Assessment of the affected area
To choose the treatment strategy, it is critically important to quickly assess the scale of the injury. Both approximate and precise instrumental methods are used.
- Rule of nines (A. Wallace): The body is conventionally divided into anatomical regions whose areas are multiples of 9%. The head and neck, as well as each upper extremity, account for 9% each. The anterior and posterior surfaces of the trunk constitute 18% each. Each lower extremity is also assessed at 18% (9% for the thigh and 9% for the lower leg with the foot). External genitalia account for 1%.
- Rule of palms (I.I. Glumov): The patient's palm is taken as 1% of their body surface area. This screening method is ideal for assessing limited foci, scattered injuries, or for calculating areas of deep necrosis against the background of extensive superficial burns.
- Direct measurement method: A transparent sterile film is applied to the wound, and its contours are traced with a marker. The film is then transferred to a grid (graph paper) to accurately calculate the absolute affected area.
- Special tables: Based on average values of anatomical region areas. For example, the area of the face is taken as 500 $cm^2$ (3.1%), the chest and abdomen as 2990 $cm^2$ (18%), and the hand as 360 $cm^2$ (2.25%).
Classification by depth
The tissue's ability to regenerate independently and the need for surgical intervention depend directly on the depth of the lesion.
- Degree I: Manifests as skin hyperemia.
- Degree II: Characterized by epidermal detachment and the formation of blisters filled with serous exudate.
- Degree IIIa: Necrosis of the superficial skin layers occurs. A key feature of this degree is the preservation of hair follicles, sweat glands, and sebaceous glands, which subsequently serve as sources of epithelization.
- Degree IIIb: Destruction of the entire thickness of the dermis occurs.
- Degree IV: Severe necrosis of the skin and deep-lying structures (subcutaneous tissue, muscles, bones).
In practice, a combination of superficial and deep lesion foci is often observed.
Treatment tactics and local therapy
Treatment begins with initial wound toilet. Healthy skin around the burn is treated with alcohol, and the surface itself is washed with tampons soaked in a warm soap solution, 0.25% ammonia solution, or 3–4% boric acid solution.
There are two main methods of wound management: closed and open. The open method is based on the accelerated formation of a dense eschar through drying (in the air, under UV irradiation). It is indicated for superficial injuries (degrees II, IIIa), as well as for burns of the face and perineum. The wound is treated 3–4 times a day with ointments containing antibiotics (chloramphenicol emulsion) or antiseptics (0.5% nitrofural ointment). If suppuration develops or deep burns are detected, the method is switched to the closed one.
In deep burns (degrees IIIb–IV), an eschar forms within the first 3–7 days. Wet necrosis is extremely dangerous due to the risk of infection spread and intoxication; therefore, the primary task is to convert it into a dry eschar. To promote drying, a Sollux lamp, UV irradiation, and treatment with a 1–5% potassium permanganate solution are used. From days 7–10, the process of eschar rejection begins.
Prehospital stage and surgical treatment
During the transportation phase (preferably no longer than 1 hour), the patient is administered analgesics, neuroleptics, and antihistamines. If evacuation is delayed, it is necessary to ensure intravenous administration of blood substitute solutions, oxygen therapy, anesthesia (nitrous oxide), and abundant alkaline drinking.
The only effective method for treating deep burns is autodermoplasty. During the surgery, dead tissues are removed (necrectomy) and the defect is closed with skin grafts.
- Most frequently, a split-thickness skin graft with a thickness of 0.2–0.4 mm, harvested by a dermatome from healthy areas of the body, is used.
- Full-thickness grafts, Filatov tube flap reconstruction, and pedicle flaps are also used.
- Cellular technologies—such as the use of cultured autologous fibroblasts for wound closure and regeneration stimulation—are actively being introduced.
Briefly: answers to topical questions
What are the periods of burn disease?
The course of burn disease is divided into four consecutive periods reflecting its pathogenetic orientation. These include burn shock, acute burn toxemia, septicotoxemia, and the convalescence period.
- Burn shock is the first period of burn disease.
- Acute burn toxemia is the second period, developing after shock.
- Septicotoxemia is the third period of the pathological process.
- Convalescence is the final period characterized by the normalization of organ and system functions.
For Wallace's rule of nines, the distribution by body parts is easy to remember: the head and each arm represent one 'nine' (9%) each, each leg, the chest-abdomen, and the back represent two 'nines' (18%) each, and the perineum accounts for the remaining 1%.
Class and exam questions
How to quickly assess the survival prognosis of an adult patient upon admission?
You can use Bokarius's approximate 'rule of hundreds': add the patient's age in years and the total burn surface area as a percentage. If the resulting sum is less than 60, the prognosis is favorable; if it is greater than 100, it is unfavorable. Frank's index, which takes into account not only the area but also the depth of the lesion, is considered more accurate.
How does a degree IIIa burn fundamentally differ from a degree IIIb burn?
In a degree IIIa burn, skin appendages (sweat and sebaceous glands, hair follicles) are preserved, allowing the wound to epithelize on its own. In a degree IIIb burn, the entire thickness of the dermis is destroyed, so spontaneous healing is impossible and skin transplantation is required.
What medications are administered in the shock trauma room for infection prevention?
Immunotherapy is used to prevent infectious complications. Patients are transfused with hyperimmune plasma (antistaphylococcal, anti-pseudomonal), specific gamma globulins, and normal human immunoglobulin.
What else to study on this topic
- Pathophysiology of burn shock and inpatient hemodynamics restoration protocols
- Features of the closed method of burn wound management and dressing change rules
- Calculation of Frank's index: scoring injury severity
- Cellular technologies in combustiology: cultured autologous keratinocytes and fibroblasts
- Indications for the use of the migrating Filatov tube flap
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