外科急诊创伤(英文)烧伤课件.ppt

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?General Impression33 yo male pt writhing in pain.Screams and begs for pain medication however poor historian.S-blistering to back and chest,R up

2、per 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 degrees of thermal burns.Discuss causes and treatments of in

3、halation 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 bodyAnatomyEpidermisDermisSubcutaneous tissueLayerslEpiderm

4、islDermislSubcutaneoslUnderlying StructureslFascialNerveslTendonslLigamentslMuscleslOrgansAnatomy&Physiology of the SkinFunctionProtection Regulation Prevention SensoryEpidermisOuter,thinner layerConsists of dead keratinized cellsProtects dehydration trauma light infectionDermisGel like matrixConsis

5、ts of collagen and elastinContains blood vessels,lymphatics,sweat glands,hair follicles,sensory fibersSubcutaneousConnective tissueAdipose tissue cushioning insulationCausesThermalElectricalChemicalRadiation ThermalMajority flame scald contact with hot objectsChild with burns from a scaldDetermining

6、 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 calculating%TBSABurn DepthSu

7、perficial Burn:1st Degree BurnlSigns&SymptomslReddened skinlPain at burn sitelInvolves only epidermisSecond DegreeInvolve epidermis and dermisPartial thickness superficial partial thickness red,painful,blistered deep partial thickness pale,mottledVery painfulInfection may evolve into 3rd degreeBurn

8、DepthPartial-Thickness Burn:2nd Degree BurnlSigns&SymptomslIntense painlWhite to red skinlBlisterslInvolves epidermis&dermisThird DegreeInvolve epidermis,dermis,subcutaneous tissueWhite,waxy,red,brown,leatheryDry and painless(muscle and bone)Burn DepthFull-Thickness Burn:3rd Degree BurnlSigns&Sympto

9、mslDry,leathery skin(white,dark brown,or charred)lLoss of sensation(little pain)lAll dermal layers/tissue may be involvedFourth DegreeInclude involvement of muscle and boneCharred in appearancePainlessPathophysiologyLocal changes-111F produce injuryArea of DamageZone of coagulationZone of stasisZone

10、 of hyperemiaJacksons Theory of Thermal WoundslZone of CoagulationlArea in a burn nearest the 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 Hyperem

11、ialPeripheral area around burn that has an increased blood flow.Jacksons Theory 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/lea

12、kageMay progress to necrosis 24-48 hoursZone of HyperemiaVasodilationInflammationViable tissueBodys Response to BurnsEmergent Phase(Stage 1)lPain responselCatecholamine releaselTachycardia,Tachypnea,Mild Hypertension,Mild AnxietyFluid Shift Phase(Stage 2)lLength 18-24 hourslBegins after Emergent Pha

13、selReaches peak in 6-8 hourslDamaged cells initiate inflammatory responselIncreased blood flow to cellslShift of fluid from intravascular to extravascular spacelMASSIVE EDEMAl“Leaky CapillariesSystemic ChangesMassive release of inflammatory mediatorsProduce vasoconstriction/dilationIncreased capilla

14、ry permeabilityEdemaFluid ShiftsInitial decrease blood flow to burned areaFollowed by increased arterial vasodilationRelease of vasoactive substance resulting in increased capillary permeability and edemaCardiovascularLoss of plasma volumeIncreased peripheral vascular resistanceDecreased cardiac out

15、put decreased blood volume decreased venous return increased blood viscosity decreased contractilityRenalDecrease circulating plasmaIncrease hematocritDecreased CO decreased renal blood flow oliguria acute renal failureGastrointestinalDecreased gastrointestinal blood flowIncreased mucosal hemorrhage

16、 20%ileusImmune SystemDepressed immune function 20%directly proportional to burn sizesepsisBodys 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 an

17、d progression to normal functionHypermetabolismFollowing severe burn and resuscitation tachycardia increased CO increased O2 demand massive proteolysis&lipolysis severe nitrogen lossSystemic ComplicationsHypothermialDisruption of skin and its ability to thermoregulateHypovolemialShift in proteins,fl

18、uids,and electrolytes to the burned tissuelGeneral electrolyte imbalanceEscharlHard,leathery product of a deep full thickness burnlDead and denatured skinSystemic ComplicationsInfectionlGreatest risk of burn is infectionOrgan FailurelRelease of myoglobinSpecial FactorslAge&HealthPhysical AbuselElder

19、ly,Infirm or YoungCritical Burn AreasFace HandsFeetGroinJointsCircumfrentialInhalation 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 InjuryTo

20、xic InhalationlSynthetic resin combustionlCyanide&Hydrogen SulfidelSystemic 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

21、 hemoglobin than oxygenlHypoxemia&HypercarbiaOther EvidenceFacial burnsProfuse secretionsCarbonaceous sputumLacrimationSinged nasal hairHoarsenessWheezingStridorEdemaHypoxemiaTachycardiaInhalation InjuryAirway Thermal BurnlSupraglottic structures absorb heat and prevent lower airway burnslMoist muco

22、sa lining the upper airwaylInjury is common from superheated steamlRisk 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 burnsl

23、Progressive respiratory obstruction and arrest due to swellingTypes 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

24、 reading 100%O2 time for elimination 40 min21%O2 time elimination 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,

25、chemicalRequire early intubationSeverely hypovolemicInjury 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 P

26、almslBest used for burns 10%BSARules of Nines184.59194.5184.54.5994.5994.574.574.5718181Rule 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 p

27、atients Acute pulmonary insufficiency 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 intravas

28、cular spaceLarge amounts fluid lost 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 functionHy

29、povolemia/renal failure-complicationsPulmonary 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 permeab

30、ilityCont minimizes edema formation 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/h

31、rFentanylVersed Special ConsiderationsCircumfrential 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 burnsPreexisitin

32、g conditions medical 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 o

33、f burn injurylRule of 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 soundsBlisters

34、Sloughing of skinHoarsenessDysphagiaDysphasiaAssessment 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 genitalia

35、30%BSAPartial 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 Burns

36、Local&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 Burn F

37、ormula4 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 soundslConsider a

38、nalgesic 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 cyanidelNon-toxi

39、c 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 unidirectional,massive,curr

40、ent 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 inconsequentialCardiac

41、 arrestRespiratory arrestVascular spasmNeurological damageImmediateVentricular asystolelOften spontaneously resumeProlonged respiratory arrestlResults in secondary cardiac arrestIschemia due to vascular spasmslMI,spinal artery syndromesLong TermSurvivors 10-20 x fatalitiesNeuropsychological and neur

42、ocognitive 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-school buses,metal top vehicleslAvo

43、id 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 electrical burns,through shoe around rubber sole.High-

44、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 contactElectrical BurnsTerminologylVoltagelDifferen

45、ce 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 thru TungstenlEmit more light the more current passed

46、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 resistancelEntrance and Exit woundslDry skin=Greater resistancelWet Skin=L

47、ess 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 ResistancelBlood vesselslNervelTissue of Greater ResistancelMusc

48、lelBoneResults inlSerious vascular and nervous injurylImmobilization of muscleslFlash burnsVoltageHigh 1000 voltsLow resistance injuryComplicationsCardiac arrythmiasRespiratory muscle paralysisThrombosisRenal failureFractures DC-direct current discrete exit AC-alternating current more explosiveCurre

49、nt 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 whipslEstablish a safety zonelLightning StrikeslHigh voltage,high cur

50、rent,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 any visible injuries lThermal burnslECG monitoringlBradycardia,Tachycardia,VF