外科學(xué)燒傷漢英雙語教學(xué)課件

1、BURNS燒傷Li aoSheng ZhiyongXia Zhaofan1958 Burn unit Shanghai/Beijing/Chongqing etc.The Chinese Academy of EngineeringYou？History of Burns in China 中國燒傷科發(fā)展史1983 CBA(Chinese Burn Association）1959 Spring Reigns Everywhere Baiyang A BOOK,A US TV SeriesTeaching Requirements 教學(xué)要求 To Grasp 掌握 Estimation of

2、burn area 燒傷面積估測 Judgement of burn depth and severity 評價燒傷深度和嚴(yán)重度Clinical manifestation , diagnosis and fluid resuscitation of burn shock 燒傷性休克的臨床表現(xiàn)、診斷和體液補充 The principle of treatment on burn wound 燒傷創(chuàng)面的治療原則 To Understand 理解Pathophysiology and clinical stages 病理生理及臨床分期The mechanism of injury on elect

3、ric and chemical burn 電燒傷和化學(xué)性燒傷的損傷機理To Acquaint 熟悉Clinical manifestation and prevention of burn infection 燒傷感染的臨床表現(xiàn)及預(yù)防The mechanism of injury, clinical manifestation, diagnosis and treatment of inhalation injury 吸入性燒傷的損傷機理、臨床表現(xiàn)、診斷和治療The principle of treatment on electric and chemical burn 電燒傷和化學(xué)性燒傷的

4、治療原則 The Incidence of Burns 燒傷的發(fā)生率： 3-5% surgical inpatients 外科住院患者 Introduction 簡介Thermal burns 熱灼傷Scald and flame burns 燒燙傷Unexpected Events 突發(fā)事件(Social Development and Stable)Unexpected Events 突發(fā)事件(Social Development and Stable)2014 Kunshan2010 Shanghai2009 ChengduInjury Area 損傷范圍Large area burn

5、大面積燒傷Systemic reactions 全身反應(yīng)Local lesions 局部損傷Small area burn 小面積燒傷. Thermal Burn 熱灼傷 Heat 高溫 Burn 燒傷Hot oilHot metal SteamFlameContinuouslow temperature burnA females whole body surface areaThe largest organ 最大的器官The Skin 皮膚 The structure 結(jié)構(gòu) FunctionEpidermis 表皮Dermis 真皮Subcutis 皮下組織Burn severity 燒

6、傷嚴(yán)重度?Therapy 治療 Burn area 燒傷區(qū)域Burn depth 燒傷深度 Estimation of Burn Area 估測燒傷面積 %Total Body Surface Area 全身表面積(%TBSA) Rule of nine 九分法 Rule of palm 掌分法9%9%9%9%9%9%13%+13%+1%13%+13%+1%21%21%13%13%5%6%7%6%Chinese rules of 9s 中國的九分判斷法(Adult)Chinese Pithy Formula 中國計算公式口 訣三三三五六七前后十三下面一屁股“五”熱得腳“七”小腿十三大二一1個9

7、2個93個95個9+1%Facial and neck 頸部 area(%)：9（12age）Chinese Rules of 9s (Child)Buttocks 臀部 and legs and feet area (%)：46（12age）2. Estimation of burn area using rule of a palm 使用手掌估測規(guī)則估計燒傷區(qū)域The hand palm= TBSA 1% Judgement of Burn Depth 判斷燒傷深度 Three degrees and four classifications 三級和四級分類法 First degree b

8、urnSecond degree burnDeep second degree burnThird degree burnFirst Degree Burn 一度燒傷(Erythematous紅斑)Red, slight swelling, pain, no blister 紅、腫、痛、無水泡No trace 無痕跡3-7 daysSecond Degree Burn 二度燒傷(Blister 水泡) Big blister, swelling, extremely painful 大水泡、腫脹、極度疼痛Texture 質(zhì)地: red, wet 紅、濕7-14 days No permanen

9、t trace 無永久性痕跡Deep Second Degree Burn 深二度燒傷White-red(mottled), wet, swelling,pain, less and little blister 白-紅（有雜色）、濕潤、腫脹、疼痛、水泡少而小3-4 weeks Scars, pigmentations 疤痕、色素沉積Third Degree Burn 三度燒傷(Eschar 焦痂)white, tan, or eschar, thrombosed veins, leathery, painless 白色、褐色或形成焦痂、血栓靜脈形成、皮革樣、無痛operations Scar

10、s, contracture deformity 疤痕、攣縮畸形Summary of Burn Depth BurndepthPathologicalchanges Clinic featuresHealingtimeOutcomeFirstdegreeepidermis (parts layers)Color: redTexture: slight swelling, no blister Feeling: pain1 weekno traceSeconddegree epidermisdermis(upper layers )Color: redTexture: big blisters,

11、 swellingFeeling: extremely painful1-2weeksno traceDeepsecond degreeepidermis,dermis( most layers)Color: white-pink/redTexture: swelling, less blisterFeeling: pain3-4weeksscarsThirddegree all layers of skin, muscle,boneColor: white, tan, eschar, Texture: leathery, non-elasticFeeling: painless operat

12、ionscars燒傷深度總結(jié) 燒傷深度病理改變臨床特征康復(fù)時間結(jié)局一度表皮 (部分層)顏色: 紅質(zhì)地: 輕度腫脹、無水泡感覺: 疼痛1 周無痕跡二度表皮真皮(上層)顏色: 紅質(zhì)地: 大水泡、腫脹感覺: 極度疼痛1-2 周無痕跡深二度表皮真皮(多數(shù)層)顏色: 白-粉/紅質(zhì)地: 腫脹、少水泡感覺: 疼痛3-4 周疤痕三度皮膚全層肌肉骨顏色: 白、褐、焦痂質(zhì)地: 皮革樣、無彈性感覺: 無痛需手術(shù)疤痕 “Fourdegrees， five classifications 四度五分法” ： 淺 深 ：Under deep fascia 深筋膜下The Judgment of Burn Severity

13、判斷燒傷嚴(yán)重程度Burn area, depth, position, patients age, associated injury, physical strength, visceral organic disease, etc. 燒傷面積、深度、位置、患者年齡、合并損傷、體力、內(nèi)臟器官疾病等 Classification of Burn Severity TBSA% 。TBSA%Mild burns： 10 。 Moderate burns： 1130 or 10Severe burns： 3150 or 1120 50 or 20 shock, combined injury, in

14、halation injuryThe Judgment of Burn Severity 判斷燒傷嚴(yán)重程度Burn area, depth, position, patients age, associated injury, physical strength, visceral organic disease, etc. 燒傷面積、深度、位置、患者年齡、合并損傷、體力、內(nèi)臟器官疾病等 燒傷嚴(yán)重程度分類 TBSA% 。TBSA%輕度燒傷： 10 。 中度燒傷： 1130 or 10重度燒傷： 3150 or 1120 50 or 20 休克、合并損傷、吸入性損傷Inhalation Inju

15、ry 吸入性損傷The mechanism of inhalation 吸入性損傷機理：Flame, Steam, Poison gas 火焰、蒸汽、毒氣- Respiratory passage 呼吸道Keys 要點:Medical history, Cause of injury 病史、傷害原因Attention 注意:High death rate 高死亡率(Asphyxia 窒息), Combined injury 合并損傷Inhalation Injury Classification 吸入性損傷分類Extent of diseaseClinical manifestationTre

16、atmentMildNose, Mouth,Pharynx Rhinothrix burn, Trachyphonia, Irritating cough, DysphagiaSymptomatic treatment， Oxygen uptakeModerateAdd throat, TracheaAdd AWO(airway obstruction), Difficult breathingTracheotomy, Atomize inhalationSevereAdd bronchus，Pulmonary alveoli Appear early, Add moist rales, Tr

17、acheotomy, Atomize inhalationInhalation Injury Classification 吸入性損傷分類患病范圍臨床表現(xiàn)治療輕度鼻、口腔、咽鼻毛燒傷、聲嘶、刺激性咳嗽、吞咽困難對癥治療、吸氧中度+喉、氣管+AWO(氣道阻塞)、呼吸困難氣管切開術(shù)、霧化吸入重度+支氣管、肺泡早期發(fā)作、 +濕啰音氣管切開術(shù)、霧化吸入MildModerateSevereTracheotomy 氣管切開術(shù)Percutaneous Tracheotomy 經(jīng)皮氣管切開術(shù)1. the Acute Phase of Exudation 急性期滲液(Shock Stage 休克期)Body f

18、luid exude 體液滲出Acute Phase of Exudation 急性期滲液Characteristics, Attention 特點、注意事項Hypovolemic Shock 低血容量性休克, 48Hthe Clinical Courses of Burn 燒傷的臨床表現(xiàn)2. Infective Stage 感染期 Characteristics 特征Infection from wound surface 傷口表面感染Enterogenic infection 腸源性感染Attention 注意- Septicemia 敗血癥Severity of Burn 燒傷嚴(yán)重程度,

19、 Whole body 全身intestinal tract3. the Repairing Stage 修復(fù)期The time node of repairing period after burn 燒傷后位于修復(fù)期的時間節(jié)點（？）Scar formation and treatment during repairing period 修復(fù)期疤痕形成和治療Wound closure 傷口閉合, Excision of eschar焦痂切除術(shù)(Early, Large area 早期、大面積)4. The Rehabilitation Stage 康復(fù)期the Idea of Integrat

20、ion 一體化理念: Early Treatment+ Rehabilitation 早期治療+康復(fù)Residual wound 殘余創(chuàng)面Scar contracture 疤痕攣縮Scar deformity 疤痕畸形Psychological counseling 心理咨詢Principles of Treatment after Burns 燒傷后治療原則Small areas and superficial burn 小面積和表面燒傷： Wounds 傷口- Self-healing, Operation 自愈、手術(shù)Large area and deep burn 大面積和深度燒傷： S

21、hock 休克- Fluid infusion 補液 Infection 感染- Antibiotics 抗生素 Wound 傷口- Operation 手術(shù) Rehabilitation 康復(fù)- Integration concept 整合觀念 Inhalation injury 吸入性損傷- Respiratory tract 呼吸道Organs 器官MODSFirst Aid，Transportation and Prime Treatment 急救、運輸和主要治療First Aid 急救Cooling, Protecting Wound 冷卻、保護傷口Transportation 運輸

22、Short 短、Fast 快、Steady 穩(wěn)固、System 系統(tǒng)Prime treatment 主要治療Mild 輕度Wound 傷口Moderate 中度/Severe 重度/Major 極重度Systemic therapy 全身治療 Burn Shock 燒傷性休克Characteristics 特征Hypovolemic shock 低血容量性休克 Plasma lossing 血漿丟失Continues loss, and slow 持續(xù)、緩慢丟失Burn area 燒傷面積15%TBSA(Adult) 5%TBSA(Child) Clinical Features 臨床表現(xiàn)Ur

23、ine reduce 尿量減少：Adult20ml/h，Child120/minThirsty 口渴Agitating 焦慮Vomiting 嘔吐Poor peripheral circulation 外周循環(huán)不良BP 血壓- Decreasing 降低, Pulse Differential Presssure 脈壓差30mmHgOxygen saturation 血氧飽和度- Decreasing 降低Laboratory Test 實驗室檢測：Hematocrit 血細(xì)胞比容(HCT)- Increasing 升高 Burn Shock Treatment 燒傷性休克治療Adult 成人

24、 1st 24h Infusion volume 輸液量:1TBSA(、), Colloid 膠體(0.5)+Electrolyte 電解質(zhì)(1.0)1.5ml/kg+Base water 基礎(chǔ)水2000ml;Electrolyte 電解質(zhì):Colloid 膠體- 2:1，1:1;Infusion Speed 輸液速度: of total volume 8h， of total volume 8-24h； 2nd 24h Infusion volume 輸液量： of 1st Colloid 膠體； of 1st Electolyte 電解質(zhì);Base water 基礎(chǔ)水2000ml;Flui

25、d to prevent burn shock 輸液防止燒傷性休克:Colloid 膠體: Plasma 血漿, Blood 血液, Dextran 右旋糖酐, Gelofusine佳樂施（血定安）;Electrolyte 電解質(zhì): Balanced Salt Solution 平衡鹽溶液, 0.9%NaCl;2 (Saline 生理鹽水) + 1(1.25% Dicarbonate 小蘇打); Alkalize urine 堿化尿液Base water 基礎(chǔ)水: 5/10 Glucose Injection 葡萄糖注射液;Q: An adult patient,50%TBSA(+), Wei

26、ght:60kg, How to calculate the Fluid infusion 如何計算輸液量? Child 兒童2YElectrolyte 電解質(zhì): Colloid 膠體：1:1；Total volume 總?cè)莘e：%TBSAweight(kg)1.75；Base water 基礎(chǔ)水：50100ml/(kg.d) How to judge the burn shock 如何判斷燒傷性休克:Quiet Patient 病人安靜(Coma 昏迷?);Peripheral vein 周圍靜脈;Urine 尿量:1ml/kg.h;Pulse 脈搏:5cmH2OL.T 實驗室檢查：Hct 血

27、細(xì)胞比容, Blood Gas Analysis 血氣分析(Acidosis 酸中毒);Smooth and steady breath 呼吸平穩(wěn)順暢;Burn Infection 燒傷感染Invade ways 入侵途徑Wound 傷口 Enterogenic infection 腸源性感染Inhalation 吸入性- Respiratory system 呼吸系統(tǒng)IatrogenicInfection 醫(yī)源性感染: Venipuncture 靜脈穿刺Clinical Features of Burn Infection 燒傷感染的臨床表現(xiàn)Body temperature 體溫:39/36

28、.5 Agitating 焦慮, Coma 昏迷, Slow 緩慢/Rapid 急速 breathing, Abdominal distension 腹脹Bad wound surface 傷口表面變質(zhì): Granulation 粗糙, Necrotic tissue 壞死組織Inflammatoryreaction 炎癥反應(yīng), Skin-autopepsia 皮膚自溶Shock 休克- Infection shock 感染性休克Infected Wound Surface 傷口表面感染To prevent infection 預(yù)防感染Early treatment 早期治療, Prevent

29、 shock 預(yù)防休克Wound treatment 創(chuàng)面治療Intelligent use antibiotics 合理使用抗生素Nutrition and surpport therapy 營養(yǎng)和支持療法Key Organs 重要器官: Wound Surface Treatment 創(chuàng)面治療Princples 原則:Protect保護, Reducing exude 減少滲液Prevent wound infection 預(yù)防傷口感染Remove necrotic tissue 清除壞死組織, Cover surface 覆蓋表面（植皮） Prevent 預(yù)防 Scar contract

30、ure and deformity疤痕攣縮及畸形Plastic 整形 Better appearance 美觀Wound surface treatment 創(chuàng)面治療:Bind up wound 包扎傷口;Half-exposure 半暴露（？）;(Iodophor 碘伏)Exposure 暴露;(Flamazine 磺胺嘧啶銀)Early stage treatment 早期治療- Wound surface 創(chuàng)面 深 。: Exposure 暴露, Operation 手術(shù) Operation 手術(shù):Shaving eschar 焦痂剃除：深 。Cutting eschar 焦痂切除： 。

31、Skin-grafting operation 植皮手術(shù)Sources 來源 Autologous skin 自體皮, alloskin 同種異體皮, xenoskin 異種皮Free skin graft 自由皮瓣移植 Ultra thin Thickness 表層, Thickness 層（Thin 薄/thick 厚）, Full Thickness 全層Flap grafting 皮瓣移植 with vessel pedicle 血管蒂, free flap 游離皮瓣 Ultra thin ThicknessThickness Full ThicknessCommonly used methods of skin-grafting 植皮手術(shù)常用方法Reticular- autologous skin 網(wǎng)狀-自體皮Stamp skin-grafting（？） Alloskin 同種異體皮/xeno