外科急诊创伤英文烧伤.ppt

BURNS LeaugeayWebreBS CCEMT P NREMT P Scenario Paramediciscalledtothesceneofastructurefire FDhasremovedavictimfromthehouse BSIScenesafe1patientA CstandbyFD PDonsceneNowwhat GeneralImpression 33yomaleptwrithinginpain Screamsandbegsforpainmedicationhoweverpoorhistorian S blisteringtobackandchest Rupperventralarealegexposedmuscle eyebrowssingedA PCN codeineM noneP noneL earliertodayE wokeuponfire A B C Transportdecision BSAburned Tx Objectives DescribethestructureandfunctionofskinDiscussthetypesofburns Explainthedegreesofthermalburns Discusscausesandtreatmentsofinhalationinjuries Identifymethodsofapproximatingburninjuries Describeandapplytreatmentmodalitiesfortheburnpatient Burns thermal Escharotomytoreleasechestwallandallowforventilationofthepatient Skin Largestorganofthebody Anatomy EpidermisDermisSubcutaneoustissue LayersEpidermisDermisSubcutaneosUnderlyingStructuresFasciaNervesTendonsLigamentsMusclesOrgans Anatomy PhysiologyoftheSkin Function ProtectionRegulationPreventionSensory Epidermis Outer thinnerlayerConsistsofdeadkeratinizedcellsProtectsdehydrationtraumalightinfection Dermis GellikematrixConsistsofcollagenandelastinContainsbloodvessels lymphatics sweatglands hairfollicles sensoryfibers Subcutaneous ConnectivetissueAdiposetissuecushioninginsulation Causes ThermalElectricalChemicalRadiation Thermal Majorityflamescaldcontactwithhotobjects Childwithburnsfromascald DeterminingSeverity 1stdegree2nddegree3rddegree 4thdegree DepthofBurn SuperficialBurnPartialThicknessBurnFullThicknessBurn FirstDegree SuperficialinvolveonlyepidermisLocalpainandrednessNoblisteringpresentHealspontaneously2 5dayswithoutscarringNotincludedwhencalculating TBSA BurnDepth SuperficialBurn 1stDegreeBurnSigns SymptomsReddenedskinPainatburnsiteInvolvesonlyepidermis SecondDegree InvolveepidermisanddermisPartialthicknesssuperficialpartialthicknessred painful blistereddeeppartialthicknesspale mottledVerypainfulInfectionmayevolveinto3rddegree BurnDepth Partial ThicknessBurn 2ndDegreeBurnSigns SymptomsIntensepainWhitetoredskinBlistersInvolvesepidermis dermis ThirdDegree Involveepidermis dermis subcutaneoustissueWhite waxy red brown leatheryDryandpainless muscleandbone BurnDepth Full ThicknessBurn 3rdDegreeBurnSigns SymptomsDry leatheryskin white darkbrown orcharred Lossofsensation littlepain Alldermallayers tissuemaybeinvolved FourthDegree IncludeinvolvementofmuscleandboneCharredinappearancePainless Pathophysiology Localchanges 111Fproduceinjury AreaofDamage ZoneofcoagulationZoneofstasisZoneofhyperemia Jackson sTheoryofThermalWoundsZoneofCoagulationAreainaburnnearesttheheatsourcethatsuffersthemostdamageasevidencedbyclottedbloodandthrombosedbloodvesselsZoneofStasisAreasurroundingzoneofcoagulationcharacterizedbydecreasedbloodflow ZoneofHyperemiaPeripheralareaaroundburnthathasanincreasedbloodflow Jackson sTheoryofThermalWounds ZoneofHyperemia ZoneofStasis ZoneofCoagulation ZoneofCoagulation CentralareaofburnNecroticfromtimeofexposure ZoneofStasis ModeratedegreeofinsultDecreasedtissueperfusionVasculardamage leakageMayprogresstonecrosis24 48hours ZoneofHyperemia VasodilationInflammationViabletissue Body sResponsetoBurns EmergentPhase Stage1 PainresponseCatecholaminereleaseTachycardia Tachypnea MildHypertension MildAnxietyFluidShiftPhase Stage2 Length18 24hoursBeginsafterEmergentPhaseReachespeakin6 8hoursDamagedcellsinitiateinflammatoryresponseIncreasedbloodflowtocellsShiftoffluidfromintravasculartoextravascularspaceMASSIVEEDEMA LeakyCapillaries SystemicChanges MassivereleaseofinflammatorymediatorsProducevasoconstriction dilationIncreasedcapillarypermeabilityEdema FluidShifts InitialdecreasebloodflowtoburnedareaFollowedbyincreasedarterialvasodilationReleaseofvasoactivesubstanceresultinginincreasedcapillarypermeabilityandedema Cardiovascular LossofplasmavolumeIncreasedperipheralvascularresistanceDecreasedcardiacoutputdecreasedbloodvolumedecreasedvenousreturnincreasedbloodviscositydecreasedcontractility Renal DecreasecirculatingplasmaIncreasehematocritDecreasedCOdecreasedrenalbloodflowoliguriaacuterenalfailure Gastrointestinal DecreasedgastrointestinalbloodflowIncreasedmucosalhemorrhage 20 ileus ImmuneSystem Depressedimmunefunction 20 directlyproportionaltoburnsize sepsis Body sResponsetoBurns HypermetabolicPhase Stage3 LastfordaystoweeksLargeincreaseinthebody sneedfornutrientsasitrepairsitselfResolutionPhase Stage4 ScarformationGeneralrehabilitationandprogressiontonormalfunction Hypermetabolism FollowingsevereburnandresuscitationtachycardiaincreasedCOincreasedO2demandmassiveproteolysis lipolysisseverenitrogenloss SystemicComplications HypothermiaDisruptionofskinanditsabilitytothermoregulateHypovolemiaShiftinproteins fluids andelectrolytestotheburnedtissueGeneralelectrolyteimbalanceEscharHard leatheryproductofadeepfullthicknessburnDeadanddenaturedskin SystemicComplications InfectionGreatestriskofburnisinfectionOrganFailureReleaseofmyoglobinSpecialFactorsAge HealthPhysicalAbuseElderly InfirmorYoung CriticalBurnAreas FaceHandsFeetGroinJointsCircumfrential InhalationInjuries LeadingcauseofdeathClosedspaceincidentPresenceofheavysmokeHistoryofunconsciousness Burns thermal Partial andfull thicknessburnsfromstructurefire Notefacialinvolvement InhalationInjury ToxicInhalationSyntheticresincombustionCyanide HydrogenSulfideSystemicpoisoningMorefrequentthanthermalinhalationburnCarbonMonoxidePoisoningColorless odorless tastelessgasByproductofincompletecombustionofcarbonproductsSuspectwithfaultyheatingunit200 xgreateraffinityforhemoglobinthanoxygenHypoxemia Hypercarbia OtherEvidence FacialburnsProfusesecretionsCarbonaceoussputumLacrimationSingednasalhair HoarsenessWheezingStridorEdemaHypoxemiaTachycardia InhalationInjury AirwayThermalBurnSupraglotticstructuresabsorbheatandpreventlowerairwayburnsMoistmucosaliningtheupperairwayInjuryiscommonfromsuperheatedsteamRiskFactorsStandingintheburnenvironmentScreamingoryellingintheburnenvironmentTrappedinaclosedburnenvironmentSymptomsStridoror Crowing inspiratorysoundsSingedfacialandnasalhairBlacksputumorfacialburnsProgressiverespiratoryobstructionandarrestduetoswelling TypesofInjuries CarbonmonoxidepoisoningInjuryaboveglottisInjurybelowglottis COPoisoning AffinityforHgb200 250X thanO2Cherryredonlypresentatlevels 40 N V HA decreasedLOC weakness tachypnea tachycardiaFalsepulseoximetryreading 100 O2 timeforelimination40min21 O2 timeelimination250minutes Carboxyhemoglobin Normal 0Smokers truckdriversinheavytraffic 1515 40 neurologicaldysfunctionweakness dizziness N V HA40 60 obtundedseveredecreasedLOCConsiderhyperbarictherapy 25 40 InjuryAboveGlottis Thermal chemicalRequireearlyintubationSeverelyhypovolemic InjuryBelowGlottis UsuallychemicalRepiratorydistressRequireearlyintubationARDSMSOF Estimating BSABurned RuleofpalmsRuleofnines BodySurfaceArea RuleofNinesBestusedforlargesurfaceareasExpedienttooltomeasureextentofburnRuleofPalmsBestusedforburns 10 BSA RulesofNines RuleofPalms Aburnequivalenttothesizeofthepatient shandisequalto1 bodysurfacearea BSA Treatment StoptheburnABC sEstimate BSAburnedCoolburnPreventhypothermia infectionPaincontrol Airway O2onALLpatientsAcutepulmonaryinsufficiencyPulmonaryedema2 3daysBronchopneumonia5 7daysConsiderintubationSx liklihoodofimpendingairwayobstruction Circulation FluidreplacementcriticaltosurvivalTissuedestructionresultsinincreasedcapillarypermeabilityProfoundfluidlossfromtheintravascularspaceLargeamountsfluidlostfromlossofskinintegrityduetoevaporation ParklandFormula 4mlxwtkgx BSAburned 24hrinfusion1sthalfoverfirst8hoursCalculatedfromtimeofinjury2nd 3rddegreeburnsonly FluidResuscitation RestoreeffectiveplasmavolumeMaintainvitalorganfunctionHypovolemia renalfailure complicationsPulmonaryedemaAssessadequacybyUAoutput CoolBurn Within30minutesinhibitslactateproductionandacidosispromotescatecholaminefunctionandardiovascularhomeostasisinhibitsburnwoundhistaminereleaseblockshistaminemediatedincreasedvascualrpermeability Con t minimizesedemaformationsuppressesthromboxanemediatorofvascularocclusionprogressivedermalischemia Hypothermia Infection CoverwithdrysterilesheetKeepwarm PainControl Morphinesulfatedecreasesamountofproteinbindingrapidlyeliminatedsmall frequentdosesmayuseupto50mg hrFentanylVersed SpecialConsiderations CircumfrentialburnsmayrequirefasciotomyPediatricsmoresusceptibletocircumfrential 6monoshiveringmechanismnorepiconvertsbrownfat BurnCenter 2nd 3rddegreeburns 10 502nd 3rddegreeburns20 TBSA2nd 3rddegreeburnstocriticalareas3rddegree 5 TBSASignificantelectrical chemicalburnsInhalationinjuryCircumfrentialburnsPreexisitingconditionsmedicalorconcomitanttrauma SceneSize upFireDepartmentSCBAandprotectiveclothingInitialAssessmentABC sMUSTbeintactConsiderETorRSIRapidevacuationofpatientifsceneisunstable AssessmentofThermalBurns FocusedandRapidTraumaAssessmentAccuratelyapproximateextentofburninjuryRuleofNinesorRuleofPalmsDepthofburnAreaofbodyeffectedAnyburntotheface hands feet jointsorgenitaliaisconsideredaseriousburn Ringing burnsAgeofpatientaffected AssessmentofThermalBurns PainChangesinskinconditionataffectedsiteAdventitioussoundsBlistersSloughingofskinHoarsenessDysphagiaDysphasia AssessmentofThermalBurnsGeneralSigns Symptoms BurnthairEdemaParesthesiaHemorrhageOthersofttissueinjuryMusculoskeletalinjuryDyspneaChestpain AssessmentofThermalBurns Anypartialorfullthicknessburninvolvinghands feet joints face orgenitalia 30 BSA PartialThickness InhalationInjury 10 BSA FullThickness Critical 2 BSA FullThickness 50 BSA Superficial 2 BSA FullThickness 15 BSA PartialThickness 50 BSA Superficial 15 BSA PartialThickness Moderate Minor BurnSeverity OngoingAssessmentNon critical ReassessQ15minCritical ReassessQ5minBurnCenterCare AssessmentofThermalBurns Local MinorBurnsLocalcoolingPartialthickness 15 ofBSAFullthickness 2 BSARemoveclothingCoolorColdwaterimmersionConsideranalgesics ManagementofThermalBurns ModeratetoSevereBurnsDrysteriledressingsPartialthickness 15 BSAFullthickness 5 BSAMaintainwarmthPreventhypothermiaConsideraggressivefluidtherapyModeratetosevereburnsBurnsoverIVsitesPlaceIVinpartialthicknessburnsite ManagementofThermalBurns ParklandBurnFormula4mLxPtwtinkgx BSA AmtoffluidPtshouldreceive ofthisamountinfirst8hrs Remainderin16hrsConsider1hourdose0 5mlxPtwtinkgx BSA Amtoffluid ManagementofThermalBurns ModeratetoSevereBurnsCautionforfluidoverloadFrequentauscultationofbreathsoundsConsideranalgesicforpainMorphineNubainPreventinfection ManagementofThermalBurns InhalationInjuryProvidehigh flowO2byNRBConsiderintubationifswellingConsiderhyperbaricoxygentherapyCyanideExposureSodiumNitrite AmylNitrite SodiumThiosulfateFormsmethemoglobinbindstocyanideNon toxicsubstancesecretedinurineInhale1ampuleofAmylNitrite300mgSodiumNitriteover2 4minutes12 5gmofSodiumThiosulfate ManagementofThermalBurns Scenario LightningInjuries Oneofthetopthreecausesofenvironmentaldeath flood tempextremes NotACorDCbutaunidirectional massive currentimpulsewithseveralreturnstrokesbacktothecloudTremendouslylargecurrentimpulsivelyflowsforanincrediblyshorttime DifferenceBetweenLightningandElectricity DurationofexposuretocurrentNotenoughtimeforskinburnsInternalburnsandrenalfailureusuallyinconsequentialCardiacarrestRespiratoryarrestVascularspasmNeurologicaldamage Immediate VentricularasystoleOftenspontaneouslyresumeProlongedrespiratoryarrestResultsinsecondarycardiacarrestIschemiaduetovascularspasmsMI spinalarterysyndromes LongTerm Survivors10 20 x fatalitiesNeuropsychologicalandneurocognitivechangesChronicpainsyndromesChestpainSympatheticnervesystemdysfunctionSleepdisorders HA cardiaceffects Demographics Sunday Saturday WednesdayNoon 6pm 6 12pmMaybeinoroutdoorsMales 16yoor26 35yo BluntInjuries MuscularcontractionsInstantaneousexpansionandcontractionofsurroundingair CardiorespiratoryArrest Onlyknowndirectcauseofdeath Cosmicdefibrillation MomentaryasystoleSpontaneousrecoveryProlongedrespiratoryarrestHypoxiaSecondarycardiacarrest Neurologic MaypresentonlymildlydisorientatedMaystillsustaindisablingneurocognitivedeficitssimilartobluntheadinjuryMaynotbeimmediatelyapparent Pain PainNumbnessAbnormalsensationsChronicpainsyndromesmaydevelopduetosympatheticNSinjury SympatheticNSInjury MaycausevascularspasmTemporaryparalysisMottlingTransienthypertensionLateproblemswith tilttestsVertigo dizzinessPainsyndromes BraininjurymayoccurDeepburnsrareSuperficialburnsmorecommonPunctate fernlike linearSecondarytometalinpockets clothingEardrumrupturecommonDirectcurrententryConcussive explosiveforceBasilarskullfx Treatment ResuscitationSpinalimmobilizationNSAIDSPreventlongtermnuerologicaldamageTreatchronicpainsyndromesIbuprofen ketoprofen naproxen Prevention AwarenessofweatherforecastEvacuationMaytravel 10milesfromthunderstorm clouds rainmaynotbepresentShelter schoolbuses metaltopvehiclesAvoidtrees smallshelters bleachers fences towers anycurrenttransmittingstructures pools water highareasAvoidusetelephones electronicequipment anycontactwithconductivesurfacesinside plumbing doingdishes EMS firedispatchradio Arcingelectricalburns throughshoearoundrubbersole High voltage 7600V alternatingcurrent Electrical Agerelatedinjurypeaksinfancy 4years20 25yearoldmales primarilyworkrelated FactorsAffectingSeverity VoltageandamperageResistanceofbodytissueTypeandpathofcurrentDurationandintensityofcontact ElectricalBurns TerminologyVoltageDifferenceofelectricalpotentialbetweentwopointsDifferentconcentrationsofelectronsAmperesStrengthofelectricalcurrentResistance Ohms Oppositiontoelectricalflow ElectricalBurns Ohm sLawV VoltageR ResistanceI CurrentBasedonelectronflowthruTungstenEmitmorelightthemorecurrentpassedthru ElectricalBurns Joule sLawP PowerSkinisresistanttoelectricalflowGreaterthecurrentthegreatertheflowthruthebodyandgreaterthereleaseofheat ElectricalBurns GreatestheatoccursatthepointsofresistanceEntranceandExitwoundsDryskin GreaterresistanceWetSkin LessresistanceLongerthecontact thegreaterthepotentialofinjuryIncreaseddamageinsidebodySmallerthepointofcontact themoreconcentratedtheenergy thegreatertheinjury ElectricalBurns ElectricalCurrentFlowTissueofLessResistanceBloodvesselsNerveTissueofGreaterResistanceMuscleBoneResultsinSeriousvascularandnervousinjuryImmobilizationofmusclesFlashburns Voltage High 1000voltsLow 1000voltsMosthouseholdcurrent 110 220voltsProduceslowvoltageinjuryconsistentwiththermalinjuryHighvoltageproducesthermalinjuryatentryandexitaswellasdeeptissueinjuryalongpathAmperageisbetterindicatorofinjury Resistance CurrententersthebodyFollowsthepathofleastresistanceExitsatgroundWhencurrentmeetsresistanceheatgeneratedburninjuryoccurs resistance injury Complications CardiacarrythmiasRespiratorymuscleparalysisThrombosisRenalfailureFractures DC directcurrentdiscreteexitAC alternatingcurrentmoreexplosive CurrentPassageMortality Handtohand 60 Handtofoot 20 Foottofoot 5 SpecialConsiderations RespiratoryCardiacConcomitanttraumaRenalfailureRequire fluidresuscitation ElectricalInjuriesSafetyTurnoffpowerEnergizedlinesactaswhipsEstablishasafetyzoneLightningStrikesHighvoltage highcurrent highenergyLastsfractionofasecondNodangerofelectricalshocktoEMS Assessment ManagementofElectricalandLightningInjuries AssesspatientEntrance ExitwoundsRemoveclothing jewelry andleatheritemsTreatanyvisibleinjuriesThermalburnsECGmonitoringBradycardia Tachycardia VForAsystoleACLSProtocolsTreatcardiac respiratoryarrestAggressiveairway ventilation andcirculatorymanagement ConsiderFluidbolusforseriousburns20ml kgConsiderSodiumBicarbonate 1mEq kgConsiderMannitol 10g Assessment ManagementofElectricalInjuries Contactelectricalburns 120 Valternatingcurrentnominal Therightkneewastheenergizedside Chemical StrongacidscoagulationnecrosisStrongbasesliqueficationnecrosisWillcontinueburninguntilneutralizedordiluted DegreeofDamage Toxicity ChemicalnatureAmountConcentrationMechanismDuration ChemicalBurns ChemicaldestroystissueAcidsFormathick insolublemasswheretheycontacttissue CoagulationnecrosisLimitsburndamageAlkalisDestroycellmembranethroughliquefactionnecrosisDeepertissuepenetrationanddeeperburns Oralcausticchemicalburns StrongAcidsandAlkalis Strongacidsandalkalismaycauseburnstothemouth pharynx esophagus andsometimestheupperrespiratoryandGItractsIngestionsofcausticandcorrosivesubstancesgenerallyproduceimmediatedamagetothemucousmembraneandtheintestinaltractAcidsgenerallycompletetheirdamagewithin1to2minutesafterexposureAlkalis particularlysolidalkalis maycontinuetocauseliquefactionoftissueanddamageforminutestohours Alkaliburntoeye SignsandSymptoms FacialburnsPaininthelips tongue throat orgumsDrooling troubleswallowingHoarseness stridor shortnessofbreathShocksecondarytobleedingorvomiting Management Establishanairway considerintubation orifnecessary cricothyrotomyContactpoisoncontrolGastriclavageorcharcoaloftencontraindicatedIVwithNSorLRRapidtransport Hydrocarbons Agroupofsaturatedandunsaturatedcompoundsderivedprimarilyfromcrudeoil coal orplantsubstancesFoundinmanyhouseholdproductsandinpetroleumdistillates Hydrocarbons ViscosityisthemostimportantphysicalcharacteristicinpotentialtoxicityThelowertheviscosity thehighertheriskofaspirationandassociatedcomplicationsClinicalfeaturesofhydrocarboningestionvarywidely dependingonthetypeofagentinvolvedMaybeimmediateordelayedinonset SignsandSymptoms BurnsduetolocalcontactWheezing dyspnea hypoxia andpneumonitisduetoaspirationorinhalationHeadache dizziness slurredspeech ataxia irregularordifficult to controlmovements anddulledreflexesFootandwristdropwithnumbnessandtinglingCardiacdysrhythmias Management Mostarenotlife threateningOccasionallygastriclavagemaybeofbenefitInseriouslysymptomaticpatients protecttheairwayandestablishanIVifNSorLRContactpoisoncontrolTransport ChemicalBurnsScenesize upHazardousmaterialsteamEstablishhot warmandcoldzonesPreventpersonnelexposurefromchemicalSpecificChemicalsPhenolDryLimeSodiumRiotControlAgents Assessment ManagementofChemicalBurns SpecificChemicalsPhenolIndustrialcleanerAlcoholdissolvesPhenolIrrigatewithcopiousamountsofwaterDryLimeStrongcorrosivethatreactswithwaterBrushoffdrysubstanceIrrigatewithcopiousamountsofcoolwaterPreventsreactionwithpatienttissues Assessment ManagementofChemicalBu