ACLS ( CH 9 ) - BURN1 BURN, COLD INJURY 急診醫學科 李芳年 醫師

ACLS ( CH 9 ) - BURN2 INJURY DUE TO BURN AND COLD

ACLS ( CH 9 ) - BURN3 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 ) - BURN4 BURN / COLD INJURIES Management Principles Timely application Maintain: Airway Hemodynamic stability Fluid / electrolyte balance Normal body temperature Prevent complications

ACLS ( CH 9 ) - BURN5 Injury Due To Burn

ACLS ( CH 9 ) - BURN6 LIFE-SAVING MEASURES Establish airway Identify signs of distress Initiate supportive measures Obtain history

ACLS ( CH 9 ) - BURN7 CLINICAL INDICATIONS Carbonaceous sputum Facial burns Hair singeing Carbon deposites Inflamed oropharynx History Inhalation Injury

ACLS ( CH 9 ) - BURN8 LIFE-SAVING MEASURES Remove all: Injurious material Clothing, jewelry Prevent hypothermia Two, large-caliber Ivs Ringer ’ s lactate

ACLS ( CH 9 ) - BURN9 ASSESSMENT History Mechanism of ijury Associated illness Allergies Tetanus status

ACLS ( CH 9 ) - BURN10 Rule of Nines

ACLS ( CH 9 ) - BURN11 ASSESSMENT Estimate Burn Size Surface of patient ’ s palm represents 1% body surface area

ACLS ( CH 9 ) - BURN12 Second-degree Burn

ACLS ( CH 9 ) - BURN13 Third-degree Burn

ACLS ( CH 9 ) - BURN14 MANAGEMENT Airway Assess for injury Establish and maintain patient airway early

ACLS ( CH 9 ) - BURN15 Inhalation Injury Early Management

ACLS ( CH 9 ) - BURN16 MANAGEMENT Breathing Assume CO exposure Inhalation of toxic fumes or carbon particles Direct thermal injury

ACLS ( CH 9 ) - BURN17 MANAGEMENT Breathing Oxygen / ventilate Endotracheal intubation ABGs Carboxyhemoglobin levels

ACLS ( CH 9 ) - BURN18 MANAGEMENT Circulation Monitor vital signs Hourly urinary outputs Adult: 30 – 50 mL / hr Child: 1.0 mL / kg / hr

ACLS ( CH 9 ) - BURN19 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 ) - BURN20 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 ) - BURN21 MANAGEMENT Maintain Peripheral Circulation Remove all connstricting devices Assess distal circulation Escharotomy – surgical consultation

ACLS ( CH 9 ) - BURN22 Escharotomy Sites

ACLS ( CH 9 ) - BURN23 Escharotomy

ACLS ( CH 9 ) - BURN24 MANAGEMENT Nasogastric Intubation Nausea, vomiting, distention Burn > 20% BSA Medications Narcotics – Spare use, IV only Antibiotics – Not indicated early

ACLS ( CH 9 ) - BURN25 MANAGEMENT Wound Care Cover with clean linen Do not Break blisters Apply antiseptics Apply cold water

ACLS ( CH 9 ) - BURN26 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 ) - BURN27 Chemical Burns

ACLS ( CH 9 ) - BURN28 Fasciotomy – Electrical Burn Electrical burn result in damage to the fascia and muscle, and may spare the overlying skin

ACLS ( CH 9 ) - BURN29 MANAGEMENT Electrical Burn ABCs Myoglobinuria ↑ Fluid: 100 mL urine / hr Mannitol: 25 g IV Metabolic acidosis Maintain adequate perfusion Sodium Bicarbonate

ACLS ( CH 9 ) - BURN30 TRANSFER CRITERIA 2nd, 3rd degree burns > 10% BSA in age 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 ) - BURN31 TRANSFER CRITERIA 3rd degree burns > 5% BSA Electrical and chemical burns Inhalation injury Pre-existing illness, associated injuries Children Special situations

ACLS ( CH 9 ) - BURN32 TRANSFER PROCEDURE Coordinate with burn-center physician Transfer with all Documentation / information Laboratory results

ACLS ( CH 9 ) - BURN33 Injury Due To Cold

ACLS ( CH 9 ) - BURN34 COLD INJURY FACTORS Temperature Duration of exposure Enviromental conditions Immobilizzation Moisture Vascular disease Open wounds

ACLS ( CH 9 ) - BURN35 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 ) - BURN36 Second-degree Frostbite

ACLS ( CH 9 ) - BURN37 Fourth-degree Frostbite

ACLS ( CH 9 ) - BURN38 MANAGEMENT Do nor delay Remove clothing Warmed blankets Rewarm frozen part

ACLS ( CH 9 ) - BURN39 MANAGEMENT Preserve damaged tissue Prevent infection Elevate and expose injured part Analgesics / tetanus / antibiotics

ACLS ( CH 9 ) - BURN40 HYPOTHERMIA Core temperature < 35 degrees Rapid / slow drop in core temperature Elderly and children at greater risk Low-range thermometer required

ACLS ( CH 9 ) - BURN41 HYPOTHERMIA Clinical Findings Core temperature < 35 degrees Depressed level of consciousness Gray, cyanotic, variable vital signs Absence of cardiorespiratory activity

ACLS ( CH 9 ) - BURN42 MANAGEMENT ABCs, IV access Oxygenate and ventilate Prevent heat loss and rewarm Assess for associated disorders Blood analyses

ACLS ( CH 9 ) - BURN43 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 ) - BURN44 ？

ACLS ( CH 9 ) - BURN45 SUMMARY Burn Injury Recognize inhalation injury Establish airway Fluid resuscitation Rremove all clothing

ACLS ( CH 9 ) - BURN46 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 ) - BURN47 SUMMARY Cold Injury Diagnose type History Clinical finding Measure core temperature Rewarming techniques Monitor and support vital signs