外科急诊创伤英文烧伤.ppt

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1、BURNSLeaugeay Webre BS, CCEMT-P, NREMT-P ScenarioParamedic is called to the scene of a structure fire. FD has removed a victim from the house. BSIScene safe1 patientA/C standbyFD/ PD on sceneNow what? General Impression33 yo male pt writhing in pain. Screams and begs for pain medication however poor

2、 historian.S- blistering to back and chest, R upper ventral area leg exposed muscle; eyebrows singedA- PCN, codeineM- noneP- noneL- earlier todayE- woke up on fire A-B-C-Transport decision?% BSA burned?Tx? ObjectivesDescribe the structure and function of skinDiscuss the types of burns.Explain the de

3、grees of thermal burns.Discuss causes and treatments of inhalation injuries.Identify methods of approximating burn injuries.Describe and apply treatment modalities for the burn patient. Burns, thermal. Escharotomy to release chest wall and allow for ventilation of the patient. SkinLargest organ of t

4、he body AnatomyEpidermisDermisSubcutaneous tissue Layersl Epidermisl Dermisl Subcutaneosl Underlying Structuresl Fascial Nerves l Tendonsl Ligamentsl Musclesl Organs Anatomy & Physiology of the Skin FunctionProtection Regulation Prevention Sensory EpidermisOuter, thinner layerConsists of dead kerati

5、nized cellsProtects dehydration trauma light infection DermisGel like matrixConsists of collagen and elastinContains blood vessels, lymphatics, sweat glands, hair follicles, sensory fibers SubcutaneousConnective tissueAdipose tissue cushioning insulation CausesThermalElectricalChemicalRadiation Ther

6、malMajority flame scald contact with hot objects Child with burns from a scald Determining Severity1st degree2nd degree3rd degree(4th degree) Depth of BurnSuperficial BurnPartial Thickness BurnFull Thickness Burn First DegreeSuperficial involve only epidermisLocal pain and rednessNo blistering prese

7、ntHeal spontaneously 2-5 days without scarringNot included when calculating % TBSA Burn DepthSuperficial Burn:1st Degree Burnl Signs & Symptomsl Reddened skinl Pain at burn site l Involves only epidermis Second DegreeInvolve epidermis and dermisPartial thickness superficial partial thickness red, pa

8、inful, blistered deep partial thickness pale, mottledVery painfulInfection may evolve into 3 rd degree Burn DepthPartial-Thickness Burn: 2nd Degree Burnl Signs & Symptomsl Intense pain l White to red skinl Blistersl Involves epidermis & dermis Third DegreeInvolve epidermis, dermis, subcutaneous tiss

9、ueWhite, waxy, red, brown, leatheryDry and painless(muscle and bone) Burn DepthFull-Thickness Burn: 3rd Degree Burnl Signs & Symptomsl Dry, leathery skin (white, dark brown, or charred) l Loss of sensation (little pain)l All dermal layers/tissue may be involved Fourth DegreeInclude involvement of mu

10、scle and boneCharred in appearancePainless PathophysiologyLocal changes- 111F produce injury Area of DamageZone of coagulationZone of stasisZone of hyperemia Jacksons Theory of Thermal Woundsl Zone of Coagulationl Area in a burn nearest the heat source that suffers the most damage as evidenced by cl

11、otted blood and thrombosed blood vesselsl Zone of Stasisl Area surrounding zone of coagulation characterized by decreased blood flow.l Zone of Hyperemia l Peripheral area around burn that has an increased blood flow. Jacksons Theory of Thermal WoundsZone of Hyperemi aZone of Stasi s Zone of Coagulat

12、i on Zone of CoagulationCentral area of burnNecrotic from time of exposure Zone of StasisModerate degree of insultDecreased tissue perfusionVascular damage/ leakageMay progress to necrosis 24-48 hours Zone of HyperemiaVasodilationInflammationViable tissue Bodys Response to BurnsEmergent Phase (Stage

13、 1)l Pain responsel Catecholamine releasel Tachycardia, Tachypnea, Mild Hypertension, Mild AnxietyFluid Shift Phase (Stage 2)l Length 18-24 hoursl Begins after Emergent Phase l Reaches peak in 6-8 hoursl Damaged cells initiate inflammatory responsel Increased blood flow to cellsl Shift of fluid from

14、 intravascular to extravascular spacel MASSIVE EDEMAl “Leaky Capillaries Systemic ChangesMassive release of inflammatory mediatorsProduce vasoconstriction/ dilationIncreased capillary permeabilityEdema Fluid ShiftsInitial decrease blood flow to burned areaFollowed by increased arterial vasodilationR

15、elease of vasoactive substance resulting in increased capillary permeability and edema CardiovascularLoss of plasma volumeIncreased peripheral vascular resistanceDecreased cardiac output decreased blood volume decreased venous return increased blood viscosity decreased contractility RenalDecrease ci

16、rculating plasmaIncrease hematocritDecreased CO decreased renal blood flow oliguria acute renal failure GastrointestinalDecreased gastrointestinal blood flowIncreased mucosal hemorrhage 20% ileus Immune SystemDepressed immune function 20% directly proportional to burn size sepsis Bodys Response to B

17、urnsHypermetabolic Phase (Stage 3)l Last for days to weeksl Large increase in the bodys need for nutrients as it repairs itselfResolution Phase (Stage 4)l Scar formationl General rehabilitation and progression to normal function HypermetabolismFollowing severe burn and resuscitation tachycardia incr

18、eased CO increased O2 demand massive proteolysis & lipolysis severe nitrogen loss Systemic ComplicationsHypothermial Disruption of skin and its ability to thermoregulateHypovolemial Shift in proteins, fluids, and electrolytes to the burned tissuel General electrolyte imbalanceEschar l Hard, leathery

19、 product of a deep full thickness burnl Dead and denatured skin Systemic ComplicationsInfectionl Greatest risk of burn is infectionOrgan Failurel Release of myoglobinSpecial Factorsl Age & HealthPhysical Abuse l Elderly, Infirm or Young Critical Burn AreasFace HandsFeetGroinJointsCircumfrential Inha

20、lation InjuriesLeading cause of death Closed space incident Presence of heavy smoke History of unconsciousness Burns, thermal. Partial- and full-thickness burns from structure fire. Note facial involvement. Inhalation InjuryToxic Inhalationl Synthetic resin combustionl Cyanide & Hydrogen Sulfidel Sy

21、stemic poisoningl More frequent than thermal inhalation burnCarbon Monoxide Poisoningl Colorless, odorless, tasteless gas l Byproduct of incomplete combustion of carbon productsl Suspect with faulty heating unitl 200 x greater affinity for hemoglobin than oxygenl Hypoxemia & Hypercarbia Other Eviden

22、ceFacial burnsProfuse secretionsCarbonaceous sputumLacrimationSinged nasal hair HoarsenessWheezingStridorEdemaHypoxemiaTachycardia Inhalation InjuryAirway Thermal Burnl Supraglottic structures absorb heat and prevent lower airway burnsl Moist mucosa lining the upper airwayl Injury is common from sup

23、erheated steaml Risk Factors l Standing in the burn environmentl Screaming or yelling in the burn environmentl Trapped in a closed burn environmentl Symptomsl Stridor or “Crowing” inspiratory soundsl Singed facial and nasal hairl Black sputum or facial burnsl Progressive respiratory obstruction and

24、arrest due to swelling Types of InjuriesCarbon monoxide poisoningInjury above glottisInjury below glottis CO PoisoningAffinity for Hgb 200-250X than O2Cherry red only present at levels 40%+N,+V, HA, decreased LOC, weakness, tachypnea, tachycardia False pulse oximetry reading 100% O2 time for elimina

25、tion 40 min21% O2 time elimination 250 minutes CarboxyhemoglobinNormal- 0Smokers, truck drivers in heavy traffic- 1515-40%- neurological dysfunction weakness, dizziness, +N, +V, HA40-60%- obtunded severe decreased LOCConsider hyperbaric therapy- 25-40% Injury Above GlottisThermal, chemicalRequire ea

26、rly intubationSeverely hypovolemic Injury Below GlottisUsually chemicalRepiratory distressRequire early intubationARDSMSOF Estimating % BSA BurnedRule of palmsRule of nines Body Surface AreaRule of Ninesl Best used for large surface areasl Expedient tool to measure extent of burnRule of Palmsl Best

27、used for burns 10% BSA Rules of Nines18 4.5 9194.5 184.5 4.59 94.5 9 9 4.574.574.57 18 181 Rule of PalmsA burn equivalent to the size of the patients hand is equal to 1% body surface area (BSA) TreatmentStop the burnABCsEstimate % BSA burnedCool burnPrevent hypothermia & infectionPain control Airway

28、O2 on ALL patients Acute pulmonary insufficiency Pulmonary edema 2-3 days Bronchopneumonia 5-7 daysConsider intubation Sx/ liklihood of impending airway obstruction CirculationFluid replacement critical to survivalTissue destruction results in increased capillary permeabilityProfound fluid loss from

29、 the intravascular spaceLarge amounts fluid lost from loss of skin integrity due to evaporation Parkland Formula4ml x wt kg x %BSA burned = 24 hr infusion1st half over first 8 hoursCalculated from time of injury2nd/ 3rd degree burns only Fluid ResuscitationRestore effective plasma volumeMaintain vit

30、al organ functionHypovolemia/ renal failure- complicationsPulmonary edemaAssess adequacy by UA output Cool BurnWithin 30 minutes inhibits lactate production and acidosis promotes catecholamine function and ardiovascular homeostasis inhibits burn wound histamine release blocks histamine mediated incr

31、eased vascualr permeability Cont minimizes edema formation suppresses thromboxane mediator of vascular occlusion progressive dermal ischemia Hypothermia & InfectionCover with dry sterile sheetKeep warm Pain ControlMorphine sulfate decreases amount of protein binding rapidly eliminated small, frequen

32、t doses may use up to 50mg/hrFentanylVersed Special ConsiderationsCircumfrential burns may require fasciotomyPediatrics more susceptible to circumfrential 10% 502nd/3rd degree burns 20% TBSA2nd/3rd degree burns to critical areas3rd degree 5% TBSASignificant electrical/ chemical burnsInhalation injur

33、yCircumfrential burnsPreexisiting conditions medical or concomitant trauma Scene Size-upl Fire Departmentl SCBA and protective clothingInitial Assessmentl ABCs MUST be intactl Consider ET or RSIl Rapid evacuation of patient if scene is unstableAssessment of Thermal Burns Focused and Rapid Trauma Ass

34、essmentl Accurately approximate extent of burn injuryl Rule of Nines or Rule of Palmsl Depth of burnl Area of body effectedl Any burn to the face, hands, feet, joints or genitalia is considered a serious burnl “Ringing” burnsl Age of patient affectedAssessment of Thermal Burns PainChanges in skin co

35、ndition at affected siteAdventitious soundsBlistersSloughing of skinHoarsenessDysphagiaDysphasiaAssessment of Thermal BurnsGeneral Signs & SymptomsBurnt hairEdemaParesthesiaHemorrhageOther soft tissue injuryMusculoskeletal injuryDyspneaChest pain Assessment of Thermal Burns Any partial or full thick

36、ness burn involving hands, feet, joints,face, or genitalia 30% BSAPartial ThicknessInhalation Injury 10% BSAFull ThicknessCritical 2% BSAFull Thickness 50% BSASuperficial 2% BSAFull Thickness 15% BSAPartial Thickness 15% BSAPartial ThicknessModerateMinor Ongoing Assessmentl Non-critical: Reassess Q

37、15 minl Critical: Reassess Q 5 minBurn Center CareAssessment of Thermal Burns Local & Minor Burnsl Local coolingl Partial thickness: 15% of BSAl Full thickness: 15% BSAl Full thickness: 5% BSAl Maintain warmthl Prevent hypothermial Consider aggressive fluid therapyl Moderate to severe burnsl Burns o

38、ver IV sites l Place IV in partial thickness burn site. Management of Thermal Burns Parkland Burn Formula4 mL x Pt wt in kg x % BSA = Amt of fluidl Pt should receive of this amount in first 8 hrs.l Remainder in 16 hrsl Consider 1 hour dose l 0.5ml x Pt wt in kg x % BSA = Amt of fluidManagement of Th

39、ermal Burns Moderate to Severe Burnsl Caution for fluid overloadl Frequent auscultation of breath soundsl Consider analgesic for painl Morphinel Nubainl Prevent infectionManagement of Thermal Burns Inhalation Injuryl Provide high-flow O2 by NRBl Consider intubation if swellingl Consider hyperbaric o

40、xygen therapyl Cyanide Exposurel Sodium Nitrite, Amyl Nitrite, Sodium Thiosulfatel Forms methemoglobin binds to cyanide l Non-toxic substance secreted in urinel Inhale 1 ampule of Amyl Nitritel 300 mg Sodium Nitrite over 2-4 minutesl 12.5 gm of Sodium ThiosulfateManagement of Thermal Burns Scenario

41、Lightning InjuriesOne of the top three causes of environmental death (flood, temp extremes)Not AC or DC but a unidirectional, massive, current impulse with several return strokes back to the cloudTremendously large current impulsively flows for an incredibly short time Difference Between Lightning a

42、nd ElectricityDuration of exposure to currentl Not enough time for skin burnsl Internal burns and renal failure usually inconsequentialCardiac arrestRespiratory arrestVascular spasmNeurological damage ImmediateVentricular asystolel Often spontaneously resumeProlonged respiratory arrestl Results in s

43、econdary cardiac arrestIschemia due to vascular spasmsl MI, spinal artery syndromes Long TermSurvivors 10-20 x fatalitiesNeuropsychological and neurocognitive changesChronic pain syndromesChest painSympathetic nerve system dysfunctionSleep disorders, HA, cardiac effects DemographicsSunday, Saturday,

44、 WednesdayNoon- 6pm, 6- 12 pmMay be in or outdoorsMales, 10 miles from thunderstorm, clouds/ rain may not be presentShelter- school buses, metal top vehiclesl Avoid trees, small shelters, bleachers, fences, towers, any current transmitting structures, pools/ water, high areas l Avoid use telephones,

45、 electronic equipment, any contact with conductive surfaces inside (plumbing, doing dishes), EMS/ fire dispatch radio Arcing electrical burns, through shoe around rubber sole. High-voltage (7600 V) alternating current ElectricalAge related injury peaks infancy-4 years 20-25 year old males- primarily

46、 work related Factors Affecting SeverityVoltage and amperageResistance of body tissueType and path of currentDuration and intensity of contact Electrical BurnsTerminologyl Voltagel Difference of electrical potential between two pointsl Different concentrations of electronsl Amperes l Strength of ele

47、ctrical currentl Resistance (Ohms)l Opposition to electrical flow Electrical BurnsOhms LawV: VoltageR: ResistanceI: CurrentBased on electron flow thru Tungsten l Emit more light the more current passed thruIRV RVI Electrical BurnsJoules LawP: PowerSkin is resistant to electrical flowl Greater the cu

48、rrent the greater the flow thru the body and greater the release of heat RIP 2 Electrical BurnsGreatest heat occurs at the points of resistancel Entrance and Exit woundsl Dry skin = Greater resistancel Wet Skin = Less resistanceLonger the contact, the greater the potential of injury l Increased dama

49、ge inside bodySmaller the point of contact, the more concentrated the energy, the greater the injury Electrical BurnsElectrical Current Flowl Tissue of Less Resistancel Blood vesselsl Nervel Tissue of Greater Resistancel Muscle l BoneResults inl Serious vascular and nervous injuryl Immobilization of

50、 musclesl Flash burns VoltageHigh 1000 voltsLow resistance injury ComplicationsCardiac arrythmiasRespiratory muscle paralysisThrombosisRenal failureFractures DC- direct current discrete exit AC-alternating current more explosive Current Passage MortalityHand to hand- 60%Hand to foot- 20%Foot to foot

51、- 5% Special ConsiderationsRespiratoryCardiac Concomitant traumaRenal failureRequire fluid resuscitation Electrical Injuriesl Safetyl Turn off powerl Energized lines act as whipsl Establish a safety zonel Lightning Strikesl High voltage, high current, high energyl Lasts fraction of a second l No dan

52、ger of electrical shock to EMSAssessment & Management of Electrical and Lightning Injuries l Assess patientl Entrance & Exit woundsl Remove clothing, jewelry, and leather itemsl Treat any visible injuries l Thermal burnsl ECG monitoringl Bradycardia, Tachycardia, VF or Asystolel ACLS Protocols l Tre

53、at cardiac & respiratory arrestl Aggressive airway, ventilation, and circulatory management.l Consider Fluid bolus for serious burnsl 20 ml/kgl Consider Sodium Bicarbonate: 1 mEq/kgl Consider Mannitol: 10 gAssessment & Management of Electrical Injuries Contact electrical burns, 120-V alternating cur

54、rent nominal. The right knee was the energized side ChemicalStrong acids coagulation necrosisStrong bases liquefication necrosisWill continue burning until neutralized or diluted Degree of Damage/ToxicityChemical natureAmountConcentrationMechanismDuration Chemical BurnsChemical destroys tissuel Acid

55、sl Form a thick, insoluble mass where they contact tissue.l Coagulation necrosis l Limits burn damagel Alkalisl Destroy cell membrane through liquefaction necrosisl Deeper tissue penetration and deeper burns Oral caustic chemical burns Strong Acids and AlkalisStrong acids and alkalis may cause burns

56、 to the mouth, pharynx, esophagus, and sometimes the upper respiratory and GI tractsIngestions of caustic and corrosive substances generally produce immediate damage to the mucous membrane and the intestinal tractl Acids generally complete their damage within 1 to 2 minutes after exposure l Alkalis,

57、 particularly solid alkalis, may continue to cause liquefaction of tissue and damage for minutes to hours Alkali burn to eye Signs and SymptomsFacial burnsPain in the lips, tongue, throat, or gumsDrooling, trouble swallowingHoarseness, stridor, shortness of breathShock secondary to bleeding or vomit

58、ing ManagementEstablish an airway, consider intubation, or if necessary, cricothyrotomyContact poison controlGastric lavage or charcoal often contraindicatedIV with NS or LRRapid transport HydrocarbonsA group of saturated and unsaturated compounds derived primarily from crude oil, coal, or plant sub

59、stancesl Found in many household products and in petroleum distillates HydrocarbonsViscosity is the most important physical characteristic in potential toxicityl The lower the viscosity, the higher the risk of aspiration and associated complicationsClinical features of hydrocarbon ingestion vary wid

60、ely, depending on the type of agent involved l May be immediate or delayed in onset Signs and SymptomsBurns due to local contactWheezing, dyspnea, hypoxia, and pneumonitis due to aspiration or inhalationHeadache, dizziness, slurred speech, ataxia (irregular or difficult-to-control movements), and du

61、lled reflexesFoot and wrist drop with numbness and tinglingCardiac dysrhythmias ManagementMost are not life-threateningOccasionally gastric lavage may be of benefitIn seriously symptomatic patients, protect the airway and establish an IV if NS or LRContact poison controlTransport Chemical Burnsl Sce

62、ne size-upl Hazardous materials teaml Establish hot, warm and cold zonesl Prevent personnel exposure from chemicall Specific Chemicalsl Phenoll Dry Limel Sodium l Riot Control AgentsAssessment & Management of Chemical Burns Specific Chemicalsl Phenoll Industrial cleanerl Alcohol dissolves Phenoll Ir

63、rigate with copious amounts of waterl Dry Limel Strong corrosive that reacts with waterl Brush off dry substancel Irrigate with copious amounts of cool water l Prevents reaction with patient tissues Assessment & Management of Chemical Burns Sodiuml Unstable metall Reacts vigorously with waterl Relea

64、ses l Extreme heatl Hydrogen gasl Ignitionl Decontaminate: Brush off dry chemicall Cover the wound with oil substanceAssessment & Management of Chemical Burns Riot Control Agentsl Agentsl CS, CN (Mace), Oleoresin, Capsicum (OC, pepper spray)l Irritation of the eyes, mucous membranes, and respiratory

65、 tract.l No permanent damagel General Signs & Symptomsl Coughing, gagging, and vomiting l Eye pain, tearing, temporary blindnessl Managementl Irrigate eyes with normal saline Assessment & Management of Chemical Burns H2 RadiationDecontamination is paramountTreated like any other burn Radiation Injur

66、yRadiationl Transmission of energyl Nuclear Energyl Ultraviolet lightl Visible Lightl Heat l Soundl X-RaysRadioactive Substancel Emits ionizing radiationl Radionuclide or Radioisotope Radiation InjuryBasic PhysicsProtonsl Positive charged particlesNeutronsl Equal in mass to protonsl No electrical chargeElectronsl Minute electrically charged particles l When emitted from radioactive substances are termed Beta Particles(continued) Radiation InjuryBasic PhysicsIsotopesl Atoms with unstable nuclear