1、烧 伤 (Burns),南京医科大学外科总论教研室 江苏省人民医院整形烧伤外科姚刚,烧伤定义：,由热力、电流、放射线及化学物质等所致的组织损伤。,一、伤情判断,面积估算 深度判断 呼吸道损伤 合并症,烧伤面积估算,中国九分法 儿童：头颈部 9+（12-年龄）双下肢 46-（12-年龄) 手掌法：,烧伤面积估算,烧伤深度估计：,三度四分法,烧伤严重性分度,轻度烧伤 9%中度烧伤 1029% 或 10%重度烧伤 总面积3049% 或 1019%或伴休克 呼吸道烧伤 、较重的复 合伤特重烧伤 总面积50%以上、或 20%以上或已有严重并发症,吸入性损伤,热力 化学物质 腐蚀 中毒 诊断1.现场密闭2
2、.呼吸道刺激 炭末痰 呼吸困难 哮鸣音3.面颈口鼻烧伤,声音嘶哑,烧伤严重程度的影响因素：,热源的物理、化学特性 作用的方式 持续的时间 损害面积的大小 组织损害的深度 受伤时外界环境情况 病人抵抗力,二、烧伤病例生理、临床分期,体液渗出期（休克期）：3648h(严重72h) 612h 烧伤 释放多种血管活性物质 毛细血管通透性增加 体液渗出(水泡、组织肿胀)(水钠白蛋白内脏也渗) Shock 急性感染期(早-6-8h,好-3-5d 消退.不好-溶痂期,持续3-4w,形成芽肉-感染率下降) 皮肤粘膜屏障受损 机体免疫功能受抑 机体抵抗力降低: 易感性增加 创面修复期 浅 -自行愈合 深 -皮岛
3、融合或植皮 -需植皮,三、治疗原则,防治休克、维持通气 创面处理 防治瘢痕 防治感染 保持内脏功能,四、现场急救、转送与初期处理,现场救护,迅速脱离现场 保持呼吸道通畅，抢救生命 简单而有效地处理严重复合伤 保护创面和保温 稳定病人情绪，镇静和止痛 大面积烧伤稳定后才能转送,初期处理 （急诊）,生命体征监测 创面评估 采集受伤史 静脉输液 其他救治措施 轻度 消毒清创 水疱处理中重度 气管切开 导尿 焦痂减压 TAT,五、烧伤休克,影响因素：面积、深度、受救时间,临床表现,心率 血压 呼吸尿量 （20ml/h） 口渴 烦躁 畏寒 血液浓缩,治疗,补液方案 量: 第一个24小时 面积x体重 x1
4、.5(2.0)+2000第二个24小时 1/2面积x体重 x1.5(2.0)+2000质: 胶体 : 晶体 = 1(1) : 2(1) + 水 方法: 先快后慢 晶-胶-水 交替输入,治疗,输液调整 尿量（3050ml/h) 儿童（ 1ml/kgh） 精神状态 口渴 脉搏 心率 血压 呼吸,六、烧伤全身性感染,感染是烧伤主要死亡原因 肠源性感染、创面感染,六、烧伤全身性感染,诊断 性格 体温 心率 呼吸 创面 白细胞计数 血培养,六、烧伤全身性感染,防治 1 纠正休克 维护防御功能 保护粘膜屏 障2 创面处理3 抗生素4 营养 水电平衡,七、创面处理,创面处理 包扎疗法 暴露疗法 半暴露疗法,
5、七、创面处理,创面处理 一期切痂术 分期切痂术 自然脱痂,七、创面处理,大面积烧伤植皮术（异体皮 异种皮） 大张异体皮开洞嵌植自体皮 自体微粒植皮 网状皮片移植术,第二节 化学烧伤 Chemical burn,特点 损伤 + 侵入 / 吸收取决于:性质 剂量 浓度 时间 一般处理原则:清水冲洗 手术解毒剂/拮抗剂,第二节 化学烧伤,酸烧伤 特点 蛋白凝固无水疱 损伤浅石炭酸-吸收 肾损伤 70%酒精清洗 氢氟酸-穿透性强 5%10%葡萄糖酸钙封闭,第二节 化学烧伤,碱烧伤 特点 组织脱水 皂化脂肪产热 碱离子穿透 损伤大而深 愈合慢 清水大量冲洗 早期切痂植皮,第二节 化学烧伤,磷烧伤 特点
6、自燃 P2O3和P2O5脱水夺氧 胞浆毒物 脏器损害 用水隔离 1%硫酸酮涂布-磷化酮 3%5%碳酸氢钠湿敷包扎 忌油质敷料 创面手术植皮 特别注意全身中毒,第三节 电烧伤,损伤机制影响因素 接触时间 电流强度 电流性质 电流路径 组织电阻 临床表现 全身性损害局部损害 入口/出口 血管损伤 跳跃式伤口,第三节 电烧伤,治疗 现场急救 断电 心肺复苏 液体复苏 碱化尿液 利尿 清创/减张 防止血管破裂 抗生素 TAT,冷冻伤,非冻结性冷伤 冻结性冷伤,植皮术,自体皮 同种异体皮 异种皮 人工皮,植皮术,游离皮片移植 刃厚皮片 0.150.25mm中厚皮片 0.30.6mm全厚皮片 皮瓣移植 带
7、蒂皮瓣游离皮,Extensive burns or burns causing more than minor discomfort should be treated by a healthcare professional. For superficial burns caused by temperature (picking up a hot object, for example), natural medicine may be helpful after the burn is cleaned with soap and cold water and gently dried.
8、Burns occur when the carpet yarn is exposed to an errant heat source and the fibers are melted or scorched. Burns should be addressed immediately. First, snip off the damaged fibers, then use a soap-less cleaner and sponge with water. If the damage is extensive, see a professional about repairs,What
9、 are the symptoms of shock? The following are the most common symptoms of shock. However, each child may experience symptoms differently. Symptoms of shock may include: cold sweat weakness irregular breathing chills pale or blue-colored lips pale or blue-colored fingernails a fast, but weak pulse na
10、usea,|Medical Treatment| Treatment depends on the severity of the burns or the nature of other injuries found. Burns are treated according to severity. Minor burns may be treated with topical antibiotic ointment and dressings. More severe burns may require surgery to clean the wounds or even skin gr
11、afting. Severe burns on the arms, legs, or hands may require surgery to remove damaged muscle or even amputation. Other injuries may require treatment. Eye injuries may require examination and treatment by an ophthalmologist, an eye specialist. Broken bones require splinting, casting, or surgery to
12、stabilize the bones. Internal injuries may require observation or surgery.,Thermal Burns SymptomsAll thermal burns (from fire or flame) cause an injury to the different layers of the skin. The type of burn and the severity of the burn you have depends on the number of layers of skin affected. Tradit
13、ionally burns were described using the word degrees (first, second, and third). Now most doctors describe burns as to their thickness (superficial, partial, and full). The skin is made up of 3 important layers: the epidermis (or the outer layer), the dermis, and finally the subcutaneous tissues. Eac
14、h corresponds roughly to the types of burns,Superficial burn or first degree: This burn involves only the epidermis, or that outermost layer of the skin. Most people are familiar with this burn in the form of sunburn. Symptoms/signs - Painful, red, area turns white when touched, no blisters, moist P
15、artial thickness burn or second degree: This burn involves the epidermis and some portion of the dermis, that second layer of the skin. This type of burn may be broken down into superficial or deep, depending on how much of the dermis (the second layer of skin) is involved. Superficial symptoms/sign
16、s - Painful, red, area turns white to touch, mottling, blisters, moist, hairs still present Deep symptoms/signs - May or may not be painful (so deep that nerve endings may be destroyed), may be moist or dry (so deep that sweat glands destroyed), may or may not turn white when area is touched, hairs
17、usually gone,Full thickness burn or third degree: This is the most severe burn. The burn involves all of the epidermis and dermisthe first 2 layers of the skin. Nerve endings, tiny blood vessels, hair follicles, and tiny sweat glands are all destroyed. If very severe, the burn may involve bone and muscle. Symptoms/signs - Painless, no sensation to touch, pearly white or charred, dry, may appear leathery,
