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Fayazov Abdulaziz Djalilovich, Ajiniyazov Rashid Saparniyazovich, Tulyaganov Davron Bakhtiyarovich, Khadjibaev Abduhakim Muminovich, Professor, General Director of Republican Research Center of Emergency Medicine, Tashkent city, Uzbekistan E-mail: uzmedicine@mail.ru
State and ways of improvement of combustiologic aid in the system of emergency medicine of Uzbekistan
Abstract: The authors studied the structure and rate of hospitalized patients with thermal injury in the period since 2002 till 2012 in the system of emergency medicine in the Republic of Uzbekistan, and showed the state and ways of improvement of combustiologic aid. The established combustiologic service allowed providing an adequate specialized assistance to victims with thermal damages.
Keywords: burn trauma, burn disease, specialized aid at burns.
Background
Burns continue to be one of the most common types of traumatic damages [1; 4; 7; 9]. Increased consumption of various energy resources in industry and everyday life determines growth rate of burn injuries. Despite these successes, among severe burned patients mortality remains high even in specialized clinics. This is contributed by an increase of both burn injuries and the proportion of large and deep burns, associated and combined damages, and the lack of unified concept of the treatment of severe burned patients [2; 5].
At the same time, disability of patients after thermal injuries remained to be poor [8; 11].
In this regard, in the system of emergency medical aid of the Republic of Uzbekistan high emphasis is placed on combustiologic service. The patients with thermal injury are became medical care at the stages of the evacuation by structural subdivisions ofEmergency Medical Services (EMS), which governed by the Republican Research center of emergency medicine (RRCEM). 13 regional branches of RRCEM are organized in the Republic of Karakalpakstan, in
all regional centers of the Republic, as well as in Chirchik city of Tashkent Region. Total number of beds of combustiologic service of EMS is 189. In the 172 district centers of the Republic the subbranches of RRCEM are functioning — emergency departments of medical aid (EDMA) at district medical unions (DMU) and city medical unions (CMU). Ambulance service and sanitary aircraft also subordinated to structure of EMS of the Republic.
Material and methods
Designed for offices of EMS diagnostic and treatment standards are focused on the mandatory evacuations of severe burned patients into specialized combustiology departments of RRCEM and its branch offices, where all of resource and human facilitates for providing quality and timely assistance to this category of victims are presented. This protocol applies primarily to large cities, where
these centers are located. Regarding the victims from rural and remote cities, diagnostic and treatment standards give wide indication for transportation of severe burned patients in specialized offices after the stabilization of their condition in EDMA or specialized care is organized in the spot with the assistance of opportunities of sanitary aircraft.
Analysis of the results of combustiology service in SEM showed that the total number of hospitalized patients with thermal injury over the period 2002 to 2012 was 85 538. Noteworthy is a steady increase of the number of patients with burn injuries. So, if in 2002 there were 6 398 patients hospitalized, with rising every year, by 2012 the figure was 8 976, representing an increase of hospitalized with thermal injury over a given period of time relative to the population of Uzbekistan by 15.9 % (Fig. 1).
Fig. 1. Trends in hospitalized patients with thermal injury in EMS
Results and discussion
Over the past period among hospitalized patients with thermal injuries the proportion of children was 61.0 % (52 178), of adults — 39.0 % (33 360), i. e., nearly two-thirds of hospitalized patients were burnt children that representatives the features of socio-psychological and behavioral status, significantly different from adults. Children, especially young children, because of their vulnerability, the inability to identify and assess the risk of hot items and agents, as well as their excessive curiosity, are more prone to thermal injury.
In the age structure dominated burnt children affected up to 3 years and was 34 728 (66.6 %) cases. Children from 3 to 7 years was 12 318 (23.6 %), and children from 7 to 15 years and from 15 to
18 years — respectively 4 020 (7.7 %) and 1 112 (2.1 %). Among adults, the number of the patients capable of working (18-60 years) accounted for 31 820 (95.4 %). The rest of 1 540 (4.6 %) patients were elderly. Thus, the bulk of the victims are young children, patients of working age, which have increased vulnerability to thermal injury due to behavioral characteristics of their psyche (children up to three years) and social activities (people of working age). This fact points to the specific goals that need to be taken into account in the development of appropriate programs to reduce thermal injuries.
As with all other forms of trauma, to thermal trauma increasingly exposed men (69.7 %). The majority (60.7 %) of patients were with burns of up to 10 % of the body surface, and in only 3.2 % cases the area of damage exceeded 60 % (Fig. 2).
up to 10% from 10%to 30% from30%to60% 60% and more
Fig. 2. Distribution of patients with burns due to the total affected area
At 21.6 % (18 476) patients were deep burns, deep burns up to 5 % of the body surface were in 71.3 % patients, 5-10 % in 16.8 % ones, 10-20 % in 6.4 % ones. The prevalence of deep burns in 3.9 % patients was 20-40 % and in 1.6 % patients was higher than the 40 %.
The result of the treatment of burn injuries depends on the time interval between injury and admission to hospital, along with the age of the victim, the area and depth of the burn wound, comorbidity. Often this term determines the prognosis and treatment tactics. The reasons for the late arrival of patients are subjective underestimation of the severity of the injury, decreased pain sensitivity in the area of deep burns, unwillingness to be hospitalized, the inability of independent access to medical care and so on. Later arrival of victims to specialized medical offices are responsible for a complicated course of burn disease and wound healing process, an unfavorable outcome [3; 10].
Of the total of patients, 73.5 % (62 871) were hospitalized during the first 6 hours after thermal injury (Fig. 3). In the period from 7 hours to 3 days hospitalized 18.1 % (15 482) of the victims. At later period specialized care was provided to 8.4 % (7 185) patients. The fact that more than a quarter of the victims (26.5 %) goes to the hospital later than 6 hours after thermal injury points to the need for increased awareness among workers of primary health care and the public about the importance of early specialized aid for burns. The diagnostic and treatment actions for burn victims at the pre-hospital tge should be with early antishock therapy. The sequence of clinical diagnostic tactics may include:
1. To stop the action of thermal agent. To do this: remove the victim from the source, giving the horizontal position, put out the fire (can be covered with a blanket — to make sure that his head was open, otherwise the victim may be poisoned with combustion products, and burns of the respiratory tract). As soon as possible to cool the burnt surface with a stream of cold water.
2. Narcotic analgesics and oxygen supply at high burn surface are always indicated. Intravenous administration of 1.0 ml. morphine or 2.0 ml. fentanyl decreases pain and negative emotions, and the inhalation of oxygen decreases hypoxia and poisoning by combustion products.
3. Strategically correct is early infusion therapy, in any of the affected area with the damage area of 20 % and above (or deep burns of 10 % and above). Delay infusion therapy even for one hour worsens the condition and prognosis. Vascular access and early fluid therapy with crystalloid solutions in the area of destruction of 10 % of the surface of the body, regardless of the severity of the condition. Infusion of plasma leads to loss of electrolytes from burn surface, which requires their replacement. To patients with deep burns over 15 % (10 % children) ofbody surface area, it is necessary to begin infusion therapy with Ringer's lactate solution of no less than 1000 ml/h for adults and 400-500 ml/h. for children, before the severity of the burn and need of indemnifying liquid will be assessed. Available oral hydration is available with alkaline using 3 g. of salt and 1.5 g. of baking soda to 1 liter of water.
4. Adheres to the burn wound pieces of clothing are needs to separate. With extensive burns, better primary dressing is dry contour aseptic bandage (tissue dressing with laces whose shape corresponds to the contour of the trunk or limb. It is used for fixing the dressing on extensive burn surface). Extensive open burned surface is closed with sterile sheets, clean cloth and linen. Warming with covering with blankets keeps heat.
5. In case of deterioration and progressive burn shock: nitrous oxide and oxygen in a ratio of 1:1, HES (hydroxyethylstarch) 6 % 250 ml. into a vein.
6. During transportation the constant control of the external breathing is necessary. Inhalation of oxygen. If laryngeal edema and suffocation — tracheal intubation and mechanical ventilation.
Fig. 3. Timing of patients' admission in specialized units after trauma
For determining the severity of the burn injury considerable importance has the nature of the thermal agent. In our study, the proportion of thermal burns from hot liquids accounted for 64.5 % (55 172) of the cases. Thermal burns due to flames appeared in 24.8 % (21 213) cases, elektroburns — 4.6 % (3 935), contact burns — 3.7 % (3 165), chemicals burns — 1.6 % (1 369) and frostbite — 0.8 % (684).
Analysis of the distribution of traumatic agents by age showed that in children the main mechanism was a thermal burn with hot liquids (84.1 %). In adults, thermal trauma approximately equally due to influence of hot liquid (36.7 %) and a flame (42.8 %) (Fig. 4). So-cio-psychological and behavioral status of children, especially young children, their inability to recognize and assess the danger of hot liquids, which constantly used in everyday life, make them vulnerable to this injury factor. In adults burns with flame and hot liquid have, as a rule, technogen character—working in the kitchen, boiler room, the explosion ofgas cylinders and others. When the flame burns, even for
a short period of his exposure, severe lesions of the skin, especially in the case of ignition of clothing were observed. Often there are electrical burns — adults in 11.8 %, and 5.4 % of children in the cases.
If children generally suffered from thermal injury at home, in adults circumstances of burns are more diverse: domestic origin were 80.5 % (68 858) of the cases, industrial burns — 15.3 % (13 087), suicide attempts — 2.8 % (2 395) and criminal burns — 1.2 % (1027), as well as in emergency situations burns received 0.2 % (171) patients. The most severe burns arise as a result of exposure to flame and electricity.
The main cause of death in burn disease are its complications, the incidence of which directly dependents on the time of existence of the burn wounds. Therefore, despite the wide arsenal of complex therapy, which allows to prevent the expressed violations of the vital organs and systems, in the primary treatment of patients with deep extensive burns main aim is to restore the lost skin in the earliest term surgically [5; 6; 10].
Fig. 4. Structure of patients due to
Surgical treatment was performed in 20.3 % (17 364) of the patients, including early surgical necrectomy — at 12.4 %, early delayed necrectomy — at 16.7 %, landmark necrectomy — at 19.4 %, the imposition oftemporary wound coverings — at 15.8 %, autoder-moplasty — at 56.3 %. In 3.2 % of patients had to make disarticulation and amputation.
Creating EMS with sufficient material and technical base changed the overall concept of the treatment of burn disease. Through this clinical combustiology introduced general methods of complex treatment using modern technology and methods of early surgical treatment of burn wounds using various types of temporary wound coverings cultured allogeneic fibroblasts, which contributed to the reduction of mortality among burnt patients. So, if in 2002, the overall mortality rate was 4.3 %, in 2012 this figure fell to 2.8 %.
Nowadays, in all specialized departments of combustiology the principles of staged treatment of burnt were developed and implemented. When emergencies with mass arrival of burnt these principles shown to be highly effective. In all units in the regional branches of RRCEM there are conditions for the providing of qualified and specialized medical care to burnt. The focus of the work of the combustiology offices paid to the application of methods of active surgical tactics of treatment, the use of synthetic temporary wound coverings
damaging agents concerning age
and various kinds of combined plastic closure of deep burns. In order to improve the quality of specialized care combustiologic course organized at the department of emergency medicine of the Tashkent Institute of Advancing of physicians, where annually raise their qualification combustiologs, masters and clinical residents.
Despite advances in the treatment of burn patients, there are still many unexplored issues. The most actual trends for further study are to develop optimal approaches to complex treatment of burnt with combined and multiply lesions. Needs to be resolved the issue of implementation in daily clinical practice of combustiologic offices in regional branches of RRCEM the using of cultured allofibroblasts in severe burnt with extensive deep burns and skin donor resources deficit. It is necessary to create a system of clinical examination of patients with sequelae of burns with development of programs of conservative and operative rehabilitation, and social reintegration.
Conclusion
Thus, the established service of combustiology allows adequate specialized aid to patients with thermal lesions. Trend to increasing of burn injury dictates the need of further improvement of the organizational and methodological work on the problem of burns in Uzbekistan, which will improve the quality of specialized medical aid to the patients with burns.
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