骨骼肌肉12.1-燒傷課件

1、Julie 王鳳怡 Occupational Terapy Department of Rehabilitation Medcine Centre West China Hospital, Sichuan University2016Burn Injury目錄CONTENTStructure of skinTypes of burnIncidence and prevalenceIntroduction 01Extent and DepthClassification of Burn02Hypertrophic scar & KeloidContractureManagementComplic

2、ations04Medical Management03Wound care, Skin graft, OperationsIntroduction PART 01Structure of skinTypes of burnIncidence and prevalenceIntroduction Structure of skin皮脂腺I(mǎi)ntroduction Structure of skin表皮 皮膚最外面的一層組織，其厚度因身體部位而不同，表皮在掌跖處最厚，在眼瞼最薄。它擔(dān)負(fù)著細(xì)胞自我更新的重要功能，也就是細(xì)胞的新陳代謝。表皮從外向內(nèi)，依次可以分作4層。 l 角質(zhì)層 位于表皮的最外部，由

3、扁平的角質(zhì)細(xì)胞組成，如魚(yú)鱗片相互重疊在一起，具有防止水分散失的功能。 l 顆粒層 由3-5層扁平細(xì)胞組成，細(xì)胞內(nèi)充滿(mǎn)粗大、不規(guī)則的透明角質(zhì)顆粒，具有折射光線的作用，能阻擋陽(yáng)光中的紫外線，異常時(shí)會(huì)呈厚繭狀。 l 有棘層 表皮層中最厚的一層，由8-12層多角形細(xì)胞所構(gòu)成，細(xì)胞之間有淋巴液流通，可供給表皮營(yíng)養(yǎng)。 l 基底層 位于表皮的最深處，與真皮緊密銜接，連接的截面呈波浪起伏狀?；准?xì)胞為稱(chēng)方形或者低柱形，具有細(xì)胞分裂能力。除了基底細(xì)胞之外，基底層還存在著黑色素細(xì)胞。大約每10個(gè)基底細(xì)胞中就約有一個(gè)黑色素細(xì)胞，呈樹(shù)枝狀突起。黑色素細(xì)胞形成黑色素后，通過(guò)樹(shù)枝狀突起將黑色素顆粒輸送到基底細(xì)胞或者毛發(fā)。

4、 Types of burn Destruction of the skin caused by thermal changes (hot water & steam scald燙傷, flame, hot fluid (oil, tar), hot metal, extreme cold) corrosive liquid腐蝕性液體: alkalis/ acid electricity radiation One of the most painful form of traumaIntroduction Introduction Incidence & prevalenceBurn Inc

5、idence and Treatment in the US: 2007 Fact SheetSurvival Rate: 94.4%Severity of Burn Injuries: Over 1/3 of admissions exceeded 10% TBSA (total body surface area), and 10% exceeded 30% TBSA.Burn Cause:46% fire/flame, 32% scald燙傷, 8% hot object contact, 4% electrical, 3% chemical, 6% others.Place of Oc

6、currence:43% home, 17% street/highway, 8% occupational, 32% otherAmerican Burn Association National Burn Repository (2005 report),as reported in American Burn Association Fact Sheet, 2007 Classification of burn: degree & extentSeverity of burn: degree & extentDegree of burns: 2 system in terms of de

7、pth of skin destructionAssessment by clinical observation (66%) accuracy) or using Laser Doppler (probes placed on a burn area to monitor micro-vascular blood flowing the dermis) 2. Extent of burns injuries:2 systems in terms of width of skin destruction: rules of nine & Lund-Browder Chart- Causes o

8、f injuries & types of burning agentsE.g. hot oil, tar, or chemical agents& electricity burn= third degree burnDegree Location 1st degreeSuperficial 2nd degree: superficialSuperficial partial thickness2nd degree: deepDeep partial thickness3rd degreeFull thicknessClassification of burn: degree & exten

9、tFirst degreeE.g. sunburnDamage only the top epidermal layer of skinErythema紅斑 (superficial redness of skin), if presswhite (blanches)No blisters, painful, no chance of infectionSelf-heal in 3 to 6 daysClassification of burn: degree & extentSecond degree (superficial)=superficial partial thicknessen

10、tire epidermis involvedHallmark: When pressure is applied to the reddened area, the area will blanch 發(fā)白but demonstrate a brisk 快速的 or rapid capillary refill upon release of the pressure. May have blistering, red & moist under blisterChance of infectionpainfulheal within 3 weeksonly a change in skin

11、color and pigmentation色素沉積 when healedClassification of burn: degree & extentSecond degree (deep)=deep partial thicknessentire epidermis and large portion of dermis involved (hair follicles, sweat glands & sebaceous glands 皮脂腺spared)capillary refill may be absent or may be sluggish緩慢的 when pressure

12、is releaseddry, ivory or pearly whiteproduce significant hypertrophic scar usually if not managed by skin graftinglonger than 3 weeks to healClassification of burn: degree & extentThird degree = full thicknessTotal destruction of skin (+ deeper tissues), e.g. subcutaneous fat, muscle etc) tan/fawn i

13、n color 棕褐色hard & dry inelasticthrombosed 形成血栓的vessels visible (blood clotted & aggregate on vessel wall vascular obstruction ischaemia necrosis)No painfulunable to heal spontaneously as no epithelial bed leftskin graftingsevere hypertrophy scarmore complicationsClassification of burn: degree & exte

14、ntClassification of burn: degree & extent（2）輕度燒傷1）10歲到50歲的人群：淺二度以上燒傷占體表總面積小于15%。2）年齡小于10歲大于50歲的人群：淺二度以上燒傷占體表總面積小于10%。3）三度或三度以上燒傷占體表總面積小于2%。（1）中度燒傷1）10歲到50歲的人群：淺二度以上燒傷占體表總面積在15%到25%之間。2）年齡小于10歲大于50歲的人群：淺二度以上燒傷占體表總面積在10%到20%之間。3）三度或三度以上燒傷占體表總面積在2%到10%之間。 Classification of burn: degree & extent（3）重度燒傷1

15、）10歲到50歲的人群：淺二度以上燒傷占體表總面積大于25%。2）年齡小于10歲大于50歲的人群：淺二度以上燒傷占體表總面積大于20%。3）三度或三度以上燒傷占體表總面積大于10%。4）任何涉及到手部、面部、腳部或會(huì)陰部位的燒傷。5）燒傷覆蓋主要的關(guān)節(jié)部位。6）圍繞四肢任意部位一圈的燒傷。7）任何傷到呼吸道的燒傷。8）電燒傷。9）燒傷伴有骨折或其他外傷疊加的復(fù)合傷。10）嬰幼兒燒傷。11）容易引起并發(fā)癥的高危人群發(fā)生燒傷。12）以上類(lèi)型的燒傷需要將病人盡快送到專(zhuān)業(yè)的燒傷科。Classification of burn: degree & extentClassification of burn

16、: degree & extentClassification of burn: degree & extentMedical ManagementAcute Management of severe burns: ABCA = airwayB = breathingC = circulationAcute Management of severe burns: ABC Life saving firstAdequate airway supply (inhalation injury) Inhalation injury: Damage is initiated by toxins and

17、particulate debris 顆粒殘?jiān)? which induce rapid local vasodilation and necrosis of the surface layer of the upper airway, which then separates from the tracheobronchial 氣管支氣管wall. Breathing difficulty High dose of O2& secure airway passage Endotracheal氣管內(nèi) tube: a tube inserted into trachea & Tracheostom

18、y氣管切開(kāi): a stoma (opening) into trachea especially for burn in face & neck Burns to chest may need escharotomy焦痂切開(kāi)術(shù).Circulation: Intravenous fluid replacement 10% surface area hypovolemic shock低血容量性休克: a severe reduction in circulating blood volume due to loss of blood into peripheral tissues by vasod

19、ilation fluid loss from burnt body surface hypoxemia低氧血癥 + fluid & electrolytic imbalance, renal failure hypotensive state shock shock: blood flow to peripheral tissues is inadequate to sustain lifeMedical ManagementSub-acute Management of severe burns Saving the limbSurgery: Escharectomy 焦痂切除術(shù)Pain

20、relief: codeine, morphine 3. Wound Care & infection controlSystemic antibiotic: prevent sepsis, e.g. penicillin青霉素(some hospital would not provide prophylactic 預(yù)防性antibiotic as it may lead to infection with multiply-resistant bacteria)Debridement清創(chuàng): removes necrotic tissue and reduces bacterial colo

21、nization, end point of debridement healthy, bleeding, viable wound bed, granulation 肉芽notedBurn wound care: - open/close methodMedical Management1. Operation procedures Surgical excision Escharotomy Surgical incision through the eschar to relieve constriction 壓縮 Escharectomy Removal of eschar to pre

22、pare for grafting Eschar= burned tissueMedical Management2. Local wound care: close methodDressings occlusive absorption bulkyBiological dressings & skin substitutes替代物 closing a wound / contamination污染物 / reducing pain and fluid loss. Biologic products(e.g.human amnion羊膜) may deliver growth factors

23、 biosynthetic生物合成wound dressing sheet (Biobrane) Topical antibiotics: most common: Silver sulfadiazine磺胺嘧啶銀(Silvadene)Prevent infection, promote removal of eschar +comfortPrepare skin for graftingRestore essential function of skinMedical ManagementBurn dressing: close methodDeeper burns typically ar

24、e treated with silver sulfadiazine to help prevent wound dehydration脫水 and provide antimicrobial抗菌 protectionMedical Management3. Skin graftsWhen epidermal bed is so destroyed that spontaneous epithelial tissue re-growth is difficult or impossible & where raw areas are more than 2.5 cm wide Skin graft: Split skin graft Full thickness / whole skin graft Skin FlapsMedical ManagementSplit skin grafts & whole skin/full thickness skin graftMedical ManagementTypes of graftsMedical ManagementComplicationsPART 03Hypertrophic scar & Keloi