骨骼肌肉烧伤

Julie 王凤怡 Occupational Terapy Department of Rehabilitation Medcine Centre West China Hospital, Sichuan University,2016Burn Injury,1,目录CONTENT,Structure of skinTypes of burnIncidence and prevalence,Introduction,01,Extent and Depth,Classification of Burn,02,Hypertrophic scar & KeloidContractureManagement,Complications,04,Medical Management,03,Wound care, Skin graft, Operations,2,Introduction,PART 01,Structure of skinTypes of burnIncidence and prevalence,3,Introduction,Structure of skin,皮脂腺,4,Introduction,Structure of skin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 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能。 l 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 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 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。,5,Introduction,Structure of skin真皮表位于表皮的下面，是一层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。 l 皮脂腺 皮脂腺开口于毛囊中，主要分泌油性物质，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 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，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 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。,6,Types 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 trauma,Introduction,7,Introduction,Incidence & prevalenceBurn Incidence and Treatment 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% occupational, 32% otherAmerican Burn Association National Burn Repository (2005 report),as reported in American Burn Association Fact Sheet, 2007 ,8,Classification of Burn,PART 02,Extent and Depth,9,Classification of burn: degree & extent,Severity of burn: degree & extentDegree of burns: 2 system in 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 of injuries & types of burning agentsE.g. hot oil, tar, or chemical agents& electricity burn= third degree burn,10,Classification of burn: degree & extent,First degreeE.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 days,11,Classification of burn: degree & extent,Second degree (superficial)=superficial partial thicknessentire epidermis involvedHallmark: 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 healed,12,Classification of burn: degree & extent,Management of burns (small area/superficial burns)Immediate comfort, e.g. codeine, aspirin, morphinePrevent infection cleansing dressing systemic antibiotics topical antibiotics for open wound, e.g. silver sulfadiazine cream; and antiseptic: e.g. silver nitrate solution, tetanus prophylaxis partial-thickness burns will heal by re-epithelialization 上皮再生from dermal skin within 1 to 2 weeks,13,Classification of burn: degree & extent,Second 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 whiteproduce significant hypertrophic scar usually if not managed by skin graftinglonger than 3 weeks to heal,14,Classification of burn: degree & extent,Third 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 visible (blood clotted & aggregate on vessel wall vascular obstruction ischaemia necrosis)No painfulunable to heal spontaneously as no epithelial bed leftskin graftingsevere hypertrophy scarmore complications,15,Classification of burn: degree & extent,Extent of burn: rules of nine,16,Classification of burn: degree & extent,17,Classification of burn: 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。,18,Classification of burn: degree & extent,（3）重度烧伤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。,19,Classification of burn: degree & extent,20,Classification of burn: degree & extent,21,Classification of burn: degree & extent,22,Medical Management,PART 02,Wound care Skin graftOperations,23,Medical Management,Acute Management of severe burns: ABCA = airwayB = breathingC = circulation,Acute Management of severe burns: ABC Life saving firstAdequate airway supply (inhalation injury) Inhalation injury: Damage is initiated by 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 & Tracheostomy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.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 vasodilation 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 life,24,Medical Management,Sub-acute Management of severe burns Saving the limbSurgery: Escharectomy 焦痂切除术Pain relief: 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: removes necrotic tissue and reduces bacterial colonization, end point of debridement healthy, bleeding, viable wound bed, granulation 肉芽notedBurn wound care: - open/close method,25,Medical Management,Sub-acute Management of severe burns Observe septicemia5. Operation:Early excision: Escharectomy 焦痂切除术 - When the skin is unable to heal after 17 to 21 days of local therapy skin grafting 6. Prevent contracture by positioning & splinting,26,Medical Management,1. Operation procedures Surgical excision Escharotomy Surgical incision through the eschar to relieve constriction 压缩 Escharectomy Removal of eschar to prepare for grafting Eschar= burned tissue,27,Medical Management,2. 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(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(Silvadene),Prevent infection, promote removal of eschar +comfort,Prepare skin for grafting,Restore essential function of skin,28,Medical Management,Burn dressing: close methodDeeper burns typically are treated with silver sulfadiazine to help prevent wound dehydration脱水 and provide antimicrobial抗菌 protection,29,Medical Management,3. Skin graftsWhen epidermal bed is so destroyed that spontaneous epithelial tissue re-growth is difficult or impossible & where raw areas are more than 2.5 cm wide Skin graft: Split skin graft Full thickness / whole skin graft Skin Flaps,30,Medical Management,Split skin grafts & whole skin/full thickness skin graft,31,Medical