Etiology and classification
Thermal agents are divided by their physical state into solid, liquid, and gaseous. Based on the nature of interaction with tissues, burns are classified as:
- Contact — upon direct contact with a heat source.
- Distant — caused by thermal radiation (visible or ultraviolet spectrum), for example, from exposure to an electric arc or "sunburns".
In wartime, injuries can be caused by specific mixtures. Napalm burns at temperatures up to 1200 °C, pyrogels up to 1600 °C (burning through metal), and thermite can heat above 3000 °C. White phosphorus spontaneously ignites in air and additionally causes severe intoxication.
Depth of tissue damage
The depth of the burn determines the clinical presentation and the tissue's ability to regenerate independently:
- Grade I: Only the epidermis is affected. Redness, edema, and pain are observed. Symptoms resolve within a few days, followed by desquamation.
- Grade II: The epidermis and papillary layer of the dermis are affected. Blisters with yellowish exudate form; the wound base is pink and sharply painful. Heals without scars.
- Grade IIIA: The lesion reaches the reticular layer of the dermis, but hair follicles and sweat glands are preserved. Tense blisters or a light yellow, waxy eschar appear. Pain sensitivity may be reduced. Spontaneous healing is possible, sometimes with scar formation.
- Grade IIIБ: Complete destruction of the epidermis and dermis with all appendages. The eschar is dark, the wound base is dry and whitish, and pain is absent. Surgical treatment is required due to the impossibility of spontaneous epithelialization.
- Grade IV: Total necrosis of the skin, subcutaneous tissue, fascia, muscles, and bones. The eschar is dense, black, or brown. Healing proceeds extremely slowly with the formation of large defects.
To quickly assess the depth of a burn, one relies on the elevation or depression of the affected area relative to healthy skin and the presence or absence of pain sensitivity.
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Burn disease: periods
In extensive deep burns (in adults — more than 15% of the body surface, in children and the elderly — more than 10%), burn disease develops. In isolated facial burns, it is rare. The course of the disease is divided into four periods:
- Burn shock (Period I): In severe trauma, a brief period of agitation is typically replaced by lethargy while consciousness is preserved. Unlike traumatic shock, blood pressure is often normal. An important diagnostic sign is a sharp drop in diuresis (oliguria or anuria), with urine potentially darkening to a cherry or black color.
- Acute burn toxemia (Period II): Begins on days 2–4. Caused by the absorption of tissue breakdown products and bacterial toxins. The main symptom is fever. Neurological disorders (agitation, delirium), gastrointestinal, and myocardial damage are possible.
- Burn septicetoxemia (Period III): From days 10–11, eschar detachment begins, contributing to infection development. Characterized by purulent discharge, remittent fever, significant protein loss, and increasing anemia. The most frequent complication is pneumonia.
- Convalescence (Period IV): The recovery stage following the rejection of necrotic masses and closure of wounds.
Briefly: answers to topical questions
What changes in internal organs and systems occur during the period of acute burn toxemia?
During the period of acute burn toxemia, multiple systemic disorders and internal organ damage develop.
- Nervous system — sleep disturbance, psychomotor agitation, confusion, delirium, auditory and visual hallucinations.
- Cardiovascular system — development of toxic myocarditis, tachycardia, muffled heart sounds.
- Respiratory system — development of pneumonia and other pulmonary complications.
- Gastrointestinal tract — nausea, frequent vomiting, intestinal paresis, toxic diarrhea, jaundice, gastrointestinal bleeding.
- Urinary system — impaired renal function, renal colic, polyuria.
- Blood — anemia, hypo- and dysproteinemia, decreased prothrombin index, leukocytosis.
What local complications can develop in deep maxillofacial burns?
In deep maxillofacial burns, local complications may develop depending on the localization of the lesion.
- Eyelids — keratitis due to corneal trauma from misdirected eyelashes and cicatricial ectropion of the eyelids with deformation of the cartilaginous plate.
- Scalp — cranial bone necrosis; surgical removal of necrotic bone areas followed by skin grafting is indicated.
- Neck — severe scars leading to significant neck deformity, including due to damage to the platysma muscle (platysma).
- Auricles — when effusion accumulates between the perichondrium and cartilage, aspiration is performed to prevent acute chondritis; suppurated effusion requires opening.
- In electrical burns of the facial soft tissues — if infection supervenes, deep abscesses (abscess, phlegmon) are possible, and at 3–4 weeks post-injury, there is a risk of erosive hemorrhage from major vessels.
What methods of skin grafting are used to close defects in deep facial burns?
Various skin grafting methods are used to close defects in deep facial burns.
- Free split-thickness skin autografting — transplantation of continuous skin grafts 0.3–0.4 mm thick (perforations are not made to preserve aesthetic outcomes).
- Local tissue flap surgery — use of opposing triangular flaps to replace the defect with structurally homogeneous tissues.
- Pedicled flap surgery — tissue transfer while preserving the nourishing vascular pedicle.
- Filatov tube pedicle flap surgery — use of tissues harvested away from the face to close extensive non-penetrating defects and scar deformities.
Which clinical signs indicate a concomitant inhalation injury?
A concomitant inhalation injury is indicated by a number of characteristic local and general clinical signs.
- Singeing of nasal hairs — observed in the area of the nostrils.
- Changes in the mucous membrane — hyperemia (hyperemia) and edema (oedema), as well as the presence of grayish-white plaque areas.
- Dysphonia — impairment of voice quality.
- Cough — accompanied by sputum production containing soot admixture.
- Respiratory impairment — clinical signs of external respiration impairment are present.
What stages does primary surgical debridement of facial burn wounds include?
Primary debridement (toilet) of facial burn wounds is performed after anesthesia and includes the following stages.
- Treatment of surrounding skin — healthy skin around the burn is wiped with alcohol, gasoline, or a 0.5% ammonia solution.
- Wound cleansing — removal of clothing fragments, foreign bodies, and exfoliated epidermis; rinsing with antiseptics.
- Management of blisters — large blisters are incised to evacuate fluid, small ones are left unopened. Blisters must not be excised, as the blister roof serves as a biological dressing.
- Preservation of fibrin — fibrin deposits are not removed.
- Drying — the wound is dried with sterile wipes.
Note: primary and early necrotomy are not used in deep facial burns due to the risk of facial nerve injury.
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What else to study on this topic
- Methods of instrument decontamination in radioactive contamination
- Specifics of surgical tactics for wounds contaminated with radioactive substances
- Chemical composition and damaging effects of incendiary mixtures (napalm, pyrogels, thermite, white phosphorus)
- Pathogenesis of metabolic disorders in the stage of burn toxemia
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Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"
Non-fire injuries of the facial soft tissuesMandibular dislocationMandibular fractureJaw immobilization in fracturesMaxillary fractureZygomatic bone and zygomatic arch fractureNasal bone fractureAssociated maxillofacial traumaComplications of maxillofacial injuriesFirearm wounds of the maxillofacial regionPrimary surgical debridement of facial woundsMaxillofacial frostbiteRadiation injuries of the maxillofacial regionNon-fire facial traumaFacial bone fracturesThermal facial injuriesComplications of pulpitis
Entire section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.