BURNS

Frostbites

CARE OF THE COMBATANT THERMAL

TRAUMA
PhD, Assistant Uluana Kuz
 Backgrounds
The small part of military trauma
consists of burns (3-5%). Whether
even mild degree of burn should
make trooper incapacitate and also
exhaust whole medical team

Thermal trauma might be just one factor of damage (e.g. explosion)

Thus care consists of complex care: general disorder and trauma
management. It is important collaboration of all specialist during the
first 48 h (shock management)
 FEATURES OF INJURIES
Multiple, complex and combined type of wounds (32,1%)
Prevalence limb injuries ( 62,6%)
Personal protective measures influence on type of injury

67,9% Isolated
Multiple
8,6%
Complex
32,1% Combined

1,6% 9,9%
25,6%
62,9%

bulet projectile explosion burns

 Anatomical distribution of the
military trauma
50,3%
Localization 2014-2022 9,5%
Head 31,9
-gunshot 7,3 First period
40,2%
-TBI 12,8
-eyes 4,0
-face 5,4 Second period
- ears & nose 15,7
14,0%
Neck 1,9 47,8% Mild
Spine 1,1
Chest 11,7 38,2% Moderate
Abdomen 7,3
Pelvis 2,6 Severe&Very
Third period
Limbs 62,5 severe
14,5% 45,8%
•lower 38,7
•upper 23,8
Burns 2,7 37,4%

Complex 26,6
 Types of thermal
Injuries
Burn – skin and other tissue damage due to local high temperature
effect, chemical agent, electric light or ionizing radiation

Etiology of burns :
✓ thermal
✓ electric-thermal
✓ chemical
✓ radiation
✓ combined
✓ combustible liquids used in warfare (termite, white
phosphor, napalm, pyrogel)
 Classification

oSuperficial (І, ІІ-А and ІІ-B) epithelization by self;

oDeep (ІІІ), requires grafting.
І degree – epidermal layer damage, redness, no blisters, mild pain

Healing 3-7 d
ІІ-А – up to papillary layer, severe pain, blisters filled by
transudation liquor, redness

Healing 1-3 weeks, residual

pigmentation
ІІ-B – deep layers of skin, dry crusts

Healing 3-6 weeks, residual

scars
ІІІ – all layers of the skin, soft and fatty tissue and sometimes
deeper. No pain, dry crusts, bottom pale or with network of
thrombosed vessels
No healing without grafting
 Diagnostics
Depth
Signs of tissue necrosis. Pale bottom of the wound or
charring, dry crust.
Circulation disorders. Reliable sign – thrombosed veins
underneath crust

Pain and temperature sensitivity.

- Billroth test – deep burn – no sensitivity if touched by
needle or pad with alcohol, superficial – severe pain.
-Epilating test, tweezers are used to pinch some hair in the
wound. If there is pain – superficial burn
 Diagnostics (TBSA- total body surface area)

Rule of the nines A head and a neck

- 9 %, forward surface of a thorax - 9
%, a back - 9 %, an abdomen - 9 %,
a loin and hips - 9 %, the upper
extremities on 9 %, thigh - 9 %, a
shin and foot - 9 %, a perineum and
external genitals - 1 % from the
body area
Rule of a palm. The adult palm area
makes 1-1,2 % of the total body
surface area. It is possible to apply a
paper stencil of patient’s hand to fast
definition of the burn area
 DIAGNOSTICS IN INFANTS
• To assess burn size in
children use Land-
Browder’s scheme
• Sum all injuries
together ( in
percentage)
according the table
below
Parts of body Newborn 1 year 5 years 10years 15 years

Head 20 17 13 10 8

Neck 2 2 2 2 2

Breast 10 10 10 10 10

Abdomen 8 8 8 8 8

Back 11 11 11 11 11

Hip 5 5 5 5 5

Genitals 1 1 1 1 1

Shoulders 8 8 8 8 8

Forearm 5 5 5 5 5

Hand 5 5 5 5 5

Thigh 19 18 11 13 16

Shin & Foot 12 +5 9+5 13+5 10+5 11+5

 Severity degree
Severity index considers with TBSA and depth. The 1% of
burn equal points below
І -ІІ-А – 1,
ІІ-B – 2,
ІІІ - 3.

Burn shock Severity index (units)

degree No Resp. Burn Resp. Burn

Mild less 30 less 20

Moderate 31-60 21-50
Severe 61-90 more 80
 Respiratory Burn
Agents:
- flame, hot air, hot particles and toxic
chemical agents – combustion products.
Mortality 22,3% - 82%.

Inhalation injury
- aspiration
and/or
inhalation of
superheated
gasses, steam,
hot liquids or
noxious
products of
incomplete
combustion in
smoke
- closed space at the moment of accident.
- open space – lots of smoke (e.g. great
fire)
 Respiratory burn
Types of inhalation injury:
• Injury caused by exposure to toxic gases
including carbon monoxide CO and/or
cyanide • Supraglottic (above the vocal cords)
injury, due to direct heat or chemicals,
causing severe mucosal edema.
• Subglottic or tracheobronchial (below the
vocal cords) airway inflammation and edema,
which may cause atelectasis and pneumonia

Reliable signs:
• Burn of a chest, a neck, a face, a nose, lips, a
tongue
• Burn and edema of back wall of a nasopharynx,
hard and soft palate
• Burnt hair in a nose, a patch of soot in tongue
• the hoarse voice, an aphonia, short breathing,
cyanosis
• Respiration (inspiration) impairment; mechanical
asphyxia
The confirmation of the diagnosis AP chest X-ray and
bronchoscopy
 Respiratory burn

І - mild degree - no respiratory distress

syndrome at the first day.
ІІ - moderate degree - respiratory
distress at the first 6-12 hours.
ІІІ - hard degree - respiratory failure
from the moment of combustion

RB degree Severity index +

Mild 15
Moderate 30
Severe 45

Prognosis
less 60 – favorable
61-120 – unfavorable
 Burn Disease
- Deep burns more 10%
- Superficial – more 25-30%

Periods
І– burn shock(erectile and torpid phase) (24-72 h);
ІІ– acute burn toxemia (14 h)
ІІІ– septicopyemia (2-3 m), depending time
of burn wounds;
ІV– convalescence (rehab) (1-2 m)
 Burn Shock
– compensatory reaction because of trauma
Degree Area of deep burns
Mild
10 - 20%
Moderate
Severe 20 -40%
Very severe more 40%

Signs
- oliguria (DD < 30 ml);
- persistent vomiting
- macrohemoglobinuria
- hypothermia
- rectal/skin temp coefficient more than 3оС
- nitrogenemia (> 40-50 mmol/L)
- acidosis (рН >7,3)
 Burn Shock Degrees (clinical signs)
Degree
Signs Mild 24-35 h Moderate Severe Very Severe
36-48 h 48- 72 h >72 h

Severity index, U <30 31-60 61-90 >90

“White spot less 2 3 >3 >3
sign” (c)
BT, С0 subfebrile Nornal <36-350 <350
HR, b/min less 90 90-110 >120 >140
SAP, mmHg 140-120 110-90 <90 <70
CVP (central 80-40 80-40 40-0 negative
vein pressure),
mmHg
Diuresis ml/kg Constipation 0,5-0,3 <0,3 anuria
before
infusion
Urine normal concentrated dark tea-colored
Gullet paresis - ± + +
 Burn Shock Degrees (lab signs)

Degree
Sign Mild 24-35 h Moderate Severe Very Severe
36-48 h 48- 72 h >72 h

Severity index, U <30 31-60 61-90 >90

Нb g/L 145-150 151-170 171-180 >180

Ht g/L 0,40-0,50 0,51-0,55 0,56-0,60 >0,60

WBC T/L 10-15 16-20 21-25 >25

Na, mmol/L    

BE, mmol/L 0-(-5) (-5)-(-7,5) (-7,5)-(- >(-10)

10)
 ACUTE BURN TOXEMIA
Accumulation of toxins, inflammatory mediators and immune
suppression.
Signs:
- renew daily diuresis
- BP increase
- swelling increase
- fewer
- hemoconcentration decrease
- WBC left shift
- high ESR
- anemia, hypo- and dysproteinemia
- decrease billirubin, glucose
- decrease coronary disorders on ECG
 ACUTE BURN TOXEMIA

Dystrophy of parenchyma
organs.
Complications:
- toxic myocarditis
- heart arrest, pneumonia
- acute renal failure
-Anemia is typical just for burns
is called burn anemia
 ACUTE BURN SEPSIS
(Septicotoxemia)
More than 20% of burn wounds are complicated by
infection
First signs appear at 8-10 day

Syndromes:
- SIRS
- burn sepsis
- burn cachexia
 ACUTE BURN SEPSIS
Clinical signs
✓Hectic fewer,
✓ Bacteriemia
✓ secondary necrosis of the wounds
✓ pus in the wounds,
✓ metastases of infection
✓ bedsores,
✓ osteoporosis,
✓ joint contractures
✓ allergic and septic damages of inner organs
✓pneumonia, lung abscess, pyopneumothorax, empyema.

Lung complications the most common reason of death

 Treatment

- Shock management,
- Infusion
- Prevention infection
complications,
- Symptomatic treatment of inner
organ complications,
- Parenteral nutrition and
hormones,
- Rehab.

Complete healing only after complete wound

closure.
Prof . Sulyma V.S.
ADVANCE BURN LIFE
SUPPORT (ABLS)
 EMERGENCY AID

Ask the Question

I’m in safety?
Release wounded against the damage factor.
Cooling of burnt surface by cold water (15С°) during
10-15 mines, or application of criopacks, heaters with
cold water.
In case of chemical injury is necessary to wash out a
wound by cold water for 30 minutes. Cover the burn
with sterile dry bandage. Don’t forget about transport
immobilization
Applying of any ointment is Prohibited
 ABLS. PRIMARY SURVEY
• Airway – maintain patency especially if
signs of respiratory burn
• Breathing and ventilation - high flow 100%
oxygen using a non-rebreather mask if
inhalation injury is suspected
• Circulation and Cardiac Status with
hemorrhage control
• Disability, Neurological Deficit and Gross
Deformity assessment – use AVPU method to
estimate the patient’s level of consciousness
Exposure and Environmental Control –
Hypothermia Control
 CIRCULATION
• 4/Infusion therapy – ASAP
Main problem – catheter indwelling as it is desirable in two
peripheral veins conducts a bore catheter of 1,2-1,4 m.
Secondary problem – Estimating initial fluid requirements

NO FORMULA

• 5 years old and younger: 125 ml Lactated Ringers (LR) per hour
• 6-13 years old: 250 ml LR per hour
• 14 years and older: 500 ml LR per hour
 TRIAGE

• Immediate – RB, Inhalation Injury – II-III degree, TBSA ≥

I 20 %

• Expectant – RB, No Inhalation Injury or I degree,

II • TBSA ≥ 20 %

III • Minimal – No RB, TBSA <20 %

• Delay
IV
 ABLS. SECONDARY SURVEY
• Accurate medical history (injury circumstances and medical history)

The burn is often the most obvious injury, but other serious and even life-threatening injuries may
be present

• Accurate pre-injury patient weight

• Complete head-to-toe evaluation of the patient

• Determination of percent TBSA of burned

• Apply adjusted fluid rates after TBSA determination

• Labs and X-rays exams

• Monitor fluid resuscitation

• Pain and anxiety management

• Psychosocial support

• Wound care
 SHOCK MANAGEMENT

:
o
First 24 hours For the second 24
Half of this total hours, use 5%
administer
volume is albumin in normal
Crystalloid using
the following programmed for saline.
the first 8 hours 5% albumin
formula:
postburn, and half volume = (* mL) •
Total Volume = (2
for the second 16 (% TBSA burned) •
mL) • (% burn) •
hours postburn (preburn body wt,
(kg weight). kg)
 OTHER MANAGEMENT
• Administration of Anti-tetanus serum and anatoxin
• Coagulopathy management
• Wound infection prevention
• Local treatment of skin depends on degree:
1.Antiseptic bandages ( Betadin) combined with
necrectomnies
2.When you see epitelization of wound use antibiotic (
Sulfanil ) and reparating oinments ( Solcoserul,
Contractubex, Aecol) to complete recovery
• III degree burns require surgery
 WOUND TREATMENT

Local treatment of burn wounds depends on their depth and location.

Most burn wound is not life-threatening. However, proper wound management
help to reduce the risk of infection.
Superficial burns treated conservative open way or closed one by using
bandages

Primary wound management:

-Clean skin around by antiseptic solutions.
-Remove dedicated epidermis, alien
bodies.
-Cut big blisters.
-Cover wounds by sterile bandages
 WOUND TREATMENT

Open way:
Require special sterile space
Heating equipment
Professional staff

Closed way:
Easier take care lots of damaged
Prevent wound infection and additional
trauma
 DEEP WOUND MANAGEMENT

2 stages : preventive surgery and plastic surgery

Preventive surgery – necrotomy and

decompression skin incisions or/and
fasciotomy
All dressings are performed under general
anaesthesia
 DEEP WOUND MANAGEMENT

• Skin incisions
 DEEP WOUND MANAGEMENT

Limb care

•Lift the limb.

•Exercises every 1hour.
•Pulse and neurological status every 1hour.
•Remove crust if compartment .
 DEEP WOUND MANAGEMENT

Remove all necrotic

tissue day by day

Wound closure by
xenografts .
Grafting.
Reconstructive
surgery
 BURN SURGERY

A – autodermoplastic technique by “free skin graft”

B – xenoplastic technique
MORE PICTURES…
 FROSTBITES
CLASSIFICATION

• Chillblains. Immersion foot or

trench foot
• Frostbites
• General hypothermia
CLASSIFICATION
 CLASSIFICATION
І degree - edema of soft tissues, skin hyperemia with
cyanotic discoloration or mottled skin. The itch,
paresthesia, shooting-pain. All these phenomenons
disappear during several days, however cold
hypersensibility leaves
ІІ degree - blisters filled with yellowish or hemorrhagic
liquid, partial necrosis of skin up to basal layer, edema and
unpleasant sensations. Term of healing is to 30 days
ІІІ degree - necrosis of a skin, a subcutaneous fat and soft
tissues. The affected areas are covered with blisters with
the dark hemorrhagic contents. The bottom of blisters is
not sensitive to a pricking also does not bleed. Defect of a
skin heals by second tension to 60 days, and big sizes
demand autoplastic surgery
ІV degree - necrosis of a skin, soft tissues and bone
structures. The demarcation of the affected areas comes
over the time of 14 days. The purulent infection frequently
joins in
 MANAGEMENT
Treatment of burns and frostbites is similar:
• Administration of Anti-tetanus serum and
anatoxin
• Antibiotics of board spectrum
• Local treatment of skin depends on degree:
1. Antiseptic bandages ( Betadin)
2. When you see epitelization of wound use
antibiotic ( Sulfanil ) and reparating oinments (
Solcoserul, Contractubex, Aecol) to complete
recovery
3. Very severe degree - Amputation
 GENERAL HYPOTERMIA
Hypothermia is a condition our bodies suffer
when the body loses heat to the environment
faster than it can produce heat thus causing the
body’s core temperature to start to drop. It can
be hastened if the body lacks sufficient
hydration, has inadequate nutrition and suffers
from fatigue
 SIGNS
• Shivering. It become uncontrollable and
possibly violent as body core loose
temperature
• The feeling of fatigue, speech that is slow and
slurred and evidence of loss of coordination,
such as stumbling and lurching while walking
will soon follow, as will loss of the fine motor
skills of the hands
• Confusion and disorientation, such as a
distorted sense of time and distance are also
common symptoms, and as death approaches,
hallucinations will occur, such as the false but
overwhelming feeling of warmth
 GENERAL HYPOTERMIA
• Mild degree. Person is fatigue, movements are slow, speech is
difficult. Pulse, respiration can be slowed, BP remains normal. The
rectal temperature is reduced up to 34˚; there is paleness, cyanosis
with marble shade, vasoconstriction, shivering, cold sensations,
coagulopathy
• Moderate degree. A body temperature decrease up to + 26-33˚С.
Movements are sharply reduced, inhibition of CNS, a drowse,
consciousness is suppressed, look is paradoxical, nonsensical,
mimicry is absent. A skin is cold, pale, cyanotic with marble shade,
bradycardia, confusion or agitation, metabolic acidosis, cold-
induced diuresis
• Severe degree. The body temperature is down + 26˚С and lower.
The consciousness is absent. The upper extremities are bent in
elbows, lower - in knee joints; to unbend them is impossible.
Muscles of front abdominal wall are strained. There are spasms,
trismus, tongue can be bitten. A skin is cold, pale, cyanotic. Pulse is
sharply rare, weak, palpated only at main arteries, BP is reduced or
not determined. Respiration is superficial, broken, hoarse. Pupils
are narrowed, do not react to light. Coma, respiratory depression,
profound hypovolemia, later apnea, asystolic arrest
 MANAGEMENT
Pre-reactive period - immediate correction of temperature of
tissues, which suffer of a cold and renewal their circulation. Local
infringements in tissues because of cold action, in early terms
can be reversible. Apply thermo-insulating bandages on the
affected areas at 24 hours; an immobilization of the affected
extremities; the general gradual warming of victims; do not
provide intensive, local warming actions (grinding, massage, hot
trays, compresses); perform vasoactive infusion therapy
(angiolytics, antioxidants, disaggregants, anticoagulants)
Early reactive period - it is necessary to provide actions similar
burn combined with local treatment of wounds, antibacterial and
thermophysical therapy. It is necessary to cover affected region
by dry bandage, to give a drink sweet hot tea, to provide
warming by dry air or wet (in a bath), first of all chest, stomach,
nape, neck, but not head. Warming should be slow, intensive with
increase of temperature on 1˚С per hour. It is strictly forbidden to
massage regions of frostbite by cord, snow
 MANAGEMENT
• Administration of anti - tetanus serum, tetanus anatoxin,
antibiotics of broad spectrum are obligatory
• Intensive infusion therapy is performed parallel, as well as at
traumatic or burn shock
• Solutions of crystalloids, glucose, medicines improving
blood rheology and microcirculation are intravenously
infused in volume of 30-60 ml/kg/d
• Intravenous introduction of 40 % solution of a glucose of 40-
80 ml, warm up to 35-40˚С, 80-120 mg of prednisolon, 10 ml of
5 % solution of ascorbic acid, Benadryl 2 % 2 ml, sodium
bicarbonate 5% 200,0 ml, lasix 40-60 mg, calcium chloride
10% 10 ml is obligatory, colloid solutions at indications
• At absence of respiration resuscitation is necessary -
artificial pulmonary ventilation “ a mouth to a mouth ”, the
closed cardiac massage
 ELECTRICAL INJURY
Gravity and character of an electrical injury is determined by such
factors:
▪ a type, a strength, a voltage of an electric current
▪ passageway through an organism
▪ duration of its action
▪ resistance of tissues
 ELECTRICAL INJURY
• The alternating current is more dangerous, than
direct. Action of an alternating current on an
organism depends on its frequency, strength and
voltage
• Low-frequency currents (50-60 Hz) are more
dangerous, than high-frequency. The current 0,05-
0,1А is considered mortal.
• The current 550V causes low-voltage damage and
1000V and more - high-voltage burns from “ Volt
arch ”. Low-voltage burns are mainly household.
Such current passes on tissues with low resistance.
The high-voltage current is extended by short way,
causes serious damages of the main vessels,
muscles, internal organs
 EFFECTS ON HUMANS BODY
General
⚫ At mild defeats there is a syncope with following
retrograde amnesia
⚫In serious cases there are deep loss of
consciousness, sharp weakening of respiration and
cardiac activity. Victim seems dead - “conditional
death ” which can getting real
⚫Massive defeats case myoglobinuria, renal
syndrome, a burn shock
⚫Death result from a cardiac failure (a fibrillation, an
asystolia), respiratory failure (a paralysis of
respiratory center), a burn shock
 EFFECTS ON HUMANS BODY
Local
Deep burns. Direct action of electric current cases
so-called “current signs ” on the entrance and exit
of electric energy, which turns in thermal. Clinically
they look like fawn spots with cylindrical seepage
of edges and impression in center. Destruction of all
tissues with an initial coagulation skin, muscles,
tendons, bones and a mumification of separate
sites. Around of a necrosis there are hyperemia,
edema, infringement of sensitivity, a clottage of
vessels

Late bleeding. As a result of blood vessels defeat

late bleeding can come. They can be observed on
way of a current where skin folds were met
 EMERGENCY AID
• The acute management at an electric trauma begins on a place of
an accident. It is necessary to disconnect immediately an electric
current, to remove from hand of the victim electric wires,
protecting self from action of a current. It is impossible to touch a
body of the victim by naked, wet hand. Use a dry wooden stick, a
board, rubber boots, mittens
• Resuscitation, immediate evacuation of the victim into medical
facility. Within transportation immediate antishock therapy which
proceeds during the necessary period. Constant monitoring of
function of cardiovascular system, kidneys, CNS, blood, urine
rates etc
• Local treatment consists of closing wounds by dry aseptic
bandages, if necessary fasciotomy. At erosive bleedings from the
main vessels manage by ligating a vessel at a distance
• The transport immobilization, administration anti- tetanus serum
and anatoxin, broad spectrum antibiotics are also obligatory
 WHITE PHOSPHORUS BURNS
✓ Degree II up to full thickness, extremally
painful
Instead of turning red, third-degree burns may
turn:
•black
•yellow
•white

✓ It’s highly flammable and can

spontaneously catch fire when it
encounters oxygen. Burning is lasting near
15 min
✓ Treatment the same as burns, but
remember about toxic effect.
✓ Surgical Debridement. Use UF lamp to
remove all contaminated parts, apply lots
of antimicrobial cream

\
 NAPALM BURNS
✓ Napalm - combustion agent combination of
gel and gas or diesel. Burning temperature
800о - 1200оС and it also generate carbon
monoxide while simultaneously removing
oxygen from the air
✓ In addition, it burns longer than gasoline (4-7
min), is more easily dispersed, and sticks to
its targets – skin and cloth.
✓ Most burns are on the open areas, 75% face.
✓ Damage – severe RB, carbon monoxide
intoxity, hyperthermia, conscience
impairment.
✓ Only 15-20% injured are able to survive.
✓ Long wound healing - 2,5-3 mth.
✓ Keloid scars and chronic ulcers
 PITFALLS

● No accurate estimation of the severity of Burn Shock,

Respiratoty burn and toxic effects of smocking agents
● dressing without anesthesia
● no circular burns incision
● long time treatment of deep burns in the not special
facility
THANK YOU