骨骼肌肉12.1-燒傷

2021BurnInjury目錄CONTENTStructureofskinTypesofburnIncidenceandprevalenceIntroduction01ExtentandDepthClassificationofBurn02Hypertrophicscar&KeloidContractureManagementComplications04MedicalManagement03Woundcare,Skingraft,OperationsIntroductionPART01StructureofskinTypesofburnIncidenceandprevalenceIntroductionStructureofskin皮脂腺I(mǎi)ntroductionStructureofskin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)充滿粗大、不規(guī)那么的透明角質(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?；鶅?nèi)幕胞為稱(chēng)方形或者低柱形，具有細(xì)胞分裂能力。除了基內(nèi)幕胞之外，基底層還存在著黑色素細(xì)胞。大約每10個(gè)基內(nèi)幕胞中就約有一個(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內(nèi)幕胞或者毛發(fā)。IntroductionStructureofskin真皮表位于表皮的下面，是一層致密和具有彈性的組織。它可以為表皮和皮膚附屬器官提供養(yǎng)分，對(duì)外界機(jī)械沖擊有緩沖作用。真皮主要由蛋白纖維結(jié)蒂組織組成，包括膠原蛋白和彈性纖維，使皮膚有一定的抗拉性，顯得柔韌和富有彈性。真皮內(nèi)還包括皮脂腺、毛囊組織、神經(jīng)以及供給表皮層養(yǎng)分的毛細(xì)血管。l皮脂腺皮脂腺開(kāi)口于毛囊中，主要分泌油性物質(zhì)，即皮脂。在局部的皮脂腺分布在頭、面、胸骨附近和肩胛間的皮膚。它的活動(dòng)隨著年齡而異，在青春期最為旺盛。l汗腺汗腺分大汗腺和小汗腺。大汗腺主要分布于身體多毛局部，腺體多在皮下脂肪中，分泌的物質(zhì)為粘稠狀乳濁液，含蛋白質(zhì)、脂質(zhì)、碳水化合物及鹽類(lèi)，經(jīng)細(xì)菌分解后生成揮發(fā)性的低級(jí)脂肪酸與其它有臭味的物質(zhì)，從而產(chǎn)生體味；小汗腺分布于全身，直接開(kāi)口在皮膚外表，腳底、手掌、額和腋是小汗腺最密集的部位，分泌的汗水以水為主，沒(méi)有異味，有起到調(diào)節(jié)體溫的作用。l毛囊組織包括毛發(fā)、毛孔和毛囊。毛發(fā)由一種角蛋白的蛋白質(zhì)組成，是皮膚的附屬物，它在管狀的毛囊內(nèi)發(fā)育。毛發(fā)普及身體的絕大局部，起保護(hù)身體皮膚的作用；毛也是皮膚外表的開(kāi)口，與皮脂腺和毛囊相連，是毛發(fā)生長(zhǎng)及油脂輸送的管道，毛孔的大小與相連的皮脂腺大小成正比；毛囊是毛孔的內(nèi)部組織，由圍繞毛根的表皮細(xì)胞組成。Typesofburn?Destructionoftheskincausedby–thermalchanges(hotwater&steam→scald燙傷,flame,hotfluid(oil,tar),hotmetal,extremecold)–corrosiveliquid腐蝕性液體:alkalis/acid–electricity–radiation?OneofthemostpainfulformoftraumaIntroductionIntroductionIncidence&prevalenceBurnIncidenceandTreatmentintheUS:2007FactSheetSurvivalRate:94.4%SeverityofBurnInjuries:Over1/3ofadmissionsexceeded10%TBSA(totalbodysurfacearea),and10%exceeded30%TBSA.BurnCause:46%fire/flame,32%scald燙傷,8%hotobjectcontact,4%electrical,3%chemical,6%others.PlaceofOccurrence:43%home,17%street/highway,8%occupational,32%otherAmericanBurnAssociationNationalBurnRepository(2005report),asreportedinAmericanBurnAssociationFactSheet,2007://ClassificationofBurnPART02ExtentandDepthClassificationofburn:degree&extentSeverityofburn:degree&extentDegreeofburns:2systemintermsofdepthofskindestructionAssessmentbyclinicalobservation(66%)accuracy)orusingLaserDoppler(probesplacedonaburnareatomonitormicro-vascularbloodflowingthedermis)2.

Extentofburnsinjuries:2systemsintermsofwidthofskindestruction:rulesofnine&Lund-BrowderChart-Causesofinjuries&typesofburningagentsE.g.hotoil,tar,orchemicalagents&electricityburn=>thirddegreeburnDegree

Location1stdegreeSuperficial2nddegree:superficialSuperficialpartialthickness2nd

degree:deepDeeppartialthickness3rddegreeFullthicknessClassificationofburn:degree&extentFirstdegreeE.g.sunburnDamageonlythetop

epidermallayerofskinErythema紅斑(superficialrednessofskin),ifpress→white(blanches)Noblisters,painful,nochanceofinfectionSelf-healin3to6daysClassificationofburn:degree&extentSeconddegree(superficial)=superficialpartialthicknessentireepidermisinvolvedHallmark:Whenpressureisappliedtothereddenedarea,theareawillblanch發(fā)白butdemonstrateabrisk快速的orrapidcapillaryrefilluponreleaseofthepressure.Mayhaveblistering,red&moistunderblisterChanceofinfectionpainfulhealwithin3weeksonlyachangeinskincolorandpigmentation色素沉積

whenhealedClassificationofburn:degree&extentManagementofburns(smallarea/superficialburns)Immediatecomfort,e.g.codeine,aspirin,morphinePreventinfection–cleansing

–dressing–systemicantibiotics–topicalantibioticsforopenwound,e.g.silversulfadiazinecream;and

antiseptic:e.g.silvernitratesolution,–tetanusprophylaxis–partial-thicknessburnswillhealbyre-epithelialization上皮再生fromdermalskinwithin1to2weeksClassificationofburn:degree&extentSeconddegree(deep)=deeppartialthicknessentireepidermisandlargeportionofdermisinvolved(hairfollicles,sweatglands&sebaceousglands皮脂腺spared)capillaryrefillmaybeabsentormaybesluggish緩慢的

whenpressureisreleaseddry,ivoryorpearlywhiteproducesignificanthypertrophicscarusuallyifnotmanagedbyskingraftinglongerthan3weekstohealClassificationofburn:degree&extentThirddegree=fullthicknessTotaldestructionofskin(+deepertissues),e.g.subcutaneousfat,muscleetc)tan/fawnincolor棕褐色hard&dryinelasticthrombosed形成血栓的vesselsvisible(bloodclotted&aggregateonvesselwall→vascularobstructionischaemia→necrosis)NopainfulunabletohealspontaneouslyasnoepithelialbedleftskingraftingseverehypertrophyscarmorecomplicationsClassificationofburn:degree&extentExtentofburn:rulesofnineClassificationofburn:degree&extentClassificationofburn: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。Classificationofburn:degree&extent〔3〕重度燒傷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。Classificationofburn:degree&extentClassificationofburn:degree&extentClassificationofburn:degree&extentMedicalManagementPART02WoundcareSkingraftOperationsMedicalManagementAcuteManagementofsevereburns:ABCA=airwayB=breathingC=circulationAcuteManagementofsevereburns:ABCLifesavingfirstAdequateairwaysupply(inhalationinjury)–Inhalationinjury:Damageisinitiatedbytoxinsandparticulatedebris顆粒殘?jiān)?whichinducerapidlocalvasodilationandnecrosisofthesurfacelayeroftheupperairway,whichthenseparatesfromthetracheobronchial氣管支氣管wall.Breathingdifficulty–HighdoseofO2&secureairwaypassage?Endotracheal氣管內(nèi)

tube:atubeinsertedintotrachea&?Tracheostomy氣管切開(kāi):astoma(opening)intotracheaespeciallyforburninface&neck?Burnstochestmayneedescharotomy焦痂切開(kāi)術(shù).Circulation:Intravenousfluidreplacement

–>10%surfacearea

?hypovolemicshock低血容量性休克:aseverereductionincirculatingbloodvolumeduetolossofbloodintoperipheraltissuesbyvasodilation→fluidlossfromburntbodysurface→hypoxemia低氧血癥

+fluid&electrolyticimbalance,renalfailure→hypotensivestate→shock?shock:bloodflowtoperipheraltissuesisinadequatetosustainlifeMedicalManagementSub-acuteManagementofsevereburnsSavingthelimbSurgery:Escharectomy焦痂切除術(shù)Painrelief:codeine,morphine3.

WoundCare&infectioncontrolSystemicantibiotic:preventsepsis,e.g.penicillin青霉素(somehospitalwouldnotprovideprophylactic預(yù)防性antibioticasitmayleadtoinfectionwithmultiply-resistantbacteria)Debridement清創(chuàng):removesnecrotictissueandreducesbacterialcolonization,endpointofdebridement→healthy,bleeding,viablewoundbed,granulation肉芽notedBurnwoundcare:--open/closemethodMedicalManagementSub-acuteManagementofsevereburnsObservesepticemia5.Operation:Earlyexcision:Escharectomy焦痂切除術(shù)&escharotomy焦痂切開(kāi)術(shù)Grafting-Donorsite:thigh,arm&headforskinregeneration,fullrecoveryofthearea(usually14to17days);-Whentheskinisunabletohealafter17to21daysoflocaltherapy→skingrafting6.Preventcontracturebypositioning&splintingMedicalManagement1.OperationproceduresSurgicalexcision?Escharotomy–Surgicalincisionthroughtheeschartorelieveconstriction壓縮?Escharectomy–Removalofeschartoprepareforgrafting?Eschar=>burnedtissueMedicalManagement2.Localwoundcare:closemethodDressings–occlusive–absorption–bulkyBiologicaldressings&skinsubstitutes替代物–closingawound/contamination污染物/reducingpainandfluidloss.Biologicproducts(e.g.humanamnion羊膜)maydelivergrowthfactors–biosynthetic生物合成wounddressingsheet(Biobrane)Topicalantibiotics:mostcommon:Silversulfadiazine磺胺嘧啶銀(Silvadene)Preventinfection,promoteremovalofeschar+comfortPrepareskinforgraftingRestoreessentialfunctionofskinMedicalManagementBurndressing:closemethodDeeperburnstypicallyaretreatedwithsilversulfadiazinetohelppreventwounddehydration脫水a(chǎn)ndprovideantimicrobial抗菌protectionMedicalManagement3.SkingraftsWhenepidermalbedissodestroyedthatspontaneousepithelialtissuere-growthisdifficultorimpossible&whererawareasaremorethan2.5cmwideSkingraft:–Splitskingraft–Fullthickness/wholeskingraft