外科急诊创伤 (英文)- 烧伤

SurgicalEmergencyTrauma:BurnsClassification·Assessment·Resuscitation·WoundCareReportTime：2026CourseOverview01BurnClassificationDepthandextentgrading02InitialAssessmentSeverityandlifethreats03EmergencyManagementPrehospitalandEDcare04FluidResuscitationCalculationandtitration05WoundCareDebridementandsurgicalplanning06ComplicationsInfectionandsystemicsequelae01BurnClassificationKnowthedepthbeforeyoutreatDepthDeterminesManagementDepthofBurnInjury5levelsSuperficialEpidermisonly;red,painful;healsindays,noscar.Superficialpartial-thicknessPapillarydermis;blisters,moist,intenselypainful;re-epithelializesin2–3weeks.Deeppartial-thicknessReticulardermis;mottledorwaxy,reducedpain;slowhealing,significantscarring.Full-thicknessEntiredermisdestroyed;white,leathery,orcharred,absentpain;requiresexcisionandgrafting.Fourth-degreeExtendsintomuscleorbone;profoundreconstructionandamputationrisk.EstimateExtentwithReliableTools烧伤面积估算：成人九分法、儿童Lund-Browder与手掌法。成人九分法RuleofNines头颈

9%每侧上肢各

9%下肢

18%每侧躯干

18%前侧/后侧各会阴

1%Lund-Browder儿童儿童烧伤评估按年龄调整头/腿比例儿童首选手掌估算患者手掌含手指≈1%TBSA床旁快速工具02InitialAssessmentAssessthewholepatient,notjustthewoundPrimarySurveyDrivesEarlyDecisions01Airway→Suspectinhalationinjurywithclosed-spacefire,facialburns,singednasalhair,carbonaceoussputum,hoarseness,orstridor.02Breathing→Checkforcircumferentialchestburnsrestrictingexcursionandsignsofcarbonmonoxideorcyanidetoxicity.03Circulation→Burnshockevolvesoverhours;establishearlylarge-boreIVaccessandbeginbalancedresuscitationwhilethesurveycontinues.04Secondarysurvey→Completedepthandextentestimation;searchforassociatedtrauma,whichcoexistsinameaningfulproportionofburnpatients.IntubateearlyratherthanwaitforedemaRecognizeWhoNeedsaBurnCenterIndicationsforTransferReferSizePartial-thicknessburns>10%TBSAinadults—transferconsiderationrequiredCriticalareasFace,hands,feet,genitalia,perineum,majorjointsDepthAnyfull-thicknessburnMechanismElectricalandchemicalburnsInhalationInhalationinjuryHostriskHigh-riskpatients—significantcomorbidities,extremesofageBeforeTransfer—StabilizeDon'tDelayAirwaySecureairway—donotdelaytransferFluidsBeginfluidresuscitationperprotocolWoundcareCoverwoundswithcleandrydressingsTopicalsAvoidtopicalagentsthatobscureassessmentClearcriteriaconvertsubjectiveimpressionintoadefensible,reproducibledispositiondecision.VS03EmergencyManagementStoptheburning,startthecareStop,Cool,andCoverattheScene01Stoptheburningprocess→Removefromsource;extinguishflames.Removesaturatedclothing,jewelry,andheat-retainingmaterial.02Coolwithinlimits→Coolrunningwaterupto20minuteswithinfirst3hours.03Coverandkeepwarm→Clean,dry,non-adherentdressings.Largesurface-areainjuriesloseheatrapidly.04InitiateIVfluids→Burns>15–20%inadults05Reassessduringtransport→Recordmechanism,time,andestimatedextentforthereceivingteam.Avoidiceandprolongedcooling—vasoconstrictionandhypothermiaworsenmajorburnsAirway,spinalprecautionswhenindicatedManageSpecialBurnsDifferentlyChemicalburns—removetheagentfirst.Eachmechanismshiftspriorityfromthevisiblewoundtowardinvisiblesystemicinjury.Earlyrecognitionchangesbothimmediateanddownstreammanagement.ChemicalburnsBrushawaydrypowders;irrigatecopiouslywithwaterforaprolongedperiodAvoidneutralizingagentsthatgenerateheatElectricalburnsAssessforcardiacarrhythmias,myoglobinuria,andcompartmentsyndromeMonitorurineoutput;maintainhighsuspicionformusclenecrosisInhalationinjuryAdministerhigh-flowoxygen;measurecarboxyhemoglobinwhereavailableConsiderspecificantidoteswhencyanidepoisoningisstronglysuspected04FluidResuscitationReplacewhatislost,titratetoresponseCalculatetheStartingVolumeAccuratebedsideweightandextentmeasurementmaketheinitialcalculationmorereliablethananymemorizedrate.补液指征成人烧伤

>20%TBSA

需液体复苏Parkland公式4mL×

体重(kg)×%TBSA前8小时：总量一半后16小时：剩余一半时钟从受伤时刻起算，非到达时刻滴定优先于处方公式仅为估算，实际输注按生理反应调整特殊人群吸入性损伤：需求更高儿科：复苏量外添加维持液TitratetoUrineOutput,NottheFormula“Formulastarts,responsedirects.”UrineOutputTargetsAdult0.5mL/kg/hr—roughly30–50mLhourlyPediatric1mL/kg/hrTitrationLogicUrineoutputrising→reduceinfusionratetopreventedemaandcompartmentsyndromesUrineoutputfalling→firstruleoutunder-resuscitation,hypovolemia,orearlyrenalinjury,thenincreasefluidsFluidChoiceLactatedRinger'sremainsthepreferredcrystalloid;colloidisgenerallyreservedforrefractoryshockaftertheinitialperiod.Treatresuscitationasadynamicprocess,notafixedcomputation.05WoundCareClean,cover,andplanforclosureClean,Debride,andDresstheWound→→TopicalAntimicrobials银磺胺嘧啶舒适佳/渗痂差莫匹罗星透痂好/酸中毒DepthGuidesClosure深度决定愈合方式：浅II度可保守深II度及全层需切痂植皮每日再评估：加深/感染/上皮化失败→升级手术1Cleanse清洁创面Gentlywashwithsalineormildantiseptictoremovedebrisandsurfacecontaminants.2Debride清除失活组织Removeblistersandnecroticdebristopreventbacterialcolonization.3Dress湿性敷料包扎Applydressingtomanageexudateandsupportamoistwoundenvironment.PlanExcisionandClosureEarlyEarlyexcisionandgraftingwithinthefirstdaysfordeepburnsreducesinfection,shortenshospitalstay,andimprovessurvivalcomparedwithdelayedremoval.01Escharotomy→Indicatedwhenperfusionorventilationiscompromised02Fasciotomy→Followswhendeepercompartmentpressuresremainelevated03Monitoring→Serialdistalperfusion,pulseoximetry,andcompartmentpressuremeasurementsRecognizemechanicalcomplicationsearlyandescalatetotheoperatingroomwithoutdelaytoprotectbothlimbsandlife.DefinitiveclosureAutograftfromunburneddonorsitesTemporarycoverageAllograft,xenograft,orsyntheticdermalsubstituteswhendonorsitesarelimited06ComplicationsAnticipatethesecondhitPreventandDetectBurnSepsisInfectionisthedominantlatecauseofdeathinburnpatientsPreventionstartswithwoundcare,notprophylacticdrugs.Systemicantibioticsarenotroutinelygivenforprophylaxis—theyselectresistantorganismswithoutpreventingwoundcolonization.Reservethemforconfirmedinfection,perioperativecoverage,ordocumentedsepsis.Diagnosisrestsonwoundchange,notclassicsignsLookfornewordeepeningnecrosis,discoloration,rapidescharseparation,orsurroundingcellulitis,confirmedbyquantitativeculture.Tracktrends,notsinglevaluesChronicinflammatoryelevationmakesfeverandleukocytosisunreliable;followtemperature,glucose,hemodynamics,andorganfunctionovertime.EarlysourcecontrolisthecornerstoneDebrideearly;directantimicrobialsbycultureandadjustassensitivitiesreturn.ManagetheSystemicConsequencesTreattheburnwound,butmanagethewholepatient.Beyondthelocalwound—anticipateandmanagethesystem