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關於燒燙傷…
• Mechanism of Thermal Injury
• Evaluation of the burn wound
• 燒燙傷的治療與照顧
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Type of Burn Injury
• Flash & Flame burns (燒傷及閃電擊傷) :
Explosion (氣爆), most common
• Scald burns (燙傷)
• Contact burns (接觸性燙傷)
• Chemical burns (化學灼傷)
• Electrical burns (電擊傷)
• Radiation injury(輻射傷害)
• Cold Injury (凍傷)
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Flash and Flame burns
• Responsible for more than half of burn injuries
• Etiology
– House fires
– Outdoor fires with use of accelerants
• propane, gasoline, and kerosene
• Flash burn
– Typically superficial to partial dermal burns with preservation of
skin covered by clothing
• Flame burn
– Typically deep dermal or full thickness burns
• Inhalation injury likely with gasoline fire and/or house fire
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Inhalation Injury
• Facial burn, burned hair of nose, bullae in
oropharyngeal area
• Examination:
– Chest X-ray
– Bronchoscope
– Arterial blood gas
• Treatment:
– Endotracheal tube or Tracheosotmy
– COHb > 25 % → give HBO (O2 : 0.3 →6.0 ml/dL)
– half-life of COHb: (UpToDate 2014)
Room air: 300 mins
High-flow O2 with Nonrebreathing mask: 90 mins
Hyperbaric oxygen (HBO): 30 mins
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Scalds
• Second most common burn injury-related admission
• Depth of scald injury depends on
– Water temperature (>110ºF or 44ºC)
– Duration of contact
• consistency of liquid (i.e. soup vs coffee vs grease)
– Skin thickness
• based on age and anatomical location
• Clothed areas may have deeper burns due to retention of
heat and longer contact with skin
– e.g. diapers or socks
• Other sources of scald burns
– Grease/oil
• typically deep dermal or full thickness burns
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Contact burns
• Typically small areas due to hot metal, plastic, glass or
coals
• Burn depth related to
– Temperature of material
– Duration of contact
– Patient-related disabilities (e.g. neuropathy)
• Commonly responsible for pediatric palm burns
• Grafting of palm can lead to life-long disability and timing
of surgery is controversial
– Early grafting restores function quickly but destroys unique
palmar nerve endings and palmar fasciocutaneous ligaments
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Chemical burns (I)
• Acids cause tanning with impermeable barrier limiting
deep penetration
– e.g. cleaning solvents
– Hydrofluoric acid burns unique in need for calcium treatment
• Topical
• Intravenous – for life-threatening hypocalcemia
• Intra-arterial – for comfort and hypocalcemia
• Alkalis combine with lipids (saponification) and dissolve
tissue
– e.g. cement or drain openers
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Chemical burns (II)
• Etiologies
– Work-related
– Assault
– Improper use of household products and harsh solvents
• Progressive damage diluted with copious H20 irrigation
– 15–20 minutes
– pH test of skin until neutral
– Attempts to neutralize causes exothermic reaction and thermal
injury
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Electrical burns (I)
• Due to very high intensity localized heat as body becomes an
‘accidental’ resistor
• Resistance:
Nerve<vessels<muscle<skin<tendon<fat<bone
• Associated injuries:
– Muscle necrosis → release myoglobulin → hematuria,
myoglobuminemia→ acute renal failure,keep urine output > 100ml/hr
– Myocardial:on EKG (arrhythmia), cardiac enzyme
– Electrolyte:Na+, K+, Ca++, Mg, ABG
– Others: fracture, nerve injury
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Electrical burns (II)
• High voltage injuries (>1000 volts)
– many work-related
– deep tissue necrosis
– arrhythmia (typically atrial fibrillation)
– cognitive deficits
– acute and delayed neuromuscular degeneration
• carpal tunnel injuries
• compartment syndromes
• early surgical intervention indicated for acidosis ± signs of
rhabdomyolysis or deterioration of neuro-sensorimotor exam
– cataract formation
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Electrical burns (III)
• Low voltage injuries (<440 volts)
– Typically small deep burns at contact points with rare
systemic injury,
– Classic pediatric injury involves oral commissure with risk
of delayed oral artery bleed
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Evaluation of the Burn Wound
• Pathophysiologic changes
• Assessment of burn depth
• Assessment of burn Area
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Pathophysiologic changes
• Jackson’s zones of Injury
– Zone of coagulation (center of wound)
– Zone of stasis (‘at risk’ for conversion)
– Zone of hyperemia (outer periphery)
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Assessment of burn depth
• First degree (一度)
– erythema (泛紅), painful
• Second degree
– Superficial (淺二度)
blister formation, pink color, painful
– Deep (深二度)
white or fixed staining of red, blister
• Third degree (三度)
– leathery, waxy appearance, painless
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1st-degree burn
• Superficial burn
– Epidermis only
– Heals in 3–4 days
– e.g. sunburn
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2nd-degree burn
• Superficial dermal burn
– extends into the papillary dermis
– pink/moist wound, hypersensitive and blanching
– heals in 2–3 weeks
– e.g. scald burn or flash burn
• Deep dermal burn
– extends into reticular dermis
– pale/dry wound, decreased sensation, and sluggish capillary refill
– if not healed by 3 weeks grafting usually indicated
– e.g. grease burn, flash burn, prolonged scald exposure
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≥ 3rd-degree burn
• Full thickness burn
– Extends through the skin to the subcutaneous area or deeper
– Black or charred, leathery, insensate
– Excise and graft early to reduce risk of infection and scarring
– e.g. flame burns, contact burns
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Adjuncts to clinical judgment
• Experienced burn surgeon 46–67% accurate in
determining which burns will heal on PBD 1
• Additional techniques proposed to identify non-healing
wounds:
– laser Doppler imaging
– thermography
– MRI
– biopsy
– ultrasound
– light reflectance
• No technique has proven superior to serial exams
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Assessment of Burn Area
• Rule of nine
• 1% TBSA (total body surface area):
by patient’s palm
• Children: check table
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Emergency Care (I)
• As the rule of “ATLS”
• Primary evaluation : ABCDs
• Secondary evaluation : wound evaluation
• C-spine Fixation : blunt injury or high voltage electric burn
(> 1000 volts)
• Disability :
• Exposure & Exams : 除去衣物、裝飾品及眼鏡
• Wound care
– Normal Saline rinsed gauze
– Keep warm (hypothermia)
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Emergency Care (II)
• Fluid Supply :
Lactate Ringer & IV route
• Urine Monitor : on foley
• Decompression of stomach : on NG
• Temperature control (注意體溫)
• Pain control
• Lab Data:
CBC, electrolyte, BUN/Cr, clotting screen, COHb, ABG, Blood type
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Evaluation (I)
• History
– Causes
– Location (indoors vs. outdoors)
– Type of liquid involved
– Duration of extraction from fire
– Other medical problems: DM, HTN…
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Evaluation (II)
• Burn center criteria
– Adults with burn injuries > 15% to 20%
– Infants, children and elderly patients with less-extensive burn
injuries should also be monitored in an intensive care setting
– airway monitoring
– frequent neurovascular checks
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Choice of Fluids & Rate of Administration
• <40% TBSA + no pulmonary injury
→ isotonic crystalloid fluid
• >40% TBSA + pulmonary injury
– Hypertonic saline: first 8 hrs
– Lactated Ringer’s: shock resustation
• Pediatric & Elderly
– Hypertonic concentration of sodium: 180 mEq/L
• Massive burn, young pediatric or severe inhalation injury
patient
– Modified hypertonic saline: 1st 8 hours
Lactated Ringer’s + 50 mEq NaHCO3
– Lactated Ringer’s: 2nd 8 hours
– 5% albumin in LR: 3rd 8 hours
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Monitor
• Urine
– The best indicator in the first 24 hours (vs. CVP)
– Adult : 30~50 mL/h, 0.5~1 mL/kg/h (weight < 30 kg)
electric burn : 1~2 cc/kg/hr
– Child : 1-2 mL/kg/hr
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Fluid Replacement after Burn Shock
• 2nd 24 hours
– Modified Brooke formula: 0.3-0.5 cc/kg/TBSA of 5% albumin
– Parkland Formula: circulating plasma volume × 20%
• Maintain fluid (IV or enteral)
– Basal: 1500 cc/m2
– Evaporative water loss: (25 + %TBSA) ×m2 × 24
• Electrolyte
– K: 120 mEq/day in adults
– Na, Ca, Mg, P
• Monitor
– Urine: 1500-2000 cc/24 h in adult, 3-4 mL/kg/h in children
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Nutrition
• NG tube & ND tube (or NJ) insertion
• Nutrition
– ND or NJ feeding
- as early as 8 hours (by endoscope), within 48 hours
- begin rate: 20-40 ml/h
- continued during surgical procedure without increase risk of aspiration
– Adult : (Curreri’s formula)
25kcal/kg + 40kcal/kg/%TBSA
– TPN: associated with increased mortality
• Protein
– Alanine (ALA) & Glutamine (GLU)
• Vitamin C : IV 1g qd (high dose)
• PPI : prevention Curling’s ulcer (Nexum), 7-10 days, Early feeding
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Other management
• Antibiotics : (常見的死因是感染)
– wound infection appears until 5~7 days after injury
– most common: Staphylococcus
• Anti-histamine : wound itching
• Anti-anxiety and pain control
• 患肢抬高
• Blood transfusion : Hb level
(↓2-3 days post injury)
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Wound management (I)
• Face & Neck: open care
• Silver Sulfadiazine (SSD, U-burn)
– Bactericidal
– Painless
– Toxicity & side-effect are both low
– Side-effect: leukopenia (白血球低下)
– Contraindication: G6PD
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Wound management (II)
• Biological dressing
– Decrease pain, water loss change 24~72小時更換一次
• Escarotomy (焦痂切開)
– full-thickness circumferential burns of the extremity
– full-thickness burns of the chest wall when the
eschar compromises
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Wound management (II)
• Biological dressing
– 可減少疼痛、水分蒸發及當自體移植用
– 如豬皮, 約24~72小時更換一次
• Escarotomy (焦痂切開)
– full-thickness circumferential burns of the extremity
– full-thickness burns of the chest wall when the
eschar compromises( 當引起呼吸困難時需做)
– 受傷1-2週後進行,以期早期植皮
• Skin Graft
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Biosynthetic Skin Substitue Dressing
• Mimic a function of skin by replacing the epidermis or
dermis, or both
• Allow for re-epithelization to occur while permitting a gas
and fluid exchange which in turn provides both protection
from bacterial influx and mechanical coverage (Demling
2000)
• Biobrane (Dow Hickam/Bertek Pharmaceuticals) and
Trans Cyte (Advanced Tissue Sciences) (Walmsley
2002)
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Advantage of Operation
• Early excision and skin grafting
– Decrease infectious complications
– Decrease length of hospital stay
– Improve survival
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• Early operative wound management
– 現代燒燙傷照護最重要的一部份
• Prompt excision and closure of burn wound
– 對大面積燒燙傷患者而言是救命的方法
• Skin substitutes and dermal replacement
– made operative wound care even more appealing for
providing temporary coverage in patients with not enough
autograft
– offer an attractive alternative to topical antimicrobial
therapy for partial thickness wounds
Purpose of Operation