外科急诊创伤(英文)-烧伤

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 historian.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 degrees 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 bodyAnatomyEpidermisDermisSubcutaneous tissueLayerslEpidermislDermislSubcutaneoslUnderlying StructureslFascialNerveslTendonslLigamentslMuscleslOrgansAnatomy&Physiology of the SkinFunctionProtection 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 fibersSubcutaneousConnective tissueAdipose tissue cushioning insulationCausesThermalElectricalChemicalRadiation ThermalMajority flame scald contact with hot objectsChild with burns 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 calculating%TBSABurn DepthSuperficial 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 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&SymptomslDry,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 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 HyperemialPeripheral 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/leakageMay 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 PhaselReaches 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 capillary 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 output 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 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 and 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,fluids,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 AbuselElderly,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 InjuryToxic 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 hemoglobin than oxygenlHypoxemia&HypercarbiaOther EvidenceFacial burnsProfuse 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 FactorsStanding 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 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 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,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 PalmslBest used for burns 10%BSARules of NinesRule 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 patients 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 intravascular 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 functionHypovolemia/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 permeabilityCont 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/hrFentanylVersed 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 burnsPreexisiting 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 AssessmentAccurately approximate extent of burn injuryRule of Nines or Rule of PalmsDepth of burnArea of body effectedAny burn to the face,hands,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 hairBurnt hairEdemaEdemaParesthesiaParesthesiaHemorrhageHemorrhageOther soft tissue injuryOther soft tissue injuryMusculoskeletal injuryMusculoskeletal injuryDyspneaDyspneaChest painChest painAssessment of Thermal BurnsAny partial or full thickness burn involving hands,feet,joints,face,or genitalia30%BSAPartial ThicknessInhalation Injury10%BSAFull ThicknessCritical2%BSAFull Thickness50%BSASuperficial2%BSAFull Thickness15%BSAPartial Thickness15%BSAPartial ThicknessModerateMinorBurn SeverityBurn SeverityOngoing AssessmentlNon-critical:Reassess Q 15 minlCritical:Reassess Q 5 minBurn Center CareAssessment of Thermal BurnsLocal&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 Formula4 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 analgesic 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-toxic 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,current 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 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 neurocognitive 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 vehicleslAvoid 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-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 BurnsTerminologylVoltagelDifference 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 thruElectrical BurnsJoules LawP:PowerSkin is resistant to electrical flowlGreater the current the greater the flow thru the body and greater the release of heatElectrical BurnsGreatest heat occurs at the points of resistancelEntrance and Exit woundslDry skin=Greater resistancelWet Skin=Less 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 ResistancelMusclelBoneResults 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 explosiveCurrent 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 current,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 or AsystolelACLS ProtocolslTreat cardiac&respiratory arrestlAggressive airway,ventilation,and circulatory management.lConsider Fluid bolus for serious burnsl20 ml/kglConsider Sodium Bicarbonate:1 mEq/kglConsider Mannitol:10 gAssessment&Management of Electrical InjuriesContact electrical burns,120-V alternating current nominal.The right knee was the energized sideChemicalStrong acids coagulation necrosisStrong bases liquefication necrosisWill continue burning until neutralized or dilutedDegree of Damage/ToxicityChemical natureAmountConcentrationMechanismDurationChemical BurnsChemical destroys tissuelAcidslForm a thick,insoluble mass where they contact tissue.lCoagulation necrosislLimits burn damagelAlkalislDestroy cell membrane through liquefaction necrosislDeeper 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 tractsIngestions of caustic and corrosive substances generally produce immediate damage to the mucous membrane and the intestinal tractlAcids generally complete their damage within 1 to 2 minutes after exposurelAlkalis,particularly solid alkalis,may continue to cause liquefaction of tissue and damage for minutes 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,cricothyrotomyContact 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 substanceslFound in many household products and in petroleum distillatesHydrocarbonsViscosity is the most important physical characteristic in potential toxicitylThe 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 lMay be immediate or delayed in onsetSigns and SymptomsBurns 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 life-threateningOccasionally gastric lavage may be of benefitIn seriously symptomatic patients,protect the airway and establish an IV if NS or LRContact poison controlTransportChemical BurnslScene size-uplHazardous materials teamlEstablish hot,warm and cold zoneslPrevent personnel exposure from chemicallSpecific ChemicalslPhenollDry LimelSodiumlRiot Control AgentsAssessment&Management of Chemical BurnsSpecific ChemicalslPhenollIndustrial cleanerlAlcohol dissolves PhenollIrrigate with copious amounts of waterlDry LimelStrong corrosive that reacts with waterlBrush off dry substancelIrrigate with copious amounts of cool waterlPrevents reaction with patient tissuesAssessment&Management of Chemical BurnsSodiumlUnstable metallReacts vigorously with waterlReleases lExtreme heatlHydrogen gaslIgnitionlDecontaminate:Brush off dry chemicallCover the wound with oil substanceAssessment&Management of Chemical BurnsRiot Control AgentslAgentslCS,CN(Mace),Oleoresin,Capsicum(OC,pepper spray)lIrritation of the eyes,mucous membranes,and respiratory tract.lNo permanent damagelGeneral Signs&SymptomslCoughing,gagging,and vomitinglEye pain,tearing,temporary blindnesslManagementlIrrigate eyes with normal salineAssessment&Management of Chemical BurnsH2RadiationDecontamination is paramountTreated like any other burnRadiation InjuryRadiationlTransmission of energylNuclear EnergylUltraviolet lightlVisible LightlHeatlSoundlX-RaysRadioactive SubstancelEmits ionizing radiationlRadionuclide or RadioisotopeRadiation InjuryBasic PhysicsProtonsProtonsllPositive charged particlesPositive charged particlesNeutronsNeutronsllEqual in mass to protonsEqual in mass to protonsllNo electrical chargeNo electrical chargeElectronsElectronsllMinute electrically charged particlesMinute electrically charged particlesllWhen emitted from radioactive When emitted from radioactive substances are termed Beta Particlessubstances are termed Beta Particles(continued)Radiation InjuryBasic PhysicsIsotopesIsotopesllAtoms with unstable nuclear compositionAtoms with unstable nuclear compositionllIonizing RadiationIonizing RadiationHalf-lifeHalf-lifellTime required for half the nuclei to lose Time required for half the nuclei to lose activity through decayactivity through decayRadiation InjuryRadioactive SubstancesAlpha ParticlesAlpha ParticlesllSlow movingSlow movingllLow-energyLow-energyllStopped by Stopped by clothing and clothing and paperpaperllPenetrate a few P