneous adipose tissue, muscles, and fascia – cellulitis, abscess, fasciitis, phlegmon, gangrene.

Vessels and nerves – lymphangitis, phlebothrombosis, erosive hemorrhage, embolism, neuritis.

Bones and joints – osteomyelitis, arthritis, chondroperichondritis.

Internal organs - acute parenchymal lung injury, tracheobronchitis, pneumonia, myocarditis, meningoencephalitis, hepatitis, pyelonephritis, acute kidney injury, erosions and ulcers of the gastrointestinal tract, otitis, encephalopathy, delirium, sepsis, multiorgan failure, burn cachexia.

Late complications of burns - scar deformity and/or contracture, alopecia, trophic ulcer, skin cancer, etc.

Following an inhalation injury, three successively occurring categories of pulmonary complications may develop:

1. Acute manifestations observed within the first 24 hours: bronchospasm, airway mucosal edema, atelectasis, pulmonary edema accompanied by tissue hypoxia.

2. Acute respiratory distress syndrome developing on days 2-5 after the injury.

3. Pneumonia and primary pulmonary embolism manifesting from day 5 post-injury onwards. The combination of thermal inhalation injury with skin burns exceeding 25% of the body surface is particularly dangerous, as pulmonary complications almost always develop in such cases.

The most dangerous complication of inhalation injury is respiratory failure, which develops against the background of airway obstruction and ARDS. Clinical manifestations of respiratory failure may not manifest within the first 24-72 hours after injury, which makes early diagnosis of airway damage and determination of indications for respiratory support particularly urgent [30, 40, 140, 463-465]. At later stages, respiratory failure may develop against the background of pneumonia and sepsis.

Criteria for Evaluating the Quality of Medical Care

Criteria for assessing the quality of primary health care in adults and children with thermal and chemical burns, sunburns, and respiratory tract burns (ICD-10 codes: T20-T25, T27, T29-T32, L55, T95)

Criteria for assessing the quality of specialized medical care in adults and children with thermal and chemical burns, sunburns, and respiratory tract burns (ICD-10 codes: T20-T25, T27, T29-T32, L55, T95)

References

Appendix A1. Working Group Composition

1. Andrey A. Alekseev, MD, PhD, Professor, Deputy Director for Innovative Development and International Cooperation, A.V. Vishnevsky National Medical Research Center of Surgery of the Russian Ministry of Health, Head of the Burn Center, A.V. Vishnevsky National Medical Research Center of Surgery of the Russian Ministry of Health, Head of the Department of Thermal Injuries, Wounds, and Wound Infection, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health (Moscow).

2. Igor Yu. Arefiev, MD, PhD, Director of the University Clinic, Privolzhsky Research Medical University of the Russian Ministry of Health, Head of the Burn Center (Nizhny Novgorod).

3. Alexander E. Bobrovnikov, MD, PhD, Associate Professor, Professor at the Department of Thermal Injuries, Wounds, and Wound Infection, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, Head of the Burn Unit, A.V. Vishnevsky National Medical Research Center of Surgery of the Russian Ministry of Health (Moscow).

4. Sergey B. Bogdanov, MD, PhD, Head of the Krasnodar Regional Burn Center, Regional Clinical Hospital No. 1 named after Prof. S.V. Ochapovsky (Krasnodar).

5. Lyudmila I. Budkevich, MD, PhD, Professor, Head of the Burn Department, Children's City Clinical Hospital No. 9 named after G.N. Speransky, Professor at the Department of Thermal Injuries, Wounds, and Wound Infection, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health (Moscow).

6. Elena A. Zhirkova, MD, PhD, Leading Researcher at the Department of Acute Thermal Injuries, N.V. Sklifosovsky Research Institute of Emergency Medicine (Moscow).

7. Evgeny V. Zinoviev, MD, PhD, Professor, Head of the Department of Thermal Injuries, Saint Petersburg I.I. Джанелидзе Research Institute of Emergency Medicine (Saint Petersburg)

8. Artem A. Kleuzovich, Anesthesiologist-Intensivist at the Department of Anesthesiology and Intensive Care with ICU beds of the Burn Center, A.V. Vishnevsky National Medical Research Center of Surgery of the Russian Ministry of Health, Assistant at the Department of Thermal Injuries, Wounds, and Wound Infection, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health (Moscow).

9. Andrey U. Lekmanov, MD, PhD, Professor, Chief Researcher, Research Institute of Pediatric Surgery, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Moscow).

10. Yury S. Polushin, MD, PhD, Academician of the Russian Academy of Sciences, Professor, Vice-Rector for Research, Head of the Research and Clinical Center of Anesthesiology and Reanimatology, Pavlov First Saint Petersburg State Medical University (Saint Petersburg).

11. Vladimir A. Rudnov, MD, PhD, Professor, Professor at the Department of Anesthesiology, Reanimatology, and Toxicology, Ural State Medical University (Yekaterinburg).

12. Igor Yu. Samatov, Cand. of Sci. (Med.), Head of the Burn Intensive Care Unit, State Novosibirsk Regional Clinical Hospital; Associate Professor at the Department of Anesthesiology and Intensive Care, Faculty of Advanced Training and Professional Retraining of Physicians named after Prof. I.P. Vereshchagin, Novosibirsk State Medical University of the Russian Ministry of Health (Novosibirsk).

13. Pavel V. Sarygin, Dr. of Sci. (Med.), Head of the Department of Reconstructive and Plastic Surgery, A.V. Vishnevsky National Medical Research Center of Surgery of the Russian Ministry of Health; Associate Professor at the Department of Thermal Injuries, Wounds, and Wound Infection, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health (Moscow).

14. Yuri I. Tyurnikov, Head of the Burn Center, F.I. Inozemtsev City Clinical Hospital of the Moscow Healthcare Department; Assistant at the Department of Thermal Injuries, Wounds, and Wound Infection, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health (Moscow).

15. Irina V. Shlyk, Dr. of Sci. (Med.), Professor, Deputy Head of the Research and Clinical Center for Anesthesiology and Intensive Care, Deputy Chief Physician for Anesthesiology and Intensive Care, Professor at the Department of Anesthesiology and Intensive Care, Academician I.P. Pavlov First Saint Petersburg State Medical University (Saint Petersburg).

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

• surgeons;

• trauma and orthopedic surgeons;

• pediatric surgeons;

• anesthesiologists-intensivists;

• emergency medicine physicians;

• medical students, residents, and graduate students.

Methods used for evidence collection/selection:

searching electronic databases and scientific publications, analyzing current scientific developments on the issue in the Russian Federation (RF) and abroad; summarizing the practical experience of Russian and international specialists.

Grades of evidence levels (GEL) for diagnostic, prophylactic, therapeutic, and rehabilitation methods (interventions), and grades of recommendation levels (GRL) for prophylactic, diagnostic, therapeutic, and rehabilitation methods (interventions)

1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

2. Scale for assessing levels of evidence (LE) for prophylactic, therapeutic, and rehabilitation methods (prophylactic, therapeutic, rehabilitation interventions)

3. Scale for assessing recommendation grades (RG) for prophylactic, diagnostic, therapeutic, and rehabilitation methods (prophylactic, diagnostic, therapeutic, rehabilitation interventions)

Methods used to formulate the recommendations – expert consensus.

Economic analysis. Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.

Method of recommendation validation:

External expert review.

Internal expert review.

Description of the guideline validation method.

The preliminary version of these guidelines was reviewed by independent experts who were asked to comment primarily on whether the interpretation of the evidence underlying the recommendations is easy to understand.

Comments received from experts were carefully systematized and discussed by the chair and members of the working group. Each item was discussed, and the resulting changes to the guidelines were recorded. If no changes were made, the reasons for declining to make changes were recorded.

Consultations and peer review: the draft recommendations were also reviewed by independent experts who were asked to comment primarily on the clarity and accuracy of the interpretation of the evidence base underlying the recommendations.

For the final editing and quality control, the guidelines were re-analyzed by the members of the working group, who concluded that all comments and feedback from the experts had been taken into account, and the risk of systematic bias in the development of the guidelines was minimized.

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its reliability. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the resulting recommendations.

Procedure for updating clinical guidelines.

The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Medical care for patients with burns and/or inhalation injury is regulated by the following regulatory legal acts:

1. Order of the Russian Ministry of Health No. 559n dated June 9, 2020, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Surgery (Combustiology)'."

Groups of medicinal products for medical use in patients with burns and/or inhalation injury

Patients with burns and/or inhalation injury, as well as their sequelae, undergo comprehensive general and local treatment, including drugs from various groups in accordance with the Anatomical Therapeutic Chemical (ATC) classification system.

Comment. All necessary medicinal products for medical use in patients with burns and/or inhalation injury are used for the prevention and treatment of certain conditions or syndromes in accordance with their indications for use and contraindications, methods of administration, and doses contained in the package leaflet of the medicinal product.

At the same time, most of the medicinal products used in patients with burns and/or inhalation injury do not have direct indications, according to the package leaflet, for "treatment of burns and/or inhalation injury."

In case of their use associated with the comorbidity of the listed conditions and syndromes indicated in the "indications" section of the package leaflet, there are developed clinical guidelines for these nosologies.

In patients with burns and/or inhalation injury, dietary supplements are not used.

Appendix B. Physician Action Algorithms

Appendix B1. Algorithms for the diagnosis and treatment of patients with burns Appendix B2. Algorithm for the diagnosis and treatment of inhalation injury

Comment: Normal pulse oximetry and/or targeted chest X-ray findings do not exclude the diagnosis of inhalation injury.

Appendix B3. Algorithm for local treatment of grade I-II burns (diagram) 

Appendix B4. Algorithm for local treatment of grade III burns (diagram)

Appendix B5. Algorithm for choosing tactics and methods of surgical treatment for burn victims

Appendix B6. Algorithm for choosing the method of active surgical preparation of deep burns for plastic closure depending on wound condition and time elapsed since injury

Appendix C. Patient Information

A burn is one of the greatest misfortunes that can happen to any person. Severely injured patients describe sustaining a burn as "moments of terror and months or years of suffering." A burn is a very insidious and dangerous type of trauma.

Neither the victim nor their loved ones can assess the severity of the injury, as all dangerous manifestations of a burn develop and accumulate gradually. Only a specialist can properly assess the severity of the sustained burn.

The treatment of serious burns is recognized worldwide as one of the most complex and expensive types of medical care, requiring the use of a large arsenal of medical resources in the diagnostic and treatment process.

First aid for burn victims

First aid for burn victims should be provided immediately, right at the scene of the incident, as self-care or mutual aid.

The first step in providing first aid is to release/move the victim away from all sources capable of causing a burn, including flames/high-temperature zones, live wires, and chemicals. The first aider must ensure their own safety and the safety of bystanders.

If clothing catches fire, follow the "Stop, Drop, and Roll" approach. Do not allow the victim to run, as this will fan the flames and lead to more rapid burns. Since flames always travel upward, assuming a horizontal position not only prevents exposure to the face, head, and hair, but also prevents the fire from spreading around the body. Flames can also be extinguished by pouring water or any non-flammable liquid.

After the thermal agent ceases to act, if possible, remove all materials in contact with the burned surface (clothing, shoes, jewelry, rings and watches in case of hand burns, etc.). No manipulations should be performed on the burn wounds at this time. Do not puncture or remove blisters, or detach adhered items (clothing, bitumen, metal splashes, plastic, etc.). Stuck clothing should not be torn off the burned surface; it is better to cut it around the wound.

Immediate cooling of the burned surface, no later than 10-15 minutes after the injury, reduces tissue overheating time, preventing the thermal agent from spreading to deeper tissues. Cooling reduces edema and relieves pain, exerting a favorable effect on the subsequent healing of burn wounds by preventing deeper tissue damage.

It is important to know that for localized burns up to 10% of the body surface, cooling of the damaged skin areas is necessary for 15-20 minutes by irrigation or immersion in cold water, using cold objects, or special cooling gels. The use of ice is not recommended, as it causes vasoconstriction and hypothermia. It is better to cool under a shower, directing the stream onto the burn surface and adjusting the water temperature so that the patient feels local relief. The ideal water temperature for cooling is 15°C. The goal is to cool the burn wound, not the patient. Special attention must be paid to the risk of hypothermia. Therefore, cooling is not performed for extensive burns.

Emergency care for a victim of electrical injury involves the rapid termination of the electric current's effect. After ensuring the safety of the scene, if the victim shows no signs of life, pre-hospital care providers must immediately initiate cardiopulmonary resuscitation.

In chemical skin injuries, clothing and powdered chemical substances should be carefully removed from the body surface. To prevent the rescuer from getting burned, personal protective equipment may be used (gloves, protective clothing, gas mask, etc.). The affected area of the skin must not be rubbed with sterile medical gauze wipes moistened with water. All chemical burns should be washed with a large amount of running cold water for at least 10–15 minutes, or for at least 1 hour if first aid was delayed. The exceptions are burns caused by concentrated sulfuric acid and quicklime, because contact with water causes an exothermic reaction that can lead to additional thermal damage. Sulfuric acid should preferably be blotted with a dry cloth before washing, while lime burns require removing residues dry first, followed by rinsing the skin with running water or treating it with any vegetable oil. A shower may be taken. Antidotes and neutralizing liquids are not used for chemical burns!

A burn victim should be given a tablet of a non-steroidal anti-inflammatory drug and a systemic antihistamine, and if vomiting is absent, especially in extensive burns, should be given fluids to drink. As "anti-shock therapy" before the ambulance arrives, the best fluids to drink are non-carbonated mineral water or water with dissolved salt and baking soda (1 tsp of salt and 0.5 tsp of soda per 1 L of water) at a rate of 1–1.5 L per hour.

At the stage of providing medical care in domestic and field settings during the transportation of victims to a medical facility—that is, until primary medical or specialized care is provided—a first-aid dressing without any medicinal substances is applied. This dressing must not contain fats, proteins, oils, or dyes (e.g., Brilliant Green solution), and wounds must not be treated with powders, as these can subsequently make it difficult to determine the depth of the injury and to perform wound debridement. The use of aerosols (e.g., Dexpanthenol), ointments, creams, and balms as first aid is not recommended. Traditional remedies should also not be used, including treating burns with toothpaste or urine!

For localized burns, the following may be used: an individual dressing packet, sterile medical gauze wipes, or films. Burns of the hands and feet can be placed in a clean plastic bag in a way that does not restrict their mobility. This "dressing" material is soft and airtight, acting as a protective barrier; furthermore, it is transparent, which allows the burn site to be inspected and subsequent dressings to be performed with practically no pain.

For extensive burns, sterile or clean sheets (preferably cotton disposable sheets) are suitable; they are used as a contour (silhouette) bandage and applied without wrapping with gauze, which takes too much time—time that is better spent on anti-shock therapy and prompt evacuation to a hospital.

First-aid dressings are applied without undressing the victim, especially in cold weather, over clothing and footwear if they are not burning or smoldering. The use of damp dressing materials should be avoided, as heat loss by the body on the way to the hospital can be significant. Conversely, general warming of the victim is necessary.

For chemical burns, only dry dressings without medications should be used, as drugs may enhance the damaging effect of the chemical agent.

If rapid delivery of burn victims to the stage of primary medical and specialized care is possible, the use of commercial wound dressings purchased at a pharmacy is unjustified.

At the same time, in cases of delayed medical care (e.g., on a hike, during disasters and mass casualty incidents), ready-made wound dressings, which should be included in first-aid kits, can be used as a first-aid bandage.

After a burn, emergency medical services must be called immediately, or if that is not possible, the victim should be taken to the nearest hospital if:

- The burn area is greater than 5% of the body surface (1% of the body surface is approximately equal to the area of the victim's palm).

- There is suspicion of a deep third-degree burn. The eyes, face, ears, hands, feet, major joint areas, perineum, or genitalia are burned.

- Burn wounds are located circularly on the extremities.

There was an injury from electric current, including lightning.

- There is suspicion of an airway burn or inhalation injury from combustion products.

- The burn is in a child or an elderly person. There are burns combined with severe concomitant diseases, such as diabetes mellitus.

At the same time, for limited superficial injuries, medical care can be provided on an outpatient basis in polyclinics and trauma centers. However, it is best to contact the nearest hospital with a burn unit. Only burn unit specialists can establish an accurate diagnosis, hospitalize burn victims if necessary, and provide recommendations on preventing post-burn scars.

Timely seeking of specialized medical care will make it possible to utilize all opportunities to save the victim's life and effectively carry out therapeutic and rehabilitation measures.

The patient must be informed about the specific features of treatment and rehabilitation. A necessary prerequisite for them is the patient's informed voluntary consent to the diagnostic and therapeutic procedures performed [478, 479].

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1.

Russian title: Visual Analog Scale for pain (VAS).

Original name: Visual analogue scale.

Source (official website of developers, validation publication):

Clark W.C., Chokhavatia S.S., Kashani A., Clark S.B. Chapter 6 - Pain Measurement. In: Argoff CE, McCleane G, editors. Pain Management Secrets. 3rd ed. -Philadelphia: Mosby, 2009. –Р.42-52.

Sinha S., Schreiner A.J., Biernaskie J., Nickerson D., Gabriel V.A. Treating pain on skin graft donor sites: review and clinical recommendations. //J Trauma Acute Care Surg. -2017. – V. 83. – I. 5. –Р. 954-964. doi: 10.1097/TA.0000000000001615

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Content (template):

Notes: We recommend performing the assessment when enrolling the patient in the study prior to intervention (treatment, surgery). Since completing the VAS questionnaire does not take much time, the assessment can be performed daily throughout the entire course of treatment. Data obtained in this manner can serve as a valuable reflection of the analgesic effect of the treatment administered. The volume of analgesic therapy should also be recorded whenever possible and included in the reporting data when assessing pain syndrome.

Appendix G2.

Russian title: Wong-Baker FACES Pain Rating Scale.

Original title: Wong–Baker Faces Pain Rating Scale.

Source (official developer website, publication with validation):

https://ru.qaz.wiki/wiki/Wong-Baker_Faces_Pain_Rating_Scale

https://wongbakerfaces.org/

Garra G. et al. The Wong-Baker pain FACES scale measures pain, not fear // Pediatric emergency care. – 2013. – Vol. 29. – No. 1. – P. 17-20.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: Designed to assess the condition of adult patients and children over 3 years of age.

Content (template):

Key (interpretation):

No hurt – 0

Hurts little bit – 2

Hurts little more – 4

Hurts even more – 6

Hurts whole lot – 8

Hurts worst – 10

Notes: The specialist assessing pain must explain to the patient in accessible terms the need to choose which of the presented faces describes their level of pain: "Show how much it hurts right now." Sometimes, using this scale, the patient may define their emotions more than their pain.

Appendix G3.

Russian title: FLACC Behavioral Scale.

Original title: Clinical validation of FLACC face, legs, activity, cry, consolability).

Source (official developer website, publication with validation):

Manworren R.C.B., Hynan L.S. Clinical validation of FLACC: preverbal patient pain scale // Pediatric nursing. – 2003. – Т. 29. – №. 2. – P. 140-146.

Pain assessment in pediatric non-verbal patients. — Moscow: Prospekt Publishing House, 2019. — 40 p. https://www.rcpcf.ru/wp-content/uploads/2019/09/Ocenka_boli_all.pdf

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: Used in children from 2 months to 3 years of age and in patients unable to report pain.

Content (template):

The scale takes into account facial expression, leg movements, the character of crying, as well as how consolable the child is and their behavioral features. The total FLACC score is the sum of points for all description items.

The minimum score is 0, and the maximum is 10 points.

Total sum across five categories: 0 points - relaxed, 1-3 - mild discomfort, 4-6 - mild pain, 7-10 - severe pain.

Notes: The higher the score, the more severe the pain and the worse the child feels.

Appendix G4.

Russian title: Rule of Nines.

Original title: Rule of Nines.

Source (official developer website, publication with validation):

Knaysi GA, Crikelair GF, Coxman B. The role of nines: its history and accuracy.// Plast Reconstr Surg.- 1968. -41. –Р.560–563.

Artz C.P., Moncrief J.A. The treatment of Burns, ed.2. -Philadelphia, WB Saunders Company, 1969.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):___________________________________________

Purpose: Determination of burn surface area in adult patients.

Content (template):

Key (interpretation):

The entire body surface area of an adult is divided into zones, each accounting for 9% of the total body surface area (100%). If lesions are present in multiple zones, the areas are summed.

Notes: The "rule of nines" is used in adult patients for a rough estimation of the area of extensive burns that completely occupy individual body zones.

Appendix G5.

Russian title: Lund-Browder chart.

Original title: Lund-Browder Chart.

Source (official developer website, publication with validation):

Lund C, Browder N. The estimation of areas of burns. //Surg Gynecol Obstet. -1944. -79. –Р.352–358.

Artz C.P., Moncrief J.A. The treatment of Burns, ed.2. -Philadelphia, WB Saunders Company, 1969.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):___________________________________________

Purpose: Determination of burn surface area in children.

Content (template):

Interpretation:

The surface area of individual body parts in children is determined using standard tables based on age-related ratios relative to the total body surface area (100%).

Explanations: The area of burn injury in children differs from that in adults. Children have a relatively larger head and smaller lower limbs, which is why the burn surface area relative to the total body surface area can be determined more accurately using the Lund-Browder chart

Appendix G6.

Russian title: Richmond Agitation-Sedation Scale (RASS scale)

Original title: Richmond Agitation-Sedation Scale (RASS)

Source (official developer website, publication with validation):

Sessler C.N., Gosnell M.S., Grap M.J., Brophy G.M., O’Neal P.V., Keane K.A., Tesoro E.P., Elswick R.K. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. //Am J Respir Crit Care Med. -2002. -166 (10). –Р.1338–1344.

https://ru.qaz.wiki/wiki/Richmond_Agitation-Sedation_Scale

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Indication: The scale is used to describe the degree of patient psychomotor agitation or the depth of sedation.

Content (template):

Three consecutive steps are used: observation, response to verbal stimulation, and response to physical stimulation.

Key (interpretation):

RASS Assessment Procedure

1. Patient observation

If the patient is alert, calm, and attentive? – 0 points.

Does the patient exhibit behavioral signs characterized by anxiety or agitation – score from +1 to +4 points using the criteria listed above in the description.

2. If the patient is somnolent, ask them in a loud voice, calling them by name, to open their eyes and look at you. Repeat this several times if necessary. Ask the patient to maintain eye contact.

If eye contact with the patient is possible and sustained for more than 10 seconds – score -1 point.

If eye contact with the patient is possible, but not sustained for 10 seconds – score -2 points.

Если patient makes any movement in response to voice, other than eye contact – score -3 points.

3. If patient does not respond to voice, physically stimulate patient by shaking shoulder and/or rubbing sternum.

If the patient responds with any movement to physical stimulation — score -4 points.

If the patient does not respond to voice or physical stimulation — score -5 points.

Notes: RASS depends on the patient's hearing and vision acuity and is not suitable for patients with severe impairments. The scale is most commonly used during mechanical ventilation to avoid inadequate or excessive sedative drug effects.

Notes: The scale allows assessment of sedative therapy and improves communication among medical personnel. It is easy to use and enables the assessment of the level of sedation or agitation within 30–60 seconds.

Appendix G7.

Russian title: Glasgow Coma Scale

Original title: The Glasgow Coma Scale, GCS

Source (official developer website, publication with validation):

https://www.glasgowcomascale.org

Teasdale G., Jennett B. Assessment of coma and impaired consciousness. A practical scale. (English) // The Lancet : journal. — Elsevier, 1974. — Vol. 2, no. 7872. — P. 81—4. — doi:10.1016/S0140-6736(74)91639-0. — PMID 4136544.

Russ Rowlett. Glasgow Coma Scale. -University of North Carolina at Chapel Hill.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):_____________________________________________________

Purpose: The scale is designed to assess the severity of impaired consciousness and coma in children over 4 years of age and adults.

Content (template):

The scale consists of three tests evaluating eye opening (E), verbal response (V), and motor response (M). A specific number of points is awarded for each test. The minimum score is 3 points, and the maximum is 15 points.

Key (interpretation):

· 15–14 points — clear consciousness

· 13–12 points — confusion

· 11–9 points — stupor

· 8–3 points — coma

Notes: Points are awarded based on the best observation during the examination.

Appendix G8.

Russian title: Assessment of the degree of nutritional impairment in burn patients.

Original title: Assessment of the degree of nutritional impairment in burn patients.

Source: Sologub V.K., Mordkovich M.R., Zayats T.L., Tarasov A.V. et al. Prolonged uniform dosed tube hyperalimentation as an intensive care method for severe burn patients (guidelines). – Moscow, 1988. – 30 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):_______________________________________________________

Purpose: Assessment of the patient's condition and degree of nutritional impairment.

Content (template):

*Weight deficit (in %) is calculated using the formula: (Wp - Wc) / Wp x 100%, where Wp is the average, i.e., usual body weight of the patient before injury (from anamnesis), kg; Wc is the current body weight of the patient (at the moment), kg.

**Absolute lymphocyte count is calculated using the formula: (leukocytes (absolute count) x lymphocytes (%)) / 100.

Key (interpretation):

Taking into account the patient's examination data (body weight deficit, body mass index, serum albumin level, blood lymphocyte level), the degree of nutritional impairment is determined using the table as mild, moderate, or severe.

Notes: The presence of all main parameters characterizing mild, any two characterizing moderate, or any single parameter characterizing severe nutritional impairment is an indication for supplementary nutrition. At the same time, indications for such nutritional support include not only the treatment of existing emaciation but also the presence of a burn injury itself.

Appendix G9.

Russian title: Vancouver Scar Scale.

Original title: The Vancouver Scar Scale (VSS).

Source (official developer website, publication with validation):

Sullivan T., Smith J. et al. Rating the burn scar.// J Burn Care Rehabil. -1990. -11. –P. 256-260.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):_______________________________________________________

Purpose: The best-known and most widely used scale for assessing post-burn scars both in routine practice and in clinical research.

Content (template):

The scale involves evaluating four scar parameters: vascularization, pigmentation, pliability, and height/thickness.

The evaluation score is the sum of points across all four parameters. The minimum score is 0, the maximum score is 13. The lower the score, the closer the scar is to normal skin. The higher the score, the worse the condition of the scar.

Notes: It is the primary scar assessment scale. It does not evaluate subjective symptoms or scar size.

Appendix G10.

Russian title: The "Rule of Hundreds" or Baux score.

Original title: Baux score.

Source (official developer website, publication with validation):

Baux S. Contribution a treatment local des Irulures thermiques etendues // There pour le doctorat en medicine № 763. - Faculte de medicine de Paris. - Edicion A.G.E.M.P. - Paris, 1961. - 21 p [454].

Osler T, Glance LG, Hosmer DW. Simplified estimates of the probability of death after burn injuries: extending and updating the Baux score. //J Trauma Acute Care Surg. -2010. -68(3). –P.690–697 [455].

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):_______________________________________________________

Purpose: Prognostic index (PI) for the severity of burn injury.

Content: Using the "rule of palms" or "rule of nines", determine the total burn area (if a dressing is applied without removal, estimate based on the bandaging area). Determine the age of the casualty.

Calculate the PI using the formula:

PI = age of the casualty (in years) + total burn area (in percentage).

Interpretation: A sum of 101 or more – poor prognosis, 81–100 – doubtful, 61–80 – relatively favorable, up to 60 – favorable prognosis.

Appendix G11.

Russian title: Frank Index (FI).

Original title: Frank Index.

Source (official developer website, publication with validation):

Frank G. The «prognostic index» in burns for a more exact characterization of their degree of severity and a more reliable statistical evaluation //Zentralbl Chir. -1960. -6; 85. -Р.272-277. [Article in German]. PMID: 13824499 [456]

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):_______________________________________________________

Purpose: Prognostic index for the severity of burn injury.

Content: Determine separately the area of superficial (grades I–II) and deep (grade III) burns. Calculate the Frank Index (FI) using the formula:

FI = SBA + DBA × 3, where SBA is the area of superficial and borderline burns (grades I–II) in % of body surface area, DBA is the area of deep burns (grade III)

Interpretation:

· up to 30 conventional units – favorable prognosis,

· 31–60 – relatively favorable,

· 60–90 – doubtful,

· greater than 91 – poor prognosis.

Notes: The FI takes into account not only the extent but also the depth of burns. The FI cannot be applied during the shock period, when it is clinically difficult to differentiate areas of superficial and deep skin lesions in the first three days, especially in borderline burns.

Appendix G12.

Russian title: Modified Injury Severity Index (MISI).

Original title: Modified Injury Severity Index (MISI).

Source (official developer website, publication with validation):

Fistal E.Ya., Kozinets G.P., Samoylenko G.E., Nosenko V.M., Fistal N.N., Soloshenko V.V. Combustiology: Textbook. - Donetsk, 2005.- 315 p [457].

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):_______________________________________________________

Purpose: Prognostic Burn Severity Index (modified Frank index).

Content:

When calculating the BSI, it is assumed that 1% of the burn corresponds to: for 1st-degree burns – 1 point, 2nd-degree – 2 points, 3rd-degree – 3 points.

For patients with inhalation injury (II), the following are additionally added:

+15 points for grade I II, +30 points for grade II II, +45 points for grade III II.

Combination with moderate mechanical trauma: +10 points.

Combination with severe mechanical trauma: +30 points.

Comorbidity in the compensation stage: +10 points.

Comorbidity in the decompensation stage: +30 points.

For a BSI score > 30 and initiation of antishock therapy 8 hours after the injury: +10 points.

For a BSI score > 30 and initiation of antishock therapy between 8 and 24 hours after the injury: +15 points.

For a BSI score > 30 and initiation of antishock therapy more than 24 hours after the injury: +20 points.

Each year over 60 years of age adds +1 point.

Interpretation:

· 30–60 points — Mild burn shock. Favorable prognosis.

· 61–90 points — Severe burn shock. Doubtful prognosis.

· Over 91 points — Extremely severe burn shock. Unfavorable prognosis.

Notes: The BSI assesses not only the prognosis for burns (taking into account burn area, depth of injury, patient age, combined trauma, comorbid pathology, and the nature and timeliness of medical care), but also the severity of burn shock and the prognosis.