骨骼肌肉烧伤 .pptx

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1、Julie王凤怡OccupationalTerapyDepartmentofRehabilitationMedcineCentreWestChinaHospital,SichuanUniversity2016BurnInjury目录CONTENTStructureofskinTypesofburnIncidenceandprevalenceIntroduction 01ExtentandDepthClassification of Burn02Hypertrophicscar&KeloidContractureManagementComplications04Medical Managemen

2、t03Woundcare,Skingraft,OperationsIntroduction PART01StructureofskinTypesofburnIncidenceandprevalenceIntroductionStructure of skin皮脂腺IntroductionStructure of skin表皮表皮 皮肤最外面的一层组织，其厚度因身体部位而不同，表皮在掌跖处最厚，在眼睑最薄。它担负着细胞自我更新的重要功能，也就是细胞的新陈代谢。表皮从外向内，依次可以分作4层。l l 角质层角质层 位于表皮的最外部，由扁平的角质细胞组成，如鱼鳞片相互重叠在一起，具有防止水分散失的功

3、能。l l 颗粒层颗粒层 由3-5层扁平细胞组成，细胞内充满粗大、不规则的透明角质颗粒，具有折射光线的作用，能阻挡阳光中的紫外线，异常时会呈厚茧状。l l 有棘层有棘层 表皮层中最厚的一层，由8-12层多角形细胞所构成，细胞之间有淋巴液流通，可供给表皮营养。l l 基底层基底层 位于表皮的最深处，与真皮紧密衔接，连接的截面呈波浪起伏状。基底细胞为称方形或者低柱形，具有细胞分裂能力。除了基底细胞之外，基底层还存在着黑色素细胞。大约每10个基底细胞中就约有一个黑色素细胞，呈树枝状突起。黑色素细胞形成黑色素后，通过树枝状突起将黑色素颗粒输送到基底细胞或者毛发。IntroductionStructur

4、e of skin真皮真皮表位于表皮的下面，是一层致密和具有弹性致密和具有弹性的组织。它可以为表皮和皮肤附属器官提供养分，对外界机械冲击有缓冲作用。真皮主要由蛋白纤维结蒂组织组成，包括胶原蛋白和弹性纤维，使皮肤有一定的抗拉性，显得柔韧和富有弹性。真皮内还包括皮脂腺、毛囊组织、神经以及供应表皮层养分的毛细血管皮脂腺、毛囊组织、神经以及供应表皮层养分的毛细血管。l l 皮脂腺皮脂腺 皮脂腺开口于毛囊中，主要分泌油性物质分泌油性物质，即皮脂。在部分的皮脂腺分布在头、面、胸骨附近和肩胛间的皮肤。它的活动随着年龄而异，在青春期最为旺盛。l l 汗腺汗腺 汗腺分大汗腺和小汗腺。大汗腺主要分布于身体多毛部分

5、，腺体多在皮下脂肪中，分泌的物质为粘稠状乳浊液，含蛋白质、脂质、碳水化合物及盐类，经细菌分解后生成挥发性的低级脂肪酸与其它有臭味的物质，从而产生体味；小汗腺分布于全身，直接开口在皮肤表面，脚底、手掌、额和腋是小汗腺最密集的部位，分泌的汗水以水为主，没有异味，有起到调节体温的作用。l l 毛囊组织毛囊组织 包括毛发、毛孔和毛囊。毛发由一种角蛋白的蛋白质组成，是皮肤的附属物，它在管状的毛囊内发育。毛发遍及身体的绝大部分，起保护身体皮肤的作用；毛也是皮肤表面的开口，与皮脂腺和毛囊相连，是毛发生长及油脂输送的管道，毛孔的大小与相连的皮脂腺大小成正比；毛囊是毛孔的内部组织，由围绕毛根的表皮细胞组成。Ty

6、pes of burn Destruction of the skin caused by thermal changes(hot water&steam scald烫伤,flame,hot fluid(oil,tar),hot metal,extreme cold)corrosive liquid腐蚀性液体:alkalis/acid electricity radiation One of the most painful form of traumaIntroductionIntroductionIncidence&prevalenceBurn Incidence and Treatmen

7、t in the US:2007 Fact SheetSurvival Rate:94.4%Severity of Burn Injuries:Over 1/3 of admissions exceeded 10%TBSA(total body surface area),and 10%exceeded 30%TBSA.Burn Cause:46%fire/flame,32%scald烫伤,8%hot object contact,4%electrical,3%chemical,6%others.Place of Occurrence:43%home,17%street/highway,8%o

8、ccupational,32%otherAmerican Burn Association National Burn Repository(2005 report),as reported in American Burn Association Fact Sheet,2007 http:/www.ameriburn.orgClassification of BurnPART02ExtentandDepthClassificationofburn:degree&extentSeverity of burn:degree&extent1.Degree of burns:2 system in

9、terms of depth of skin destructionAssessment by clinical observation(66%)accuracy)or using Laser Doppler(probes placed on a burn area to monitor micro-vascular blood flowing the dermis)2.Extent of burns injuries:2 systems in terms of width of skin destruction:rules of nine&Lund-Browder Chart-Causes

10、of injuries&types of burning agentsE.g.hot oil,tar,or chemical agents&electricity burn=third degree burnDegree Location 1st degreeSuperficial 2nd degree:superficialSuperficial partial thickness2nd degree:deepDeep partial thickness3rd degreeFull thicknessClassificationofburn:degree&extentFirst degree

11、E.g.sunburnDamage only the top epidermal layer of skinErythema红斑(superficial redness of skin),if presswhite(blanches)No blisters,painful,no chance of infectionSelf-heal in 3 to 6 daysClassificationofburn:degree&extentSecond degree(superficial)=superficial partial thicknessentire epidermis involvedHa

12、llmark:When pressure is applied to the reddened area,the area will blanch 发白but demonstrate a brisk 快速的 or rapid capillary refill upon release of the pressure.May have blistering,red&moist under blisterChance of infectionpainfulheal within 3 weeksonly a change in skin color and pigmentation色素沉积 when

13、 healedClassificationofburn:degree&extentSecond degree(deep)=deep partial thicknessentire epidermis and large portion of dermis involved(hair follicles,sweat glands&sebaceous glands 皮脂腺spared)capillary refill may be absent or may be sluggish缓慢的 when pressure is releaseddry,ivory or pearly whiteprodu

14、ce significant hypertrophic scar usually if not managed by skin graftinglonger than 3 weeks to healClassificationofburn:degree&extentThird degree=full thicknessTotal destruction of skin(+deeper tissues),e.g.subcutaneous fat,muscle etc)tan/fawn in color 棕褐色hard&dry inelasticthrombosed 形成血栓的vessels vi

15、sible(blood clotted&aggregate on vessel wall vascular obstruction ischaemia necrosis)No painfulunable to heal spontaneously as no epithelial bed leftskin graftingsevere hypertrophy scarmore complicationsClassificationofburn:degree&extentExtent of burn:rules of nineClassificationofburn:degree&extentC

16、lassificationofburn:degree&extent（2）轻度烧伤1）10岁到50岁的人群：浅二度以上烧伤占体表总面积小于15%。2）年龄小于10岁大于50岁的人群：浅二度以上烧伤占体表总面积小于10%。3）三度或三度以上烧伤占体表总面积小于2%。（1）中度烧伤1）10岁到50岁的人群：浅二度以上烧伤占体表总面积在15%到25%之间。2）年龄小于10岁大于50岁的人群：浅二度以上烧伤占体表总面积在10%到20%之间。3）三度或三度以上烧伤占体表总面积在2%到10%之间。Classificationofburn:degree&extent（3）重度烧伤1）10岁到50岁的人群：浅二

17、度以上烧伤占体表总面积大于25%。2）年龄小于10岁大于50岁的人群：浅二度以上烧伤占体表总面积大于20%。3）三度或三度以上烧伤占体表总面积大于10%。4）任何涉及到手部、面部、脚部或会阴部位的烧伤。5）烧伤覆盖主要的关节部位。6）围绕四肢任意部位一圈的烧伤。7）任何伤到呼吸道的烧伤。8）电烧伤。9）烧伤伴有骨折或其他外伤叠加的复合伤。10）婴幼儿烧伤。11）容易引起并发症的高危人群发生烧伤。12）以上类型的烧伤需要将病人尽快送到专业的烧伤科。Classificationofburn:degree&extentClassificationofburn:degree&extentClassif

18、icationofburn:degree&extentMedical ManagementPART02WoundcareSkingraftOperationsMedicalManagementAcute Management of severe burns:ABCA=airwayB=breathingC=circulationAcute Management of severe burns:ABC Life saving firstAdequate airway supply(inhalation injury)Inhalation injury:Damage is initiated by

19、toxins and particulate debris 颗粒残渣,which induce rapid local vasodilation and necrosis of the surface layer of the upper airway,which then separates from the tracheobronchial 气管支气管wall.Breathing difficulty High dose of O2&secure airway passage Endotracheal气管内 tube:a tube inserted into trachea&Tracheo

20、stomy气管切开:a stoma(opening)into trachea especially for burn in face&neck Burns to chest may need escharotomy焦痂切开术焦痂切开术.Circulation:Intravenous fluid replacement 10%surface area hypovolemic shock低血容量性休克:a severe reduction in circulating blood volume due to loss of blood into peripheral tissues by vaso

21、dilation fluid loss from burnt body surface hypoxemia低氧血症+fluid&electrolytic imbalance,renal failure hypotensive state shock shock:blood flow to peripheral tissues is inadequate to sustain lifeMedicalManagementSub-acute Management of severe burns 1.Saving the limbSurgery:Escharectomy 焦痂切除术2.Pain rel

22、ief:codeine,morphine 3.Wound Care&infection controlSystemic antibiotic:prevent sepsis,e.g.penicillin青霉素(some hospital would not provide prophylactic 预防性antibiotic as it may lead to infection with multiply-resistant bacteria)Debridement清创清创:removes necrotic tissue and reduces bacterial colonization,e

23、nd point of debridement healthy,bleeding,viable wound bed,granulation 肉芽notedBurn wound care:-open/close methodMedicalManagementSub-acute Management of severe burns 4.Observe septicemia5.Operation:Early excision:Escharectomy 焦痂切除术&escharotomy 焦痂切开术Grafting -Donor site:thigh,arm&head for skin regener

24、ation,full recovery of the area (usually 14 to 17 days);-When the skin is unable to heal after 17 to 21 days of local therapy skin grafting 6.Prevent contracture by positioning&splintingMedicalManagement1.Operation procedures Surgical excision Escharotomy Surgical incision through the eschar to reli

25、eve constriction 压缩 Escharectomy Removal of eschar to prepare for grafting Eschar=burned tissueMedicalManagement2.Local wound care:close methodDressings occlusive absorption bulkyBiological dressings&skin substitutes替代物 closing a wound/contamination污染物/reducing pain and fluid loss.Biologic products(

26、e.g.human amnion羊膜)may deliver growth factors biosynthetic生物合成wound dressing sheet(Biobrane)Topical antibiotics:most common:Silver sulfadiazine磺胺嘧啶银磺胺嘧啶银(Silvadene)Prevent infection,promote removal of eschar+comfortPrepare skin for graftingRestore essential function of skinMedicalManagementBurn dres

27、sing:close methodDeeper burns typically are treated with silver sulfadiazine to help prevent wound dehydration脱水 and provide antimicrobial抗菌 protectionMedicalManagement3.Skin graftsWhen epidermal bed is so destroyed that spontaneous epithelial tissue re-growth is difficult or impossible&where raw ar

28、eas are more than 2.5 cm wide Skin graft:Split skin graft Full thickness/whole skin graft Skin FlapsMedicalManagementSplit skin grafts&whole skin/full thickness skin graftMedicalManagementTypes of graftsMedicalManagementComplicationsPART03Hypertrophicscar&KeloidContractureManagementComplicationofbur

29、nsComplicationofburns-ScarFormation of hypertrophic scarScar formation is a natural process in wound healing(Hunter,p.1269).But problems result when wound healing has gone beyond Hypertrophic scar,keloid contracture(by the contractile nature of the hypertrophic scar)Complicationofburns-ScarMajor fac

30、tors affecting formation of hypertrophic scarComplicationofburns-ScarNormal epidermis&hypertrophic scarComplicationofburns-ScarCharacteristics of hypertrophic scars(early to mature phase)if untreatedComplicationofburns-ScarComplicationofburns-ScarComplicationofburns-ScarComplications of hypertrophic scar ContractureComplicationofburns-ScarComplications of hypertrophic scarPermanent deformities leading to functional problems in ADLTHANKYOU!