A minor burn in a child is treated. What to do if a child is scalded by boiling water. Diagnostic criteria at the inpatient level

All young children actively learn about the world around them. And even parental prohibitions can not always save curious children from rather dangerous research. As a result, babies can develop a wide variety of injuries. One of the extremely unpleasant moments is a child's burn. Unfortunately, it is not always possible to protect the baby from this injury. Therefore, parents should know how to provide first aid to the baby.

Varieties of burns

The fearlessness and curiosity of young researchers is simply amazing. Children are not afraid of fire. They are attracted by electrical outlets, admirable by beautiful bottles of chemicals. According to doctors, it is a child's burn that is one of the most frequent reasons with which parents turn to medical institutions. And most often obtained in a domestic environment.

Burns can be:

1. Thermal... These are injuries caused by exposure to high temperatures.
2. Chemical... They are caused by various household chemicals.
3. Solar... The result of prolonged exposure to scorching rays.
4. Electric... Injuries resulting from improper use of household appliances or “exploration” of outlets.

In any of these cases, the child needs to provide first aid quickly and competently. Of course, treatment methods will differ slightly depending on the type of injury.

Burns

There is another important criterion to consider. You must be able to determine how serious the child's burn is. Indeed, in difficult situations, the baby immediately needs qualified medical help.

There are 4 degrees of burns for children:

1. Only the surface layers are affected. The damaged area turns red, swells. The child complains of pain and burning sensation in this area.
2. Such injuries are characterized by a great depth of damage. They cover not only the surface layer, but also the subcutaneous tissue. The child experiences severe pain which lasts long enough. The second degree is characterized by the formation of thin-walled bubbles filled with liquid.
3. The lesion covers the superficial and deep skin tissues. Burns of 3 degrees are divided into types: A and B. The first type is characterized by the formation of thick-walled blisters and scabs. However, healthy epithelial cells, hair follicles and secretory glands are preserved. Due to them, tissue regeneration occurs. Grade B is characterized by severe damage. Can be observed purulent inflammation, tissue necrosis. The burn is a moist open wound. After himself, he leaves a scar.
4. This is the most severe degree. It is characterized by charring and the formation of black scabs.

At home, only grade 1 and 2 lesions can be treated. Grade 3 and 4 injuries require the patient to be hospitalized.

Thermal burn

Kids love to be near their mother in the kitchen. But it is here that many dangers lie in wait for them. Little researchers simply do not understand that there is boiling water in the cup, and they can reach for it. They do not think that there is a red-hot saucepan on the stove, and they stretch their fingers towards it.

As a result, baby's delicate skin is damaged. A child's burn with boiling water is the most common household injury. It is greatly aggravated by the presence of clothing. Garments quickly absorb hot liquids and significantly worsen the effects of injury.

Sometimes a burn may occur with a red-hot metal object (touching a hot pot, iron). Such injuries are rarely deep. They almost never cover a large area. After all, the child's instinct of self-preservation is triggered, and he abruptly removes his hand from the red-hot object.

First aid

Parents should know if, as a result of careless actions, a child still has a burn, what to do in this situation.

First aid consists of the following measures:

1. It is necessary to remove hot wet clothes from the baby as soon as possible. After all, it continues to burn the skin. You should act especially quickly if things are synthetic. It is necessary to take off clothes very carefully so as not to damage the integument, on which blisters could appear, and not to cause the baby even more discomfort. Your best bet is to cut the items up and take them off right away before they stick to your skin. If the clothes are stuck to the body, never open the fabric.
2. To relieve the burning sensation and reduce the temperature, it is necessary to pour cold water over the damaged area. Continue cooling the burn for 10-15 minutes. It is strictly forbidden to use ice. This will greatly aggravate the injury.
3. Do not lubricate the wound with fatty ointments, oil. Such actions contribute to the preservation of a high temperature at the site of the burn. As a result, the damage significantly spreads in breadth and depth.
4. Apply a gauze bandage to the burn site after wetting it with cold water. Soda solution will ease the suffering of the child. For 1 glass of water - 1 tsp. soda. The periodically drying dressing should be watered with cold water. If gauze is not on hand, it can be used to protect the wound from infection.
5. Assisting a child with a burn, an aerosol can be applied to the damaged area (after exposure to cold water): "Panthenol", "Levizol", "Levian".
6. Special gel wipes have proven to be excellent. They are most often used for 2nd degree burns.
7. It is strictly forbidden to open the blisters that appear. They protect the damaged area from germs and prevent fluid loss.
8. Do not treat the affected area with iodine or similar antiseptics.
9. Even with minor burns, it is recommended to give the child a pain reliever (Panadol medicine) and an antihistamine (Diphenhydramine, Claritin, Suprastin, Pipolfen).

Be sure to show your child to the doctor! At 3 and 4 degrees of burns, an appeal to specialists should be immediate. With such lesions, an ambulance should be called immediately.

Sunburn

This is another fairly common injury. Baby skin is very delicate. She is able to burn quickly. Sometimes it is enough to spend half an hour on the beach for a child to develop a sunburn. Such damage is extremely unpleasant and dangerous. After all, it is impossible to determine this injury by touch or by eye. As a rule, sunburn appears on the skin after a few hours.

That is why it is necessary to protect the child from the sun's rays during the first days of his stay on the beach. It is recommended to use special creams or lotions to protect baby's skin. However, you should not completely rely on them.

What to do?

If you are observing a child, then your actions should be as follows:

1. Initially, try to relieve the pain as much as possible. To do this, spray the burned areas with Panthenol aerosol. Sour cream or kefir will provide a good effect. You can resort to the help of green strong tea. Use a freshly brewed drink, always chilled. Using a cotton swab, apply liberally to the burnt integument. This procedure is recommended to be repeated as often as possible.
2. To reduce pain, give your child an analgesic: Panadol.

If there is a rise in temperature or chills, then immediately consult a doctor.

Chemical burn

Any house contains big variety chemical agents. Of course, they should be kept out of the reach of children. But if the baby got a forbidden bottle, then it is likely that a chemical burn may form in the child.

Acid damage can be determined by the following symptoms:

1. Strong pain.
2. A characteristic spot forms on the skin. When exposed to sulfuric acid, it becomes dark gray or black. Salt - leaves behind a gray tint. Nitric acid produces an orange or yellow spot. Carbic or acetic acid is characterized by a greenish tint.

If a child's burn is provoked by alkali, then the following symptoms appear:

1. Strong pain
2. Wet deep burn. From above it is covered with a light crust.
3. Signs of body intoxication are often observed: nausea, headache.

First aid

The main thing is not to panic. In addition, you need to know how to help a child with a burn.

Your actions should be as follows:

1. Call an ambulance immediately.
2. Rinse the damaged area thoroughly with running cool water. This procedure should last at least 15-20 minutes.
3. Cover the burn with a sterile dressing.
4. If you are sure that the damage is caused by alkali, you can apply a napkin dipped in diluted vinegar (1 part vinegar to 4 parts water) or boric acid(for 1 tbsp. of water - 1 tsp.).
5. If it is not possible to call a team of doctors, immediately take the child to the trauma unit.

Electric burn

This is an extremely serious injury. Electrical burns are characterized by deep tissue damage. Moreover, they are fraught with serious consequences. Therefore, with such injuries, parents need to call an ambulance as soon as possible.

How to help a child

With such lesions, it is very important to act correctly and quickly. What to do if an electrical burn occurs? must be rendered immediately) must be saved.

This consists of the following activities:

1. Eliminate the effect of the current. It is strictly forbidden to grasp the power supply with bare hands. Electrical appliance or the wire must be thrown away with a wooden stick. The child can be pulled by the edges of the clothing.
2. If the baby does not have a heartbeat or breathing, it is necessary to urgently perform a heart massage and resort to artificial respiration.
3. Take patient to hospital immediately.

Features of injuries in a child under one year old

Burns in babies are dangerous for their serious consequences. That is why, with such injuries, it is recommended to show the baby to the doctor.

The area of ​​the lesion is an important factor. If a burn of 1 or 2 degrees occupies an area of ​​more than 8% (this is the size of the victim's palm), then such injuries are assessed as severe and require an obligatory call to an ambulance. But these conditions apply to children over 12 months old.

A child's burn under one year old is assessed somewhat differently. Indeed, in babies, the skin is much thinner, it is distinguished by a developed circulatory and lymphatic network. Due to this, the integuments have a higher thermal conductivity. Therefore, even a small burn can cause deep damage in a baby up to a year old. In infants, if 3-5% of the skin is damaged, it is necessary to call an ambulance.

What medications can be used after a child's burn to relieve unpleasant symptoms? It is best to consult your doctor. A competent specialist will select the most effective means.

Most often, with damage of 1, 2 degrees, the following medications can help:

1. "Panthenol". It is best to use an aerosol. He is able to help with any thermal burns. It is recommended to use it for sun injuries. It is allowed to apply the product to the skin with cracks and abrasions.
2. Olazol. The drug is an excellent pain reliever. It protects against the development and reproduction of microorganisms. The tool provides accelerated healing.
3. Solcoseryl. For the treatment of burn injuries, a gel or ointment is used. The tool effectively fights against thermal damage... It will be beneficial if the child
4. Anti-burn gel wipes. Such a remedy effectively cools the wound surface, anesthetizes it. The napkin ensures the destruction of germs. This tool is very easy to use. It can be easily replaced as needed.

Folk remedies

If there is not a single medication at hand, from the ones listed above, what should be done? What can a child get from burns?

1. If you can use raw potatoes. The tuber must be grated. The gruel is placed on the affected area and covered with a bandage. Change the grated potatoes as they heat up.
2. Significantly weaken unpleasant symptoms cabbage leaf... A sheet is put on the burn and tied. After a few minutes, the pain subsides. And after half an hour it completely disappears.
3. A freshly cut aloe leaf will benefit. Remove the skin from it. Such a sheet is applied to the damaged area for 12 hours.

If your child gets burned, the main thing is not to panic. Try to assess the extent of the damage correctly and call an ambulance if necessary. In the meantime, give the correct first aid.

In this article, we will tell you in detail what treatment of burns in a child in modern and folk ways most effective depending on the type and degree of burns.
A burn is called damage to the skin (later, possibly organs) as one of the external factors. Thermal burn appears after contact with hot objects, liquid. Steam burns are also possible.

At lung treatment child burn an ointment is applied, which is applied to the damaged area of ​​the skin ... It is recommended to leave the body open, or bandage. Use a piece of sterile bandage once. Until the skin is very sore, it is impossible to stop the daily dressings of the burned parts of the child's body. Is the pain dulling a little? So everything heals and the bandage is no longer needed. How to treat a burn at home?

Burn ointment you can cook it yourself, for this we need 2 onions, a glass of sunflower oil, 2/3 of a thin candle, a sterilized jar. Fry chopped onion in oil (wait for a golden hue to appear). Then, through cheesecloth, filter the mass into a jar, send the remaining fried onions to the trash. We throw a candle to the hot oil, which will immediately begin to melt. After a while, the consistency will become homogeneous, with the density of petroleum jelly. Burn ointment for treatment baby is ready. The product is natural, therefore it is recommended to store it in the refrigerator.

There are 4 degrees of burn.

At the first degree of burns, the skin turns red, swelling is possible in the damaged area. Period full recovery lasts no more than five days.

For a second degree burn on reddened skin after a while, bubbles appear with a transparent or yellowish content, which then open up and expose the germ ball of red skin. Infection is not excluded. Then the recovery period takes up to two weeks. No scars remain.

For a third degree burn skin cells are dead, a gray or black scab is visible on the affected area.

With a fourth degree burn, the victim not only charred the skin, but also affected muscles, tendons, and in severe cases, bones. The body rejects dead tissue, this process takes a couple of weeks. The patient's recovery takes a long time. Deep burns leave scars, they provoke dehydration if the face, joints, and neck have been burned. Then cicatricial contractures remain on the joints and neck.

Possible complications from burns: infection, (in case of electric shock), shock provoked by dehydration (lethargy and pallor, rapid pulse, cold sweating, breathing problems and loss of consciousness).

Treatment of burns in a child provides not only the elimination of painful symptoms and the prevention of harm to health, but also the correct treatment of damaged skin areas so that no scars and scars remain on the body. Below you will find information about what degrees of burns exist, what symptoms characterize one or another degree of burns, how to provide first aid for burns and how to treat burns with folk remedies.

Burns are a very unpleasant phenomenon that can have serious consequences... Unfortunately, burns in children are very common. Little pranksters do not yet realize the danger of high temperatures and try to check everything in a tactile way. Well, parents do not always manage to keep track of their fidgets, so the skill of providing first aid to a child is very important.

Causes of burns

Most often, children's burns are of a household nature. Tissue damage can be triggered by various factors:

• thermal (objects or substances heated to a certain temperature);
• chemical (chemically active substances that corrode tissue);
• electrical (household appliances and power sources);
• solar (prolonged exposure to direct rays);
• ionizing (lamps and ion radiation devices).

As a rule, outlets, an iron (read about), a stove, an oven, matches, boiling water (during the cooking process) and wires are especially dangerous. These elements are within walking distance of the kid and can become the subject of his games.

Not only the skin can be affected, but also the mucous membranes. Very often children are scalded with hot tea and soup. Sometimes, due to the neglect of the parents, the child may even drink a chemical liquid, which has a damaging effect on both the oral cavity and the esophagus.

Degrees

• "Panthenol";
• Olazol;
• Solcoseryl;
• anti-burn gel dressings.

Folk remedies can also be helpful:

• mask of raw grated potatoes;
• cabbage leaf (a cooled leaf is applied to the wound);
• fresh aloe leaf (used without the skin).

The main thing in emergency situation do not panic and remember how to treat a burn in a child. From the parents, it will be enough to provide first aid, the doctor will do the rest. Stay confident and avoid tantrums in the baby, try to numb the injury immediately after the incident.

RCHD (Republican Center for Healthcare 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 Thermal burns of the head and neck first degree (T20.1), Thermal burns of the wrist and hand first degree (T23.1), Thermal burns of the ankle and foot first degree (T25 .1), Thermal burn of the shoulder girdle and upper limb, excluding wrist and hand, first degree (T22.1), Thermal burn of the area hip joint and lower extremities, excluding ankle and foot, first degree (T24.1), Thermal first degree torso burn (T21.1), Chemical burns classified by area of ​​the affected body surface (T32), First degree chemical burns to the head and neck degree (T20.5), Chemical burns of the wrist and hand, first degree (T23.5), Chemical burns of the ankle and foot, first degree (T25.5), Chemical burns of the shoulder girdle and upper limb, excluding the wrist and hand, first degree (T22.5), Chemical burn of the hip and lower limb, excluding ankle and foot, first degree (T24.5), Chemical burn of the trunk of the first degree (T21.5)

Pediatric combustiology, Pediatrics

general information

Short description

Approved
Joint Commission on the Quality of Medical Services
Ministry of Health and social development Republic of Kazakhstan
dated June 09, 2016
Protocol No. 4

Burns -

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

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

In the process of development burn disease there are 4 main periods (stages) of its course:
Burn shock,
Burn toxemia,
Septicotoxemia,
· Convalescence.

Date of protocol development: 2016 year

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

Evidence level scale:

A	High quality meta-analysis, systematic review of RCTs, or large RCTs with very low likelihood (++) of bias that can be generalized to the relevant population.
V	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias that can be generalized to the relevant population ...
WITH	A cohort or case-control study or controlled study without randomization with a low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly extended to the relevant population.
D	Case series description or uncontrolled research or expert opinion.

Classification

Classification [ 2]

1. By the 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) chemical (industrial chemical substances, household chemicals)
4) radiation or radiation (solar, damage from a radioactive source)

2. By the depth of the lesion:
1) Surface:



2) Deep:

3. By the factor of influence of the external environment:
1) physical
2) chemical

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

Diagnostics (outpatient clinic)

DIAGNOSTICS AT THE AMBULATORY LEVEL

Diagnostic criteria

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

Anamnesis:

Physical examination: estimate general state(consciousness, the color of intact skin, the state of breathing and cardiac activity, blood pressure, heart rate, respiratory rate, the presence of 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 at the stage inpatient care.

Diagnostics (ambulance)

DIAGNOSTICS AT THE STAGE OF EMERGENCY EMERGENCY

Diagnostic measures:
· Collection of complaints and anamnesis;
· Physical examination (measurement of blood pressure, temperature, pulse counting, calculation of NPV) with an assessment of the general somatic status;
· Examination of the lesion site with an assessment of the area and depth of the burn;
· ECG in case of electrical injury, lightning.

Diagnostics (hospital)

DIAGNOSTICS AT STATIONARY LEVEL

Diagnostic criteria at the inpatient level:

Complaints: 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, respiratory and cardiac activity, blood pressure, heart rate, respiratory rate, the presence of 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 research:
... ECG for electrical injury, lightning.

Diagnostic algorithm

2) The “palm” method - the area of ​​the scalded person's palm is approximately 1% of the surface of his body.

3) Estimation of the depth of the burn:

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

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

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

The area and depth of the lesion are written as a fraction, in the numerator of which is indicated total area burn and next in brackets - the area of ​​deep lesion (in percentage), and in the denominator - the degree of burn.

An example of a diagnosis: Thermal burn (boiling water, steam, flame, contact) 28% PT (SB - IV = 12%) / I-II-III AB-IV degree of the back, buttocks, left lower limb. Severe burn shock.
For greater clarity, a skitsa (diagram) is put into the history of the disease, on which the area, depth and localization of the burn are graphically recorded using symbols, while superficial burns (I-II st.) Are painted over in red, III AB st. - in blue and red, IV Art. - in blue.

Predictive indices of thermal injury severity.

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

Table 1 Burn Shock Diagnostic Criteria

Signs	Shock I degree (mild)	Shock II degree (severe)	Shock III degree (extremely severe)
1. Violation of behavior or consciousness	Excitation	Alternating arousal and stunning	Stunning-sopor-coma
2. Changes in hemodynamics a) heart rate b) HELL C) CVP d) microcirculation	> norms by 10% Normal or increased + marbling	> norms by 20% Norm 0 spasm	> norms by 30-50% 30-50% - acrocyanosis
3. Dysuric disorders	Moderate oliguria	oliguria	Severe oliguria or anuria
4.Hemo concentration	Hematocrit up to 43%	Hematocrit up to 50%	Hematocrit above 50%
5. Metabolic disorders(acidosis)	BE 0 = -5 mmol / l	BE -5 = -10 mmol / l	BE< -10 ммоль/л
6.disorders of the gastrointestinal tract a) Vomiting b) Bleeding from the gastrointestinal tract			More than 3 times

List of main diagnostic measures:

List of additional diagnostic measures:

Laboratory:
· Biochemical blood test (bilirubin, AST, ALT, total protein, albumin, urea, creatinine, residual nitrogen, glucose) - for verification of SPON and examination before surgery (LE A);
· Blood electrolytes (potassium, sodium, calcium, chlorides) - to assess the water-electrolyte balance and examination before surgery (LE A);
· Coagulogram (PT, TV, PTI, APTT, fibrinogen, INR, D-dimer, PDF) - to diagnose coagulopathies and DIC syndrome and examination before surgery in order to reduce the risk of bleeding (LE A);
· Blood for sterility, blood for blood culture - for verification of the pathogen (UD A);
· Indicators of the acid-base state of 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 - diagnostics in case of suspicion of a hospital staphylococcus strain (UD C);
· Determination of daily losses of urea with urine - to determine the loss of daily nitrogen and calculate the nitrogen balance, with negative dynamics of weight and the clinic of hypercatabolism syndrome (UD V);
· Determination of procalcitonin in blood serum - for the diagnosis of sepsis (LE A);
· Determination of presepsin in blood serum - for the diagnosis of sepsis (LE A);
· Thromboelastography - for a more detailed assessment of hemostasis disorders (LE B);
· Immunogram - to assess the immune status (UD V);
· 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 x-ray - for the diagnosis of toxic pneumonia and thermal inhalation lesions (UD A);
Ultrasound of the abdominal cavity and kidneys, pleural cavity, NSG (children under 1 year old) - to assess the toxic damage to internal organs and identify background 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 (UD C);
Measurement of CVP, if central vein and unstable hemodynamics for the assessment of BCC (LE C);
EchoCG to assess the state of the cardiovascular system (UD A));
· Monitors with the possibility of invasive and non-invasive monitoring of the main indicators of central hemodynamics and myocardial contractility (Doppler, PiCCO) - in case of acute heart failure and shock of 2-3 degrees in unstable condition (LE B));
· Indirect calorimetry, shown to patients in OARIT on mechanical ventilation - to monitor the true energy consumption, with hypercatabolism syndrome (UD V);
· FGDS - for the diagnosis of burn stress ulcers of Kurling, as well as for setting a transpyloric probe for gastrointestinal paresis (UD A);
· Bronchoscopy - for thermal inhalational lesions, for TBD lavage (UD A);

Differential diagnosis

Differential diagnosis and justification for additional research: not performed, careful history taking is recommended.

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Treatment

Preparations (active ingredients) used in the treatment

Azithromycin (Azithromycin)

Albumin human

Amikacin

Aminophylline

Amoxicillin

Ampicillin

Aprotinin

Benzylpenicillin (Benzylpenicillin)

Vancomycin (Vancomycin)

Gentamicin

Heparin sodium

Hydroxymethylquinoxalindioxide (Dioxidine)

Hydroxyethyl starch

Dexamethasone

Dexpanthenol

Dextran

Dextrose

Diclofenac (Diclofenac)

Dobutamine

Dopamine

Doripenem

Ibuprofen

Imipenem

Potassium chloride

Calcium chloride

Ketorolac (Ketorolac)

Clavulanic acid

Platelet concentrate (CT)

Cryoprecipitate

Lincomycin (Lincomycin)

Meropenem

Metronidazole (Metronidazole)

Milrinone

Morphine

Sodium chloride

Nitrofural

Norepinephrine

Omeprazole (Omeprazole)

Ofloxacin

Paracetamol (Paracetamol)

Pentoxifylline

Plasma, fresh frozen

Povidone - iodine (Povidone - iodine)

Prednisolone

Procaine

Protein C, Protein S (Protein C, Protein S)

Ranitidine

Sulbactam

Sulfanilamide

Tetracycline (Tetracycline)

Ticarcillin (Ticarcillin)

Tramadol (Tramadol)

Tranexamic acid

Trimeperidine

Coagulation Factor II, VII, IX and X in combination (Prothrombin complex)

Famotidine

Fentanyl

Phytomenadione

Chinifuryl (Chinifurylum)

Chloramphenicol

Cefazolin (Cefazolin)

Cefepime

Cefixime

Cefoperazone

Cefotaxime (Cefotaxime)

Cefpodoxime (Cefpodoxime)

Ceftazidime

Ceftriaxone

Cilastatin

Esomeprazole

Epinephrine

Erythromycin

Erythrocyte mass

Ertapenem

Etamsylate

Groups of drugs according to ATC used in treatment

(A02A) Antacids

(R06A) Antihistamines for systemic use

(B01A) Anticoagulants

(A02BA) Histamine H 2 receptor blockers

(C03) Diuretics

(J06B) Immunoglobulins

(A02BC) Proton pump inhibitors

(A10A) Insulins and their analogues

(C01C) Cardiac drugs (excluding cardiac glycosides)

(H02) Systemic corticosteroids

(M01A) Non-steroidal anti-inflammatory drugs

(N02A) Opioids

C04A Peripheral vasodilators

(A05BA) Drugs for the treatment of liver diseases

B03A Iron supplements

(A12BA) Potassium supplements

(A12AA) Calcium supplements

(B05AA) Blood plasma and plasma substitutes

(R03DA) Xanthine derivatives

(J02) Antifungal agents for systemic use

(J01) Antimicrobial drugs for system use

(B05BA) Parenteral nutrition solutions

Treatment (outpatient clinic)

TREATMENT AT THE AMBULATORY LEVEL

Treatment tactics

Drug-free treatment:
· General mode.
· Table number 11 - a balanced vitamin and protein diet.
· An increase in water load, taking into account possible restrictions due to concomitant diseases.
· Treatment under the supervision of the medical staff of outpatient institutions (traumatologist, surgeon of the polyclinic).

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

List of essential medicines:
Topical agents (LE D).
Ointments containing chloramphenicol (levomekol, levosin)
Ointments containing ofloxacin (oflomelid)
Ointments containing dioxidine (5% dioxidine ointment, dioxycol, methyldioxylin, 10% mafenide acetate ointment)
Ointments containing iodophores (1% iodopyrone ointment, betadine ointment, iodometrixilene)
Ointments containing nitrofurans (furagel, 0.5% quinifuril ointment)
Fat-based ointments (0.2% furacillin ointment, streptocid liniment, gentamicin ointment, polymyxin ointment, teracycline, erythromycin ointment)
Wound coverings (UD C):
· Antibacterial spongy dressings adsorbing exudate;


Cooling dressings with hydrogel
Aerosol preparations: panthenol (UD V).

List of additional medicines: no.

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

Indications for consultation with specialists: does not need.
Preventive measures: no.

Patient monitoring: dynamic monitoring of the child, dressings in 1-2 days.

Treatment effectiveness indicators:
· No pain in burn wounds;
Lack of signs of infection:
· Epithelialization of burn wounds 5-7 days after receiving burns.

Treatment (ambulance)

EMERGENCY STAGE TREATMENT

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 i / m use is trimeperidine (UDA).
Infusion therapy: at the rate of 20 ml / kg / h, starting solution Sodium chloride 0.9% or Ringer's solution.

Treatment (hospital)

STATIONARY TREATMENT

Treatment tactics

The choice of tactics for treating burns in children depends on the age, area and depth of burns, premorbid background and concomitant diseases, from the stage of development of burn disease and possible development its complications. Medical treatment is indicated for all burns. Surgical treatment is indicated for deep burns. In this case, the tactics and principle of treatment are selected in order to prepare burn wounds for surgery and create conditions for engraftment of transplanted skin grafts, prevention of post-burn scars.

Drug-free treatment

· Mode: general, bed, semi-bed.

· Nutrition:
a) The patients burn department who are on enteral nutrition over 1 year old - diet number 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 breast-feeding or artificial feeding
(adapted milk formulas, enriched with protein) + complementary foods (children over 6 months old).
b) In most burn patients, how the response to injury develops hypermetabolism-hypercatabolism syndrome, which is characterized by (UD A):
· Dysregulatory changes in the "anabolism-catabolism" system;
· A sharp increase in the need for energy donors and plastic material;
· An increase in energy demand with a parallel development of pathological tolerance of body tissues to "common" nutrients.

The result of the formation of the syndrome is the development of resistant 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 the syndrome of hypermetabolism-hypercatabolism, it is necessary:
1) determination of the degree of nutritional deficiency
2) determination of metabolic requirements (by calculation method or indirect calorimetry)
3) carrying out metabolic monitoring (at least once a week)

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

Degree Parameters	Easy	Average	Heavy
Albumin (g / L)	28-35	21-27	<20
Total protein (g / L)	>60	50-59	<50
Lymphocytes (abs.)	1200-2000	800-1200	<800
MT deficit (%) 10-20 21-30> 30	10-20	21-30	>30

· For this group of patients, it is recommended to prescribe additional pharmacological nutrition - mixtures for siping (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 (LE B).
· Consumption of high doses of vitamin C leads to stabilization of the endothelium, thereby reducing capillary leakage (LEV). Recommended doses: ascorbic acid 5% 10-15 mg / kg.

c) Enteral tube feeding it is introduced by the drip method, within 16-18 hours a day, less often - by the fractional method. In most children in critical conditions, a delayed evacuation of contents from the stomach and volume intolerance are formed, therefore, the drip method of introducing enteral nutrition is preferable. Also, regular opening of the probe is not required, unless there is an urgent reason (bloating, vomiting, or retching). The environments used for food must be adapted (LEV).

d) Technique for the treatment of intestinal insufficiency syndrome (SKN) (LE B).
In the presence of stagnant intestinal contents in the stomach, lavage is carried out to clean wash water. Then the stimulation of peristalsis begins (motilium at an age-specific dose, or erythromycin in powder at a dose of 30 mg per year of life, but not more than 300 mg once, 20 minutes before an enteral feeding attempt). The first injection of fluid is carried out by drop, 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.
Upon receipt negative result(no passage of the mixture through the gastrointestinal tract and the presence of discharge through the probe more ½ volume injected), the installation of a transpyloric or nasojejunal probe is recommended.

e) Contraindications for enteral / tube feeding:
· Mechanical intestinal obstruction;
· Ongoing gastrointestinal bleeding;
Acute destructive pancreatitis (severe course) - only the introduction of liquid

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

g) Contraindications for parenteral nutrition:
· Development of refractory shock;
· Overhydration;
· Anaphylaxis to the components of nutrient media.
· Not eliminated hypoxemia against the background of ARDS.

Respiratory therapy:

Indications for transfer to mechanical ventilation (UD A):

General principles of mechanical ventilation:
· Intubation should be performed 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 state of the lungs is determined by the oxygenation index (OI) - PaO2 / FiO2: mild - OI< 300, средне тяжелый - ИО < 200 и тяжелый - ИО < 100(УД А);
Some patients with ARDS may receive non-invasive ventilation for respiratory distress medium severity. Such patients should be with stable hemodynamics, awake, in a comfortable environment, with regular airway sanitation (LE B);
· In patients with ARDS, the tidal volume is 6 ml / kg (target body weight) (LEV B).
· It is possible to increase the partial pressure of CO2 (permissive hypercapnia) to decrease the plateau pressure or the volume of the oxygen mixture (UD C);
· It is necessary to regulate the value of positive expiratory pressure (PEEP) depending on the IO - the lower the IO, the higher the PEEP (from 7 to 15 cm of water column), taking into account hemodynamics (UD A);
· Use the maneuver of opening the alveoli (recruitment) or HF, in patients with difficult to treat acute hypoxemia (LE C);
· Patients with severe ARDS may lie on their stomach (prone position), unless it is risky (LE C);
· Patients undergoing mechanical ventilation should be in a reclining position (if not contraindicated) (LE B), the head end of the bed should be raised by 30-45 ° (LE C);
With a decrease in the severity of ARDS, one should strive to transfer the patient from mechanical ventilation to support spontaneous breathing;
· It is not recommended to carry out long-term drug sedation 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) with early ARDS and with IO 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 is the patient's physiological need;
The first 8 hours - ½ of the calculated volume of liquid, then the second and third 8-hour intervals - ¼ of the calculated volume.
2nd and next dayVtotal = 1x body weight (kg) x% burn + FP
With a burn area of ​​more than 50%, the infusion volume should be calculated at a maximum of 50%.
In this case, the volume of infusion should not exceed 1/10 of the child's weight, the remaining volume is recommended to be administered per os.

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

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

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

Isogenic protein drugs (plasma, albumin) are used no earlier than 2 days after injury, however, their early administration is justified for use in starting therapy only in case of arterial hypotension, early development DIC syndrome (UD A).
They retain water in the bloodstream (1 g of albumin binds 18-20 ml of fluid), prevent dyshydria. Protein preparations are transfused for 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 safe and efficacious as well as crystalloids (LEO C).

For burn shock with severe impairments microcirculation and hypoproteinemia below 60 g / l, hypoalbuminemia below 35 g / l. The calculation of the required dose of albumin can be made on the basis 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) Components of blood (UD A):
Criteria and indications for prescription and transfusion
erythrocyte-containing blood components during the neonatal period are: the need to maintain a hematocrit above 40%, hemoglobin above 130 g / l in children with severe cardiopulmonary pathology; with moderately severe cardiopulmonary insufficiency, the hematocrit level should be above 30% and hemoglobin above 100 g / l; in a stable state, as well as when carrying out small planned operations, 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 readings: (Нb norm - Нb of the patient x weight (in kg) / 200 or by hematocrit: Нt - Ht of the patient x BCC / 70.

The transfusion rate of EO is 2-5 ml / kg of body weight per hour under the obligatory control of hemodynamic and respiratory parameters.
· Do not use erythropoietin to treat anemia caused by sepsis (septicotoxemia) (LEVEL 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 prior heparin therapy).

The dosage of FFP should be based on the patient's body weight: 12-20 ml / kg regardless of age.
A transfusion of platelet concentrate (LE 2D) should be given when:
- the number of platelets is<10х109/л;
- the number of platelets 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 when it is necessary to limit the volume of parenteral administration of fluids.

The calculation of the need for cryoprecipitate transfusion is 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 (factor VIII level required - factor VIII level available) = amount of factor VIII required for transfusion (IU).

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

In the absence of the possibility of determining factor VIII, the calculation of the need is carried out on the basis of: one unit dose of cryoprecipitate per 5-10 kg of the recipient's body weight.
· All transfusions are carried out in accordance with the 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 the rules for storage, transfusion of blood, its components and preparations" , as amended by the Order of the Ministry of Health of the Republic of Kazakhstan No. 501 dated July 26, 2012;

Pain relief (UD 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 action of narcotic analgesics. The preferred form of administration is parenteral.

Table 3 - List of narcotic and non-narcotic analgesics

Drug name	Dosage and age restrictions	Note
Morphine	Subcutaneous injection (all doses are adjusted according to response): 1-6 months —100-200 mcg / kg every 6 hours; 6 months to 2 years -100-200 mcg / kg every 4 hours; 2-12 years -200 mcg / kg every 4 hours; 12-18 years old - 2.5-10 mg every 4 hours. When administered intravenously for 5 minutes, then by continuous intravenous infusion 10- 30 μg / kg / hour (adjustable depending on the answer);	Dosages are prescribed based on the recommendations of BNF children. In the official instructions, the drug is allowed from 2 years old.
Trimeperidine	Children over 2 years old, depending on age: for children 2-3 years old, a single dose is 0.15 ml of a 20 mg / ml solution (3 mg of trimeperidine), the maximum daily dose is 0.6 ml (12 mg); 4-6 years: single - 0.2 ml (4 mg), maximum daily dose - 0.8 ml (16 mg); 7-9 years: single - 0.3 ml (6 mg), maximum daily intake - 1.2 ml (24 mg); 10-12 years: single - 0.4 ml (8 mg), maximum daily intake - 1.6 ml (32 mg); 13-16 years old: single - 0.5 ml (10 mg), maximum daily intake - 2 ml (40 mg).	The dosage of the drug is from the official instructions for the drug Promedol RK-LS-5 No. 010525, there is no drug in BNF children.
Fentanyl	W / m 2mkg / kg	The dosages of the drug are from the official instructions for the drug fentanyl RK-LS-5 # 015713, in BNF children it is recommended to be administered percutaneously in the form of a patch.
Tramadol	For children aged 2 to 14 years, the dose is set at the rate of 1-2 mg / kg of body weight. The daily dose is 4-8 mg / kg of body weight, divided into 4 administrations.	The dosage of the drug from the official instructions for the drug tramadol-M RK-LS-5 No. 018697, BNFchildren recommends the drug from the age of 12.
Ketorolac	IV: 0.5-1 mg / kg (max. 15 mg) followed by 0.5 mg / kg (max. 15 mg) every 6 hours as needed; Maximum. 60 mg daily; The course is 2-3 days 6 months to 16 years (parenteral form).	i / v, i / m introduction for at least 15 seconds. The enteral form is contraindicated until the age of 18, the dosages are from BNF children, in the official instructions the drug is allowed from the age of 18.
Paracetamol	Per os: 1-3 months 30-60 mg every 8 hours; 3-12 months 60-120 mg every 4-6 hours (Max. 4 doses in 24 hours); 1–6 years 120–250 mg every 4–6 hours (max. 4 doses in 24 hours); 6-12 years 250-500 mg every 4-6 hours (max. 4 doses in 24 hours); 12-18 years old 500 mg every 4-6 hours. Per rectum: 1-3 months 30-60 mg every 8 hours; 3-12 months 60-125 mg every 6 hours as needed; 1-5 years 125-250 mg every 6 hours; 5-12 years 250-500 mg every 6 hours; 12-18 years old 500 mg every 6 hours. Intravenous infusion over 15 minutes. Child weighing less than 50 kg 15 mg / kg every 6 hours; Maximum. 60 mg / kg per day. Child weighing more than 50 kg 1 g every 6 hours; Maximum. 4 g per day.	intravenous administration for at least 15 seconds, the recommended form of administration is Per rectum. Dosages from BNFchildren, in official instructions parenteral form from 16 years of age.
Diclofenac sodium	Per os: 6 months to 18 years 0.3-1 mg / kg (max. 50 mg) 3 times a day for 2-3 days. Perrectum: 6-18 years old 0.5-1 mg / kg (max. 75 mg) 2 times a day for max. 4 days. IV infusion or deep IV injections 2-18 years 0.3-1 mg / kg once or twice daily for a maximum of 2 days (max. 150 mg per day).	Forms for intramuscular injection registered in Kazakhstan. Dosages from BNF children, in official instructions parenteral form from 6 years of age.

Antibiotic therapy (UD A) :

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

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

Name of drugs	Doses (from official instructions)
Benzylpenicillin sodium	50-100 U / kg in 4-6 receptions NB!!!
Ampicillin	newborns - 50 mg / kg every 8 hours in the first week of life, then 50 mg / kg every 6 hours IM children weighing up to 20 kg - 12.5-25 mg / kg every 6 hours. NB!!! not effective against strains of staphylococcus that form penicillinase and against most gram-negative bacteria
Amoxicillin + sulbactam	For children under 2 years old - 40-60 mg / kg / day in 2-3 doses; for children from 2 to 6 years old - 250 mg 3 times a day; from 6 to 12 years old - 500 mg 3 times a day.
Amoxicillin + clavulanate	From 1 to 3 months (weighing more than 4 kg): 30 mg / kg of body weight (in terms of the total dose of active substances) every 8 hours, if the child weighs less than 4 kg - every 12 hours. from 3 months to 12 years: 30 mg / kg of body weight (in terms of the total dose of active substances) with an interval of 8 hours, in case of a severe course of infection - with an interval of 6 hours. Children over 12 years of age (weight over 40 kg): 1.2 g of the drug (1000mg + 200mg) with an interval of 8 hours, in case of a severe course of infection - with an interval of 6 hours. NB!!! Each 30 mg of the drug contains 25 mg of amoxicillin and 5 mg of clavulanic acid.
Ticarcillin + clavulonic acid	Children weighing more than 40 kg 3 g of ticarcillin every 6-8 hours. The maximum dose is 3 g of ticarcillin every 4 hours. Children under 40 kg and newborns. The recommended dose for children is 75 mg / kg body weight every 8 hours. The maximum dose is 75 mg / kg body weight every 6 hours. Premature babies weighing less than 2 kg 75 mg / kg every 12 hours.
Cefazolin	1 month and older - 25-50 mg / kg / day divided into 3 - 4 injections; for severe infections - 100 mg / kg / day NB!!! Indicated for use only for surgical antibiotic prophylaxis.
Cefuroxime	30-100 mg / kg / day in 3-4 injections. For most infections, the optimal daily dose is 60 mg / kg. NB!!! According to WHO recommendations, it is not recommended for use, as it forms a high resistance of microorganisms to antibiotics.
Cefotaxime	Premature up to 1 week of life 50-100 mg / kg in 2 administrations with an interval of 12 hours; 1-4 weeks 75-150 mg / kg / day IV in 3 injections. For children under 50 kg, the daily dose is 50-100 mg / kg, in equal doses at intervals of 6-8 hours. The daily dose should not exceed 2.0 g. Children of 50 kg or more are prescribed in the same dose as for adults. 2.0 g with an interval of 8-12 hours.
Ceftazidime	Up to 1 month - 30 mg / kg per day (frequency of 2 injections). From 2 months to 12 years - intravenous infusion of 30-50 mg / kg per day (frequency of 3 injections). The maximum daily dose for children should not exceed 6g.
Ceftriaxone	For newborns (up to two weeks of age) 20-50 mg / kg / day. Infants (from 15 days) and up to 12 years of age, the daily dose is 20-80 mg / kg. In children from 50 kg and more, an adult dosage of 1.0-2.0 g is used once a day or 0.5-1 g every 12 hours.
Cefixime	A single dose for children under 12 years of age is 4-8 mg / kg, daily 8 mg / kg of body weight. Children weighing more than 50 kg or over 12 years old should receive the recommended dose for adults, daily dose - 400 mg, single 200-400 mg. The average duration of the course of treatment is 7-10 days. NB!!! The only 3-generation cephalosporin used per os.
Cefoperazone	The daily dose is 50-200 mg / kg of body weight, which is administered in equal parts in 2 doses, the duration of administration is at least 3-5 minutes.
Cefpodoxime	Contraindicated under 12 years of age.
Cefoperazone + sulbactam	The daily dose is 40-80 mg / kg in 2-4 doses. For serious infections, the dose can be increased to 160 mg / kg / day for a 1: 1 ratio of the main components. The daily dose is divided into 2-4 equal parts.
Cefepim	Contraindicated in children under 13 years of age
Ertapenem	Infants and children (aged 3 months to 12 years) 15 mg / kg 2 times / day (not exceeding the dose of 1 g / day) intravenously.
Imipenem + cilastatin	Over 1 year 15/15 or 25/25 mg / kg every 6 hours.
Meropenem	3 months to 12 years 10-20 mg / kg every 8 hours
Doripenem	The safety and effectiveness of the drug in the treatment of children under the age of 18 has not been established.
Gentamicin	Children under the age of 3 years are prescribed gentamicin sulfate exclusively for health reasons. Daily doses: newborns 2 - 5 mg / kg, children aged 1 to 5 years - 1.5 - 3 mg / kg, 6 - 14 years old - 3 mg / kg. The maximum daily dose for children of all age groups is 5 mg / kg. The drug is administered 2 to 3 times a day.
Amikacin	Contraindications for children under 12 years of age
Erythromycin	Children from 6 years old to 14 years old are prescribed in a daily dose of 20-40 mg / kg (in 4 divided doses). Multiplicity of appointment is 4 times. NB!!! Works as a prokinetic. See power section.
Azithromycin	on day 1, 10 mg / kg of body weight; in the next 4 days - 5 mg / kg once a day.
Vancomycin	10 mg / kg and injected intravenously every 6 hours.
Metronidazole	From 8 weeks to 12 years - a daily dose of 20-30 mg / kg as a single dose or 7.5 mg / kg every 8 hours. The daily dose may be increased to 40 mg / kg, depending on the severity of the infection. Children under 8 weeks of age - 15 mg / kg as a single dose daily or 7.5 mg / kg every 12 hours. The course of treatment is 7 days.

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

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

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

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 repeated dose is required for:
· Long-term and traumatic surgery for more than 4 hours;
· Prolonged respiratory support in the postoperative period (more than 3 hours).

Correction of hemostasis :

Table 5 - Differential diagnosis

phase	Platelet count	PV	APTT	Fibri-nogen	Coagulation factor vania	ATIII	RMFK	D-dimer
Hypercoagulation	N	N	N / ↓	N /	N	↓	N /	N /
Hypocoagulation	↓↓			↓↓	↓↓	↓↓

Anticoagulants (UD A):

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

Correction of Plasma Factor Deficiency (UD A):
· Fresh frozen plasma donation - indications and dose are described above (LE A).
· Cryoprecipitate donation - indications and doses are described above (LE A).
Complex blood coagulation factor: II, IX, VII, X, Protein C, Protein S-
with a shortage and limited volumes (UD A).

Antifibrinolytic therapy:

Table 5 - Antifibrinolytic drugs.

*

the drug is excluded from the RLF.

Hemostatics:
Etamsylate is indicated for capillary bleeding and thrombocytopenia
(UD V).
· Fitomenadion is prescribed for hemorrhagic syndrome with hypoprothrombenemia (LE 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 endothelial damage caused by them, 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 its use in children. The BNF of children also does not have a drug, but the Cochrane Library has randomized and quasi-randomized trials evaluating the efficacy of pentoxifylline as an adjunct to antibiotics for the treatment of children with suspected or confirmed neonatal sepsis. Pentoxifylline added to antibiotic treatment has reduced sepsis mortality in neonates, 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 (LE D).

Xanthine derivatives
Aminophylline has a peripheral venodilatory effect, reduces pulmonary vascular resistance, lowers pressure in the "small" circle of blood circulation. Increases renal blood flow, has a moderate diuretic effect. Expands the extrahepatic biliary tract. It inhibits platelet aggregation (inhibits platelet activation factor and PgE2 alpha), increases the resistance of erythrocytes 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 algorithm for the treatment of burn shock (UD D).

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

Table 7 - List of drugs used to prevent stress ulcers

Name	Doses from BNF, since in the instructions these drugs are contraindicated in childhood.
Omeprazole	Introduced IV over 5 minutes or by IV infusion from 1 month to 12 years, initial dose of 500 micrograms / kg (max. 20 mg) once a day, increased to 2 mg / kg (max. 40 mg) once a day day, if necessary, 12-18 years 40 mg once daily. Per os from 1 month to 12 years 1-2 mg / kg (max. 40 mg) once a day, 12-18 years 40 mg once a day. For young children, a liquid form of release is recommended, since the drug is disinactivated when the capsules are opened.
Esomeprazole	Per os from 1-12 years old with a weight of 10-20 kg 10 mg once a day, with a weight over 20 kg 10-20 mg once a day, from 12-18 years old 40 mg once a day.
Ranitidine	Per os newborns 2 mg / kg 3 times a day, maximum 3 mg / kg 3 times a day, 1-6 months 1 mg / kg 3 times a day; maximum 3 mg / kg 3 times a day, from 6 months to 3 years 2-4 mg / kg twice a day, 3-12 years 2-4 mg / kg (max. 150 mg) twice a day; up to max. 5 mg / kg (max. 300 mg) twice a day, 12-18 years old 150 mg twice a day or 300 mg at night; increase if necessary, up to 300 mg twice daily or 150 mg 4 times a day for 12 weeks. IV neonates 0.5-1 mg / kg every 6-8 hours, 1 month 18 years 1 mg / kg (max. 50 mg) every 6-8 hours (can be subsidized as intermittent infusion at a rate of 25 mg / hour ). I / O forms are not registered in the RK.
Famotidine	No data were found for permission to use this drug in childhood.

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

Inotropic therapy: Table 8 - Inotropic myocardial support (LE A):

Name drugs	Receptors	Contract-ness	hs	constriction	Vasodi-lation	Dosage in μg / kg / min
Dopamine	DA1, α1, β1	++	+	++		3-5 DA1, 5-10 β1, 10-20 α1
Dobutamine *	β1	++	++	-	+	5-10 β1
Adrenalin	β1, β2 α1	+++	++	+++	+/-	0,05-0,3β 1, β 2 , 0.4-0.8 β1, β2 α1, 1-3 β1, β2 α 1
Noradrene-lin *	β1, α1	+	+	+++	-	0.1-1 β1, α1
Milrinon *	Inhibiting the isozyme phosphodiesterase III in the myocardium	+++	+	+/-	+++	first, a "loading dose" is administered - 50 μg / kg for 10 minutes; then - a maintenance dose of 0.375-0.75 μg / kg / min. The total daily dose should not exceed 1.13 mg / kg / day

*

drugs are not registered in the Republic of Kazakhstan, however, upon request, they are imported as a single import.

Corticosteroids: prednisolone is prescribed intravenously in case of burn shock of 2-3 degrees of severity, in a course of 2-3 days (UD V)

Table 9 - Corticosteroids

Correction of stress hyperglycemia:

· With caution interpret the level of glucose in capillary blood, more accurately the determination of glucose in arterial or venous blood (LE B).
· It is recommended to start dosing insulin when 2 consecutive blood glucose values> 8 mmol / L. The goal of insulin therapy is to maintain blood glucose levels below 8 mmol / L (ELB);
· The carbohydrate load during parenteral nutrition should not exceed 5 mg / kg / min (UD V).

Diuretics (LE A) :
Contraindicated on the first day, due to the high risk of hypovolemia.
It is prescribed in the following days with oliguria and anuria, in age-related dosages.

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

Antianemic drugs (LE A): if indicated, refer to the clinical protocol for iron deficiency anemia in children. MH RK No. 23 dated December 12, 2013.
With thermal inhalational lesion or with the addition of secondary pneumonia, are shown inhalation with mucolytics, bronchodilators and inhaled glucocorticosteroids.

Essential Medicines List: narcotic analgesics, NSAIDs, antibiotics, proton pump inhibitors or H2 histamine blockers, peripheral vasodilators, xanthine derivatives, anticoagulants, corticosteroids, dextran, glucose 5%, 10%, saline 0.9% or Ringer's solution, Ca 2+ and K + preparations, preparations for local treatment.
The list of additional drugs, depending on the severity of the course and complications: erythrocyte-containing blood products, FFP, albumin, hemostatics, diuretics, immunoglobulins, inotropic drugs, parenteral nutrition (glucose 15%, 20%, amino acid solutions, fat emulsions), iron preparations, HES, antihistamines, antacids, hepatoprotectors, antifungals.

Surgery [ 1,2, 3]:

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

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

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

Indications to early surgical necrectomy (Burmistrova 1984):
With localization of a deep burn mainly on the limbs,
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:
An extremely serious general condition in early dates after injury due to the vastness total defeat
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 wet necrosis in burn wounds.

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

IV. Alloplasty and xenoplasty - allogeneic and xenogenic skin is used as a temporary wound covering for wounds in case of extensive burns, due to the lack of donor resources. After a while, it becomes necessary 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 the start of treatment, the area and depth of the burn lesion, the localization of the burn, the stage of the course of the wound process planned surgical tactics treatment, as well as the availability of appropriate equipment, drugs and dressings.

Table 10 - Algorithm for local treatment of burn wounds

Degree of burn	Morphological signs	Clinical signs	Features of local treatment
II	Death and desquamation of the epithelium	Pink wound surface devoid of epidermis	Dressings with PEG-based ointments (ointments containing chloramphenicol, dioxidine, nitrofurans, iodophores). Change of dressings in 1-2 days
IIIA	Death of the epidermis and part of the dermis	White patches of ischemia or purple wound surfaces followed by a thin, dark scab	Surgical necrectomy, staged scab removal during dressings, or spontaneous scab rejection when dressing is changed. PEG-based dressings (levomekol, levosin). Change of dressings in 1-2 days
IIIB	Total death of the epidermis and dermis	White areas of the so-called. "Pigskin" or dark thick scab	1.Before NE surgery, dressings with antiseptic solutions for quick drying of a scab, prevention of perifocal inflammation, reduction of intoxication. Change of dressings daily. 2. In case of a local burn and the impossibility of performing NE - the imposition of a keratolytic ointment for 2-3 days to reject the scab. 3. After NE in the early stages, the use of solutions and ointments on PEG, then ointments on a fat basis, stimulating regeneration. With the development of hypergranulations - ointments containing corticosteroids.

Table 11 - The main classes of antimicrobial substances used in the local treatment of burn wounds (LE D).

Mechanism of action	Main representatives
Oxidants	3% hydrogen peroxide solution, potassium permanganate, iodophores (povidone-iodine)
Inhibitors of synthesis and metabolism nucleic acids	Dyes (ethacridine lactate, dioxidine, quinoxidine, etc.) Nitrofurans (furacillin, furagin, nitazol).
Disruption of the structure of the cytoplasmic membrane	Polymyxins Chelating agents (Ethylenediaminetetraacetic acid (EDTA, Trilon-B)), Surfactants (Roccal, 50% aqueous solution of alkyldimethylbenzylammonium chloride (Catamine AB, Catapol, etc.) Cationic antiseptics (Chlorhexidine Mira, decamethoxin). Ionophores (valinomycin, gramicidin C, amphotericin, etc.)
Silver preparations	Silver sulfathiazyl 2% (Argosulfan), sulfadiazine silver salt 1% (sulfargin), silver nitrate.
Suppression of protein synthesis	Antibiotics included in multicomponent ointments: 1) chloramphenicol (levomekol, levosin), 2) ofloxocin (oflomelid), 3) tyrothricin (tyrosur), 4) lincomycin, 5) erythromycin, 6) tetracycline, 7) sulfonamides (sulfadiazine, dermazine , streptocide), etc.)

Wound dressings that shorten healing time (LE C):
· Antibacterial spongy dressings adsorbing exudate;
· Soft silicone coatings with adhesive properties;
· Contact patch for a wound with a polyamide mesh with an open cellular structure.
Drugs used to cleanse wounds from dead tissue (LE D):
Keratolytics (salicylic ointment 20-40%, 10% benzoic acid),
· Enzymes (trypsin, chymotrypsin, cathepsin, collagenase, gelatinase, streptokinase, grass, asperase, esterase, pankepsin, elestolitin).

Other treatments

Detoxification methods: ultrafiltration, hemodiafiltration, hemodialysis, peritoneal dialysis.
Indications:
· To support the life of a patient with irreversible lost kidney function.
For the purpose of detoxification in sepsis with multiple organ failure, therapeutic plasma exchange can be performed with removal and replacement of up to 1-1.5 total plasma volume (UD V);
· Diuretics should be used to correct water overload (> 10% of total body weight) after recovery from shock. If diuretics are ineffective, renal replacement therapy may be used to prevent water overload (LEV B);
With the development of renal failure with oligoanuria, or with high rates of azotemia, electrolyte disturbances, renal replacement therapy is carried out;
· The use of intermittent hemodialysis or continuous veno-venous hemofiltration (CVVH) has no advantage (LEV B);
· CVVH is more convenient for patients with unstable hemodynamics (LE B). Ineffectiveness of vasopressors and fluid resuscitation are extrarenal indications for initiating CVVH;
· CVVH or intermittent dialysis may be used in patients with concomitant acute brain injury or other causes of increased intracranial pressure or generalized cerebral edema (LE: 2B).
· For the rules of using renal replacement therapy, see "Acute renal failure" and chronic kidney disease in children.

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

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

Hyperbaric oxygenation(UD S) - the use of HBO contributes to the elimination of general and local hypoxia, a decrease in bacterial contamination, an increase in the sensitivity of microflora to antibiotics, the normalization of microcirculation, an increase in the body's immunobiological defense and the activation of metabolic processes.

Vacuum therapy (UDC) - indicated in children with deep burns after surgical or chemical necrectomy; accelerates the self-cleaning of the wound from the remnants of non-viable soft tissues, 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 can have a negative impact on wound healing;
· Sepsis of any etiology, occurring against the background of the phenomena of multiple organ failure (severe sepsis), septic shock;
· The concentration of procalcitonin in the blood ≥2 ng / ml;
· Thermal inhalational 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 burn treatment in order to prevent joint contractures: adduction 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 for the prevention of contracture:

Neck, front	Slight extension by placing a rolled towel under the shoulders
Shoulder joint	Abduction 90⁰ to 110 if possible with 10⁰ shoulder flexion in neutral rotation
Elbow joint	Forearm supination extension
Brush, back surface	Wrist joint extended 15⁰-20⁰, metacarpophalangeal joint in 60⁰-90⁰ flexion, interphalangeal joints in full extension
Hand, extensor tendons	The wrist joint is extended 15⁰-20⁰, the metacarpophalangeal joint is 30⁰-40⁰ of extension
Brush, palmar surface	The wrist joint is extended 15⁰-20⁰, the interphalangeal and metacarpophalangeal joints are in full extension, thumb in lead
Chest and shoulder joint	90⁰ abduction and gentle rotation (pay attention to the risk of ventral dislocation of the shoulder)
Hip joint	Abduction 10⁰-15⁰, in full extension and neutral rotation
Knee-joint	The knee joint is extended, the ankle joint is 90⁰ dorsiflexion

Splinting for the prevention of equinus 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 reinstallation of tires should be carried out 3 times a day, in order to prevent pressure on neurovascular bundles, bone protrusions.

Breathing exercises.

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

Physical treatments depending on the indication:
· UFO therapy or bioptron therapy of burn wounds and donor sites with signs of inflammation of the wound surface. Indications for prescribing UFO 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 impaired respiratory function No. 5.
· Magnetotherapy for the purpose of dehydration of scar tissue, efficient 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- the use of special clothing made of elastic fabric. The pressure is physical factor, capable of positively changing the structure of skin scars on their own or after scarification, removal. Compression therapy is applied continuously for 6 months, up to 1 year or more, and staying without a bandage should not exceed 30 minutes a day. During the early post-burn period, elastic compression can be applied to wounds during the healing period after most wounds have healed, but some are left open. The use of pressure bandages has both prophylactic and therapeutic purposes. For prophylactic purposes, compression is applied after plastic wounds with split skin, as well as after reconstructive operations. In these cases, the dosed pressure is shown 2 weeks after the operation, then the compression gradually increases. For therapeutic purposes, compression is used when excessive scar growth occurs.

Indications for specialist consultation:
Consultation with an ophthalmologist with an examination of the vessels of the fundus, to exclude corneal burns and assess edema in the fundus.
Consultation with a hematologist - to exclude blood diseases;
Consultation with an otolaryngologist - to exclude URT burns and their treatment. Consultation with a traumatologist - in the presence of an injury;
Dentist consultation - upon detection of oral cavity burns and foci of infection, followed by treatment;
Consultation with a cardiologist - in the presence of abnormalities from the ECG and Echo KG, cardiac pathology;
Consultation with a neurologist - in the presence of neurological symptoms;
Consultation with an infectious disease specialist - if available 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 drugs.
Nephrologist's consultation to exclude kidney pathology;
Consultation with an efferentologist for the implementation of methods of efferent therapy.

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

Treatment efficacy indicators.
1) Criteria for the effectiveness of ABT: regression of SPON, absence of suppuration in the wound (sterile cultures on the 3rd, 7th day), absence of generalization of infection and secondary foci.
2) Criteria for the effectiveness of ITT: presence of stable hemodynamics, adequate diuresis, lack of hemoconcentration, normal CVP numbers, etc.
3) Criteria for the effectiveness of vasopressors: is determined by the increase in blood pressure, decrease in heart rate, normalization of TPVS.
4) Criteria for the effectiveness of local treatment: epithelialization of burn wounds without the formation of rough scars and the development of post-burn deformities, joint contractures.

Hospitalization

Indications for planned hospitalization: no.

Indications for emergency hospitalization:
· Children, regardless of age, with burns of the 1st degree of more than 10% of the body surface;
· Children, regardless of age, with burns of II-III A degree more than 5% of the body surface;
· Children under 3 years of age with burns of II-III A degree of 3% or more of the body surface;
· Children with IIIB-IV degree burns, regardless of the area of ​​the lesion;
· Children under 1 year old with burns of II-IIIA degree 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 ​​the lesion.

Information

Sources and Literature

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Astamirov, A.U. Lekmanov, S.F. G.N. Speransky ", Moscow edition" Emergency Medicine ". 8. Astamirov MK The role of central hemodynamic disturbances and their effect on oxygen delivery to tissues in the acute period of burn injury in children: Abstract of the thesis. Candidate of Medical Sciences M., 2001.25s. 9. Borovik TE, Lekmanov AU, Erpuleva Yu. V. The role of early nutritional support in children with burn injury in preventing the catabolic orientation of metabolism // Pediatrics. 2006. No. 1. S.73-76. 10. Erpuleva Yu. V. Nutritional support in children in critical conditions: Abstract of the thesis. ... Doctor of Medical Sciences. M., 2006.46s. 11. Lekmanov AU, Azovskiy DK, Pilyutik SF, Gegueva EN Targeted correction of hemodynamics in children with severe traumatic injuries on the basis of transpulmonary thermodilution // Anesthesiol. and reanimatol. 2011. No. 1. S.32-37. 12. Lekmanov AU, Budkevich LI, Soshkina VV Optimization of antibiotic therapy in children with extensive burn injury, based on the level of procalcitonin // Westintens. 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. Rainier, Jean [revised to Rainier, 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 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. 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Information

Abbreviations used in the protocol:

D-dimer - fibrin breakdown product;
FiO2 is the oxygen content in the inhaled air-oxygen mixture;
Hb - hemoglobin;
Ht - hematocrit;
PaO2 - partial tension of oxygen in arterial blood;
PaСO2 - partial tension of carbon dioxide in arterial blood;
PvO2 - partial tension of oxygen in venous blood;
PvCO2 - partial tension of carbon dioxide in venous blood;
ScvO2 - saturation of the central venous blood;
SvO2 - saturation of mixed venous blood;
ABT - antibacterial therapy;
Blood pressure 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 ventilation of the lungs;
IT - infusion therapy;
ITT - infusion-transfusion therapy;
KOS - acid-base state;
CT - computed tomography;
LII - leukocyte intoxication index;
INR - international normalized ratio;
NE - necrectomy;
OPSS - total peripheral vascular resistance;
ARDS, acute respiratory distress syndrome;
BCC - the volume of circulating blood;
PT - prothrombin time;
PDF - fibrinogen degradation products;
PCT - procalcitonin;
PON - multiple organ failure;
PTI - prothrombin index;
PEG - polyethylene glycol;
CA - spinal anesthesia;
SBP - systolic blood pressure;
FFP - fresh frozen plasma
SI - cardiac index;
SKN - intestinal insufficiency syndrome
SPON - multiple organ failure syndrome;
SIRS - systemic inflammatory response syndrome;
ОШ - burn shock;
TV - thrombin time;
TM - platelet mass
LE — level of evidence;
US - ultrasound;
Ultrasound - ultrasound examination;
UO - stroke volume of the heart;
FA - fibrinolytic activity;
CVP - central venous pressure;
CNS - central nervous system;
NPV - frequency of respiratory movements;
HR - heart rate;
EDA - epidural anesthesia;
ECG - electrocardiography;
MRSA - Methicillin-resistant staphylococci

List of protocol developers with qualification data:
1) Bekenova Lyaziza Anuarbekovna - doctor - combustiologist of the highest category of the GKP on the REM "City Children's Hospital No. 2" in Astana.
2) Ramazanov Zhanatay Kolbaevich - candidate medical sciences, doctor-combustiologist of the highest category of the RSE at the PHV "Research Institute of Traumatology and Orthopedics".
3) Zhanaspaeva Galiya Amangazievna - candidate of medical sciences, chief freelance rehabilitologist of the Ministry of Health and Social Development of the Republic of Kazakhstan, a rehabilitologist of the highest category of the Republican State Enterprise at the PHV “Research Institute of Traumatology and Orthopedics”.
4) Iklasova Fatima Baurzhanovna - doctor clinical pharmacology, anesthesiologist-resuscitator of the first category. GKP on REM "City Children's Hospital No. 2", Astana.

No Conflict of Interest Statement: no.

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

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

Annex 1
to the typical structure
Clinical protocol
diagnosis and treatment

The ratio of the codes ICD-10 and ICD-9:

ICD-10		ICD-9
The code	Name	The code	Name
T31.0 / T32.0	Thermal / chemical burn 1-9% PT		Other local excision of the affected skin and subcutaneous tissue
T31.1 / T32.1	Thermal / chemical burn 11-19% PT	86.40	Radical excision of the affected skin area
T31.2 / T32.2	Thermal / chemical burn 21-29% PT	86.60	Free full flap, unspecified otherwise
T31.3 / T32.3	Thermal / chemical burn 31-39% PT	86.61	Free full layer flap on the hand
T31.4 / T32.4	Thermal / chemical burn 41-49% PT	86.62	Another skin flap on the hand
T31.5 / T32.5	Thermal / chemical burn 51-59% PT	86.63	Free full-thickness flap of a different location
T31.6 / T32.6	Thermal / chemical burn 61-69% PT	86.65	Skin xenotransplantation
T31.7 / T32.7	Thermal / chemical burn 71-79% PT	86.66	Skin allotransplantation
T31.8 / T32.8	Thermal / chemical burn 81-89% PT	86.69	Other types of skin flap of other localization
T31.9 / T32.9	Thermal / chemical burn 91-99% PT	86.70	Pedunculated flap, unspecified otherwise
T20.1-3	Thermal burns of the head and neck of I-II-III degree	86.71	Cutting and preparation of pedunculated or broad-based flaps
T20.5-7	Chemical burns of the head and neck of I-II-III degree	86.72	Moving the leg flap
T21.1-3	Thermal burns of the trunk of I-II-III degree	86.73	Fixation of a pedicle flap or a flap on a wide base of the hand
T21.5-7	Chemical burns of the trunk of I-II-III degree	86.74	Fixation of a flap on a wide leg or a flap on a wide base to other parts of the body
T22.1-3	Thermal burns of the shoulder girdle and upper limb area, excluding the wrist and hand, I-II-III degrees	86.75	Revision of a pedunculated flap or a wide base flap
T22.5-7	Chemical burns of the shoulder girdle and upper limb, excluding the wrist and hand, I-II-III degrees	86.89	Other methods of restoration and reconstruction of skin and subcutaneous tissue
T23.1-3	Thermal burns of the wrist and hand of the I-II-III degree	86.91	Primary or delayed necrectomy with one-stage autodermoplasty
T23.5-7	Chemical burns of the wrist and hand of the I-II-III degree	86.20	Excision or destruction of the affected area or tissue of the skin and subcutaneous tissue
T24.1-3	Thermal burns of the hip joint and lower extremity, excluding the ankle joint and the foot of the I-II-III degree	86.22	Surgical treatment a wound, an infected area, or a skin burn
T24.5-7	Chemical burns of the hip joint and lower extremity, excluding the ankle joint and the foot of the I-II-III degree	86.40	Radical excision
T25.1-3	Thermal burns of the ankle joint and foot I-II-III degree
T25.5-7	Chemical burns of the ankle joint and foot I-II-III degree

Attached files

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Not every adult knows how to act if a child is burned. In such a situation, many succumb to panic. It is important to remember in which cases it is necessary to immediately call a team of doctors, and when you can independently help the victim. A burn in a child requires appropriate treatment so that there are no scars or scars left in the future. The further condition of the baby depends on the speed and correctness of the provision of first aid and the precise determination of the area of ​​damage.

Types and severity of burns

Burns in children, as in adults, are divided into 4 types according to the degree of damage:

• 1 degree. At this stage, only outer layer epidermis (the epidermis is the top layer of the skin). The child experiences severe pain, the skin begins to itch and redden, but the blisters do not appear.
• 2nd degree. The entire thickness of the epidermis is burned. The affected area becomes very soft, persistent redness is observed. Large bubbles appear. Prolonged contact with a hot object, for example, contact with the surface of the stove or boiling water, leads to this degree of burns. Healing lasts up to 14 days.
• 3 degree. Not only the epidermis is damaged, but also the dermis (the lower layer of the skin). The skin takes on a pale appearance, it is very dry, it can be hard. With severe burns, sensitivity is lost. Grade 3 more often occurs upon contact with electric current, hot liquids, chemicals. Blisters at this stage often burst, leaving open wounds... Healing takes up to 2 months.
• 4 degree. The most severe condition is accompanied by damage to the dermis, muscle and bone tissue. Very deep wounds remain, and even charring can be observed. Appears upon prolonged contact with high voltage as well as under the influence of high temperature after the explosion. The burn is often accompanied by purulent complications in the form of an abscess, phlegmon.

All types of burns are divided into 4 types due to their occurrence:

• thermal;
• chemical;
• electrical;
• beam.

Thermal injuries occur due to contact with hot steam, boiling water, boiling liquids, oils, and open fire. Chemical burns are provoked by the following substances: acids, alkalis, phosphorus, some cauterizing solutions like kerosene.

Not only the depth is important, but also the area of ​​the burn. The easiest way to evaluate is by the palm of the baby. An area equal to the palm is equal to one percent of the entire body area. The larger the area, the worse the forecast.

An electrical type of injury occurs after contact with electrical appliances, bare wires, after a lightning strike. The ray appearance is observed after prolonged exposure to ionizing, infrared, ultraviolet rays.

Chemical, electrical, thermal and radiation injuries require proper first aid. Special attention should be paid to assessing the area that has been burnt. Damage area is calculated using the "nine" method. According to this principle, each part of the body has its own percentage:

• head and neck area - 9%;
• hand - 9%;
• leg - 18%;
• the front part of the body - 18%;
• rear part torso - 18;
• perineum - 1%.

They also calculate the area of ​​the burn by the area of ​​the palm. It is believed that the surface of the palm from the inside is equal to 1% of the entire body area. When calling the medical staff, indicate the approximate area of ​​the burn, this will help the ambulance team to prepare.

When to call an ambulance

You need to seek help from a medical institution if:

• baby burn;
• a large area of ​​the body is affected;
• there are open wounds;
• the affected area is the size of the victim's palm or more;
• there was an injury to the head, mouth, lips, nose (this means the risk of injury respiratory system);
• clothes adhered to the skin as a result of contact with open fire, steam or a hot surface;
• there are signs of 2, 3 and 4 degrees of damage.

If there are blisters on the skin with a thick and dark fluid inside, then this indicates the presence of an infection in the wound. Self-medication in this case will only aggravate the condition.

What to do if a child is burned: first aid

The skin of babies is delicate and very thin, so it is quickly injured. First aid for a child with a burn depends on the degree of tissue damage. If a child has injuries of 1 and 2 degrees, then the first aid should be as follows:

1. Eliminate the source of the defeat.
2. If the burn occurs due to hot oil, boiling water, then the place of the damaged area must be lowered under running water for 15-20 minutes to cool. Do not use ice.
3. If bubbles appear with clear liquid inside, then on the skin it is necessary to apply a clean sterile napkin, pre-moistened with cold water.
4. If the area that was burned is larger in area than the palm of the injured child, you should immediately call an ambulance.

First aid for children with burns involves the use of quick-acting agents: Panthenol spray, Olazol cream. This therapy is suitable for grade 1 and 2 wounds, but it is important to consider the area of ​​exposure. It is possible to treat a child's burn with a cream, spray or ointment only after the area has cooled.

If the injury is in the third degree, first aid should be as follows:

1. Remove the source of injury.
2. Apply a clean, damp cloth over the wound site. If the area is too large, you can wrap your entire body in a cold, damp sheet.
3. Call an ambulance.
4. Burns of this degree are very painful. Any pain reliever (Ibuprofen, Nurofen) will help the child. If this is not the case, an antipyretic agent (Paracetamol) will help out.
5. Give the victim constantly a large number of water, it is desirable to slightly salt it.

It is important not to pierce the formed bubbles, not to tear off the adhered clothes from the child's body. If there is grade 3, then applying any sprays or creams to the burn site is contraindicated.

Further treatment of burns in children

When a child is burned, but the area of ​​damage is small, and the wound has redness or blistering, then such an injury can be treated at home. To learn how to treat a burn and not harm your child even more, it's best to ask for medical help.

Medicines

It is important for parents to understand that the process of wound healing in a baby after a burn has its own cycle. If 1-2 degree of injury is noted, then as pharmacy products the following will do:

• Treat the wound for the first two days antiseptic compounds without alcohol - Betadine, Dioxizol, Panthenol.
• To rid the tissue of puffiness, you can apply Nitacid or Oflokain ointments.
• When there is a cleansing of the burn from dead cells, antiseptic ointments on a fatty basis (Streptonitol) are suitable.
• The fastest tissue regeneration is started by Solcoseryl, Algofin and sea ​​buckthorn oil.
• The best way to relieve a child's burn is Argosulfan. Practically has no contraindications, it is allowed for use by children from one year old.

If there is a burn of the child's palm, scalp, lips, nose, then you should not neglect medical help. Calling an ambulance in this case is mandatory, because damage to the upper respiratory tract is possible.

Surgery

If the affected area differs in the 3rd degree of damage, then further treatment must be prescribed by a doctor. Often, grade 3 is treated in a hospital by administering tetanus toxoid, pain relievers and sedatives. The blisters with thick contents are incised and an anti-burn gel dressing is applied.

In case of severe tissue damage of grade 4, surgeons carry out anti-shock therapy, and skin transplantation is possible.

Folk remedies

A child can smear a burn with products from traditional medicine... This will help the fastest healing... But be sure to discuss any additional methods of therapy with your doctor.

It is important to urgently call the ambulance team and continue treatment in the hospital. There is a chance of getting burn shock.

A few simple recipes:

• Compress of grated raw potatoes. Wash and peel the vegetable. Grate on a coarse grater, put on sterile gauze or several layers of bandage. Keep in place of the burn for about 20 minutes. Do not use the method for injuries with open blisters.
• Antiseptic dressing of calendula or arnica (ointment, tincture). The method is used to avoid infection. The bandage is only attached to lesions with closed blisters. Only the skin around the wound should be treated.
• Lotions based on lavender oil. The method is good only at the stage of wound healing; it cannot be used immediately after tissue damage. In 10 ml olive oil add 3-4 drops of lavender essential oil. Apply the prepared mixture to a clean bandage and keep it on the skin for 2 hours.
• Aloe juice compress. Choose thick and fleshy leaves from the plant. Rinse them well and remove the top skin. One transparent pulp should remain, which is then finely chopped to a state of gruel. Put the prepared mass on a clean bandage and apply to the wound. The method is approved for the treatment of burns of 1-2 degrees.

What to do if a child burns his hand? When the skin of the hands is damaged, the main thing is to quickly cool the damaged area. At first, it is enough to keep your hands under running water for 20 minutes, and then you can apply a cool damp cloth. Further treatment comes down to regular processing of the skin with Panthenol. As an additional therapy, compresses based on furacilin and raw potatoes will help.

What to do with a chemical burn in a child: treatment features

If a child has spilled a chemical liquid on himself, then the algorithm of actions is as follows:

1. Remove clothing with chemical residues.
2. Keep the damaged area under running water for 25 minutes.
3. If the burn was provoked by acid, then it must be treated with a 2% soda solution or just soapy water.
4. If alkali has caused the injury, a weak acetic acid solution or lemon juice will help neutralize its effect.
5. After neutralizing the chemical composition, apply a damp, clean cloth to the damaged area.
6. Subsequent treatment should be monitored by a physician.

With minor damage, a chemical burn goes away without special treatment, but with profuse tissue damage, an ambulance should be called.

Dangerous consequences

The burn is manifested not only by local tissue damage. In children, a systemic reaction in the form of a burn disease often develops in parallel. It includes 4 stages:

• burn shock;
• burn toxemia;
• septicopyemia;
• convalescence period.

The first stage takes from 1 to 3 days. Children during this period suffer greatly from pain, they constantly cry and scream. The child has an increase in blood pressure, tachycardia, body temperature may decrease. After 3-6 hours, the child, on the contrary, becomes passive, he stops responding to environment.

Burn toxemia is the period when damaged tissue enters the systemic circulation. Children during this period are experiencing a febrile state, convulsions, arrhythmias may appear.

If you decide to take a risk and treat a small burn of 1 - 2 degrees on your own, pay attention to the fact that all ointments and creams cannot be rubbed. They need to be applied to the skin, as if creating a protective layer.

The third stage involves wound suppuration, the baby's condition is greatly aggravated, the appearance of serious complications is often noted, up to pneumonia, sepsis, lymphadenitis.

How to prevent household burns in children

To prevent your child from becoming a victim of a household burn, follow these tips:

• Children should be in the kitchen only during meals, this is not a place for games.
• It is better to cook dishes on the distant stove burners.
• Remove matches, lighters higher on the shelves so that the child does not get them.
• Do not leave hot dishes, kettles, cups of hot drinks on the edge of the table.
• Cords from an electric kettle, iron, curling iron, should not hang in free access at the bottom of the wall.
• You cannot leave your baby unattended.
• Keep corrosive, chemical liquids out of the reach of children.

Constant supervision of the baby gives a guarantee of his safety, so do not neglect these tips.