بنام خداوند جان آفرین

دکتر بهشتی متخصص بیماریهای پوست و مو عضو هیئت علمی دانشگاه

سوختگی پوست تعریف : سوختگی عبارتست از آسیب پوستی ناشی از یک انرژی پاتولو ژیک که این انرژی می تواند ناشی از حرارت یا الکتریسیته یا مواد شیمیایی و یا اشعه آفتاب ورادیاسیون باشد.

سوختگی پوست پوست اولین عضو در اغلب سوختگیهاست. وسعت زیاد پوست بدن و سوختگی آن میتواند آسیب های جدی برای بیمار ایجاد کند. مساحت پوست : 0.25 متر مربع در بچه ها و 1.8 متر مربع در بزرگسالان.

وظائف پوست 1) اولین سد دفاعی بدن 2) کنترل دمای بدن 3) عضو حسی 4) تولید ویتامین 5) زیبائی ظاهری ونقش آن در مسائل جنسی 6) نقش پوست در ایمنی بدن ِ

شیوع با توجه به متفاوت بودن شدت سوختگی و عدم مراجعه بسیاری از موارد سوختگی های سطحی به مراکز بیمارستانی آمار دقیق در دست نیست. در امریکا در سال 2 میلیون نفر مبتلا به سوختگی به مراکز درمانی مراجعه می کنند. در انگلستان در سال مورد به علت سوختگی شدیدتر در بیمارستان بستری می شوند.

شیوع در امریکا مورد مرگ در سال به علت سوختگی گزارش میشود. علت مرگ اغلب ناشی از آسیب های ریوی ناشی از استنشاق دوده میباشد. 50% علت مرگ ناشی از سوختگی آتش سوزی منازل گزارش میشود.

تعیین شدت سوختگی 1) وسعت سوختگی 2) عمق سوختگی 3) سن بیمار 4) وضعیت جسمانی قبلی بیمار 5) محل سوختگی 6) شدت جراحات و صدمات همراه با سوختگی در بیمار

ارزیابی بیمار Objective: 1) تعیین علت سوختگی 2( زمان سوختگی 3) مدت زمان سوختگی 4) نوع ماده ای که منجر به سوختگی شده است

عمق سوختگی تعیین عمق سوختگی در مراحل اولیه سوختگی مشکل است. گاه تا مرحله ترمیم سوختگی نمیتوان عمق سوختگی را مشخص کرد دقیق ترین راه تشخیص بیوپسی پوستی است Wound excision until fine punctate bleeding occurs

Depth of burn Partial thickness burn = involves epidermis Deep partial thickness = involves dermis Full thickness = involves all of skin

Partial thickness superficial سوختگی محدود به اپیدرم است معمولا بهبودی سریع و خودبخودی اتفاق میافتد

Partial thickness burns Sunburn is a very superficial burn. Expect blistering and peeling in a few days. Maintain hydration orally. Heals in 3-6 days- generally no scaring Topical creams provide relief. No need for antibiotics

Partial thickness deep سوختگی در تمام اپیدرم و قسمت هایی از درم است بهبودی خودبخودی امکان پذیر است در برخی موارد میتواند منجر به تشکیل اسکار شود

Mixed partial and full thickness  Central yellow area might be full thickness.  Outer edges are probably partial thickness.  Initial management is the same.  Later will need skin grafts for the full thickness areas.

Deeper partial thickness Blisters are typical of partial thickness burns. Don’t be in a hurry to break the blisters. Heals in days Blisters provide biologic dressing and comfort. Once blisters break, red raw surface will be very painful.

Full thickness شامل تخریب اپیدرم و درم و هیپودرم و گاها عضلات و استخوان هاست ترمیم بافت های از دست رفته مشکل است برای ترمیم پوست نیاز به گرافت پوست می باشد

Full thickness burn Yellow, “leathery” appearance; or charred Often have no sensation (nerve endings destroyed) Outer edges might be partial thickness. Initial management same as partial thickness. Later will need skin grafts.

Subjective: 1) مشکلات وبیماری های قبلی بیمار 2) سایز و عمق سوختگی 3) سن بیمار 4) ناحیه ای از بدن که دچار سوختگی شده است 5) علت سوختگی

Estimate the size of the burn The patient’s own palm is about 1% of his body surface area. “Rule of Nines ”

Rule of 9s ABA

Burn size in small children The head accounts for about 18% (instead of 9%). The legs account for about 13% (instead of 18%).

Minor burn  15 percent TBSA or less in adults  10 percent TBSA or less in children and older adults  2 percent TBSA or less full-thickness burn in children or adults without cosmetic or functional risk to eyes, ear, face, hands, feet, or perineum

The two commonly used methods of assessing TBSA: in adults are the Lund-Browder chart and "Rule of Nines,“  whereas in children, the Lund-Browder chart is the recommended method because it takes into account the relative percentage of body surface area affected by growth.

 15 to 25 percent TBSA in adults with less than 10 percent full-thickness burn  10 to 20 percent TBSA partial-thickness burn in children under 10 and adults over 40 years of age with less than 10 percent full-thickness burn  10 percent TBSA or less full-thickness burn in children or adults without cosmetic or functional risk to eyes, ears, face, hands, feet, or perineum Moderate burn

Major burn  25 percent TBSA or greater  20 percent TBSA or greater in children under 10 and adults over 40 years of age  10 percent TBSA or greater full-thickness burn  All burns involving eyes, ears, face, hands, feet, or perineum that are likely to result in cosmetic or functional impairment  All high-voltage electrical burns  All burn injury complicated by major trauma or inhalation injury  All poor-risk patients with burn injury

تشخیص های افتراقی

زرد زخم

کاپینگ گزش حشرات

نوروپاتی دیابتی و

درمان

اقدامات اولیه 1) باز کردن راه هوائی 2) کنترل تنفس بیمار 3) بررسی نبض وفشار خون و جریان خون بیمار 4) تسکین درد

Care of small burns  Clean entire limb with soap and water (also under nails).  Apply antibiotic cream (no PO or IV antibiotic).  Dress limb in position of function, and elevate it.  No hurry to remove blisters unless infection occurs.  Give pain meds as needed (PO, IM, or IV)   Rinse daily in clean water; in shower is very practical.  Gently wipe off with clean gauze.

Blisters break on their own Upper arm burn day 1 day 2 Burn “looks worse” the next day because of blisters breaking and oozing

Blisters  In the pre-hospital setting, there is no hurry to remove blisters.  Leaving the blister intact initially is less painful and requires fewer dressing changes.  The blister will either break on its own, or the fluid will be resorbed.

American Burn Assoc says send these to a burn center Partial thickness burns >10% BSA Burns involving the face, hands, feet, genitalia, perineum, or major joints full thickness/3 degree burn Electrical, Chemical, and Inhalation burns In combat, all but the most superficial burn should be evacuated

Airway?  “Flash” burns may refer to those that suddenly flare up, then die down quickly.  Patients may have burnt facial hair and carbon on lips.  Patients with this kind of facial burn will probably NOT need an artificial airway.  Give humidified oxygen while under close observation.

Causes of death in burn patients Circulation: “failure of resuscitation ”  Cardiovascular collapse, or acute MI  Acute renal failure  Other end organ failure  Missed non-thermal injury

Escharotomy - indications  Circulation to distal limb is in danger due to swelling. Progressive loss of sensation / motion in hand / foot. Progressive loss of pulses in the distal extremity by palpation or doppler.  In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.

Neuro status  The burn itself does not alter the level of consciousness.  If patient is not alert, think of other causes:  hypovolemia  carbon monoxide  head injury  Don’t allow swollen eyelids to prevent you from examining the pupils.  Test sensation and motion in burned extremities.

Circulation Record vital signs.  Check distal pulses and nail beds. Keep him warm! Loss of skin impairs ability to retain heat and fluids. Being cold will cause vasoconstriction.  Monitor urine output (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hr  Monitor at least HCT and urine specific gravity.  When available, monitor electrolytes.

Edema Formation  Amount of edema can be immense (even without facial burns)  Depression of mental status can worsen problem  Edema peaks at 12 to 24 hours  Pediatric patients even more concerning

Upper arm burn  Blisters show probable partial thickness burn.  Area without blister might be deeper partial thickness. 121

Arm burn 4 days

Arm burn 7 days – note the exudate

After debridement

Debride blister using simple instruments

Causes of death in burn patients  Airway Facial edema, and/or airway edema  Breathing Toxic inhalation (CO, +/- CN) Respiratory failure due to smoke injury or ARDS

Circumferential burn Burn requiring escharotomy Electrical burn Chemical burn

Face Mouth Neck Hands and feet Genitalia

 Shower daily, rinse off old cream, apply new cream.  Insert Foley catheter if unable to urinate due to swelling.

Circumferential burn  Limb is burned all the way around.  Soft tissues under the skin always swell with burns (due to capillary leak of fluids in first day or so).  There is a loss of skin expansion due to the loss of turgor/elasticity in burned tissue  Pressure inside limb gradually increases.  Eventually, pressure inside limb exceeds arterial pressure.  This requires escharotomy to relieve the pressure.

Hands and feet Fingers might develop contractures if active measures are not taken to prevent them.

Hands and feet  Allow use of the hands in dressings by day.  Splint in functional position by night.  Keep elevated to reduce swelling.

Face Be VERY concerned for the airway!! Eyelids, lips and ears often swell alarmingly. In fact, they look even worse the next day. But they will start to improve daily after that. Cleanse eyes with warm water or saline. Apply antibiotic ointment or liquid tears until lids are no longer swollen shut. Bacitracin cream/ointment will serve

سوختگی ناشی از مواد اسیدی

Phosphorus  Particles of phosphorus must be removed from under the skin.  Pick them off with forceps.  Must apply wet dressing to prevent re-igniting.

Electrical burn  Outer skin might not appear too bad.  But heat was conducted along the bone.  Causes the most damage.  Burns from inside out.  Usually requires fasciotomy

QUESTIONS? SUMMARY Describe how to estimate the body surface area of burn. Describe how to calculate initial fluid requirements in a patient with a large burn. Describe intial management of a patient with a large burn. Discuss indications and complications of escharotomy.