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