外科急诊创伤烧伤.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,JacksonsTheoryofThermalWoundsZoneofCoagulationAreainaburnnearesttheheatsourcethatsuffersthemostdamageasevidencedbyclottedbloodandthrombosedbloodvesselsZoneofStasisAreasurroundingzoneofcoagulationcharacterizedbydecreasedbloodflow.ZoneofHyperemiaPeripheralareaaroundburnthathasanincreasedbloodflow.,JacksonsTheoryofThermalWounds,ZoneofHyperemia,ZoneofStasis,ZoneofCoagulation,ZoneofCoagulation,CentralareaofburnNecroticfromtimeofexposure,ZoneofStasis,ModeratedegreeofinsultDecreasedtissueperfusionVasculardamage/leakageMayprogresstonecrosis24-48hours,ZoneofHyperemia,VasodilationInflammationViabletissue,BodysResponsetoBurns,EmergentPhase(Stage1)PainresponseCatecholaminereleaseTachycardia,Tachypnea,MildHypertension,MildAnxietyFluidShiftPhase(Stage2)Length18-24hoursBeginsafterEmergentPhaseReachespeakin6-8hoursDamagedcellsinitiateinflammatoryresponseIncreasedbloodflowtocellsShiftoffluidfromintravasculartoextravascularspaceMASSIVEEDEMA“LeakyCapillaries,SystemicChanges,MassivereleaseofinflammatorymediatorsProducevasoconstriction/dilationIncreasedcapillarypermeabilityEdema,FluidShifts,InitialdecreasebloodflowtoburnedareaFollowedbyincreasedarterialvasodilationReleaseofvasoactivesubstanceresultinginincreasedcapillarypermeabilityandedema,Cardiovascular,LossofplasmavolumeIncreasedperipheralvascularresistanceDecreasedcardiacoutputdecreasedbloodvolumedecreasedvenousreturnincreasedbloodviscositydecreasedcontractility,Renal,DecreasecirculatingplasmaIncreasehematocritDecreasedCOdecreasedrenalbloodflowoliguriaacuterenalfailure,Gastrointestinal,DecreasedgastrointestinalbloodflowIncreasedmucosalhemorrhage20%ileus,ImmuneSystem,Depressedimmunefunction20%directlyproportionaltoburnsize,sepsis,BodysResponsetoBurns,HypermetabolicPhase(Stage3)LastfordaystoweeksLargeincreaseinthebodysneedfornutrientsasitrepairsitselfResolutionPhase(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,AffinityforHgb200-250XthanO2Cherryredonlypresentatlevels40%+N,+V,HA,decreasedLOC,weakness,tachypnea,tachycardiaFalsepulseoximetryreading,100%O2timeforelimination40min21%O2timeelimination250minutes,Carboxyhemoglobin,Normal-0Smokers,truckdriversinheavytraffic-1515-40%-neurologicaldysfunctionweakness,dizziness,+N,+V,HA40-60%-obtundedseveredecreasedLOCConsiderhyperbarictherapy-25-40%,InjuryAboveGlottis,Thermal,chemicalRequireearlyintubationSeverelyhypovolemic,InjuryBelowGlottis,UsuallychemicalRepiratorydistressRequireearlyintubationARDSMSOF,Estimating%BSABurned,RuleofpalmsRuleofnines,BodySurfaceArea,RuleofNinesBestusedforlargesurfaceareasExpedienttooltomeasureextentofburnRuleofPalmsBestusedforburns5%TBSASignificantelectrical/chemicalburnsInhalationinjuryCircumfrentialburnsPreexisitingconditionsmedicalorconcomitanttrauma,SceneSize-upFireDepartmentSCBAandprotectiveclothingInitialAssessmentABCsMUSTbeintactConsiderETorRSIRapidevacuationofpatientifsceneisunstable,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,15%BSA,PartialThickness,Moderate,Minor,BurnSeverity,OngoingAssessmentNon-critical:ReassessQ15minCritical:ReassessQ5minBurnCenterCare,AssessmentofThermalBurns,Local&MinorBurnsLocalcoolingPartialthickness:5%BSAMaintainwarmthPreventhypothermiaConsideraggressivefluidtherapyModeratetosevereburnsBurnsoverIVsitesPlaceIVinpartialthicknessburnsite.,ManagementofThermalBurns,ParklandBurnFormula4mLxPtwtinkgx%BSA=AmtoffluidPtshouldreceiveofthisamountinfirst8hrs.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 xfatalitiesNeuropsychologicalandneurocognitivechangesChronicpainsyndromesChestpainSympatheticnervesystemdysfunctionSleepdisorders,HA,cardiaceffects,Demographics,Sunday,Saturday,WednesdayNoon-6pm,6-12pmMaybeinoroutdoorsMales,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,OhmsLawV:VoltageR:ResistanceI:CurrentBasedonelectronflowthruTungstenEmitmorelightthemorecurrentpassedthru,ElectricalBurns,JoulesLawP:PowerSkinisresistanttoelectricalflowGreaterthecurrentthegreatertheflowthruthebodyandgreaterthereleaseofheat,ElectricalBurns,GreatestheatoccursatthepointsofresistanceEntranceandExitwoundsDryskin=GreaterresistanceWetSkin=LessresistanceLongerthecontact,thegreaterthepotentialofinjuryIncreaseddamageinsidebodySmallerthepointofcontact,themoreconcentratedtheenergy,thegreatertheinjury,ElectricalBurns,ElectricalCurrentFlowTissueofLessResistanceBloodvesselsNerveTissueofGreaterResistanceMuscleBoneResultsinSeriousvascularandnervousinjuryImmobilizationofmusclesFlashburns,Voltage,High1000voltsLowresistanceinjury,Complications,CardiacarrythmiasRespiratorymuscleparalysisThrombosisRenalfailureFractures,DC-directcurrentdiscreteexitAC-alternatingcurrentmoreexplosive,CurrentPassageMortality,Handtohand-60%Handtofoot-20%Foottofoot-5%,SpecialConsiderations,RespiratoryCardiacConcomitanttraumaRenalfailureRequirefluidresuscitation,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&ManagementofChemicalBurns,SodiumUnstablemetalReactsvigorouslywithwaterReleasesExtremeheatHydrogengasIgnitionDecontaminate:BrushoffdrychemicalCoverthewoundwithoilsubstance,Assessment&ManagementofChemicalBurns,RiotControlAgentsAgentsCS,CN(Mace),Oleoresin,Capsicum(OC,pepperspray)Irritationoftheeyes,mucousmembranes,andrespiratorytract.NopermanentdamageGeneralSigns&SymptomsCoughing,gagging,andvomitingEyepain,tearing,temporaryblindnessManagementIrrigateeyeswithnormalsaline,Assessment&ManagementofChemicalBurns,H2,Radiation,DecontaminationisparamountTreatedlikeanyotherburn,RadiationInjury,RadiationTransmissionofenergyNuclearEnergyUltravioletlightVisibleLightHeatSoundX-RaysRadioactiveSubstanceEmitsionizingradiationRadionuclideorRadioisotope,RadiationInjuryBasicPhysics,ProtonsPositivechargedparticlesNeutronsEqualinmasstoprotonsNoelectricalchargeElectronsMinuteelectricallychargedparticlesWhenemittedfromradioactivesubstancesaretermedBetaParticles,(continued),RadiationInjuryBasicPhysics,IsotopesAtomswithunstablenuclearcompositionIonizingRadiationHalf-lifeTimerequiredforhalfthenucleitoloseactivitythroughdecay,RadiationInjuryRadioactiveSubstances,AlphaParticlesSlowmovingLow-energyStoppedbyclothingandpaperPenetrateafewcelllayersonskinMinorexternalhazardHARMFULifingested,BetaParticlesSmallerthanAlphaHigherenergythanalphaStoppedbyaluminumorsimilarmaterialsLesslocaldamagethanalphaHARMFULifinhaledoringested,RadiationInjuryRadioactiveSubstances,GammaRaysHighlyenergizedPenetratedeeperthan