Burn disease in young children. Features of the course of burns in children. Burn hazard for children

Most clinicians believe that young children tolerate burns much worse than adults. General phenomena in their body develop with a smaller area of ​​damage than in adults; mortality is high. Burns covering an area of ​​5–8% of the child’s body surface cause signs of shock and require general treatment; over 20% are life-threatening.

Meanwhile, organizing proper treatment and care for a burned child- quite a difficult task.

The reasons for the more severe course of burns in children, as well as the difficulties associated with their treatment and care, are explained by some anatomical and physiological characteristics of childhood, characteristic of the first 5–6 years of life. At school age, children become more independent, more conscious, the body matures, and care becomes easier.

After a severe widespread burn, a child may experience irritability, poor sleep, bedwetting, absent-mindedness and other emotional, volitional and mental disorders for a long time.

Despite significant advances made in the treatment of burnt victims, the number of children dying from complications is still very high.

The outcome of a burn primarily depends on the extent and depth of the thermal injury. Children tolerate superficial burns relatively easily. If the burn does not exceed 70% of the body surface in size, the child usually recovers. The situation is completely different with deep third and fourth degree burns. In these cases, death can occur even in a relatively small area, and the younger the child, the more severe the burn disease and the less likely there is for a favorable outcome.

Anatomical and physiological characteristics of the child’s body that influence the course of burns and complicate their treatment

Currently, deep burns covering an area of ​​more than 30% of the body surface are considered critical for infants and toddlers; for older children - deep burns exceeding 40% of the body surface in size.

The cause of death in the vast majority of children is infection, which causes general infection of the body and death even before plastic closure of the wounds becomes possible.

“Burns in children”, N.D. Kazantseva

Relevance. Burns are complex trauma resulting from high temperature, chemical, electrical or radiation exposure of the body that destroys and/or damages the skin and underlying tissue. The young age of patients, the lack of ability to verbalize, and the dominance of general symptoms over local status make the diagnosis and treatment of burns in children of the first year of life especially difficult. The features of burn injury in infants have been poorly studied. At the same time, household burn injury occupies one of the leading places in the structure of childhood injuries. In appearance, these are predominantly thermal burns, which occur when some or all cells of the skin or other tissues are destroyed under the influence of: hot liquids (burns with boiling water or steam); hot solid objects (contact burns); flame (flame burns).

Target. Monitoring the structure, clinical manifestations, treatment methods in order to optimize the algorithm for managing infants with burn injury.

Research methods. Statistical, mathematical.

Research results. At the Pediatric Surgery Clinic of VSMU named after. N.N. Burdenko, at the Voronezh Regional Clinical Hospital No. 1, over the past 2 years, we have observed 30 children with burn injuries under the age of 1 year. Of these: 13 girls and 17 boys. Age distribution: 2 months. – 1 child; 3 months – 1 child; 4-6 months – 4 children; 7-10 months – 21 children; 11-12 months – 3 children. According to the timing of admission to the hospital: in the first 6 hours from the moment of receiving a burn injury - 19 children were admitted; 12-24 hours – 6 children; over 1 day – 5 people. Among them, distribution according to the depth of the lesion: thermal burn with boiling water - 67% (20 children): I degree - 6%, II degree - 43%, III degree - 18%; contact burn (stove, iron, hot battery) - 33% (10 children): II degree - 23%, III degree - 10%. By area, burns with boiling water predominated: no more than 5% - in 75%, an area of ​​6-9% - 5%, an area of ​​10% or more - 20% of patients. The affected area in all children with contact burns did not exceed 5%. According to the localization of thermal burns with boiling water - the areas of the feet (50%), hands (40%), less often the lower legs (30%), chest and forearms (27%), buttocks, thighs (20%); for contact burns - the area of ​​the hands (90%). All admissions underwent a range of examinations, including: general clinical blood and urine tests, biochemical blood test, assessment of acid-base status, bacteriological cultures from burn surfaces, clinical assessment of the state of central hemodynamics (blood pressure, diuresis, skin, pulse), electrocardiographic study with calculation systolic indicator. It is known that burn shock can develop in children in the first months of life with damage already covering an area of ​​5-7%, therefore, to assess the severity of shock, the Frank Index (IF) was calculated for all infants: mild shock - FI 30-70, severe shock - FI 71 -130, extremely severe shock IF more than 130. Thus, among children with a lesion area of ​​up to 10%, no IF deviations were identified. For lesions with an area of ​​10% or more of the surface, the IF was distributed as follows:

Table No. 1.

As can be seen from Table No. 1, mild shock was diagnosed in three patients with boiling water burns, and severe shock was diagnosed in one child.

Analysis of laboratory data showed the presence of mild anemia in 40%, leukocytosis in 20% of patients. A case of severe anemia occurred in one patient with a large area affected by boiling water (II, III degree burn, area 28%). Proteinuria was observed in two patients with a large depth and area affected by boiling water (III degree burns, areas 13% and 28%). In a biochemical blood test: hypoproteinemia in 30% of children, increased C-reactive protein in 15% of children, hyperazotemia in 10%, electrolyte disturbances in 20%. Signs of metabolic acidosis in 15% of children. According to the results, tank. crops: 30% - St.aureus seeding, 10% - E.coli, 15% - Ps. aeruginosae.

In 20% of children with burn injury, there was a decrease in blood pressure (standard 85-100 mmHg); deviation of blood pressure was recorded only in one case (standard 40-60 mmHg). Tachycardia over 130 beats per minute was observed in 63%, there was no bradycardia. A decrease in hourly diuresis was noted in 20% of patients with III degree thermal burns from boiling water. The symptom of a “white spot” lasting more than 3 seconds was noted in 20% of patients with boiling water burns; pale skin in 23%. Blood pressure and pulse were monitored every 6 hours.

Changes in ECG indicators in children of the first year of life with burn injury

(note: the symbol ↓ is shortening, the symbol is extension)

Table No. 2.

As can be seen from Table No. 2, in the majority of infants with burn injury, according to electrocardiography, there was a shortening of the QT and RR intervals, and an increase in systolic value. It is known that the systolic indicator is the percentage of ventricular systole to the duration of the entire cardiac cycle. It is calculated using the formula systolic index = QT/R-R x 100 (in percent). The obtained indicators of the examined children were compared with the values ​​of the systolic indicator depending on the duration of the cardiac cycle using a table of standards. The presence of a difference between the systolic indicator in infants with burn injury and the systolic indicator in healthy children indicates an increased functioning of the heart muscle under conditions of traumatic impact on the body.

Treatment results. For first degree burns, the wound was cleaned, then wet-dry dressings with “talk”, “Branolind”, “Atrauman Ag” dressings were applied. For second degree burns - primary surgical treatment of the burn wound under general anesthesia, then wet-dry dressings with antiseptics. For third degree burns - tangential necrectomy followed by autodermoplasty with a split flap after preoperative preparation and local treatment (application of aseptic wet-dry dressings). The volume of infusion therapy was determined using the Evans formula. Composition: predominantly crystalloids; colloids (10% aminoven solution) were prescribed for children with degree II with an area of ​​more than 10% and for degree III. Intravenous analgesia: 50% solution of metamizole sodium, 0.1 ml. x 2 times a day, for 2-3 days for first degree burns, up to 5 days for second and third degree burns. As part of complex therapy, patients received antibacterial therapy based on the sensitivity of the isolated microflora (the starting antibiotic was oxacillin). For burn shock, along with infusion therapy, hormone therapy, antisecretory therapy, and analgesia with narcotic analgesics (Promedol) were administered. Normalization of heart rate, blood pressure and pain relief were noted by the beginning of the second day for first-degree burns, and by the beginning of 3-5 days for second- and third-degree burns.

Conclusions.

1. Children aged 7-10 months of life (beginning of crawling, first steps) are at risk of burn injury.

2. Burns from boiling water are the most common type of thermal injury in children in the first year of life.

3. Burns with boiling water predominate, with an area of ​​up to 5%, depth of II, III degrees; among contact burns, superficial and widespread were also not noted.

4. All infants with a lesion area of ​​10% or more had a high IF, indicating the presence of mild (in three cases) and severe (in one case) burn shock.

5. In case of thermal burns in children, signs of anemia, proteinuria, metabolic acidosis, and changes in biochemical blood tests were revealed.

6. Significant changes in central hemodynamics were noted in the form of a decrease in systolic blood pressure, tachycardia, and a decrease in hourly diuresis.

7. Disturbances in the functioning of the cardiovascular system were revealed according to ECG data: shortening of the QT, RR intervals, increased systolic index.

8. Examination and treatment of infants with thermal burns should be comprehensive and aimed not only at the local status, but also at relieving pain, infectious and inflammatory syndromes, and hemodynamic disorders.

Bibliography

1. www.pediatr-russia.ru (Federal clinical guidelines for emergency medical care for burns in children, 2015).

2. Isakov Yu.F., Razumovsky A.Yu., Dronov A.F. Pediatric surgery. – M.: GEOTAR-Media, 2015. –1040 p.

3. Bairov G.A. Pediatric traumatology. Ed. 2nd, supplemented and revised / G.A. Bairov. – St. Petersburg, 1999. – 384 p.

4. Fistal E.Ya., Kozinets G.P., Samoilenko G.E., Nosenko V.M. Combustiology of childhood: Textbook / E.Ya. Fistal et al. – Donetsk: “Weber”, 2007. – 233 p.

5. Shen N.P. Burns in children / N.P. Shen. – M.: Triada-X, 2011. – 148 p.

6. Makuey-Jones K., Molyneux E., Phillips B. et al. Modern emergency care for critical conditions in children: trans. from English - M.: MEDpress-inform, 2009. - 208 p.

7. Belyaeva L.M. Fundamentals of pediatric cardiology / Belyaeva L.M., D.Sh. Goldovskaya, L.Ya. Davydovsky, R.E. Maso. – Mn.: Navuka and technology, 1991. – 383 p.

8. Prakhov A.V. Clinical electrocardiography in the practice of pediatricians: a guide for doctors / A.V. Prakhov. – N. Novgorod: Nizhny Novgorod State Medical Academy, 2009. - 156 p.

Summary

The article analyzes the characteristics of burns in children, the development of burn disease of varying severity, provides classification, diagnostic measures and standards for providing first and qualified aid with the use of new approaches in clinical practice in the treatment of such patients. The presented material is aimed at increasing the level of knowledge of pediatricians in the field of emergency medicine.

Keywords

burns, children, diagnosis, assistance.

In Ukraine and the CIS countries, burn pathology continues to be one of the most pressing and socially important problems of childhood traumatism due to the fact that the structure of burn traumatism has changed significantly towards more severe injuries and an increase in the proportion of deep lesions. Children make up a large and often difficult contingent of surgical inpatients (14.0 per 10,000 child population). Unfortunately, most injured children in the acute period receive treatment in general surgical hospitals, and not in specialized centers.

The immaturity of tissue structures at an early age in children and the imperfection of protective and adaptive reactions are the reasons for the long-term existence of pathological post-burn disorders, which, in turn, can lead to irreversible changes even with lesions limited in area.
The success of treatment, and sometimes the fate of the victim, largely depends on the timeliness and completeness of medical care in the first hours after the injury.

ABOUT features of tissue and physiological development of a child that influence the provision of emergency care for burn injuries

Epidemiology of childhood burns

Determination of the burned surface area in children

Classification of burn wounds

First degree - epidermal burn. The dominant pathological process is serous edema. Alteration occurs within one anatomical formation (epidermis) and is usually manifested by a combination of clinical signs: skin hyperemia, interstitial edema and the formation of loose, light yellow blisters filled with liquid content. Healing of such wounds occurs independently within 5-12 days and always without scarring.

Second degree - dermal superficial burn. Blisters often form, but they are thick-walled (within the dermis), extensive, tense, or ruptured. When the stratum corneum of the epidermis is detached, a thin necrotic scab of light yellow, light brown or gray color is formed. The scab is formed within the dermis, and the paranecrosis zone is in the subcutaneous fat.

With inadequate treatment, second degree burns can deepen due to unrestored microcirculation in the area of ​​paranecrosis and transform into third degree burns.

Third degree - dermal deep burn, full-thickness skin necrosis. Third degree burns include lesions of the skin, its appendages and subcutaneous fatty tissue as a single anatomical and functional formation up to the superficial fascia. Treatment is surgical.

Fourth degree - subfascial burn. Damage and/or exposure of tissues located deeper than the native fascia or aponeurosis (muscles, tendons, blood vessels, nerves, bones and joints), regardless of their location. The specificity of such burns is associated with rapidly developing secondary changes in tissue due to subfascial edema, progressive thrombosis, or even damage to internal organs. All this requires urgent surgical interventions.

First aid for burns in children

Features of chemical burns

Acids and salts of heavy metals lead to the coagulation of proteins in tissues and their dehydration, i.e. comes coagulative necrosis: A dense, dry crust of dead tissue forms.

Action of alkalis based on the breakdown of proteins and saponification of fats, and therefore forms liquefaction necrosis. The scab is usually loose, surrounded by a crown of hyperemia. Intoxication is more pronounced. Burns caused by nitric acid, phenol, mercury salts, or phosphoric acid may cause toxic damage to the liver and kidneys.

First aid for chemical burns is aimed at quickly stopping the action of the agent. To do this, wash the affected area with running water for 15 minutes or more. The exception is burns caused by organic aluminum compounds and concentrated sulfuric acid, the interaction of which with water is accompanied by a reaction producing heat. If damaged by organic aluminum compounds, treat the surface topically with gasoline or kerosene in the form of bandages or lotions. Further treatment of a chemical burn is not fundamentally different from thermal tissue damage.

Electrical injury. The first step is to determine whether the child is still in contact with an electrical source and take measures to eliminate it. Using dry wood, rubber or plastic usually provides good insulation.

All victims with burns, regardless of their area and depth of damage, must be examined by a surgeon or combustiologist. The following categories of burn patients require hospitalization: children under three years of age who have a burn of more than 10-12%; children with electrical burns; children with burns of the face, neck, arms, perineum; with suspected thermal inhalation injury; children with burdened premorbid background.

Actions of the doctor upon admission of the child to the department

Assessment of the child's respiratory system. Physical examination should include a careful direct examination of the oropharynx in order to detect soot stains, hyperemia, and edema. Increasing upper airway obstruction resulting from rapidly developing edema may require intubation. If you are burned by a flame in an enclosed area or if you inhale smoke for a long time, there is a serious risk of carbon monoxide poisoning. Anxiety and hypoxia in a child are more likely to indicate respiratory distress syndrome caused by damage to the respiratory tract.

The patient's characteristic cherry color will indicate carbon monoxide poisoning. Research is needed into the dynamics of the level of arterial gases and carboxyhemoglobin. High levels of carbon dioxide are one of the first signs of extensive pulmonary damage from the toxic effects of smoke inhalation and require oxygen therapy or a hyperbaric oxygen therapy session.

Bronchoscopy increases the possibility of diagnosing damage to the respiratory tract and carrying out sanitation of the tracheobronchial tree. Repeat examinations may be needed depending on the condition.

A chest x-ray should be obtained on admission, but even in cases of severe airway injury, changes in the initial x-ray are rarely observed.

General assessment of the condition of the burned child. A complete picture of the patient’s condition should be obtained, details of the history of his concomitant pathology (presence of allergies to medications, preventive vaccinations) should be clarified.

At the same time, all vital functions of the body (pressure, pulse, breathing pattern, temperature, as well as the patient’s consciousness) are recorded and subsequently monitored.

Blood should be taken to determine the group and Rh factor, its clinical tests (hemoglobin, hematocrit number, determination of the leukocyte formula), the state of the blood coagulation system (platelets, coagulogram), plasma electrolytes (Na, K, C1), protein level and osmolarity , a general analysis of urine to determine its volume, specific gravity or osmolarity.

Other special blood tests are ordered depending on the patient's condition. Diagnosis of burn shock is carried out taking into account the area of ​​thermal damage and the age of the child. Determining the severity of burn shock is possible using diagnostic criteria (Table 1).
Table 1. Diagnostic criteria for burn shock in children

The assessment of shock severity is reliable if at least 3 signs are taken into account simultaneously.

Standard of treatment measures

1. About pain relief. The method of choice for pain relief in children is atalgesia (analgin 25% solution 0.2 ml/kg with seduxen 0.5% - 0.5 mg/kg; ketamine 0.5-1.0 mg/kg intravenously or intramuscularly 2 mg/kg. For children over one year old - promedol 1% solution 0.1 mg/kg with seduxen).
2. Venous access. To carry out transfusion therapy during transportation, puncture (catheterization) of a peripheral vein is sufficient. If intravenous access is not possible, medications can, as an exception, be injected into the muscles of the floor of the mouth. If the child is intubated, the intratracheal route of administration can be used. The dose of drugs in such cases should be age-specific, and their concentration should be diluted 10 times.
3. Immobilization. Especially during transportation, immobilization of the limb is necessary for infusion therapy, fixation to prevent the removal of catheters and contour dressings.
4.Infusion therapy. It must be remembered that the main purpose of intravenous fluid administration in the first hours of a burn injury is to restore normal cardiac output and diuresis. When drawing up an infusion therapy regimen, you need to take into account the recommended formulas for calculating infusion therapy in children. The most popular formula for calculating the requirements for infusion therapy was proposed by Parkland (first 24 hours: Ringer's lactate solution 4 ml / kg per percentage of the burned surface, children weighing less than 20 kg add a maintenance volume of fluid equal to 50-75% of their daily fluid intake to this volume needs (1500 ml/m2/day)).

Initial therapy includes the administration of crystalloid solutions 20 ml/kg, rheopolyglucin at a dose of 10 ml/kg, then 20% glucose with insulin 5 ml/kg. Sodium should be the major ion in any fluid chosen: hypotonic, isotonic, or hypertonic. To quickly restore intravascular volume, solutions of hydroxyethyl starch (6-10%) can be administered, which, due to their large molecules, do not leave the vascular bed and help restore the integrity of the capillary wall.

Infusion therapy is carried out under the control of the rate of diuresis in the range of 0.5-1 ml/kg/day. Half of the total volume is administered in the first 8 hours after the burn injury, and the other half in the subsequent 16 hours.

The volume of infusion therapy on the second day is reduced by a quarter of what was initially calculated. Colloidal solutions are used to improve diuresis and treat hypoalbuminemia. Intravenous therapy at the end of the 2nd day of the burn period should ensure normal concentrations of sodium, phosphorus, calcium and potassium in the blood serum.

Damage to the respiratory tract is accompanied by a violation of alveolo-capillary integrity, which can lead to fluid overload in the interstitium of the lungs. Therefore, when large volumes are administered to a child, strict monitoring of water balance is required.

High voltage electrical current causes deep muscle damage, releasing myoglobin and hemochromogens, causing the risk of kidney damage.

We prescribe glucocorticosteroids for severe burn shock, respiratory tract burns and unfavorable premorbid background - 3-8 mg/kg prednisolone.

5. Oxygen therapy. It is preferable to inhale humidified oxygen through a respiratory mask.
6. K atherization of the bladder. From the first minutes of a child’s admission to the hospital, the bladder is catheterized to monitor diuresis - one of the most important methods for monitoring infusion therapy in the first days after a burn.
7. Nasogastric tube. Gastric drainage will reduce the risk of vomiting and aspiration. The oral cavity should be treated with antiseptic agents.

Drug therapy and resuscitation aids in the stage of burn shock are aimed at eliminating the following pathogenetic disorders.
— Reducing the manifestations of hypercoagulation syndrome and preventing consumption coagulopathy: heparin (200-300 units/kg/day), antiplatelet agents (pentoxifylline, dipyridamole).
— Normalization of membrane permeability is achieved by the introduction of corticosteroids, proteolysis inhibitors, and antihistamines.
— Maintaining macroerg metabolism and ensuring synthetic adaptation reactions: a complex of vitamins C, B1, B6, ATP, nicotinic acid, riboxin is used.
— To prevent the development of acute ulcers of the gastrointestinal tract, H2-blockers and antacids are prescribed, and for intestinal decontamination — enterosorbents and eubiotics.
— To optimize cardiac activity and normalize mesenteric and renal blood flow, sympathomimetic amines are used - dopamine in mediator doses (1-5 mcg/kg/min).
— To eliminate metabolic acidosis, sodium bicarbonate is prescribed. Correction should be carried out at pH values ​​less than 7.2.
— Until normal renal activity is restored, hydration solutions should not contain potassium preparations, which are prescribed after the first 12-24 hours for hypokalemia.
— The therapy should be adjusted according to clinical and laboratory parameters.

The presence of concomitant pathology or developmental anomalies in a child requires great attention when drawing up an infusion therapy program.

On an outpatient basis, only I-II degree burns with a lesion area of ​​no more than 10% of the body surface are treated. The victims with all other injuries are hospitalized. Second degree burns in the face, scalp, feet, groin and perineum are recommended to be treated in a hospital.

Local treatment should be aimed at quickly cleaning wounds from necrotic tissue, preventing secondary contamination of wounds, stimulating reparative processes, and promptly closing wounds in the early stages.

For first degree burns, the burn wound is cleaned with saline or an antiseptic (iodopyrone, chlorhexidine). A dry aseptic dressing is applied to the wound, aerosols with film-forming polymers (Furoplast, Akutol, Naxol, etc.), and water-soluble ointments (streptonitol, nitacid, oflocain, dermazin, levomekol, levosin) are used. Non-narcotic analgesics are used for pain relief.

For second degree burns, the burn surface is treated. After primary toileting of the wounds, the blisters are incised at their base and an aseptic bandage is applied. If the contents of the blisters are cloudy, then the exfoliated epidermis is excised, the wound surface is treated and a water-soluble ointment bandage is applied.

For III-IV degree burns, treatment is only in a hospital setting. General treatment includes anti-shock, transfusion therapy, combating infectious complications, and nutritional therapy. The nature and scope of treatment depends on the stage of the burn disease.

Our experience proves both the possibility and necessity of transporting children in the first hours (24 hours) after a burn, subject to infusion antishock therapy accompanied by an anesthesiologist and combustiologist. It should be remembered that the most optimal time for transfer to a specialized burn clinic is the first 6-8 hours after injury.

Thus, the success of treatment, and sometimes the fate of the injured child, largely depends on the timeliness and completeness of medical care in the first hours after the injury, and knowledge of the specifics of burns in children by non-surgical specialists will help avoid mistakes in both organizational and treatment issues.

Bibliography

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2. Baindurashvili A.G., Afonichev K.A., Brasol M.A. et al. Rehabilitation of children with consequences of thermal injury / Sat. scientific Proceedings of the First Congress of Combustiologists of Russia. - M., 2005. - P. 221-222.
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12. Combustiology: a handbook for intern doctors and cadets of the higher medical specialties of the IV level of accreditation / E.Ya. Fistal, G.P. Kozinets, G.Ye. Samoilenko and spivat. - Kiev: Interlink, 2004. - 184 p.

– a type of injury that occurs when tissue is damaged by physical and chemical factors (thermal energy, electricity, ionizing radiation, chemicals, etc.). The clinical picture of burns in children depends on the factor involved, the location, depth, and extent of tissue damage and includes local (pain, hyperemia, swelling, blistering) and general manifestations (shock). The main tasks of diagnosing burns in children are to determine the nature of the burn injury, the depth and area of ​​damage, for which infrared thermography and measuring techniques are used. Treatment of burns in children requires anti-shock therapy, cleaning the burn surface, and applying bandages.

General information

Burns in children - thermal, chemical, electrical, radiation damage to the skin, mucous membranes and underlying tissues. Among the total number of people with burn injury, children make up 20–30%; Moreover, almost half of them are children under 3 years old. The mortality rate due to burns among children reaches 2-4%, in addition, about 35% of children remain disabled annually. The high prevalence of burns in the pediatric population, the tendency to develop burn disease and severe post-burn disorders make the prevention and treatment of burn injury in children a priority in pediatric surgery and traumatology.

The peculiarities of children's anatomy and physiology are such that the skin of children is thinner and more delicate than that of adults, has a developed circulatory and lymphatic network and, therefore, has greater thermal conductivity. This feature contributes to the fact that exposure to a chemical or physical agent, which in an adult causes only superficial damage to the skin, leads to a deep burn in a child. The helplessness of children during injury causes longer exposure to the damaging factor, which also contributes to the depth of tissue damage. In addition, imperfection of compensatory and regulatory mechanisms in children can lead to the development of burn disease even with damage to 5-10%, and in infancy or with a deep burn - only 3-5% of the body surface. Thus, any burns in children are more severe than in adults, since in childhood disorders of blood circulation, metabolism, and the functioning of vital organs and systems occur more quickly.

Causes and classification of burns in children

Depending on the damaging agent, burns in children are divided into thermal, chemical, electrical and radiation. The occurrence of thermal burns in children in most cases is caused by skin contact with boiling water, steam, open fire, melted fat, or hot metal objects. Young children are most often scalded by hot liquids (water, milk, tea, soup). Often, burns in children occur as a result of parental negligence, when they immerse the child in a bath that is too hot or leave them to warm up with heating pads for a long time. At school age, various pyrotechnic fun, lighting fires, “experiments” with flammable mixtures, etc. pose a particular danger to children. Such pranks with fire, as a rule, end in failure, since they often lead to extensive thermal burns. Thermal burns in children usually affect the integumentary tissue, but burns of the eyes, respiratory tract and digestive tract can also occur.

Chemical burns are less common and usually occur when household chemicals are not stored correctly and within the reach of children. Young children may accidentally spill acid or alkali on themselves, spill powdery substances, spray dangerous chemicals, or drink caustic liquids by mistake. When aggressive chemicals are ingested, a burn to the esophagus in children is combined with a burn to the oral cavity and respiratory tract.

The causes of electrical burns in young children are malfunction of electrical appliances, their improper storage and operation, the presence in the house of electrical outlets accessible to the child, and exposed exposed wires. Older children usually get electrical burns when playing near high-voltage lines, riding on the roofs of electric trains, or hiding in transformer boxes.

Radiation burns in children are most often associated with skin exposure to direct sunlight for a long period of time. In general, thermal burns in children account for about 65-80% of cases, electrical burns - 11%, and other types - 10-15%.

Within the framework of this topic, the features of thermal burns in children will be considered.

Symptoms of thermal burns in children

Depending on the depth of tissue damage, thermal burns in children can be of four degrees.

First degree burn(epidermal burn) is characterized by superficial damage to the skin due to short-term or low-intensity exposure. Children experience local pain, hyperemia, swelling and a burning sensation. At the site of the burn, slight peeling of the epidermis may be observed; superficial burns in children heal in 3-5 days on their own, completely without a trace or with the formation of slight pigmentation.

Second degree burn(superficial dermal burn) occurs with complete necrosis of the epidermis, under which clear liquid accumulates, forming blisters. Swelling, pain and redness of the skin are more pronounced. After 2–3 days, the contents of the bubbles become thick and jelly-like. Healing and restoration of the skin lasts about 2 weeks. With second degree burns in children, the risk of infection of the burn wound increases.

Third degree burn(deep dermal burn) can be of two types: IIIa degree - with preservation of the basal layer of the skin and IIIb degree - with necrosis of the entire thickness of the skin and partially the subcutaneous layer. Third degree burns in children occur with the formation of dry or wet necrosis. Dry necrosis is a dense scab of brown or black color, insensitive to touch. Wet necrosis has the appearance of a yellowish-gray scab with a sharp swelling of the tissue in the burn area. After 7-14 days, the scab begins to be rejected, and the complete healing process is delayed for 1-2 months. Epithelization of the skin occurs due to the preserved germ layer. IIIb degree burns in children heal with the formation of rough, inelastic scars.

IV degree burn(subfascial burn) is characterized by damage and exposure of tissues lying deeper than the aponeurosis (muscles, tendons, blood vessels, nerves, bones and cartilage). Visually, with fourth degree burns, a dark brown or black scab is visible, through the cracks of which the affected deep tissues are visible. With such lesions, the burn process in children (wound cleansing, formation of granulations) proceeds slowly, local, primarily purulent, complications often develop - abscesses, phlegmons, arthritis. IV degree burns are accompanied by a rapid increase in secondary changes in tissues, progressive thrombosis, damage to internal organs and can result in the death of the child.

Burns of I, II and IIIa degrees in children are regarded as superficial, burns of IIIb and IV degrees - as deep. In pediatrics, as a rule, there is a combination of burns of various degrees.

Burn disease in children

In addition to local phenomena, burns in children often develop severe systemic reactions, which are characterized as burn disease. During a burn disease, there are 4 periods - burn shock, acute burn toxemia, burn septicopyemia and recovery.

Burn shock lasts 1-3 days. In the first hours after receiving a burn, children are excited, react sharply to pain, and scream (erectile phase of shock). Chills, increased blood pressure, increased breathing, and tachycardia are noted. In severe shock, body temperature may drop. 2–6 hours after the burn, children enter the torpid phase of shock: the child is adynamic, inhibited, makes no complaints and practically does not react to the environment. The torpid phase is characterized by arterial hypotension, rapid thready pulse, severe pallor of the skin, severe thirst, oliguria or anuria, and in severe cases, vomiting “coffee grounds” due to gastrointestinal bleeding. First degree burn shock develops in children with superficial damage to 15-20% of the body area; II degree – for burns of 20-60% of the body surface; III degree - more than 60% of the body area. Rapidly progressing burn shock leads to the death of the child on the first day.

With further development, the period of burn shock is replaced by a phase of burn toxemia, the manifestations of which are caused by the entry of decay products from damaged tissues into the general bloodstream. At this time, children who have received burns may experience fever, delirium, convulsions, tachycardia, arrhythmia; in some cases, coma. Against the background of toxemia, toxic myocarditis, hepatitis, acute erosive-ulcerative gastritis, secondary anemia, nephritis, and sometimes acute renal failure can develop. The duration of the period of burn toxemia is up to 10 days, after which, with deep or extensive burns in children, the septicotoxemia phase begins.

Burn septicotoxemia is characterized by the addition of a secondary infection and suppuration of the burn wound. The general condition of children with burns remains serious; complications are possible in the form of otitis media, ulcerative stomatitis, lymphadenitis, pneumonia, bacteremia, burn sepsis and burn exhaustion. During the recovery phase, the processes of restoration of all vital functions and scarring of the burn surface predominate.

Diagnosis of burns in children

Diagnosis of burns in children is made on the basis of anamnesis and visual examination. To determine the area of ​​the burn in young children, Lund-Browder tables are used, taking into account the change in the area of ​​​​various parts of the body with age. For children over 15 years of age, the rule of nine is used, and for limited burns, the rule of the palm is used.

Children with burns need to have their hemoglobin and hematocrit examined, a general urine test, and a biochemical blood test (electrolytes, total protein, albumin, urea, creatinine, etc.). In case of suppuration of a burn wound, the wound discharge is collected and bacteriologically inoculated for microflora.

It is mandatory (especially in case of electrical trauma in children) to be performed and repeated in the dynamics of the ECG. In case of a chemical burn of the esophagus in children, esophagoscopy (EGD) is necessary. If the respiratory tract is affected, bronchoscopy and lung radiography are required.

Treatment of burns in children

First aid for burns in children involves stopping the action of the thermal agent, freeing the affected area of ​​skin from clothing and cooling it (by washing with water, an ice pack). To prevent shock at the prehospital stage, the child can be given analgesics.

In a medical institution, primary treatment of the burn surface, removal of foreign bodies and scraps of epidermis are carried out. Anti-shock measures for burns in children include adequate pain relief and sedation, infusion therapy, antibiotic therapy, and oxygen therapy. Children who have not received appropriate preventive vaccinations are given emergency immunization against tetanus.

Local treatment of burns in children is carried out by closed, open, mixed or surgical methods. With the closed method, the burn wound is covered with an aseptic bandage. For dressings, antiseptics (chlorhexidine, furatsilin), film-forming aerosols, ointments (ofloxacin + lidocaine, chloramphenicol + methyluracil, etc.), enzyme preparations (chymotrypsin, streptokinase) are used. The open method of treating burns in children involves refusing to apply bandages and managing the patient under conditions of strict asepsis. It is possible to switch from a closed method to an open one to speed up the recovery process, or from an open to a closed one if an infection develops.

During the rehabilitation period, children with burns are prescribed exercise therapy, physiotherapy (Ural irradiation, laser therapy, magnetic laser therapy, ultrasound),

Prevention of burns in children, first of all, requires increased responsibility on the part of adults. A child should not be allowed to come into contact with fire, hot liquids, chemicals, electricity, etc. To do this, in a house where there are small children, safety measures must be provided (storing household chemicals in an inaccessible place, special plugs in sockets, hidden electrical wiring, etc.). d.). Constant supervision of children and a strict ban on touching dangerous objects are required.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2016

Thermal burns classified according to body surface area affected (T31), Thermal burn of the head and neck, first degree (T20.1), Thermal burn of the wrist and hand, first degree (T23.1), Thermal burn of the ankle and foot area, first degree (T25.1), Thermal burn of the shoulder girdle and upper limb, excluding the wrist and hand, first degree (T22.1), Thermal burn of the hip joint and lower limb, excluding the ankle and foot, first degree (T24.1) , Thermal burn of the torso, first degree (T21.1), Chemical burns classified according to the area of ​​the affected body surface (T32), Chemical burn of the head and neck, first degree (T20.5), Chemical burn of the wrist and hand, first degree (T23. 5), Chemical burn of the ankle and foot area of ​​the first degree (T25.5), Chemical burn of the shoulder girdle and upper limb, excluding the wrist and hand, first degree (T22.5), Chemical burn of the hip joint and lower limb, excluding ankle and foot, first degree (T24.5), Chemical burn of the torso, first degree (T21.5)

Combustiology for children, Pediatrics

general information

Short description

Approved
Joint Commission on Healthcare Quality
Ministry of Health and Social Development of the Republic of Kazakhstan
dated "09" June 2016
Protocol No. 4

Burns -

damage to body tissues resulting from exposure to high temperature, various chemicals, electric current and ionizing radiation.

Burn disease - This is a pathological condition that develops as a consequence of extensive and deep burns, accompanied by peculiar dysfunctions of the central nervous system, metabolic processes, activity of the cardiovascular, respiratory, genitourinary, hematopoietic systems, damage to the gastrointestinal tract, liver, development of disseminated intravascular coagulation syndrome, endocrine disorders, etc. d.

In development burn disease There are 4 main periods (stages) of its course:
burn shock
burn toxemia,
· septicotoxemia,
· convalescence.

Date of development of the protocol: 2016

Protocol users: combustiologists, traumatologists, surgeons, general surgeons and traumatologists in hospitals and clinics, anesthesiologists-resuscitators, ambulance and emergency doctors.

Level of evidence scale:

Classification

Classification [ 2]

1. By type of traumatic agent
1) thermal (flame, steam, hot and burning liquids, contact with hot objects)
2) electrical (high and low voltage current, lightning discharge)
3) chemicals (industrial chemicals, household chemicals)
4) radiation or radiation (solar, damage from a radioactive source)

2. According to the depth of the lesion:
1) Surface:



2) Deep:

3. According to the environmental impact factor:
1) physical
2) chemical

4. By location:
1) local
2) remote (inhalation)

Diagnostics (outpatient clinic)

OUTPATIENT DIAGNOSTICS

Diagnostic criteria

Complaints: for burning and pain in the area of ​​burn wounds.

Anamnesis:

Physical examination: assess the general condition (consciousness, color of intact skin, state of breathing and cardiac activity, blood pressure, heart rate, respiratory rate, chills, muscle tremors, nausea, vomiting, soot on the face and mucous membrane of the nasal cavity and mouth, “pale spot syndrome”) .

Laboratory research: not necessary

not necessary

Diagnostic algorithm: see below for inpatient care.

Diagnostics (ambulance)

DIAGNOSTICS AT THE EMERGENCY CARE STAGE

Diagnostic measures:
· collection of complaints and medical history;
· physical examination (measurement of blood pressure, temperature, pulse count, respiratory rate count) with assessment of general somatic status;
· inspection of the affected area with assessment of the area and depth of the burn;
· ECG in case of electrical injury, lightning strike.

Diagnostics (hospital)

DIAGNOSTICS AT THE INPATIENT LEVEL

Diagnostic criteria at the hospital level:

Complaints: for burning and pain in the area of ​​burn wounds, chills, fever;

Anamnesis: find out the type and duration of action of the damaging agent, the time and circumstances of the injury, age, concomitant diseases, allergic history.

Physical examination: assess the general condition (consciousness, color of intact skin, state of breathing and cardiac activity, blood pressure, heart rate, respiratory rate, chills, muscle tremors, nausea, vomiting, soot on the face and mucous membrane of the nasal cavity and mouth, “pale spot symptom”) .

Laboratory research:
Bacterial culture from a wound to determine the type of pathogen and sensitivity to antibiotics.

Instrumental studies:
. ECG in case of electrical injury, lightning strike.

Diagnostic algorithm

2) “Palm” method - the area of ​​the burnt person’s palm is approximately 1% of the surface of his body.

3) Assessing the depth of the burn:

A) superficial:
I degree - hyperemia and swelling of the skin;
II degree - necrosis of the epidermis, blisters;
IIIA degree - skin necrosis with preservation of the papillary layer and skin appendages;

B) deep:
IIIB degree - necrosis of all layers of skin;
IY degree - necrosis of the skin and deep tissues;

When formulating a diagnosis, it is necessary to reflect a number of features injuries:
1) type of burn (thermal, chemical, electrical, radiation),
2) localization,
3) degree,
4) total area,
5) area of ​​deep damage.

The area and depth of the lesion are written as a fraction, the numerator of which indicates the total area of ​​the burn and next to it in parentheses the area of ​​the deep lesion (in percent), and the denominator indicates the degree of the burn.

Diagnosis example: Thermal burn (boiling water, steam, flame, contact) 28% PT (SB - IV=12%) / I-II-III AB-IV degrees of the back, buttocks, left lower limb. Severe burn shock.
For greater clarity, a skitsa (diagram) is included in the medical history, on which the area, depth and localization of the burn is graphically recorded using symbols, while superficial burns (I-II stages) are painted over in red, III AB stage. - blue and red, IV century. - in blue.

Prognostic indices of thermal injury severity.

Franc Index. When calculating this index, 1% of the body surface is taken equal to one conventional unit (cu) in the case of surface and three conventional units. in case of deep burn:
— the prognosis is favorable — less than 30 USD;
- the forecast is relatively favorable - 30-60 USD;
- the forecast is doubtful - 61-90 USD;
— the prognosis is unfavorable — more than 90 USD.
Calculation: % burn surface + % burn depth x 3.

Table 1 Diagnostic criteria for burn shock

List of additional diagnostic measures:

Laboratory:
· biochemical blood test (bilirubin, AST, ALT, total protein, albumin, urea, creatinine, residual nitrogen, glucose) - to verify MODS and examination before surgery (UD A);
· blood electrolytes (potassium, sodium, calcium, chlorides) - to assess water-electrolyte balance and examination before surgery (UD A);
· coagulogram (PT, TV, PTI, APTT, fibrinogen, INR, D-dimer, PDF) - for the purpose of diagnosing coagulopathies and DIC syndrome and examination before surgery to reduce the risk of bleeding (UD A);
· blood for sterility, blood for blood culture - to verify the pathogen (UD A);
· indicators of the acid-base state of the blood (pH, BE, HCO3, lactate) - to assess the level of hypoxia (UD A);
· determination of blood gases (PaCO2, PaO2, PvCO2, PvO2, ScvO2, SvO2) - to assess the level of hypoxia (UD A);
· PCR from a wound for MRSA - diagnosis for suspected hospital strain of staphylococcus (UD C);
· determination of daily urea losses in urine - to determine daily nitrogen losses and calculate nitrogen balance, with negative weight dynamics and clinical manifestations of hypercatabolism syndrome (UD B);
· determination of procalcitonin in blood serum - for the diagnosis of sepsis (LE A);
· determination of presepsin in blood serum - for the diagnosis of sepsis (UD A);
· thromboelastography - for a more detailed assessment of hemostatic impairment (UD B);
· Immunogram - to assess the immune status (UD B);
· Determination of osmolarity of blood and urine - to control the osmolarity of blood and urine (UD A);

Instrumental:
· ECG - to assess the state of the cardiovascular system and examination before surgery (UD A);
· chest radiography - for the diagnosis of toxic pneumonia and thermal inhalation injuries (UD A);
· Ultrasound of the abdominal cavity and kidneys, pleural cavity, NSG (children under 1 year) - to assess toxic damage to internal organs and identify underlying diseases (UD A);
· examination of the fundus - to assess the state of vascular disorders and cerebral edema, as well as the presence of eye burns (LE C);
· measurement of central venous pressure, in the presence of a central vein and unstable hemodynamics to assess the volume of blood volume (LE C);
· EchoCG to assess the state of the cardiovascular system (LE A));
· monitors with the possibility of invasive and non-invasive monitoring of the main indicators of central hemodynamics and myocardial contractility (Doppler, PiCCO) - for acute heart failure and shock of 2-3 degrees in an unstable condition (UD B));
· indirect calorimetry, indicated for patients in the intensive care unit on mechanical ventilation - to monitor true energy consumption, with hypercatabolism syndrome (UD B);
· FGDS - for the diagnosis of burn stress Curling ulcers, as well as for placement of a transpyloric probe for gastrointestinal paresis (UD A);
· Bronchoscopy - for thermal inhalation lesions, for lavage TBD (UD A);

Differential diagnosis

Differential diagnosis and rationale for additional studies: is not carried out, a careful history taking is recommended.

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Treatment

Drugs (active ingredients) used in treatment

Groups of drugs according to ATC used in treatment

Treatment (outpatient clinic)

OUTPATIENT TREATMENT

Treatment tactics

Non-drug treatment:
· general mode.
· table No. 11 - balanced vitamin and protein diet.
· increasing water load, taking into account possible restrictions due to concomitant diseases.
· treatment under the supervision of medical staff of outpatient institutions (traumatologist, polyclinic surgeon).

Drug treatment:
· Pain relief: NSAIDs (paracetamol, ibuprofen, ketorolac, diclofenac) in age-specific dosages, see below.
· Tetanus prophylaxis for unvaccinated patients. Treatment under the supervision of medical staff of outpatient institutions (traumatologist, polyclinic surgeon).
Antibiotic therapy on an outpatient basis, indications for burn area less than 10% only in the following cases:
— prehospital time more than 7 hours (7 hours without treatment);
— the presence of a burdened premorbid background.
Empirically, ampicillin + sulbactam, amoxicillin + clavulonate, or amoxicillin + sulbactam are prescribed in the presence of an allergy to lincomycin in combination with gentamicin, or macrolides.
· Local treatment: First aid: applying bandages with 0.25-0.5% solutions of novocaine or using cooling bandages or aerosols (panthenol, etc.) for 1 day. On the 2nd and subsequent days, apply bandages with antibacterial ointments, silver-containing ointments (see below at the stage of inpatient care). Dressings are recommended to be done after 1-2 days.

List of essential medicines:
Products for topical use (EL D).
· Ointments containing chloramphenicol (levomekol, levosin)
· Ointments containing ofloxacin (oflomelid)
· Ointments containing dioxidin (5% dioxidin ointment, dioxicol, methyldioxylin, 10% mafenide acetate ointment)
· Ointments containing iodophors (1% iodopyrone ointment, betadine ointment, iodometricylene)
· Ointments containing nitrofurans (furagel, 0.5% quinifuril ointment)
· Fat-based ointments (0.2% furacillin ointment, streptocide liniment, gentamicin ointment, polymyxin ointment, teracycline, erythromycin ointment)
Wound coverings (LE C):
· antibacterial sponge dressings that absorb exudate;


cooling bandages with hydrogel
Aerosol preparations: panthenol (UD B).

List of additional medicines: No.

Other treatments: First aid is cooling the burned surface. Cooling reduces swelling and relieves pain, and has a great influence on the further healing of burn wounds, preventing deepening of the damage. At the prehospital stage, first aid bandages can be used to cover the burn surface for the period of transportation of victims to a medical facility and until the moment of first medical or specialized care. The primary dressing should not contain fats and oils due to subsequent difficulties in cleaning wounds, as well as dyes, because they can make it difficult to recognize the depth of the lesion.

Indications for specialist consultation: not necessary.
Preventive measures: no.

Monitoring the patient's condition: dynamic monitoring of the child, dressings after 1-2 days.

Indicators of treatment effectiveness:
· no pain in burn wounds;
no signs of infection:
· epithelization of burn wounds 5-7 days after receiving burns.

Treatment (ambulance)

TREATMENT AT THE EMERGENCY STAGE

Drug treatment

Pain relief: non-narcotic analgesics (ketorolac, tramadol, diclofenac, paracetamol) and narcotic analgesics (morphine, trimeperidine, fentanyl) in age-specific dosages (see below). NSAIDs in the absence of signs of burn shock. Of the narcotic analgesics, the safest is the intramuscular use of trimeperidine (UDA).
Infusion therapy: at the rate of 20 ml/kg/h, starting solution Sodium chloride 0.9% or Ringer's solution.

Treatment (inpatient)

INPATIENT TREATMENT

Treatment tactics

The choice of treatment tactics for burns in children depends on the age, area and depth of burns, premorbid background and concomitant diseases, the stage of development of the burn disease and the possible development of its complications. Drug treatment is indicated for all burns. Surgical treatment is indicated for deep burns. At the same time, the tactics and principles of treatment are selected with the aim of preparing burn wounds for surgery and creating conditions for the engraftment of transplanted skin grafts and the prevention of post-burn scars

Non-drug treatment

· Mode: general, bed, semi-bed.

· Nutrition:
A) Burn department patients on enteral nutrition older than 1 year - diet No. 11, according to the order of the Ministry of Health of the Republic of Kazakhstan No. 343 dated April 8, 2002.
Up to 1 year breastfeeding or bottle feeding
(adapted milk formulas enriched with protein) + complementary foods (for children over 6 months).
b) In most burn patients, the response to injury develops hypermetabolism-hypercatabolism syndrome, which is characterized by (UD A):
· disregulatory changes in the “anabolism-catabolism” system;
· a sharp increase in the need for donors of energy and plastic material;
· an increase in energy demand with the parallel development of pathological tolerance of body tissues to “ordinary” nutrients.

The result of the formation of the syndrome is the development of resistance to standard nutritional therapy, and the formation of severe protein-energy deficiency due to the constant predominance of the catabolic type of reactions.

To diagnose hypermetabolism-hypercatabolism syndrome, it is necessary:
1) determination of the degree of nutritional deficiency
2) determination of metabolic needs (calculation method or indirect calorimetry)
3) conducting metabolic monitoring (at least once a week)

Table 2 - Determination of the degree of nutritional deficiency(UD A):

· For this group of patients, it is recommended to prescribe additional pharmaconutrients - siping mixtures (LE C).
· In patients in shock, early enteral nutrition is recommended, i.e. in the first 6-12 hours after the burn. This leads to a decrease in the hypermetabolic response, prevents the formation of stress ulcers, and increases the production of immunoglobulins (UD B).
· Consumption of large doses of vitamin C leads to stabilization of the endothelium, thereby reducing capillary leakage (UD B). Recommended doses: ascorbic acid 5% 10-15 mg/kg.

c) Enteral tube feeding is administered by drop method, over 16-18 hours a day, less often - by fractional method. Most children in critical conditions develop delayed gastric emptying and volume intolerance, so the drip method of administering enteral nutrition is preferable. Regular opening of the tube is also not required unless there are urgent reasons (bloating, vomiting or retching). The media used for nutrition must be adapted (UD B).

d) Method of treatment of intestinal failure syndrome (IFS) (UD B).
In the presence of stagnant intestinal contents in the stomach, lavage is performed to clean washing water. Then stimulation of peristalsis begins (motilium in an age-related dose, or erythromycin powder in a dose of 30 mg per year of life, but not more than 300 mg once, 20 minutes before attempting enteral nutrition). The first introduction of liquid is carried out by drip, slowly in a volume of 5 ml/kg/hour, with a gradual increase every 4-6 hours, with good tolerance, to the physiological volume of nutrition.
If a negative result is obtained (no passage of the mixture through the gastrointestinal tract and the presence of discharge through the probe more than ½ volume administered), installation of a transpyloric or nasojejunal tube is recommended.

e) Contraindications for enteral/tube feeding:
· mechanical intestinal obstruction;
· ongoing gastrointestinal bleeding;
Acute destructive pancreatitis (severe) - only fluid administration

f) Indications for parenteral nutrition.
· all situations where enteral nutrition is contraindicated.
development of burn disease and hypermetabolism in patients with burns
any area and depth in combination with enteral tube feeding.

g) Contraindications to parenteral nutrition:
development of refractory shock;
overhydration;
· anaphylaxis to components of culture media.
· unresolved hypoxemia due to ARDS.

Respiratory therapy:

Indications for transfer to mechanical ventilation (UD A):

General principles of mechanical ventilation:
· intubation is carried out using non-depolarizing muscle relaxants (in the presence of hyperkalemia) (LE A);
· Mechanical ventilation is indicated for patients with acute respiratory distress syndrome (ARDS). The severity of ARDS and the dynamics of the lung condition are determined by the oxygenation index (IO) - PaO2/FiO2: light - IO< 300, средне тяжелый - ИО < 200 и тяжелый - ИО < 100(УД А);
· Some patients with ARDS may benefit from non-invasive ventilation for moderate respiratory failure. Such patients should be hemodynamically stable, conscious, in comfortable conditions, with regular sanitation of the respiratory tract (UD B);
· in patients with ARDS, tidal volume is 6 ml/kg (correct body weight) (LE B).
· it is possible to increase the partial pressure of CO2 (permissive hypercapnia) to reduce the plateau pressure or the volume of the oxygen mixture (UD C);
· the value of positive expiratory pressure (PEEP) should be adjusted depending on the AI ​​- the lower the AI, the higher the PEEP (from 7 to 15 cm water column), necessarily taking into account hemodynamics (UD A);
· use the alveolar opening maneuver (recruitment) or HF in patients with difficult-to-treat acute hypoxemia (LE C);
· Patients with severe ARDS can lie on their stomach (prone position) unless this poses a risk (LE: C);
· patients undergoing mechanical ventilation should be in a reclining position (if this is not contraindicated) (LE B), the head end of the bed should be raised by 30-45° (LE C);
· when the severity of ARDS decreases, one should strive to transfer the patient from mechanical ventilation to support spontaneous breathing;
· long-term drug sedation is not recommended in patients with sepsis and ARDS (LE B);
· the use of muscle relaxation in patients with sepsis (LE C) is not recommended, only for a short time (less than 48 hours) in early ARDS and with AI less than 150 (LE C).

Drug treatment

Infusion-transfusion therapy (UD B):

A) Calculation of volumes using the Evans formula:
1 day Vtotal = 2x body weight (kg) x% burn + FP, where: FP - physiological need of the patient;
The first 8 hours - ½ of the calculated volume of liquid, then the second and third 8-hour period - ¼ of the calculated volume each.
2nd and subsequent daysVtotal = 1x body weight (kg) x% burn + PT
If the burn area is more than 50%, the infusion volume should be calculated at a maximum of 50%.
In this case, the infusion volume should not exceed 1/10 of the child’s weight; the remaining volume is recommended to be administered per os.

B) Correction of infusion volume for thermal inhalation injury and ARDS: In the presence of thermal inhalation injury or ARDS, the volume of infusion is reduced by 30-50% of the calculated value (LE C).

C) Composition of infusion therapy: Starting solutions should include crystalloid solutions (Ringer's solution, 0.9% NaCl, 5% glucose solution, etc.).
Plasma substitutes with hemodynamic action: starch, HES or dextran are allowed from the first day at the rate of 10-15 ml/kg (UD B), but preference is given to low molecular weight solutions (dextran 6%) (UD B).

The inclusion of K+ drugs in therapy is advisable by the end of the second day from the moment of injury, when the level of K+ in plasma and interstitium is normalized (LE A).

Isogenic protein preparations (plasma, albumin) are used no earlier than 2 days after injury, however, their early administration is justified for use in initial therapy only in the case of arterial hypotension and early development of disseminated intravascular coagulation syndrome (UDA).
They retain water in the bloodstream (1 g of albumin binds 18-20 ml of liquid) and prevent dyshydria. Protein preparations are transfused in case of hypoproteinemia (LE A).

The larger the area and depth of the burns, the earlier the introduction of colloidal solutions begins. Albumin has been shown to be as safe and effective as crystalloids (LE: C).

In case of burn shock with severe microcirculation disorders and hypoproteinemia below 60 g/l, hypoalbuminemia below 35 g/l. Calculation of the required dose of albumin can be made based on the fact that 100 ml of 10% and 20% albumin increase the level of total protein by 4-5 g/l and 8-10 g/l, respectively.

E) Blood components (LE A):
· Criteria and indications for prescription and transfusion
erythrocyte-containing blood components during the neonatal period are: the need to maintain hematocrit above 40%, hemoglobin above 130 g/l in children with severe cardiopulmonary pathology; with moderately severe cardiopulmonary failure, the hematocrit level should be above 30% and hemoglobin above 100 g/l; in a stable condition, as well as during minor planned operations, the hematocrit should be above 25% and hemoglobin above 80 g/l.

The calculation of transfused erythrocyte-containing components must be made based on the level of hemoglobin reading: (Hb norm - Hb of the patient x weight (in kg) / 200 or according to hematocrit: Ht - Ht of the patient x BCC /70.

The rate of EO transfusion is 2-5 ml/kg body weight per hour under mandatory monitoring of hemodynamics and respiration.
· Erythropoietin should not be used to treat anemia caused by sepsis (septicotoximia) (LE: 1B);
· Laboratory signs of deficiency of coagulation hemostasis factors can be determined by any of the following indicators:
prothrombin index (PTI) less than 80%;
prothrombin time (PT) more than 15 seconds;
international normalized ratio (INR) more than 1.5;
fibrinogen less than 1.5 g/l;
active partial thrombin time (APTT) more than 45 seconds (without previous heparin therapy).

Dosing of FFP should be based on the patient's body weight: 12-20 ml/kg, regardless of age.
Platelet concentrate transfusion should be given (LE 2D) when:
- platelet count is<10х109/л;
- the platelet count is less than 30x109/l and there are signs of hemorrhagic syndrome. For surgical/other invasive interventions when a high platelet count is required - at least 50x109/l;
· Cryoprecipitate, as an alternative to FFP, is indicated only in cases where it is necessary to limit the volume of parenteral fluid administration.

The need for cryoprecipitate transfusion is calculated as follows:
1) body weight (kg) x 70 ml/kg = blood volume (ml);
2) blood volume (ml) x (1.0 - hematocrit) = plasma volume (ml);
3) plasma volume (ml) H (required level of factor VIII - available level of factor VIII) = required amount of factor VIII for transfusion (IU).

Factor VIII (IU) required: 100 units = number of cryoprecipitate doses required for a single transfusion.

If it is not possible to determine factor VIII, the calculation of the requirement is based on the following: one single dose of cryoprecipitate per 5-10 kg of recipient body weight.
· all transfusions are carried out in accordance with Order of the Ministry of Health of the Republic of Kazakhstan No. 666 dated November 6, 2009 No. 666 “On approval of the nomenclature, rules for procurement, processing, storage, sale of blood and its components, as well as rules for storage, transfusion of blood, its components and preparations” , as amended by Order of the Ministry of Health of the Republic of Kazakhstan No. 501 dated July 26, 2012;

Pain relief (LE A): Of the entire arsenal, the most effective is the use of narcotic analgesics, which with prolonged use cause addiction. This is another side of the consequences of extensive burns. In practice, we use a combination of narcotic and non-narcotic analgesics, benzodiazepines and hypnotics to relieve pain and prolong the effect of narcotic analgesics. The preferred form of administration is parenteral.

Table 3 - List of narcotic and non-narcotic analgesics

Antibacterial therapy (LE A) :

Hospital stage:
Selection of antibacterial therapy based on local microbiological data and antibiotic sensitivity of each patient.

Table 4 - The main antibacterial drugs registered in the Republic of Kazakhstan and included in the KNF:

With an affected area of ​​up to 40% of the body surface, in children with an uncomplicated premorbid background, the empirical drugs of choice are protected penicillins; in the presence of allergies, lincomycin in combination with gentamicin (LE C).

When the affected area is more than 40% of the body surface, in children with a complicated premorbid background, the empirical drugs of choice are inhibitor-protected cephalosporins, 3rd generation cephalosporins (LE C).

Drugs that create high resistance of microorganisms are regularly excluded from widespread use. These include a number of I-II generation cephalosporins (UD B).

Surgical antibiotic prophylaxis is indicated 30 minutes before surgery in the form of a single administration of cefazalin at a rate of 30-50 mg/kg.

A repeat dose is required when:
· long and traumatic surgical intervention for more than 4 hours;
· extended respiratory support in the postoperative period (more than 3 hours).

Correction of hemostasis :

Table 5 - Differential diagnosis

Heparin is prescribed in the hypercoagulation stage for the treatment of disseminated intravascular coagulation syndrome at a dosage of 100 units/kg/day in 2-4 doses, under the control of aPTT, when administered intravenously, it is selected so that the activated partial thromboplastin time (aPTT) is 1.5- 2.5 times more than the control.
A common side effect of this drug is thrombocytopenia, pay attention, especially in the phase of septicotoximia.

Correction of plasma factor deficiency (UD A):
· donation of fresh frozen plasma - indications and dose are described above (LE A).
· subsidy of cryoprecipitate - indications and doses are described above (LE A).
· blood clotting factor complex: II, IX, VII, X, Protein C, Protein S-
in case of shortage and limited volumes (LE A).

Antifibrinolytic therapy:

Table 5 - Antifibrinolytic drugs.

the drug is excluded from the RLF.

Hemostatics:
Etamsylate is indicated for capillary bleeding and thrombocytopenia
(UD B).
· Phytomenadione is prescribed for hemorrhagic syndrome with hypoprothrombnemia (UD A).

Disaggregants:
Pentoxifylline inhibits the aggregation of erythrocytes and platelets, improving the pathologically altered deformability of erythrocytes, reduces the level of fibrinogen and the adhesion of leukocytes to the endothelium, reduces the activation of leukocytes and the damage they cause to the endothelium, and reduces increased blood viscosity.
However, in the official instructions, the drug is not recommended for use in children and adolescents under 18 years of age, since there are no studies on use in children. The BNF of children also does not include the drug, but the Cochrane Library contains randomized and quasi-randomized studies evaluating the effectiveness of pentoxifylline as an addition to antibiotics for the treatment of children with suspected or confirmed neonatal sepsis. Pentoxifylline added to antibiotics has reduced mortality from neonatal sepsis, but more research is needed (LE C).
The All-Russian Association of Combustiologists “World Without Burns” recommends the inclusion of pentoxifylline in the algorithm for the treatment of thermal injury (UD D).

Xanthine derivatives
Aminophylline has a peripheral venodilating effect, reduces pulmonary vascular resistance, and reduces pressure in the pulmonary circulation. Increases renal blood flow and has a moderate diuretic effect. Expands extrahepatic bile ducts. Inhibits platelet aggregation (suppresses platelet activating factor and PgE2 alpha), increases the resistance of red blood cells to deformation (improves the rheological properties of blood), reduces thrombus formation and normalizes microcirculation. Based on this, the All-Russian Association of Combustiologists “World without Burns” recommends this drug in the treatment algorithm for burn shock (UD D).

Prevention of stress ulcers :
· stress ulcers should be prevented using H2-histamine receptor blockers (famotidine is contraindicated in childhood) or proton pump inhibitors (UD B);
· when preventing stress ulcers, it is better to use proton pump inhibitors (LE C);
· Prevention is carried out until the general condition is stabilized (UD A).

Table 7 - List of drugs used to prevent stress ulcers

Antacids are not used in the prevention of stress ulcers, but are used in the complex treatment of stress ulcers (UD C).

Inotropic therapy: Table 8 - Inotropic support of the myocardium (UD A):

The drugs are not registered in the Republic of Kazakhstan, but upon application they are imported as a single import.

Corticosteroids: prednisolone is prescribed intravenously for burn shock of 2-3 degrees of severity, a course of 2-3 days (LE B)

Table 9 - Corticosteroids

· interpret the level of glucose in capillary blood with caution; more accurately determine glucose in arterial or venous blood (UD B).
· It is recommended to begin dosed insulin administration when 2 consecutive blood glucose values ​​are >8 mmol/l. The goal of insulin therapy is to maintain blood glucose levels no higher than 8 mmol/l (LE B);
· Carbohydrate load during parenteral nutrition should not exceed 5 mg/kg/min (LE B).

Diuretics (LE A) :
Contraindicated on the first day, due to the high risk of hypovolemia.
Prescribed in the following days for oliguria and anuria, in age-specific dosages.

Immunoglobulins :
Extremely severe burn injury over 30% of the body surface in children
early age, accompanied by pronounced changes in the immunological status. The administration of immunoglobulins leads to an improvement in laboratory parameters (decrease in procalcitonin) (LE: 2C). Registered drugs included in the RLF or CNF are used.

Antianemic drugs (UD A): if indicated, refer to the clinical protocol for iron deficiency anemia in children. Ministry of Health of the Republic of Kazakhstan No. 23 dated December 12, 2013.
In case of thermal inhalation damage or secondary pneumonia, it is indicated inhalation with mucolytics, bronchodilators and inhaled glucocorticosteroids.

List of essential medicines: narcotic analgesics, NSAIDs, antibiotics, proton pump inhibitors or H2 histamine blocker, peripheral vasodilators, xanthine derivatives, anticoagulant, corticosteroids, dextran, glucose 5%, 10%, saline 0.9% or Ringer's solution, Ca 2+ and K preparations + , preparations for local treatment.
List of additional medications, depending on the severity and complications: red blood cell-containing blood products, FFP, albumin, hemostatic agents, diuretics, immunoglobulins, inotropic drugs, parenteral nutrition (glucose 15%, 20%, amino acid solutions, fat emulsions), iron supplements, HES, antihistamines, antacids, hepatoprotectors, antifungals.

Surgery [ 1,2, 3]:

I. Free skin grafting
a) split skin flap - the presence of extensive granulating wounds;
b) full-thickness skin flap - the presence of granulating wounds on the face and functionally active areas;

Wound readiness criteria for skin graft transplantation:
- no signs of inflammation,
-lack of pronounced exudation,
-high adhesiveness of wounds,
-presence of marginal epithelialization.

II. Necrectomy - excision of a burn wound located under a scab.
1) Primary surgical necrectomy (up to 5 days)
2) Delayed surgical necrectomy (after 5 days)
3) Secondary surgical necrectomy (repeated necrectomy if there is doubt about the radicality of primary or delayed necrectomy)
4) Staged surgical necrectomy - operations performed in parts (for extensive skin lesions)
5) Chemical necrectomy - using keratolytic ointments (salicylic ointment 20-40%)

Indications to early surgical necrectomy (Burmistrova 1984):
· when a deep burn is localized mainly on the extremities,
· if there are sufficient donor resources,
· in the absence of signs of burn shock,
in the absence of signs of early sepsis,
provided that no more than 5 days have passed since the injury,
· in the absence of acute inflammation in wounds and surrounding tissues.

Contraindications to surgical necrectomy:
· extremely severe general condition in the early stages after injury, due to the extent of the general damage
· severe thermal inhalation lesions of the upper respiratory tract, with, as a consequence, dangerous pulmonary complications,
· severe manifestations of toxemia, generalization of infection and septic course of the disease,
· unfavorable course of the wound process with the development of wet necrosis in burn wounds.

III. Necrotomy - dissection of the burn scab is performed for circular burns of the torso and limbs, for the purpose of decompression, and is performed in the first hours after the injury.

IV. Alloplasty and xenoplasty - allogeneic and xenogeneic skin is used as a temporary wound covering for extensive burns due to the shortage of donor resources. After some time, there is a need to remove them and finally restore the skin with autologous skin.

Local treatment: Local treatment of burn wounds should be determined by the general condition of the child at the time of treatment, the area and depth of the burn lesion, the location of the burn, the stage of the wound process, the planned surgical treatment tactics, as well as the availability of appropriate equipment, drugs and dressings.

Table 10 - Algorithm for local treatment of burn wounds

Table 11 - Main classes of antimicrobial substances used in the local treatment of burn wounds (EL D).

Wound coverings that reduce healing time (LE C):
· Antibacterial sponge dressings that absorb exudate;
· soft silicone coatings with adhesive properties;
· contact pad for the wound with a polyamide mesh with an open cellular structure.
Preparations used to cleanse wounds of dead tissue (EL D):
· keratolytics (salicylic ointment 20-40%, 10% benzoic acid),
· enzymes (trypsin, chymotrypsin, cathepsin, collagenase, gelatinase, streptokinase, travase, asperase, esterase, pankepsin, elestolitin).

Other treatments

Detoxification methods: ultrafiltration, hemodiafiltration, hemodialysis, peritoneal dialysis.
Indications:
· to maintain the life of a patient with irreversible loss of kidney function.
· for the purpose of detoxification in sepsis with multiple organ failure, therapeutic plasma exchange can be carried out with the removal and replacement of up to 1-1.5 of the total plasma volume (UD V);
Diuretics should be used to correct fluid overload (> 10% of total body weight) after recovery from shock. If diuretics fail, renal replacement therapy may be used to prevent fluid overload (LE B);
· with the development of renal failure with oligoanuria, or with high rates of azotemia, electrolyte disturbances, renal replacement therapy is carried out;
There is no benefit to the use of intermittent hemodialysis or continuous venovenous hemofiltration (CVVH) (LE B);
· CVVH is more convenient to perform in patients with hemodynamic instability (LE B). Failure of vasopressors and fluid resuscitation are nonrenal indications for initiating CVVH;
· CVVH or intermittent dialysis may be used in patients with underlying acute brain injury or other causes of increased intracranial pressure or generalized cerebral edema (LE: 2B).
· see the rules for using renal replacement therapy in “Acute renal failure” and chronic kidney disease in children.

Fluidizing bed- use is indicated in the treatment of seriously ill patients, it creates unfavorable conditions for the development of microflora and facilitates the management of burn wounds, especially those located on the back surface of the torso and limbs (UD A).

Ultrasonic cavitation (sanitation)(UD C) - the use of low-frequency ultrasound in the complex treatment of burns helps accelerate the cleansing of wounds from necrotic tissue, accelerates the synthesis of collagen, and the formation of granulation tissue in the proliferative stage of inflammation; cleans and prepares burn wounds for autodermoplasty and stimulates their independent healing.
Indication To perform ultrasound sanitation is the presence of a deep burn in a child of any location and area at the stage of rejection of necrotic tissue. Contraindication is the unstable general condition of the patient, associated with the manifestation of a purulent process in the wound and generalization of infection.

Hyperbaric oxygenation(UD C) - the use of HBO helps eliminate general and local hypoxia, reduce bacterial contamination, increase the sensitivity of microflora to antibiotics, normalize microcirculation, increase the immunobiological defense of the body and activate metabolic processes.

Vacuum therapy (VA)C) - indicated for children with deep burns after surgical or chemical necrectomy; accelerates self-cleaning of the wound from the remains of non-viable soft tissue, stimulates the maturation of granulation tissue in preparation for autodermoplasty, accelerates the engraftment of autografts.
Contraindications:
· severe general condition of the patient;
· malignant tissue in the area of ​​thermal burn or confirmed oncological pathology of other organs;
· victims with acute or chronic skin pathology, which may have a negative impact on wound healing;
· sepsis of any etiology, occurring against the background of symptoms of multiple organ failure (severe sepsis), septic shock;
· concentration of procalcitonin in the blood ≥2 ng/ml;
· thermal inhalation injury, aggravating the severity of the disease and worsening the course of the wound process;
· persistent bacteremia.

Positioning (position treatment) . It is used from the first 24 hours of treatment of burns to prevent joint contractures: adductor contracture of the shoulder, flexion contracture of the elbow, knee and hip joints, extension contracture of the interphalangeal joints of the fingers.

Position in bed to prevent contracture:

Splinting for equinus prevention according to indications. It is used for a long time, from 2-3 weeks before surgery, 6 weeks after surgery, up to 1-2 years according to indications. Removal and re-installation of splints should be carried out 3 times a day in order to prevent pressure on neurovascular bundles and bone protrusions.

Breathing exercises.

Physical exercise. Passive joint development should be carried out twice a day under anesthesia. Active and passive exercises are not performed after autotransplantation for 3-5 days,
Xenografts, synthetic dressings, and surgical debridements are not contraindications for exercise.

Physical methods of treatment depending on indications:
· UV therapy or bioptron therapy of burn wounds and donor sites with signs of inflammation of the wound surface. Indications for prescribing ultraviolet irradiation therapy are signs of suppuration of a burn wound or donor site, the maximum number of procedures is No. 5. Bioptron therapy course - No. 30.
· Inhalation therapy with signs of respiratory dysfunction No. 5.
· Magnetotherapy for the purpose of dehydration of scar tissue, effective transport of oxygen to tissues and its active utilization, improvement of capillary circulation due to the release of heparin into the vascular bed. The course of treatment is 15 daily procedures.

Electrophoresis with the enzyme preparation lidase, for the purpose of depolymerization and hydrolysis of hyaluronic, chondroitinsulfuric acids, scar resorption. The course of treatment is 15 daily procedures.
· Ultraphonophoresis with ointments: hydrocortisone, contractubex, fermenkol post-burn scars for the purpose of depolymerization and softening of post-burn scars, 10-15 procedures.
· Cryotherapy for keloid scars in the form of cryomassage 10 procedures.

Compression therapy- use of special clothing made of elastic fabric. Pressure is a physical factor that can positively change the structure of skin scars independently or after scarification or removal. Compression therapy is used continuously for 6 months, up to 1 year or more, and staying without a bandage should not exceed 30 minutes per day. During the early post-burn period, elastic compression may be applied to wounds during the healing period after most wounds have healed but some areas remain open. The use of pressure bandages has both preventive and therapeutic purposes. For preventive purposes, compression is used after repair of wounds with split skin, as well as after reconstructive operations. In these cases, dosed pressure is indicated 2 weeks after surgery, then the compression gradually increases. For therapeutic purposes, compression is used when excessive scar growth occurs.

Indications for consultation with specialists:
Consultation with an ophthalmologist to examine the vessels of the fundus to exclude corneal burns and assess swelling in the fundus.
Consultation with a hematologist - to exclude blood diseases;
Consultation with an otolaryngologist to exclude burns of the upper respiratory tract and their treatment. Consultation with a traumatologist - if there is an injury;
Consultation with a dentist - when identifying burns of the oral cavity and foci of infection with subsequent treatment;
Consultation with a cardiologist - in the presence of ECG and EchoCG abnormalities, heart pathology;
Consultation with a neurologist - in the presence of neurological symptoms;
Consultation with an infectious disease specialist - in the presence of viral hepatitis, zoonotic and other infections;
Consultation with a gastroenterologist - in the presence of pathology of the gastrointestinal tract;
Consultation with a clinical pharmacologist to adjust the dosage and combination of medications.
Consultation with a nephrologist to exclude kidney pathology;
Consultation with an efferentologist to conduct efferent therapy methods.

Indications for hospitalization in the ICU: burn shock grade 1-2-3, presence of signs of SIRS, respiratory failure grade 2-3, cardiovascular failure grade 2-3, acute renal failure, acute liver failure, bleeding (from wounds, gastrointestinal tract, etc.), edema brain, GCS below 9 points.

Indicators of treatment effectiveness.
1) ABT effectiveness criteria: regression of MODS, absence of suppuration in the wound (sterile cultures on days 3, 7), absence of generalization of infection and secondary foci.
2) ITT effectiveness criteria: presence of stable hemodynamics, adequate diuresis, absence of hemoconcentration, normal CVP numbers, etc.
3) Criteria for the effectiveness of vasopressors: determined by an increase in blood pressure, a decrease in heart rate, and normalization of peripheral vascular resistance.
4) Criteria for the effectiveness of local treatment: epithelization of burn wounds without the formation of rough scars and the development of post-burn deformities and joint contractures.

Hospitalization

Indications for planned hospitalization: none.

Indications for emergency hospitalization:
· children, regardless of age, with first-degree burns of more than 10% of the body surface;
· children, regardless of age, with II-III A degree burns of more than 5% of the body surface;
· children under 3 years of age with II-III A degree burns of 3% or more of the body surface;
· children with IIIB-IV degree burns, regardless of the area of ​​damage;
· children under 1 year of age with II-IIIA degree burns of 1% or more of the body surface;
· children with II-IIIAB-IV degree burns of the face, neck, head, genitals, hands, feet, regardless of the area of ​​damage.

Information

Sources and literature

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   1. 1. Paramonov B.A., Porembsky Ya.O., Yablonsky V.G. Burns: A Guide for Doctors. St. Petersburg, 2000. – P.480. 2. Vikhriev B.S., Burmistrov V.M. Burns: A Guide for Doctors. - L.: Medicine, 1986. – P.252 3. Rudovsky V. et al. Theory and practice of burn treatment. M., “Medicine” 1980. P.374. 4. Yudenich V.V. Treatment of burns and their consequences. Atlas. M., “Medicine”, 1980. P.191. Nazarov I.P. et al. Burns. Intensive therapy. Tutorial. Krasnoyarsk “Phoenix” 2007 5. Shen N.P. – Burns in children, M., 2011 6. Order of the Ministry of Health of the Republic of Kazakhstan No. 666 dated November 6, 2009 No. 666 “On approval of the Nomenclature, Rules for the procurement, processing, storage, sale of blood and its components, as well as Rules for storage and blood transfusion , its components and preparations” as amended by Order of the Ministry of Health of the Republic of Kazakhstan No. 501 dated July 26, 2012; 7. Modern intensive therapy of severe thermal injury in children M.K. Astamirov, A.U. Lekmanov, S.F. Pilyutik Federal State Institution "Moscow Research Institute of Pediatrics and Children's Surgery" of the Ministry of Health and Social Development of Russia, State Healthcare Institution "Children's City Clinical Hospital No. 9 named after. G.N. Speransky”, Moscow edition “Emergency Medicine”. 8. Astamirov M.K. The role of central hemodynamic disorders and their influence on the delivery of oxygen to tissues in the acute period of burn injury in children: Abstract of thesis. Candidate of Medical Sciences M., 2001. 25 p. 9. Borovik T. E., Lekmanov A. U., Erpuleva Yu. V. The role of early nutritional support in children with burn injury in preventing the catabolic direction of metabolism // Pediatrics. 2006. No. 1. P.73-76. 10. Erpuleva Yu. V. Nutritional support in children in critical conditions: Abstract of thesis. ...doctor of medical sciences. M., 2006. 46 p. 11. Lekmanov A. U., Azovsky D. K., Pilyutik S. F., Gegueva E. N. Targeted correction of hemodynamics in children with severe traumatic injuries based on transpulmonary thermodilution // Anesthesiol. and resuscitator. 2011. No. 1. P.32-37. 12. Lekmanov A.U., Budkevich L.I., Soshkina V.V. Optimization of antibacterial therapy in children with extensive burn injury, based on the level of procalcitonin//Western Intens. ter. 2009. No. 1 P.33-37. 13. Contents lists available at SciVerse Science Direct Clinical Nutrition 14. journal homepage: http://www.elsevier.com/locate/clnu ESPEN endorsed recommendations: Nutritional therapy in major burnsq 15. Acute upper gastrointestinal bleeding in over 16s: management https ://www.nice.org.uk/guidance/cg141 16. JaMa 2013 November 6; 310(17):1809-17. DOI: 10.1001/jama.2013.280502. 17. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. 18. Annane D1, Siami S, Jaber S, Martin C. JAMA. March 12, 2013; 311(10): 1071. Regnier, Jean [corrected to Regnier, Jean]; Cle"h, Christophe [corrected to Clec"h, Christophe]. 19. Colloid solutions for fluid resuscitation First published: 11 July 2012 20. Assessed as up-to-date: 1 December 2011 Editorial Group: Cochrane Injuries Group DOI: 10.1002/14651858.CD001319.pub5View/save citation 21. Cited by: 4 articles Refreshcitation count Citing literature 22. Albumin versus synthetic plasma volume expanders: a review of the clinical and cost-effectiveness and guidelines for use http://www.cadth.ca/media/pdf/l0178_ plasma_ protein_ products_ htis-2.pdf 23. BNF for children 2013-2014 bnfc.org 24. Pentoxifylline for the treatment of sepsis and necrotizing enterocolitis in neonates 25. First published: 5 October 2011 Assessed as up-to-date: 10 July 2011 Editorial Group: Cochrane Neonatal Group DOI: 10.1002/14651858.CD004205.pub2View/save citation Cited by: 7 articles Refreshcitation count Citing literature 26. Order of the Ministry of Health of the Republic of Kazakhstan No. 343 dated April 8, 2002 27. Kazakhstan National Formulary KNMF.kz 28. Large reference book of medicines Authors: Ziganshina, V.K. Lepakhin, V.I. Peter 2011 29. Branski L.K., Herndon D.N., Byrd J.F. et. al. Transpulmonarythermodilution for hemodynamic measure mens in severely burnt children//Crit.Care. 2011. Vol.15(2). P.R118. 30. Chung K.K., Wolf S.E., Renz E.M. et. al. High frequency percussive ventilation and low tidal volume ventilation in burns: a randomized controlled trial//Crit.Care Med. 2010 Vol.38(10). P. 1970-1977. 31. EnKhbaatar P., Traber D. L. Pathophysiology of acute lung injury in combined burn and smoke inhalation injury//Clin.Sci. 2004. Voll.107(2). P. 137-143. 32. Herndon D. N. (ed). Total burn care. Third edition. Saunders Elsvier, 2007. 278 S. 33. Latenser B. A. Critical care of the burn patient: the first 48 hours//Crit.Care Med. 2009. Vol.37(10). P.2819-2826. 34. Pitt R. M., Parker J. 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Information

Abbreviations used in the protocol:

D-dimer is a fibrin breakdown product;
FiO2 - oxygen content in the inhaled air-oxygen mixture;
Hb - hemoglobin;
Ht - hematocrit;
PaO2 - partial oxygen tension in arterial blood;
PaСO2 - partial tension of carbon dioxide in arterial blood;
PvO2 - partial tension of oxygen in venous blood;
PvСO2 - partial tension of carbon dioxide in venous blood;
ScvO2 - central venous blood saturation;
SvO2 - saturation of mixed venous blood;
ABT - antibacterial therapy;
BP blood pressure;
ALT - alanine aminotransferase;
APTT - activated partial thromboplastin time;
AST - aspartate aminotransferase.
HBO-hyperbaric oxygenation
DIC - disseminated intravascular coagulation;
Gastrointestinal tract - gastrointestinal tract;
RRT - renal replacement therapy;
IVL - artificial lung ventilation;
IT - infusion therapy;
ITT - infusion-transfusion therapy;
AOS - acid-base state;
CT - computed tomography;
LII - leukocyte intoxication index;
INR - international normalized ratio;
NE - necrectomy;
TPR - total peripheral vascular resistance;
ARDS - acute respiratory distress syndrome;
BCC - circulating blood volume;
PT - prothrombin time;
FDP - fibrinogen degradation products;
PCT - procalcitonin;
MON - multiple organ failure;
PTI - prothrombin index;
PEG - polyethylene glycol;
SA - spinal anesthesia;
SBP - systolic blood pressure;
FFP - fresh frozen plasma
SI - cardiac index;
ISI - intestinal failure syndrome
MODS - multiple organ failure syndrome;
SIRS - systemic inflammatory response syndrome;
OS - burn shock;
TV - thrombin time;
TM - platelet mass
EL - level of evidence;
US - ultrasound;
Ultrasound - ultrasound examination;
SV - stroke volume of the heart;
FA - fibrinolytic activity;
CVP - central venous pressure;
CNS - central nervous system;
RR - respiratory rate;
HR - heart rate;
EDA - epidural anesthesia;
ECG - electrocardiography;
MRSA - Methicillin-resistant staphylococci

List of protocol developers with qualification information:
1) Bekenova Lyaziza Anuarbekovna - doctor - combustiologist of the highest category at the State Clinical Hospital at the PCV "City Children's Hospital No. 2" in Astana.
2) Ramazanov Zhanatay Kolbaevich - Candidate of Medical Sciences, combustiologist of the highest category at the Russian State Enterprise at the Scientific Research Institute of Traumatology and Orthopedics.
3) Zhanaspaeva Galiya Amangazievna - Candidate of Medical Sciences, chief freelance rehabilitation specialist of the Ministry of Health of the Republic of Kazakhstan, rehabilitation physician of the highest category of the Russian State Enterprise at the Scientific Research Institute of Traumatology and Orthopedics.
4) Iklasova Fatima Baurzhanovna - clinical pharmacology doctor, anesthesiologist-resuscitator of the first category. GKP at the RVC "City Children's Hospital No. 2" in Astana.

Disclosure of no conflict of interest: No.

List of reviewers:
1) Elena Alekseevna Belan - Candidate of Medical Sciences, RSE at the Scientific Research Institute of Traumatology and Orthopedics, combustiologist of the highest category.

Indication of the conditions for reviewing the protocol: Review of the protocol 3 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

Annex 1
to a standard structure
Clinical protocol
diagnosis and treatment

Correlation of ICD-10 and ICD-9 codes:

Attached files

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