外科急诊创伤英文烧伤.ppt

BURNS,Leaugeay Webre BS, CCEMT-P, NREMT-P,Scenario,Paramedic is called to the scene of a structure fire. FD has removed a victim from the house. BSI Scene safe 1 patient A/C standby FD/ PD on scene Now what?,General Impression,33 yo male pt writhing in pain. Screams and begs for pain medication however poor historian. S- blistering to back and chest, R upper ventral area leg exposed muscle; eyebrows singed A- PCN, codeine M- none P- none L- earlier today E- woke up on fire,A- B- C- Transport decision? % BSA burned? Tx?,Objectives,Describe the structure and function of skin Discuss the types of burns. Explain the degrees 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.,Skin,Largest organ of the body,Anatomy,Epidermis Dermis Subcutaneous tissue,Layers Epidermis Dermis Subcutaneos Underlying Structures Fascia Nerves Tendons Ligaments Muscles Organs,Anatomy & Physiology of the Skin,Function,Protection Regulation Prevention Sensory,Epidermis,Outer, thinner layer Consists of dead keratinized cells Protects dehydration trauma light infection,Dermis,Gel like matrix Consists of collagen and elastin Contains blood vessels, lymphatics, sweat glands, hair follicles, sensory fibers,Subcutaneous,Connective tissue Adipose tissue cushioning insulation,Causes,Thermal Electrical Chemical Radiation,Thermal,Majority flame scald contact with hot objects,Child with burns from a scald,Determining Severity,1st degree 2nd degree 3rd degree (4th degree),Depth of Burn,Superficial Burn Partial Thickness Burn Full Thickness Burn,First Degree,Superficial involve only epidermis Local pain and redness No blistering present Heal spontaneously 2-5 days without scarring Not included when calculating % TBSA,Burn Depth,Superficial Burn: 1st Degree Burn Signs & Symptoms Reddened skin Pain at burn site Involves only epidermis,Second Degree,Involve epidermis and dermis Partial thickness superficial partial thickness red, painful, blistered deep partial thickness pale, mottled Very painful Infection may evolve into 3rd degree,Burn Depth,Partial-Thickness Burn: 2nd Degree Burn Signs & Symptoms Intense pain White to red skin Blisters Involves epidermis & dermis,Third Degree,Involve epidermis, dermis, subcutaneous tissue White, waxy, red, brown, leathery Dry and painless (muscle and bone),Burn Depth,Full-Thickness Burn: 3rd Degree Burn Signs & Symptoms Dry, leathery skin (white, dark brown, or charred) Loss of sensation (little pain) All dermal layers/tissue may be involved,Fourth Degree,Include involvement of muscle and bone Charred in appearance Painless,Pathophysiology,Local changes- 111F produce injury,Area of Damage,Zone of coagulation Zone of stasis Zone of hyperemia,Jacksons Theory of Thermal Wounds Zone of Coagulation Area in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels Zone of Stasis Area surrounding zone of coagulation characterized by decreased blood flow. Zone of Hyperemia Peripheral area around burn that has an increased blood flow.,Jacksons Theory of Thermal Wounds,Zone of Hyperemia,Zone of Stasis,Zone of Coagulation,Zone of Coagulation,Central area of burn Necrotic from time of exposure,Zone of Stasis,Moderate degree of insult Decreased tissue perfusion Vascular damage/ leakage May progress to necrosis 24-48 hours,Zone of Hyperemia,Vasodilation Inflammation Viable tissue,Bodys Response to Burns,Emergent Phase (Stage 1) Pain response Catecholamine release Tachycardia, Tachypnea, Mild Hypertension, Mild Anxiety Fluid Shift Phase (Stage 2) Length 18-24 hours Begins after Emergent Phase Reaches peak in 6-8 hours Damaged cells initiate inflammatory response Increased blood flow to cells Shift of fluid from intravascular to extravascular space MASSIVE EDEMA “Leaky Capillaries,Systemic Changes,Massive release of inflammatory mediators Produce vasoconstriction/ dilation Increased capillary permeability Edema,Fluid Shifts,Initial decrease blood flow to burned area Followed by increased arterial vasodilation Release of vasoactive substance resulting in increased capillary permeability and edema,Cardiovascular,Loss of plasma volume Increased peripheral vascular resistance Decreased cardiac output decreased blood volume decreased venous return increased blood viscosity decreased contractility,Renal,Decrease circulating plasma Increase hematocrit Decreased CO decreased renal blood flow oliguria acute renal failure,Gastrointestinal,Decreased gastrointestinal blood flow Increased mucosal hemorrhage 20% ileus,Immune System,Depressed immune function 20% directly proportional to burn size,sepsis,Bodys Response to Burns,Hypermetabolic Phase (Stage 3) Last for days to weeks Large increase in the bodys need for nutrients as it repairs itself Resolution Phase (Stage 4) Scar formation General rehabilitation and progression to normal function,Hypermetabolism,Following severe burn and resuscitation tachycardia increased CO increased O2 demand massive proteolysis & lipolysis severe nitrogen loss,Systemic Complications,Hypothermia Disruption of skin and its ability to thermoregulate Hypovolemia Shift in proteins, fluids, and electrolytes to the burned tissue General electrolyte imbalance Eschar Hard, leathery product of a deep full thickness burn Dead and denatured skin,Systemic Complications,Infection Greatest risk of burn is infection Organ Failure Release of myoglobin Special Factors Age & Health Physical Abuse Elderly, Infirm or Young,Critical Burn Areas,Face Hands Feet Groin Joints Circumfrential,Inhalation Injuries,Leading 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 Injury,Toxic Inhalation Synthetic resin combustion Cyanide & Hydrogen Sulfide Systemic poisoning More frequent than thermal inhalation burn Carbon Monoxide Poisoning Colorless, odorless, tasteless gas Byproduct of incomplete combustion of carbon products Suspect with faulty heating unit 200x greater affinity for hemoglobin than oxygen Hypoxemia & Hypercarbia,Other Evidence,Facial burns Profuse secretions Carbonaceous sputum Lacrimation Singed nasal hair,Hoarseness Wheezing Stridor Edema Hypoxemia Tachycardia,Inhalation Injury,Airway Thermal Burn Supraglottic structures absorb heat and prevent lower airway burns Moist mucosa lining the upper airway Injury is common from superheated steam Risk Factors Standing in the burn environment Screaming or yelling in the burn environment Trapped in a closed burn environment Symptoms Stridor or “Crowing” inspiratory sounds Singed facial and nasal hair Black sputum or facial burns Progressive respiratory obstruction and arrest due to swelling,Types of Injuries,Carbon monoxide poisoning Injury above glottis Injury below glottis,CO Poisoning,Affinity for Hgb 200-250X than O2 Cherry red only present at levels 40% +N,+V, HA, decreased LOC, weakness, tachypnea, tachycardia False pulse oximetry reading,100% O2 time for elimination 40 min 21% O2 time elimination 250 minutes,Carboxyhemoglobin,Normal- 0 Smokers, truck drivers in heavy traffic- 15 15-40%- neurological dysfunction weakness, dizziness, +N, +V, HA 40-60%- obtunded severe decreased LOC Consider hyperbaric therapy- 25-40%,Injury Above Glottis,Thermal, chemical Require early intubation Severely hypovolemic,Injury Below Glottis,Usually chemical Repiratory distress Require early intubation ARDS MSOF,Estimating % BSA Burned,Rule of palms Rule of nines,Body Surface Area,Rule of Nines Best used for large surface areas Expedient tool to measure extent of burn Rule of Palms Best used for burns 10% BSA,Rules of Nines,Rule of Palms,A burn equivalent to the size of the patients hand is equal to 1% body surface area (BSA),Treatment,Stop the burn ABCs Estimate % BSA burned Cool burn Prevent hypothermia & infection Pain control,Airway,O2 on ALL patients Acute pulmonary insufficiency Pulmonary edema 2-3 days Bronchopneumonia 5-7 days Consider intubation Sx/ liklihood of impending airway obstruction,Circulation,Fluid replacement critical to survival Tissue destruction results in increased capillary permeability Profound fluid loss from the intravascular space Large amounts fluid lost from loss of skin integrity due to evaporation,Parkland Formula,4ml x wt kg x %BSA burned = 24 hr infusion 1st half over first 8 hours Calculated from time of injury 2nd/ 3rd degree burns only,Fluid Resuscitation,Restore effective plasma volume Maintain vital organ function Hypovolemia/ renal failure- complications Pulmonary edema Assess adequacy by UA output,Cool Burn,Within 30 minutes inhibits lactate production and acidosis promotes catecholamine function and ardiovascular homeostasis inhibits burn wound histamine release blocks histamine mediated increased vascualr permeability,Cont,minimizes edema formation suppresses thromboxane mediator of vascular occlusion progressive dermal ischemia,Hypothermia & Infection,Cover with dry sterile sheet Keep warm,Pain Control,Morphine sulfate decreases amount of protein binding rapidly eliminated small, frequent doses may use up to 50mg/hr Fentanyl Versed,Special Considerations,Circumfrential burns may require fasciotomy Pediatrics more susceptible to circumfrential 6 mo no shivering mechanism norepi converts brown fat,Burn Center,2nd/3rd degree burns 10% 50 2nd/3rd degree burns 20% TBSA 2nd/3rd degree burns to critical areas 3rd degree 5% TBSA Significant electrical/ chemical burns Inhalation injury Circumfrential burns Preexisiting conditions medical or concomitant trauma,Scene Size-up Fire Department SCBA and protective clothing Initial Assessment ABCs MUST be intact Consider ET or RSI Rapid evacuation of patient if scene is unstable,Assessment of Thermal Burns,Focused and Rapid Trauma Assessment Accurately approximate extent of burn injury Rule of Nines or Rule of Palms Depth of burn Area of body effected Any burn to the face, hands, feet, joints or genitalia is considered a serious burn “Ringing” burns Age of patient affected,Assessment of Thermal Burns,Pain Changes in skin condition at affected site Adventitious sounds Blisters Sloughing of skin Hoarseness Dysphagia Dysphasia,Assessment of Thermal Burns General Signs & Symptoms,Burnt hair Edema Paresthesia Hemorrhage Other soft tissue injury Musculoskeletal injury Dyspnea Chest pain,Assessment of Thermal Burns,Any partial or full thickness burn involving hands, feet, joints, face, or genitalia,30% BSA,Partial Thickness,Inhalation Injury,10% BSA,Full Thickness,Critical,2% BSA,Full Thickness,50% BSA,Superficial,2% BSA,Full Thickness,15% BSA,Partial Thickness,50% BSA,Superficial,15% BSA,Partial Thickness,Moderate,Minor,Burn Severity,Ongoing Assessment Non-critical: Reassess Q 15 min Critical: Reassess Q 5 min Burn Center Care,Assessment of Thermal Burns,Local & Minor Burns Local cooling Partial thickness: 15% of BSA Full thickness: 2% BSA Remove clothing Cool or Cold water immersion Consider analgesics,Management of Thermal Burns,Moderate to Severe Burns Dry sterile dressings Partial thickness: 15% BSA Full thickness: 5% BSA Maintain warmth Prevent hypothermia Consider aggressive fluid therapy Moderate to severe burns Burns over IV sites Place IV in partial thickness burn site.,Management of Thermal Burns,Parkland Burn Formula 4 mL x Pt wt in kg x % BSA = Amt of fluid Pt should receive of this amount in first 8 hrs. Remainder in 16 hrs Consider 1 hour dose 0.5ml x Pt wt in kg x % BSA = Amt of fluid,Management of Thermal Burns,Moderate to Severe Burns Caution for fluid overload Frequent auscultation of breath sounds Consider analgesic for pain Morphine Nubain Prevent infection,Management of Thermal Burns,Inhalation Injury Provide high-flow O2 by NRB Consider intubation if swelling Consider hyperbaric oxygen therapy Cyanide Exposure Sodium Nitrite, Amyl Nitrite, Sodium Thiosulfate Forms methemoglobin binds to cyanide Non-toxic substance secreted in urine Inhale 1 ampule of Amyl Nitrite 300 mg Sodium Nitrite over 2-4 minutes 12.5 gm of Sodium Thiosulfate,Management of Thermal Burns,Scenario,Lightning Injuries,One 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 cloud Tremendously large current impulsively flows for an incredibly short time,Difference Between Lightning and Electricity,Duration of exposure to current Not enough time for skin burns Internal burns and renal failure usually inconsequential Cardiac arrest Respiratory arrest Vascular spasm Neurological damage,Immediate,Ventricular asystole Often spontaneously resume Prolonged respiratory arrest Results in secondary cardiac arrest Ischemia due to vascular spasms MI, spinal artery syndromes,Long Term,Survivors 10-20x fatalities Neuropsychological and neurocognitive changes Chronic pain syndromes Chest pain Sympathetic nerve system dysfunction Sleep disorders, HA, cardiac effects,Demographics,Sunday, Saturday, Wednesday Noon- 6pm, 6- 12 pm May be in or outdoors Males, 16 yo or 26- 35 yo,Blunt Injuries,Muscular contractions Instantaneous expansion and contraction of surrounding air,Cardiorespiratory Arrest,Only known direct cause of death “Cosmic defibrillation” Momentary asystole Spontaneous recovery Prolonged respiratory arrest Hypoxia Secondary cardiac arrest,Neurologic,May present only mildly disorientated May still sustain disabling neurocognitive deficits similar to blunt head injury May not be immediately apparent,Pain,Pain Numbness Abnormal sensations Chronic pain syndromes may develop due to sympathetic NS injury,Sympathetic NS Injury,May cause vascular spasm Temporary paralysis Mottling Transient hypertension Late problems with + tilt tests Vertigo/ dizziness Pain syndromes,Brain injury may occur Deep burns rare Superficial burns more common Punctate, fern like, linear Secondary to metal in pockets/ clothing Ear drum rupture common Direct current entry Concussive/ explosive force Basilar skull fx,Treatment,Resuscitation Spinal immobilization NSAIDS Prevent long term nuerological damage Treat chronic pain syndromes Ibuprofen, ketoprofen, naproxen,Prevention,Awareness of weather forecast Evacuation May travel 10 miles from thunderstorm, clouds/ rain may not be present Shelter- school buses, metal top vehicles Avoid trees, small shelters, bleachers, fences, towers, any current transmitting structures, pools/ water, high areas Avoid use telephones, 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,Electrical,Age related injury peaks infancy-4 years 20-25 year old males- primarily work related,Factors Affecting Severity,Voltage and amperage Resistance of body tissue Type and path of current Duration and intensity of contact,Electrical Burns,Terminology Voltage Difference of electrical potential between two points Different concentrations of electrons Amperes Strength of electrical current Resistance (Ohms) Opposition to electrical flow,Electrical Burns,Ohms Law V: Voltage R: Resistance I: Current Based on electron flow thru Tungsten Emit more light the more current passed thru,Electrical Burns,Joules Law P: Power Skin is resistant to electrical flow Greater the current the greater the flow thru the body and greater the release of heat,Electrical Burns,Greatest heat occurs at the points of resistance Entrance and Exit wounds Dry skin = Greater resistance Wet Skin = Less resistance Longer the contact, the greater the potential of injury Increased damage inside body Smaller the point of contact, the more concentrated the energy, the greater the injury,Electrical Burns,Electrical Current Flow Tissue of Less Resistance Blood vessels Nerve Tissue of Greater Resistance Muscle Bone Results in Serious vascular and nervous injury Immobilization of muscles Flash burns,Voltage,High 1000 volts Low 1000 volts Most household current- 110-220 volts Produces low voltage injury consistent with thermal injury High voltage produces thermal injury at entry and exit as well as deep tissue injury along path Amperage is better indicator of injury,Resistance,Current enters the body Follows the path of least resistance Exits at ground When current meets resistance heat generated burn injury occurs resistance injury,Complications,Cardiac arrythmias Respiratory muscle paralysis Thrombosis Renal failure Fractures,DC- direct current discrete exit AC-alternating current more explosive,Current Passage Mortality,Hand to hand- 60% Hand to foot- 20% Foot to foot- 5%,Special Considerations,Respiratory Cardiac Concomitant trauma Renal failure Require fluid resuscitation,Electrical Injuries Safety Turn off power Energized lines act as whips Establish a safety zone Lightning Strikes High voltage, high current, high energy Lasts fraction of a second No danger of electrical shock to EMS,Assessment & Management of Electrical and Lightning Injuries,Assess patient Entrance & Exit wounds Remove clothing, jewelry, and leather items Treat any visible injuries Thermal burns ECG monitoring Bradycardia, Tachycardia, VF or Asystole ACLS Protocols Treat cardiac & respiratory arrest Aggressive airway, ventilation, and circulatory management. Consider Fluid bolus for serious burns 20 ml/kg Consider Sodium Bicarbonate: 1 mEq/kg Consider Mannitol: 10 g,Assessment & Management of Electrical Injuries,Contact electrical burns, 120-V alternating current nominal. The right knee was the energized side,Chemical,Strong acids coagulation necrosis Strong bases liquefication necrosis Will continue burning until ne