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BURN , COLD INJURY 90-02-24 急診醫學科 李芳年 醫師 ACLS ( CH 9 ) - BURN 1 INJURY DUE TO BURN AND COLD ACLS ( CH 9 ) - BURN 2 OBJECTIVES 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 3 BURN / COLD INJURIES Management Principles Timely application Maintain: Airway Hemodynamic stability Fluid / electrolyte balance Normal body temperature Prevent complications ACLS ( CH 9 ) - BURN 4 Injury Due To Burn ACLS ( CH 9 ) - BURN 5 LIFE-SAVING MEASURES Establish airway Identify signs of distress Initiate supportive measures Obtain history ACLS ( CH 9 ) - BURN 6 CLINICAL INDICATIONS Carbonaceous sputum Facial burns Hair singeing Carbon deposites Inflamed oropharynx History Inhalation Injury ACLS ( CH 9 ) - BURN 7 LIFE-SAVING MEASURES Remove all: Injurious material Clothing, jewelry Prevent hypothermia Two, large-caliber Ivs Ringer’s lactate ACLS ( CH 9 ) - BURN 8 ASSESSMENT History Mechanism of ijury Associated illness Allergies Tetanus status ACLS ( CH 9 ) - BURN 9 Rule of Nines ACLS ( CH 9 ) - BURN 10 ASSESSMENT Estimate Burn Size Surface of patient’s palm represents 1% body surface area ACLS ( CH 9 ) - BURN 11 Second-degree Burn ACLS ( CH 9 ) - BURN 12 Third-degree Burn ACLS ( CH 9 ) - BURN 13 MANAGEMENT Airway Assess for injury Establish and maintain patient airway early ACLS ( CH 9 ) - BURN 14 Inhalation Injury Early Management ACLS ( CH 9 ) - BURN 15 MANAGEMENT Breathing Assume CO exposure Inhalation of toxic fumes or carbon particles Direct thermal injury ACLS ( CH 9 ) - BURN 16 MANAGEMENT Breathing Oxygen / ventilate Endotracheal intubation ABGs Carboxyhemoglobin levels ACLS ( CH 9 ) - BURN 17 MANAGEMENT Circulation Monitor vital signs Hourly urinary outputs Adult: 30 – 50 mL / hr Child: 1.0 mL / kg / hr ACLS ( CH 9 ) - BURN 18 MANAGEMENT Circulation – Estimate of Fluid Needs 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 ACLS ( CH 9 ) - BURN 19 MANAGEMENT Develop Treatment plan Estimate burn size / depth Identify associated injuries Weigh patient Baseline blood analyses Chest films Document on flow sheet ACLS ( CH 9 ) - BURN 20 MANAGEMENT Maintain Peripheral Circulation Remove all connstricting devices Assess distal circulation Escharotomy – surgical consultation ACLS ( CH 9 ) - BURN 21 Escharotomy Sites ACLS ( CH 9 ) - BURN 22 Escharotomy ACLS ( CH 9 ) - BURN 23 MANAGEMENT Nasogastric Intubation Nausea, vomiting, distention Burn > 20% BSA Medications Narcotics – Spare use, IV only Antibiotics – Not indicated early ACLS ( CH 9 ) - BURN 24 MANAGEMENT Wound Care Cover with clean linen Do not Break blisters Apply antiseptics Apply cold water ACLS ( CH 9 ) - BURN 25 MANAGEMENT Acid / Alkali Burns Duration, concentration, and amount Flush with copious amount of water for 20 – 30 minutes Brush away dry chemical before irrigation ACLS ( CH 9 ) - BURN 26 Chemical Burns ACLS ( CH 9 ) - BURN 27 Electrical burn result in damage to the fascia and muscle, and may spare the overlying skin Fasciotomy – Electrical Burn ACLS ( CH 9 ) - BURN 28 MANAGEMENT Electrical Burn ABCs Myoglobinuria ↑Fluid: 100 mL urine / hr Mannitol: 25 g IV Metabolic acidosis Maintain adequate perfusion Sodium Bicarbonate ACLS ( CH 9 ) - BURN 29 TRANSFER CRITERIA 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 30 TRANSFER CRITERIA 3rd degree burns > 5% BSA Electrical and chemical burns Inhalation injury Pre-existing illness, associated injuries Children Special situations ACLS ( CH 9 ) - BURN 31 TRANSFER PROCEDURE Coordinate with burn-center physician Transfer with all Documentation / information Laboratory results ACLS ( CH 9 ) - BURN 32 Injury Due To Cold ACLS ( CH 9 ) - BURN 33 COLD INJURY FACTORS Temperature Duration of exposure Enviromental conditions Immobilizzation Moisture Vascular disease Open wounds ACLS ( CH 9 ) - BURN 34 TISSUE-FREEZING INJURY FROSTBITE 1st Degree: Hyperemia, edema 2nd Degree: Vesicles, parttial-thickness skin necrosis 3rd Degree: Full-thickness skin necrosis 4th Degree: Skin, muscle, bone necrosis ACLS ( CH 9 ) - BURN 35 Second-degree Frostbite ACLS ( CH 9 ) - BURN 36 Fourth-degree Frostbite ACLS ( CH 9 ) - BURN 37 MANAGEMENT Do nor delay Remove clothing Warmed blankets Rewarm frozen part ACLS ( CH 9 ) - BURN 38 MANAGEMENT Preserve damaged tissue Prevent infection Elevate and expose injured part Analgesics / tetanus / antibiotics ACLS ( CH 9 ) - BURN 39 HYPOTHERMIA Core temperature < 35 degrees Rapid / slow drop in core temperature Elderly and children at greater risk Low-range thermometer required ACLS ( CH 9 ) - BURN 40 HYPOTHERMIA Clinical Findings Core temperature < 35 degrees Depressed level of consciousness Gray, cyanotic, variable vital signs Absence of cardiorespiratory activity ACLS ( CH 9 ) - BURN 41 MANAGEMENT ABCs, IV access Oxygenate and ventilate Prevent heat loss and rewarm Assess for associated disorders Blood analyses ACLS ( CH 9 ) - BURN 42 MANAGEMEN Passive External Rewarming Active Core Rewarming Warm enviroment Warmed blankets and IV fluids Surgical rewarming techniques Do not delay transfer Not dead until warm and dead ACLS ( CH 9 ) - BURN 43 ACLS ( CH 9 ) - BURN 44 SUMMARY Burn Injury Recognize inhalation injury Establish airway Fluid resuscitation Rremove all clothing ACLS ( CH 9 ) - BURN 45 SUMMARY Burn Injury 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 46 SUMMARY Cold Injury Diagnose type History Clinical finding Measure core temperature Rewarming techniques Monitor and support vital signs ACLS ( CH 9 ) - BURN 47