Download ATLS: Burn & cold injuries

BURN , COLD INJURY
90-02-24
急診醫學科
李芳年 醫師
ACLS ( CH 9 ) - BURN
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INJURY DUE TO
BURN AND COLD
ACLS ( CH 9 ) - BURN
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OBJECTIVES
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Estimate burn size, and determine
presence of associated injuries.
Outline innitial stabilization,
treatment measures, and
transfer criteria.
Identify special problems and
methods of treatment.
ACLS ( CH 9 ) - BURN
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BURN / COLD INJURIES
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Management Principles
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Timely application
Maintain:
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Airway
Hemodynamic stability
Fluid / electrolyte balance
Normal body temperature
Prevent complications
ACLS ( CH 9 ) - BURN
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Injury Due To Burn
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LIFE-SAVING MEASURES
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Establish airway
Identify signs of distress
Initiate supportive measures
Obtain history
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CLINICAL INDICATIONS
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Carbonaceous sputum
Facial burns
Hair singeing
Carbon deposites
Inflamed oropharynx
History
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Inhalation Injury
ACLS ( CH 9 ) - BURN
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LIFE-SAVING MEASURES
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Remove all:
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Injurious material
Clothing, jewelry
Prevent hypothermia
Two, large-caliber Ivs
Ringer’s lactate
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ASSESSMENT
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History
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Mechanism of ijury
Associated illness
Allergies
Tetanus status
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Rule of Nines
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ASSESSMENT
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Estimate Burn Size
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Surface of patient’s palm represents
1% body surface area
ACLS ( CH 9 ) - BURN
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Second-degree Burn
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Third-degree Burn
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MANAGEMENT
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Airway
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Assess for injury
Establish and maintain patient
airway early
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Inhalation Injury
Early Management
ACLS ( CH 9 ) - BURN
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MANAGEMENT
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Breathing
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Assume CO exposure
Inhalation of toxic fumes or carbon
particles
Direct thermal injury
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MANAGEMENT
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Breathing
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Oxygen / ventilate
Endotracheal intubation
ABGs
Carboxyhemoglobin levels
ACLS ( CH 9 ) - BURN
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MANAGEMENT
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Circulation
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Monitor vital signs
Hourly urinary outputs
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Adult: 30 – 50 mL / hr
Child: 1.0 mL / kg / hr
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MANAGEMENT
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Circulation – Estimate of Fluid Needs
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2 – 4 mL Ringer’s lactate / kg / % BSA
in first 24 hours
One-half in first 8 hours
One-half in next 16 hours
Based on time from injury
Monitor patient response
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MANAGEMENT
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Develop Treatment plan
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Estimate burn size / depth
Identify associated injuries
Weigh patient
Baseline blood analyses
Chest films
Document on flow sheet
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MANAGEMENT
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Maintain Peripheral Circulation
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Remove all connstricting devices
Assess distal circulation
Escharotomy – surgical consultation
ACLS ( CH 9 ) - BURN
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Escharotomy
Sites
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Escharotomy
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MANAGEMENT
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Nasogastric Intubation
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Nausea, vomiting, distention
Burn > 20% BSA
Medications
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Narcotics – Spare use, IV only
Antibiotics – Not indicated early
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MANAGEMENT
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Wound Care
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Cover with clean linen
Do not
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Break blisters
Apply antiseptics
Apply cold water
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MANAGEMENT
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Acid / Alkali Burns
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Duration, concentration, and amount
Flush with copious amount of water for
20 – 30 minutes
Brush away dry chemical before
irrigation
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Chemical Burns
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
Electrical burn
result in damage
to the fascia and
muscle, and may
spare the
overlying skin
Fasciotomy – Electrical Burn
ACLS ( CH 9 ) - BURN
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MANAGEMENT
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Electrical Burn
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ABCs
Myoglobinuria
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↑Fluid: 100 mL urine / hr
Mannitol: 25 g IV
Metabolic acidosis
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Maintain adequate perfusion
Sodium Bicarbonate
ACLS ( CH 9 ) - BURN
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TRANSFER CRITERIA
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2nd, 3rd degree burns > 10% BSA
in age < 10 and > 50 years
2nd, 3rd degree burns > 20% BSA
2nd, 3rd degree burns to face, eyes,
ears, hands, feet, genitalia,
perineum, and major loints
ACLS ( CH 9 ) - BURN
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TRANSFER CRITERIA
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3rd degree burns > 5% BSA
Electrical and chemical burns
Inhalation injury
Pre-existing illness, associated injuries
Children
Special situations
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TRANSFER PROCEDURE
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Coordinate with burn-center physician
Transfer with all
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Documentation / information
Laboratory results
ACLS ( CH 9 ) - BURN
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Injury Due To Cold
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COLD INJURY FACTORS
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Temperature
Duration of exposure
Enviromental conditions
Immobilizzation
Moisture
Vascular disease
Open wounds
ACLS ( CH 9 ) - BURN
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TISSUE-FREEZING INJURY
FROSTBITE
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1st Degree: Hyperemia, edema
2nd Degree: Vesicles, parttial-thickness
skin necrosis
3rd Degree: Full-thickness skin necrosis
4th Degree: Skin, muscle, bone necrosis
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Second-degree Frostbite
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Fourth-degree Frostbite
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MANAGEMENT
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Do nor delay
Remove clothing
Warmed blankets
Rewarm frozen part
ACLS ( CH 9 ) - BURN
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MANAGEMENT
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Preserve damaged tissue
Prevent infection
Elevate and expose injured part
Analgesics / tetanus / antibiotics
ACLS ( CH 9 ) - BURN
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HYPOTHERMIA
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Core temperature < 35 degrees
Rapid / slow drop in core temperature
Elderly and children at greater risk
Low-range thermometer required
ACLS ( CH 9 ) - BURN
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HYPOTHERMIA
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Clinical Findings
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Core temperature < 35 degrees
Depressed level of consciousness
Gray, cyanotic, variable vital signs
Absence of cardiorespiratory activity
ACLS ( CH 9 ) - BURN
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MANAGEMENT
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ABCs, IV access
Oxygenate and ventilate
Prevent heat loss and rewarm
Assess for associated disorders
Blood analyses
ACLS ( CH 9 ) - BURN
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MANAGEMEN
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Passive External Rewarming
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Active Core Rewarming
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Warm enviroment
Warmed blankets and IV fluids
Surgical rewarming techniques
Do not delay transfer
Not dead until warm and dead
ACLS ( CH 9 ) - BURN
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ACLS ( CH 9 ) - BURN
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SUMMARY
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Burn Injury
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Recognize inhalation injury
Establish airway
Fluid resuscitation
Rremove all clothing
ACLS ( CH 9 ) - BURN
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SUMMARY
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Burn Injury
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Identify extend, depth of burn
Establish fluid guidelines
Initiate burn flow sheet
Obtain baseline lab / radiology
Maintain peripheral circulation
Identify burns requiring transfer
ACLS ( CH 9 ) - BURN
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SUMMARY
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Cold Injury
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Diagnose type
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History
Clinical finding
Measure core temperature
Rewarming techniques
Monitor and support vital signs
ACLS ( CH 9 ) - BURN
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