最新外科急诊创伤(英文)-烧伤精品课件.ppt

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1、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?LayerslEpidermislDermislSubcutaneoslUnderlying StructureslFascialNerveslTendonslLigamentslMuscleslOrgansAnatomy & Physiology of the SkinFunct

2、ionProtection Regulation Prevention SensoryEpidermisOuter, thinner layerConsists of dead keratinized cellsProtects dehydration trauma light infectionDermisGel like matrixConsists of collagen and elastinContains blood vessels, lymphatics, sweat glands, hair follicles, sensory fibersSubcutaneousConnec

3、tive tissueAdipose tissue cushioning insulationCausesThermalElectricalChemicalRadiation ThermalMajority flame scald contact with hot objectsChild with burns from a scaldDetermining Severity1st degree2nd degree3rd degree(4th degree)Depth of BurnSuperficial BurnPartial Thickness BurnFull Thickness Bur

4、nFirst DegreeSuperficial involve only epidermisLocal pain and rednessNo blistering presentHeal spontaneously 2-5 days without scarringNot included when calculating % TBSABurn DepthSuperficial Burn:1st Degree BurnlSigns & SymptomslReddened skinlPain at burn sitelInvolves only epidermisSecond DegreeIn

5、volve epidermis and dermisPartial thickness superficial partial thickness red, painful, blistered deep partial thickness pale, mottledVery painfulInfection may evolve into 3rd degreeBurn DepthPartial-Thickness Burn: 2nd Degree BurnlSigns & SymptomslIntense painlWhite to red skinlBlisterslInvolves ep

6、idermis & dermisThird DegreeInvolve epidermis, dermis, subcutaneous tissueWhite, waxy, red, brown, leatheryDry and painless(muscle and bone)Burn DepthFull-Thickness Burn: 3rd Degree BurnlSigns & SymptomslDry, leathery skin (white, dark brown, or charred)lLoss of sensation (little pain)lAll dermal la

7、yers/tissue may be involvedFourth DegreeInclude involvement of muscle and boneCharred in appearancePainlessPathophysiologyLocal changes- 111F produce injuryArea of DamageZone of coagulationZone of stasisZone of hyperemiaJacksons Theory of Thermal WoundslZone of CoagulationlArea in a burn nearest the

8、 heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vesselslZone of StasislArea surrounding zone of coagulation characterized by decreased blood flow.lZone of HyperemialPeripheral area around burn that has an increased blood flow.Jacksons Theory of Thermal Wo

9、undsZone of HyperemiaZone of StasisZone of CoagulationZone of CoagulationCentral area of burnNecrotic from time of exposureZone of StasisModerate degree of insultDecreased tissue perfusionVascular damage/ leakageMay progress to necrosis 24-48 hoursZone of HyperemiaVasodilationInflammationViable tiss

10、ueBodys Response to BurnsEmergent Phase (Stage 1)lPain responselCatecholamine releaselTachycardia, Tachypnea, Mild Hypertension, Mild AnxietyFluid Shift Phase (Stage 2)lLength 18-24 hourslBegins after Emergent PhaselReaches peak in 6-8 hourslDamaged cells initiate inflammatory responselIncreased blo

11、od flow to cellslShift of fluid from intravascular to extravascular spacelMASSIVE EDEMAl“Leaky CapillariesSystemic ChangesMassive release of inflammatory mediatorsProduce vasoconstriction/ dilationIncreased capillary permeabilityEdemaFluid ShiftsInitial decrease blood flow to burned areaFollowed by

12、increased arterial vasodilationRelease of vasoactive substance resulting in increased capillary permeability and edemaCardiovascularLoss of plasma volumeIncreased peripheral vascular resistanceDecreased cardiac output decreased blood volume decreased venous return increased blood viscosity decreased

13、 contractilityRenalDecrease circulating plasmaIncrease hematocritDecreased CO decreased renal blood flow oliguria acute renal failureGastrointestinalDecreased gastrointestinal blood flowIncreased mucosal hemorrhage 20% ileusImmune SystemDepressed immune function 20% directly proportional to burn siz

14、esepsisBodys Response to BurnsHypermetabolic Phase (Stage 3)lLast for days to weekslLarge increase in the bodys need for nutrients as it repairs itselfResolution Phase (Stage 4)lScar formationlGeneral rehabilitation and progression to normal functionHypermetabolismFollowing severe burn and resuscita

15、tion tachycardia increased CO increased O2 demand massive proteolysis & lipolysis severe nitrogen lossSystemic ComplicationsHypothermialDisruption of skin and its ability to thermoregulateHypovolemialShift in proteins, fluids, and electrolytes to the burned tissuelGeneral electrolyte imbalanceEschar

16、lHard, leathery product of a deep full thickness burnlDead and denatured skinSystemic ComplicationsInfectionlGreatest risk of burn is infectionOrgan FailurelRelease of myoglobinSpecial FactorslAge & HealthPhysical AbuselElderly, Infirm or YoungCritical Burn AreasFace HandsFeetGroinJointsCircumfrenti

17、alInhalation InjuriesLeading cause of death Closed space incident Presence of heavy smoke History of unconsciousnessBurns, thermal. Partial- and full-thickness burns from structure fire. Note facial involvement.Inhalation InjuryToxic InhalationlSynthetic resin combustionlCyanide & Hydrogen SulfidelS

18、ystemic poisoninglMore frequent than thermal inhalation burnCarbon Monoxide PoisoninglColorless, odorless, tasteless gaslByproduct of incomplete combustion of carbon productslSuspect with faulty heating unitl200 x greater affinity for hemoglobin than oxygenlHypoxemia & HypercarbiaOther EvidenceFacia

19、l burnsProfuse secretionsCarbonaceous sputumLacrimationSinged nasal hairHoarsenessWheezingStridorEdemaHypoxemiaTachycardiaInhalation InjuryAirway Thermal BurnlSupraglottic structures absorb heat and prevent lower airway burnslMoist mucosa lining the upper airwaylInjury is common from superheated ste

20、amlRisk FactorslStanding in the burn environmentlScreaming or yelling in the burn environmentlTrapped in a closed burn environmentlSymptomslStridor or “Crowing” inspiratory soundslSinged facial and nasal hairlBlack sputum or facial burnslProgressive respiratory obstruction and arrest due to swelling

21、Types of InjuriesCarbon monoxide poisoningInjury above glottisInjury below glottisCO 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 elimination 40 min21% O2 time e

22、limination 250 minutesCarboxyhemoglobinNormal- 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 early intubationSeverely hyp

23、ovolemicInjury Below GlottisUsually chemicalRepiratory distressRequire early intubationARDSMSOFEstimating % BSA BurnedRule of palmsRule of ninesBody Surface AreaRule of NineslBest used for large surface areaslExpedient tool to measure extent of burnRule of PalmslBest used for burns 10% BSARules of N

24、ines184.59194.5184.54.5994.5994.574.574.5718181Rule 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 controlAirwayO2 on ALL patients Acute pulmonary insufficien

25、cy Pulmonary edema 2-3 days Bronchopneumonia 5-7 daysConsider intubation Sx/ liklihood of impending airway obstructionCirculationFluid replacement critical to survivalTissue destruction results in increased capillary permeabilityProfound fluid loss from the intravascular spaceLarge amounts fluid los

26、t from loss of skin integrity due to evaporationParkland Formula4ml x wt kg x %BSA burned = 24 hr infusion1st half over first 8 hoursCalculated from time of injury2nd/ 3rd degree burns onlyFluid ResuscitationRestore effective plasma volumeMaintain vital organ functionHypovolemia/ renal failure- comp

27、licationsPulmonary edemaAssess adequacy by UA outputCool BurnWithin 30 minutes inhibits lactate production and acidosis promotes catecholamine function and ardiovascular homeostasis inhibits burn wound histamine release blocks histamine mediated increased vascualr permeabilityCont minimizes edema fo

28、rmation suppresses thromboxane mediator of vascular occlusion progressive dermal ischemiaHypothermia & InfectionCover with dry sterile sheetKeep warmPain ControlMorphine sulfate decreases amount of protein binding rapidly eliminated small, frequent doses may use up to 50mg/hrFentanylVersed Special C

29、onsiderationsCircumfrential 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 injuryCircumfrential burnsPreexisiting conditions medical

30、or concomitant traumaScene Size-uplFire DepartmentlSCBA and protective clothingInitial AssessmentlABCs MUST be intactlConsider ET or RSIlRapid evacuation of patient if scene is unstableAssessment of Thermal BurnsFocused and Rapid Trauma AssessmentlAccurately approximate extent of burn injurylRule of

31、 Nines or Rule of PalmslDepth of burnlArea of body effectedlAny burn to the face, hands, feet, joints or genitalia is considered a serious burnl“Ringing” burnslAge of patient affectedAssessment of Thermal BurnsPainChanges in skin condition at affected siteAdventitious soundsBlistersSloughing of skin

32、HoarsenessDysphagiaDysphasiaAssessment of Thermal BurnsGeneral Signs & SymptomsBurnt hairEdemaParesthesiaHemorrhageOther soft tissue injuryMusculoskeletal injuryDyspneaChest painAssessment of Thermal BurnsAny partial or full thickness burn involving hands, feet, joints,face, or genitalia30% BSAParti

33、al ThicknessInhalation Injury10% BSAFull ThicknessCritical2% BSAFull Thickness50% BSASuperficial2% BSAFull Thickness15% BSAPartial Thickness15% BSAPartial ThicknessModerateMinorOngoing AssessmentlNon-critical: Reassess Q 15 minlCritical: Reassess Q 5 minBurn Center CareAssessment of Thermal BurnsLoc

34、al & Minor BurnslLocal coolinglPartial thickness: 15% of BSAlFull thickness: 15% BSAlFull thickness: 5% BSAlMaintain warmthlPrevent hypothermialConsider aggressive fluid therapylModerate to severe burnslBurns over IV siteslPlace IV in partial thickness burn site.Management of Thermal BurnsParkland B

35、urn Formula4 mL x Pt wt in kg x % BSA = Amt of fluidlPt should receive of this amount in first 8 hrs.lRemainder in 16 hrslConsider 1 hour dosel0.5ml x Pt wt in kg x % BSA = Amt of fluidManagement of Thermal BurnsModerate to Severe BurnslCaution for fluid overloadlFrequent auscultation of breath soun

36、dslConsider analgesic for painlMorphinelNubainlPrevent infectionManagement of Thermal BurnsInhalation InjurylProvide high-flow O2 by NRBlConsider intubation if swellinglConsider hyperbaric oxygen therapylCyanide ExposurelSodium Nitrite, Amyl Nitrite, Sodium ThiosulfatelForms methemoglobin binds to c

37、yanidelNon-toxic substance secreted in urinelInhale 1 ampule of Amyl Nitritel300 mg Sodium Nitrite over 2-4 minutesl12.5 gm of Sodium ThiosulfateManagement of Thermal BurnsScenarioLightning InjuriesOne of the top three causes of environmental death (flood, temp extremes)Not AC or DC but a unidirecti

38、onal, massive, current impulse with several return strokes back to the cloudTremendously large current impulsively flows for an incredibly short timeDifference Between Lightning and ElectricityDuration of exposure to currentlNot enough time for skin burnslInternal burns and renal failure usually inc

39、onsequentialCardiac arrestRespiratory arrestVascular spasmNeurological damageImmediateVentricular asystolelOften spontaneously resumeProlonged respiratory arrestlResults in secondary cardiac arrestIschemia due to vascular spasmslMI, spinal artery syndromesLong TermSurvivors 10-20 x fatalitiesNeurops

40、ychological and neurocognitive changesChronic pain syndromesChest painSympathetic nerve system dysfunctionSleep disorders, HA, cardiac effectsDemographicsSunday, Saturday, WednesdayNoon- 6pm, 6- 12 pmMay be in or outdoorsMales, 10 miles from thunderstorm, clouds/ rain may not be presentShelter- scho

41、ol buses, metal top vehicleslAvoid trees, small shelters, bleachers, fences, towers, any current transmitting structures, pools/ water, high areaslAvoid use telephones, electronic equipment, any contact with conductive surfaces inside (plumbing, doing dishes), EMS/ fire dispatch radioArcing electric

42、al burns, through shoe around rubber sole. High-voltage (7600 V) alternating currentElectricalAge related injury peaks infancy-4 years 20-25 year old males- primarily work relatedFactors Affecting SeverityVoltage and amperageResistance of body tissueType and path of currentDuration and intensity of

43、contactElectrical BurnsTerminologylVoltagelDifference of electrical potential between two pointslDifferent concentrations of electronslAmpereslStrength of electrical currentlResistance (Ohms)lOpposition to electrical flowElectrical BurnsOhms LawV: VoltageR: ResistanceI: CurrentBased on electron flow

44、 thru TungstenlEmit more light the more current passed thruIRV RVI Electrical BurnsJoules LawP: PowerSkin is resistant to electrical flowlGreater the current the greater the flow thru the body and greater the release of heatRIP2Electrical BurnsGreatest heat occurs at the points of resistancelEntranc

45、e and Exit woundslDry skin = Greater resistancelWet Skin = Less resistanceLonger the contact, the greater the potential of injurylIncreased damage inside bodySmaller the point of contact, the more concentrated the energy, the greater the injuryElectrical BurnsElectrical Current FlowlTissue of Less R

46、esistancelBlood vesselslNervelTissue of Greater ResistancelMusclelBoneResults inlSerious vascular and nervous injurylImmobilization of muscleslFlash burnsVoltageHigh 1000 voltsLow resistance injuryComplicationsCardiac arrythmiasRespiratory muscle paralysisThrombosisRenal failureFractures DC- direct

47、current discrete exit AC-alternating current more explosiveCurrent Passage MortalityHand to hand- 60%Hand to foot- 20%Foot to foot- 5%Special ConsiderationsRespiratoryCardiac Concomitant traumaRenal failureRequire fluid resuscitationElectrical InjurieslSafetylTurn off powerlEnergized lines act as wh

48、ipslEstablish a safety zonelLightning StrikeslHigh voltage, high current, high energylLasts fraction of a secondlNo danger of electrical shock to EMSAssessment & Management of Electrical and Lightning InjurieslAssess patientlEntrance & Exit woundslRemove clothing, jewelry, and leather itemslTreat an

49、y visible injuries lThermal burnslECG monitoringlBradycardia, Tachycardia, VF or AsystolelACLS ProtocolslTreat cardiac & respiratory arrestlAggressive airway, ventilation, and circulatory management.lConsider Fluid bolus for serious burnsl20 ml/kglConsider Sodium Bicarbonate: 1 mEq/kglConsider Manni

50、tol: 10 gAssessment & Management of Electrical InjuriesContact electrical burns, 120-V alternating current nominal. The right knee was the energized sideChemicalStrong acids coagulation necrosisStrong bases liquefication necrosisWill continue burning until neutralized or dilutedDegree of Damage/Toxi