外科急诊创伤(英文)-烧伤课件

1、BURNSLeaugeay Webre BS, CCEMT-P, NREMT-PScenarioParamedic 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?General Impression33 yo male pt writhing in pain. Screams and begs for pain medication however poor h

2、istorian.S- blistering to back and chest, R upper ventral area leg exposed muscle; eyebrows singedA- PCN, codeineM- noneP- noneL- earlier todayE- woke up on fireA-B-C-Transport decision?% BSA burned?Tx?ObjectivesDescribe the structure and function of skinDiscuss the types of burns.Explain the degree

3、s of thermal burns.Discuss causes and treatments of inhalation injuries.Identify methods of approximating burn injuries.Describe and apply treatment modalities for the burn patient.Burns, thermal. Escharotomy to release chest wall and allow for ventilation of the patient.SkinLargest organ of the bod

4、yFunctionProtection 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 fibersChild with b

5、urns from a scaldDetermining Severity1st degree2nd degree3rd degree(4th degree)Depth of BurnSuperficial BurnPartial Thickness BurnFull Thickness BurnFirst DegreeSuperficial involve only epidermisLocal pain and rednessNo blistering presentHeal spontaneously 2-5 days without scarringNot included when

6、calculating % TBSASecond DegreeInvolve 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 BurnSigns & SymptomsIntense painWhite to

7、 red skinBlistersInvolves epidermis & dermisThird DegreeInvolve epidermis, dermis, subcutaneous tissueWhite, waxy, red, brown, leatheryDry and painless(muscle and bone)Burn DepthFull-Thickness Burn: 3rd Degree BurnSigns & SymptomsDry, leathery skin (white, dark brown, or charred)Loss of sensation (l

8、ittle pain)All dermal layers/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 WoundsZone of CoagulationArea

9、 in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vesselsZone of StasisArea surrounding zone of coagulation characterized by decreased blood flow.Zone of HyperemiaPeripheral area around burn that has an increased blood flow.Jacksons Th

10、eory of Thermal WoundsZone 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 HyperemiaVasodilationInfla

11、mmationViable tissueBodys Response to BurnsEmergent Phase (Stage 1)Pain responseCatecholamine releaseTachycardia, Tachypnea, Mild Hypertension, Mild AnxietyFluid Shift Phase (Stage 2)Length 18-24 hoursBegins after Emergent PhaseReaches peak in 6-8 hoursDamaged cells initiate inflammatory responseInc

12、reased blood flow to cellsShift of fluid from intravascular to extravascular spaceMASSIVE EDEMA“Leaky CapillariesSystemic ChangesMassive release of inflammatory mediatorsProduce vasoconstriction/ dilationIncreased capillary permeabilityEdemaFluid ShiftsInitial decrease blood flow to burned areaFollo

13、wed by 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 de

14、creased 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 b

15、urn sizesepsisBodys Response to BurnsHypermetabolic Phase (Stage 3)Last for days to weeksLarge increase in the bodys need for nutrients as it repairs itselfResolution Phase (Stage 4)Scar formationGeneral rehabilitation and progression to normal functionHypermetabolismFollowing severe burn and resusc

16、itation tachycardia increased CO increased O2 demand massive proteolysis & lipolysis severe nitrogen lossSystemic ComplicationsHypothermiaDisruption of skin and its ability to thermoregulateHypovolemiaShift in proteins, fluids, and electrolytes to the burned tissueGeneral electrolyte imbalanceEschar

17、Hard, leathery product of a deep full thickness burnDead and denatured skinSystemic ComplicationsInfectionGreatest risk of burn is infectionOrgan FailureRelease of myoglobinSpecial FactorsAge & HealthPhysical AbuseElderly, Infirm or YoungCritical Burn AreasFace HandsFeetGroinJointsCircumfrentialInha

18、lation 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 InhalationSynthetic resin combustionCyanide & Hydrogen SulfideSystemic p

19、oisoningMore frequent than thermal inhalation burnCarbon Monoxide PoisoningColorless, odorless, tasteless gasByproduct of incomplete combustion of carbon productsSuspect with faulty heating unit200 x greater affinity for hemoglobin than oxygenHypoxemia & HypercarbiaOther EvidenceFacial burnsProfuse

20、secretionsCarbonaceous sputumLacrimationSinged nasal hairHoarsenessWheezingStridorEdemaHypoxemiaTachycardiaInhalation InjuryAirway Thermal BurnSupraglottic structures absorb heat and prevent lower airway burnsMoist mucosa lining the upper airwayInjury is common from superheated steamRisk FactorsStan

21、ding in the burn environmentScreaming or yelling in the burn environmentTrapped in a closed burn environmentSymptomsStridor or “Crowing” inspiratory soundsSinged facial and nasal hairBlack sputum or facial burnsProgressive respiratory obstruction and arrest due to swellingTypes of InjuriesCarbon mon

22、oxide 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 elimination 250 minutesCarbo

23、xyhemoglobinNormal- 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 hypovolemicInjury Below Glotti

24、sUsually chemicalRepiratory distressRequire early intubationARDSMSOFEstimating % BSA BurnedRule of palmsRule of ninesBody Surface AreaRule of NinesBest used for large surface areasExpedient tool to measure extent of burnRule of PalmsBest used for burns 10% BSARules of NinesRule of PalmsA burn equiva

25、lent 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 insufficiency Pulmonary edema 2-3 days Bronchopneumonia 5-7 daysConsider intubation

26、Sx/ liklihood of impending airway obstructionCirculationFluid replacement critical to survivalTissue destruction results in increased capillary permeabilityProfound fluid loss from the intravascular spaceLarge amounts fluid lost from loss of skin integrity due to evaporationParkland Formula4ml x wt

27、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- complicationsPulmonary edemaAssess adequacy by UA outputCool BurnWithin 30 mi

28、nutes inhibits lactate production and acidosis promotes catecholamine function and ardiovascular homeostasis inhibits burn wound histamine release blocks histamine mediated increased vascualr permeabilityCont minimizes edema formation suppresses thromboxane mediator of vascular occlusion progressive

29、 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 ConsiderationsCircumfrential burns may require fasciotomyPediatrics more s

30、usceptible 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 or concomitant traumaScene Size-upFire DepartmentSCBA and protective clot

31、hingInitial AssessmentABCs MUST be intactConsider ET or RSIRapid evacuation of patient if scene is unstableAssessment of Thermal BurnsFocused and Rapid Trauma AssessmentAccurately approximate extent of burn injuryRule of Nines or Rule of PalmsDepth of burnArea of body effectedAny burn to the face, h

32、ands, feet, joints or genitalia is considered a serious burn“Ringing” burnsAge of patient affectedAssessment of Thermal BurnsPainChanges in skin condition at affected siteAdventitious soundsBlistersSloughing of skinHoarsenessDysphagiaDysphasiaAssessment of Thermal BurnsGeneral Signs & SymptomsBurnt

33、hairEdemaParesthesiaHemorrhageOther soft tissue injuryMusculoskeletal injuryDyspneaChest painAssessment of Thermal BurnsAny partial or full thickness burn involving hands, feet, joints,face, or genitalia30% BSAPartial ThicknessInhalation Injury10% BSAFull ThicknessCritical2% BSAFull Thickness50% BSA

34、Superficial2% BSAFull Thickness15% BSAPartial Thickness15% BSAPartial ThicknessModerateMinorBurn SeverityOngoing AssessmentNon-critical: Reassess Q 15 minCritical: Reassess Q 5 minBurn Center CareAssessment of Thermal BurnsLocal & Minor BurnsLocal coolingPartial thickness: 15% of BSAFull thickness:

35、15% BSAFull thickness: 5% BSAMaintain warmthPrevent hypothermiaConsider aggressive fluid therapyModerate to severe burnsBurns over IV sitesPlace IV in partial thickness burn site.Management of Thermal BurnsParkland Burn Formula4 mL x Pt wt in kg x % BSA = Amt of fluidPt should receive of this amount

36、 in first 8 hrs.Remainder in 16 hrsConsider 1 hour dose0.5ml x Pt wt in kg x % BSA = Amt of fluidManagement of Thermal BurnsModerate to Severe BurnsCaution for fluid overloadFrequent auscultation of breath soundsConsider analgesic for painMorphineNubainPrevent infectionManagement of Thermal BurnsInh

37、alation InjuryProvide high-flow O2 by NRBConsider intubation if swellingConsider hyperbaric oxygen therapyCyanide ExposureSodium Nitrite, Amyl Nitrite, Sodium ThiosulfateForms methemoglobin binds to cyanideNon-toxic substance secreted in urineInhale 1 ampule of Amyl Nitrite300 mg Sodium Nitrite over

38、 2-4 minutes12.5 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 unidirectional, massive, current impulse with several return strokes back to the cloudTremendously large current i

39、mpulsively flows for an incredibly short timeDifference Between Lightning and ElectricityDuration of exposure to currentNot enough time for skin burnsInternal burns and renal failure usually inconsequentialCardiac arrestRespiratory arrestVascular spasmNeurological damageImmediateVentricular asystole

40、Often spontaneously resumeProlonged respiratory arrestResults in secondary cardiac arrestIschemia due to vascular spasmsMI, spinal artery syndromesLong TermSurvivors 10-20 x fatalitiesNeuropsychological and neurocognitive changesChronic pain syndromesChest painSympathetic nerve system dysfunctionSle

41、ep disorders, HA, cardiac effectsDemographicsSunday, Saturday, WednesdayNoon- 6pm, 6- 12 pmMay be in or outdoorsMales, 10 miles from thunderstorm, clouds/ rain may not be presentShelter- school buses, metal top vehiclesAvoid trees, small shelters, bleachers, fences, towers, any current transmitting

42、structures, pools/ water, high areasAvoid use telephones, electronic equipment, any contact with conductive surfaces inside (plumbing, doing dishes), EMS/ fire dispatch radioArcing electrical burns, through shoe around rubber sole. High-voltage (7600 V) alternating currentElectricalAge related injur

43、y 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 contactElectrical BurnsTerminologyVoltageDifference of electrical potential between two pointsDifferent concent

44、rations of electronsAmperesStrength of electrical currentResistance (Ohms)Opposition to electrical flowElectrical BurnsOhms LawV: VoltageR: ResistanceI: CurrentBased on electron flow thru TungstenEmit more light the more current passed thruElectrical BurnsJoules LawP: PowerSkin is resistant to elect

45、rical flowGreater the current the greater the flow thru the body and greater the release of heatElectrical BurnsGreatest heat occurs at the points of resistanceEntrance and Exit woundsDry skin = Greater resistanceWet Skin = Less resistanceLonger the contact, the greater the potential of injuryIncrea

46、sed damage inside bodySmaller the point of contact, the more concentrated the energy, the greater the injuryElectrical BurnsElectrical Current FlowTissue of Less ResistanceBlood vesselsNerveTissue of Greater ResistanceMuscleBoneResults inSerious vascular and nervous injuryImmobilization of musclesFl

47、ash burnsVoltageHigh 1000 voltsLow resistance injuryComplicationsCardiac arrythmiasRespiratory muscle paralysisThrombosisRenal failureFractures DC- direct current discrete exit AC-alternating current more explosiveCurrent Passage MortalityHand to hand- 60%Hand to foot- 20%Foot to foot- 5%Special Con

48、siderationsRespiratoryCardiac Concomitant traumaRenal failureRequire fluid resuscitationElectrical InjuriesSafetyTurn off powerEnergized lines act as whipsEstablish a safety zoneLightning StrikesHigh voltage, high current, high energyLasts fraction of a secondNo danger of electrical shock to EMSAsse

49、ssment & Management of Electrical and Lightning InjuriesAssess patientEntrance & Exit woundsRemove clothing, jewelry, and leather itemsTreat any visible injuries Thermal burnsECG monitoringBradycardia, Tachycardia, VF or AsystoleACLS ProtocolsTreat cardiac & respiratory arrestAggressive airway, vent

50、ilation, and circulatory management.Consider Fluid bolus for serious burns20 ml/kgConsider Sodium Bicarbonate: 1 mEq/kgConsider Mannitol: 10 gAssessment & Management of Electrical InjuriesContact electrical burns, 120-V alternating current nominal. The right knee was the energized sideChemicalStrong

51、 acids coagulation necrosisStrong bases liquefication necrosisWill continue burning until neutralized or dilutedDegree of Damage/ToxicityChemical natureAmountConcentrationMechanismDurationChemical BurnsChemical destroys tissueAcidsForm a thick, insoluble mass where they contact tissue.Coagulation ne

52、crosisLimits burn damageAlkalisDestroy cell membrane through liquefaction necrosisDeeper tissue penetration and deeper burnsOral caustic chemical burnsStrong Acids and AlkalisStrong acids and alkalis may cause burns to the mouth, pharynx, esophagus, and sometimes the upper respiratory and GI tractsI

53、ngestions of caustic and corrosive substances generally produce immediate damage to the mucous membrane and the intestinal tractAcids generally complete their damage within 1 to 2 minutes after exposureAlkalis, particularly solid alkalis, may continue to cause liquefaction of tissue and damage for m

54、inutes to hoursAlkali burn to eyeSigns and SymptomsFacial burnsPain in the lips, tongue, throat, or gumsDrooling, trouble swallowingHoarseness, stridor, shortness of breathShock secondary to bleeding or vomitingManagementEstablish an airway, consider intubation, or if necessary, cricothyrotomyContac

55、t poison controlGastric lavage or charcoal often contraindicatedIV with NS or LRRapid transportHydrocarbonsA group of saturated and unsaturated compounds derived primarily from crude oil, coal, or plant substancesFound in many household products and in petroleum distillatesHydrocarbonsViscosity is t

56、he most important physical characteristic in potential toxicityThe lower the viscosity, the higher the risk of aspiration and associated complicationsClinical features of hydrocarbon ingestion vary widely, depending on the type of agent involved May be immediate or delayed in onsetSigns and Symptoms

57、Burns due to local contactWheezing, dyspnea, hypoxia, and pneumonitis due to aspiration or inhalationHeadache, dizziness, slurred speech, ataxia (irregular or difficult-to-control movements), and dulled reflexesFoot and wrist drop with numbness and tinglingCardiac dysrhythmiasManagementMost are not

58、life-threateningOccasionally gastric lavage may be of benefitIn seriously symptomatic patients, protect the airway and establish an IV if NS or LRContact poison controlTransportChemical BurnsScene size-upHazardous materials teamEstablish hot, warm and cold zonesPrevent personnel exposure from chemic

59、alSpecific ChemicalsPhenolDry LimeSodiumRiot Control AgentsAssessment & Management of Chemical BurnsSpecific ChemicalsPhenolIndustrial cleanerAlcohol dissolves PhenolIrrigate with copious amounts of waterDry LimeStrong corrosive that reacts with waterBrush off dry substanceIrrigate with copious amou

60、nts of cool waterPrevents reaction with patient tissuesAssessment & Management of Chemical BurnsSodiumUnstable metalReacts vigorously with waterReleases Extreme heatHydrogen gasIgnitionDecontaminate: Brush off dry chemicalCover the wound with oil substanceAssessment & Management of Chemical BurnsRio