Evakuatsiya obozhzhennykh i yeye svyaz' s rezul'tatami lecheniya. Sozdaniye shkaly otsenki tyazhesti sostoyaniya postradavshikh s termicheskoy travmoy Annotatsiya Aktual'nost'. Evakuatsiya obozhzhennykh v spetsializirovannyye lechebnyye uchrezhdeniya, takzhe kak i printsipy organizatsii meditsinskoy pomoshchi yavlyayutsya vazhnymi voprosami, voznikayushchimi v khode vooruzhennykh konfliktov i chrezvychaynykh situatsiy. V nastoyashcheye vremya sozdany i ispol'zuyutsya mnozhestvo shkal, s pomoshch'yu kotorykh vozmozhno dat' boleye tochnuyu otsenku tyazhesti povrezhdeniy i sostoyaniya ranenykh, kotoryye s uspekhom primenyayutsya na etapakh meditsinskoy evakuatsii (TS, TRISS, AIS, ISS, shkaly VPKH, shkaly ostroy travmy i dr.). Odnako dlya obozhzhennykh ne sushchestvuyet obshcheprinyatoy shkaly, blagodarya kotoroy mozhno ne tol'ko otsenit' tyazhest' travmy i sostoyaniye obozhzhennykh, no i prinyat' resheniye otnositel'no ikh diagnostiki i lecheniya. Tsel'. Otsenka vliyaniya srokov transportirovki na etap spetsializirovannoy pomoshchi, khirurgicheskoy taktiki i vozrasta postradavshikh s tyazhelymi ozhogami na rezul'taty lecheniya, a takzhe provedeniye analiza vozmozhnosti sozdaniya novykh otsenochnykh shkal obozhzhennykh dlya opredeleniya u nikh tyazhesti sostoyaniya. Metody. Provedeno statisticheski-analiticheskoye issledovaniye 606 patsiyentov kliniki termicheskikh porazheniy Voyenno-meditsinskoy akademii, postupivshikh v period s 2003 po 2018 goda. S pomoshch'yu paketa prikladnykh programm Microsoft Excel s ispol'zovaniyem opisatel'noy statistiki byli vydeleny vazhnyye parametry, kotoryye mogut vliyat' na tyazhest' sostoyaniya porazhennykh. Rezul'taty. Ustanovleno, chto letal'nost' snizhena v gruppe operirovannykh obozhzhennykh, dostavlennykh v kliniku za pervyye 3 chasa posle travmy. Optimal'noy taktikoy lecheniya takikh patsiyentov yavlyayetsya vypolneniye nekrektomii na 3-i sutki posle polucheniya ozhoga. Vyyavleno, chto u patsiyentov starshe 70 let otmechalos' naibol'sheye chislo letal'nykh iskhodov. Prinyato resheniye dlya boleye tochnoy otsenki sostoyaniya porazhennykh na razlichnykh etapakh evakuatsii sozdat' shkalu tyazhesti sostoyaniya, kotoraya budet vklyuchat' v sebya krome osnovnykh parametrov: ploshchadi, glubiny ozhoga i vozrasta patsiyenta, dopolnitel'nyye kriterii takiye kak, sroki transportirovki postradavshikh i vypolneniya khirurgicheskogo lecheniya, dlitel'nost' nakhozhdeniya v otdelenii reanimatsii i intensivnoy terapii. Obshchaya summa ballov, vychislennykh s pomoshch'yu dannoy shkaly, budet ravna kolichestvennoy kharakteristike tyazhesti sostoyaniya obozhzhennogo. Zaklyucheniye. Takoy vazhnyy etap razvitiya predstavleniya ob otsenke tyazhesti sostoyaniya patsiyentov s termicheskoy travmoy budet sposobstvovat' boleye effektivnomu i tochnomu vychisleniyu veroyatnosti letal'nogo iskhoda obozhzhennykh, a takzhe prognozirovaniyu rezul'tatov lecheniya. Klyuchevyye slova: termicheskaya travma; tyazheloobozhzhennyye; evakuatsiya; tyazhest' sostoyaniya; spetsializirovannaya pomoshch'; otsenochnaya shkala Ещё 2747 / 5000 Результаты перевода Evacuation of the burned and its relationship with the results of treatment. Creation of a scale for assessing the severity of the condition of victims with thermal injury

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Relevance.
Thermal lesions are currently considered one of the most severe pathologies both in peacetime and in wartime. And the transformation of the system of organizing medical care for the burned is one of the most pressing issues of emergencies and armed conflicts [3].
In recent decades, the number of local wars has increased, which in turn led to a change in the previously existing system of staged treatment, including severely burned ones [2]. The emergence of methods to save the life of victims in critical condition has significantly reduced the overall mortality rate among those affected. However, questions continue to arise regarding more effective care for the wounded, which is made possible by bringing specialized surgical care as close as possible to the scene. An important step was the fast delivery of the burned to the hospital with the provision of the necessary immediate medical measures during the evacuation.
But unfortunately, even with a quick and properly organized evacuation, early surgical treatment is not always possible. The decision on the tactics of surgical treatment must be made individually for each patient, taking into account all the accompanying factors: the severity of the injury (depth and area of ​​the burn wounds), the general condition of the victim, possible complications, as well as the time of transportation to the stage of specialized care. Only the combination of all these conditions will help the combustiologist make a decision regarding the timing of early surgical treatment.
Currently, there are a large number of scales for assessing the severity of injuries and the condition of the wounded and injured, which are used by doctors of various surgical specialties at the stages of medical evacuation. For example, scales for assessing the severity of injuries: ASCOT, AIS, SMART, TRISS, VHF scales; assessing the condition of the victim and predicting the outcome of treatment (APACHE I, II, III; TISS, SUPPORT), etc. But, in order to assess the severity of the condition of the burned, there is no generally accepted rating scale that would have parameters that could be used to characterize not only the severity of injury and the condition of the burned person, but also to decide on further diagnosis and treatment.
Goal.
Characteristics of the results of treatment of victims with thermal injury, depending on the timing of their delivery to the stage of specialized care, age and surgical tactics. Conducting a comparative assessment of the Frank index (IF) and the severity index (ITS), followed by an analysis of the need to create new scales of the severity of the condition in burned patients.
Research methods. 1. Study design. The work is based on the results of a statistical and analytical study of 606 patients in the clinic of thermal injuries of the VMedA in the period from 2003 to 2018. We used data from our own observations of patients, personal participation in receiving patients, assessing the severity of injury and condition, as well as the presence at operations in patients admitted to the clinic in 2015-2018.
To solve the set tasks and achieve the research goal, methods available in clinical practice were used to determine the depth and area of ​​the burn, the severity of the patient's condition, the tactics of conservative and surgical treatment.
The area was determined according to Walless's “rule of nines” and according to the “palm rule” (the victim's palm has an area of ​​approximately 1% of the body surface area). The depth of the burn was assessed using a four-degree classification. The severity of the injury was determined by the index of the severity of the lesion (Frank's index), expressed in arbitrary units (units): 1% of the superficial burn was equal to 1 unit, and 1% of the deep one - to 3 units. The probability of lethal outcome was assessed using grids and finding the severity index (ITS).
2. Eligibility criteria. It was necessary to analyze the possibility of including the following parameters in the scale of severity of the burned condition: the area of ​​burn wounds, the age of the victims, the timing of their transportation and stay in the OARIT, and the initiation of surgical treatment.
3. Conditions of the event. The data of the patient's case histories were provided by the archive of the clinic of thermal injuries of the Military Medical Academy. CM. Kirov, as well as with the help of the medical analytical information system "Ermedis".
4. Duration of research. The selection of patients (case histories), the compilation of tables with the necessary assessment criteria was carried out from 2015 to 2018, then the analysis and processing of the data obtained were performed.
5. The main outcome of the study. The expected results of the study are evidence of the advantages of faster delivery of burned patients to the hospital and early surgery, as well as the feasibility of creating new rating scales.
6. Analysis in subgroups. The group of patients under study included victims with an area of ​​a superficial burn of more than 20%, a deep burn of more than 10% (Frank index ≥ 20 units). Deaths among all subjects were 52.8% (317 people). Distribution of patients non the severity of burn injury shows that 122 people (20.4%) had supercritical burns over a given period of time.
7. Methods of registration of outcomes. The results of the study were displayed in the form of tables, graphs and scales.
8. Statistical analysis. Medical records were processed using Microsoft Excel using descriptive statistics, paired two-sample t-test for means, two-sample t-test with different and equal variances. The same methods were used to determine the parameters that largely affect the severity of the condition of the burned.
Results. After analyzing the effect of the time from the moment of receiving a burn to hospitalization in the clinic of thermal injuries of the medical device on the outcome of treatment, it was determined that the delivery of burned patients during the first hour reduced mortality to 45.6% compared to victims whose transportation was delayed by 12-24 hours (68 ,4%).
In a group of patients requiring surgical treatment, it was necessary to make a decision about the possibility of performing necrectomy and its timing. An analysis of the time from getting a burn to surgery showed that in the majority of burned patients (17.7%), surgical treatment was carried out in the first 3 days, 4.8% of patients were operated on in terms of 3 to 7 days, after 7 days - 3, 8% of victims.
However, given that most of the patients under study developed burn disease, which could lead to purulent-septic complications with a quick fatal outcome, no operations were performed (43.7%). In this case, the unfavorable risk of surgical intervention could exceed the effect of its implementation.
The group of burned patients with only a superficial burn with an area of ​​more than 20% (19.1%) did not require necrectomy at all. The Frank index in such affected individuals was the smallest (30.1 ± 1.4 units), respectively, the deep burn area did not have a significant effect on the condition of the victims.
When analyzing the effect of the timing of necrectomy on the final result of treatment, it was found that with its delayed (after 7 or more days) the percentage of deaths was the highest and amounted to 55.6%. In accordance with the data obtained, the most optimal timing for the start of surgery is the first 3 days (mortality rate was 35.0%).
In the group of operated patients (n = 145), the analysis of the delivery time of patients to the stage of specialized care was carried out. As a result, 49% of the victims who underwent necrectomy were admitted to the hospital within 1-3 hours after the injury. Among those burned at the same time, the percentage of deaths was the smallest (18.3%), and those who were delivered 12-24 hours after the injury all died. Also, a high mortality rate (81.8%) was observed in the burned, hospitalized more than a day after the incident.
When analyzing the effect of the age of the studied patients, it was noted that after 70 years there was a sharp rise in mortality (from 27.5 - 55.8% to 86.4-100%). It follows that the victims of the older age group suffer from burn disease worse. In 5 severely burned patients, whose age was more than 90 years, the lethal outcome was 100%. A decrease in mortality was observed in the age group of young and middle-aged patients (from 21 to 30 years old), which is explained by the large reserves of the body of such affected. At the same time, in the group over 70 years of age, the severity of thermal injury was higher relative to younger patients (IF = 81.9 ± 2.9 and 70.6 ± 6.4, respectively).
To develop a new rating scale, it was necessary to compare the severity of injury (IF) and severity of the condition (ITS), in order to justify the need to add other parameters. As a result, a direct dependence of deaths on the value of the indicators used was revealed. In the group of patients whose trauma severity was assessed using IF (area and depth of burns), mortality increased with an increase in the index: with IF = 20-40 units. lethal outcomes were observed in 21.1% of patients, and with IF = 101-200 units. - 91.6%. Among the affected, whose Frank Index exceeded 200 units, the death toll reached 100%.
A similar tendency towards increased mortality is observed in the group of patients assessed using ITS. The burned, whose condition was defined as mild (ITS = 0.01-0.09), the number of deaths was 12.8%; with an average severity of the condition (ITS = 0.1-0.24) - 26.7%, with a severe degree (ITS = 0.24-0.54) - 61.2%, with an extremely severe degree (0.55 -0.99) - 75.9%. In those affected with a critical severity of the condition (ITS = 1), the number of deaths was 99%.
The distribution of burned victims into groups depending on the performance of surgical interventions determined the advantage of evaluating victims using ITS. The decision to perform necrectomy when assessing patients by IF is based only on the area and depth of the burn, the mortality in this case is higher compared to the definition of ITS, which takes into account the age of the victim.
However, for more accurate and to effectively assess the severity of the condition of patients with thermal injury and facilitate diagnosis at the stage of specialized care (in a burn hospital), it would be advisable to assign certain points according to some additional criteria, which may also affect the results of treatment of burned patients.
Based on the analysis of literature data and a number of statistical studies, it was assumed that such parameters are: the area of ​​deep and superficial burns, the patient's age, the time from the moment of the incident to hospitalization. In the process of further diagnostics and treatment, for a quantitative and even more accurate assessment of the severity of the condition, the time from the moment of getting a burn to the beginning of the surgical intervention, as well as the duration of the stay of the affected person in the intensive care unit, can be added to the total score.
By analyzing the literature, where there is already a proven separation of some signs, the age of the patients and the area of ​​deep and superficial burns were distributed. Taking into account the classification of age according to WHO, the score was as follows: 18-44 years (young age) - 1 point (p.), 45-59 years (average age) - 2 p., 60-74 years (old age) - 3 b., 75-89 years (old age) - 4 p.,> 90 years (longevity) - 5 p. According to the Guidelines for Military Field Surgery (2013), points were assigned in the area of ​​deep and superficial burns in such a way that Sgl = 0% - 1 point, Sgl = 0-1% - 2 points, Sgl = 2 -10% - 3 points, Sgl = 11-50% - 4 points, Sgl> 50% - 5 points; Sпов = 0-10% - 1 point, Sпов = 11-20% - 2 points, Sпов = 21-40% - 1 point, Sпов = 41-50% - 1 point, Sпов> 50% - 5 b.
The following parameters were determined using the above-described statistical-analytical methods for determining the dependence of mortality on the delivery time and surgical treatment for burned patients. Time from the moment of the incident to hospitalization in the clinic: ttr-state ≤3 h - 1 p., Ttr-state = 4-12 h - 2 p., Ttr-state = 13-24 h - 3 p., Ttr-state = 25-71 - 4 points, ttr-gos≥72 - 5 points; terms from the moment of receiving a burn injury to the beginning of surgical measures: necrectomy was not required - 0 p., ttr-operas ≤ 1 day. - 1 p., Ttr-opera = 2-3 days. - 2 p., Ttr-opera = 4-10 days. - 3 p., Ttr-opera = 11-29 days. - 4b., Ttr-oper ≥30 days. - 5 B.; the duration of the patient's stay in the ARIT: 0 days - 0 p.,> 60 days. - 1 p., 43-60 p. - 2 p., 22-42 days - 3 p., 8-21 days. - 4 p., 1-7 days. - 5 B.
Then, for each of the criteria, the total score is calculated, which will quantitatively characterize the severity of the burned condition. This sum of points in the future will correspond to the traditional qualitative classification of severity: "light", "medium", "heavy", "extremely heavy", "critical".
Discussion.
Taking into account the experience of armed conflicts of the last century, wounded with severe burn injuries have always been patients of the "second stage" for evacuation to the stage of specialized care. It was considered advisable to wait for the release of the injured from the burn shock, and then ensure their transportation. However, according to literary sources on sanitary losses, the number of deaths among the burned remains high (from 1.5 to 25%).
Therefore, this clinical and statistical study on the need for the fastest possible evacuation of victims to a specialized medical institution, as well as early surgical treatment, is an important component of effective tactics for managing burned patients and reducing mortality.
Such an analysis is a confirmation of the evidence of most scientists about the optimal timing of necrectomy. Earlier, operations interrupt the course of burn disease and reduces the possibility of complications.
It is also extremely necessary to have criteria that allow not only to assess the severity of the burn injury, but also the condition of the victim, which will allow more accurate solutions to issues of diagnosis and treatment.
Conclusion.
Thus, during transportation of the burned to the hospital from 1 to 3 hours after injury, the lethality was the lowest and amounted to 18.3%. It has been confirmed that the optimal time to start performing surgical treatment in victims is the first 3 days after receiving a burn. Mortality in this case was 35.0%, which is 20.6% lower than in patients operated on for more than 7 days. It was found that in the affected over 70 years, the number of deaths ranged from 88.2 to 100.0% and exceeded the mortality rate in younger patients by 49.8%.
As a result of a comparative analysis of the index of the probable severity of the condition and the Frank index, it was shown that ITS more accurately estimates the victim, which further contributes to a more correct choice of treatment tactics and a decrease in mortality of such affected by 15.7%. However, it would be advisable to add additional criteria to the new scale of the severity of the condition (timing of delivery of burned patients and carrying out surgical treatment, the duration of stay in the intensive care unit). The amount of points for the proposed school  ale will become a quantitative characteristic of the severity of the burned condition.
The results obtained will always be relevant when choosing a more effective and adequate tactics for managing the affected, both at the time of the first examination at the prehospital stage, and in the process of further treatment at the stage of specialized medical care.

About the authors

Mariya Sergeevna Gudkova

Author for correspondence.
Email: visyal.key@yandex.ru
ORCID iD: 0000-0002-8359-1875
SPIN-code: 6004-1995

Курсант 6 курса Военно-медицинской академии имени С.М. Кирова

References