1、Julie 王鳳怡 Occupational Terapy Department of Rehabilitation Medcine Centre West China Hospital, Sichuan University,2016Burn Injury,目錄CONTENT,,Structure of skinTypes of burnIncidence and prevalence,Introduction,01,

2、,Extent and Depth,Classification of Burn,02,,Hypertrophic scar & KeloidContractureManagement,Complications,04,,Medical Management,03,Wound care, Skin graft, Operations,Introduction,PART 01,Structure of skinTypes o

3、f burnIncidence and prevalence,Introduction,Structure of skin,皮脂腺,Introduction,Structure of skin表皮 皮膚最外面的一層組織，其厚度因身體部位而不同，表皮在掌跖處最厚，在眼瞼最薄。它擔(dān)負(fù)著細(xì)胞自我更新的重要功能，也就是細(xì)胞的新陳代謝。表皮從外向內(nèi)，依次可以分作4層。 l 角質(zhì)層 位于表皮的最外部，由扁平的角質(zhì)細(xì)胞組成，如魚鱗片相互重

4、疊在一起，具有防止水分散失的功能。 l 顆粒層 由3-5層扁平細(xì)胞組成，細(xì)胞內(nèi)充滿粗大、不規(guī)則的透明角質(zhì)顆粒，具有折射光線的作用，能阻擋陽光中的紫外線，異常時會呈厚繭狀。 l 有棘層 表皮層中最厚的一層，由8-12層多角形細(xì)胞所構(gòu)成，細(xì)胞之間有淋巴液流通，可供給表皮營養(yǎng)。 l 基底層 位于表皮的最深處，與真皮緊密銜接，連接的截面呈波浪起伏狀。基底細(xì)胞為稱方形或者低柱形，具有細(xì)胞分裂能力。除了基底細(xì)胞之外，基底層還存在著黑色素

5、細(xì)胞。大約每10個基底細(xì)胞中就約有一個黑色素細(xì)胞，呈樹枝狀突起。黑色素細(xì)胞形成黑色素后，通過樹枝狀突起將黑色素顆粒輸送到基底細(xì)胞或者毛發(fā)。,Introduction,Structure of skin真皮表位于表皮的下面，是一層致密和具有彈性的組織。它可以為表皮和皮膚附屬器官提供養(yǎng)分，對外界機(jī)械沖擊有緩沖作用。真皮主要由蛋白纖維結(jié)蒂組織組成，包括膠原蛋白和彈性纖維，使皮膚有一定的抗拉性，顯得柔韌和富有彈性。真皮內(nèi)還包括皮脂腺、毛囊組

6、織、神經(jīng)以及供應(yīng)表皮層養(yǎng)分的毛細(xì)血管。 l 皮脂腺 皮脂腺開口于毛囊中，主要分泌油性物質(zhì)，即皮脂。在部分的皮脂腺分布在頭、面、胸骨附近和肩胛間的皮膚。它的活動隨著年齡而異，在青春期最為旺盛。 l 汗腺 汗腺分大汗腺和小汗腺。大汗腺主要分布于身體多毛部分，腺體多在皮下脂肪中，分泌的物質(zhì)為粘稠狀乳濁液，含蛋白質(zhì)、脂質(zhì)、碳水化合物及鹽類，經(jīng)細(xì)菌分解后生成揮發(fā)性的低級脂肪酸與其它有臭味的物質(zhì)，從而產(chǎn)生體味；小汗腺分布于全身，直接開口在皮

7、膚表面，腳底、手掌、額和腋是小汗腺最密集的部位，分泌的汗水以水為主，沒有異味，有起到調(diào)節(jié)體溫的作用。 l 毛囊組織 包括毛發(fā)、毛孔和毛囊。毛發(fā)由一種角蛋白的蛋白質(zhì)組成，是皮膚的附屬物，它在管狀的毛囊內(nèi)發(fā)育。毛發(fā)遍及身體的絕大部分，起保護(hù)身體皮膚的作用；毛也是皮膚表面的開口，與皮脂腺和毛囊相連，是毛發(fā)生長及油脂輸送的管道，毛孔的大小與相連的皮脂腺大小成正比；毛囊是毛孔的內(nèi)部組織，由圍繞毛根的表皮細(xì)胞組成。,Types of burn

8、? Destruction of the skin caused by – thermal changes (hot water & steam → scald燙傷, flame, hot fluid (oil, tar), hot metal, extreme cold) – corrosive liquid腐蝕性液體: alkalis/ acid – electricity – radiati

9、on ? One of the most painful form of trauma,Introduction,Introduction,Incidence & prevalenceBurn Incidence and Treatment in the US: 2007 Fact SheetSurvival Rate: 94.4%Severity of Burn Injuries: Over 1/3 o

10、f admissions exceeded 10% TBSA (total body surface area), and 10% exceeded 30% TBSA.Burn Cause:46% fire/flame, 32% scald燙傷, 8% hot object contact, 4% electrical, 3% chemical, 6% others.Place of Occurrence:43% home, 17%

11、 street/highway, 8% occupational, 32% otherAmerican Burn Association National Burn Repository (2005 report),as reported in American Burn Association Fact Sheet, 2007 http://www.ameriburn.org,Classification of Burn,PART

12、 02,Extent and Depth,Classification of burn: degree & extent,Severity of burn: degree & extentDegree of burns: 2 system in terms of depth of skin destructionAssessment by clinical observation (66%) accur

13、acy) or using Laser Doppler (probes placed on a burn area to monitor micro-vascular blood flowing the dermis) 2. Extent of burns injuries:2 systems in terms of width of skin destruction: rules of nine & Lund-Br

14、owder Chart- Causes of injuries & types of burning agentsE.g. hot oil, tar, or chemical agents& electricity burn=> third degree burn,Classification of burn: degree & extent,First degreeE.g. sunburnDam

15、age only the top epidermal layer of skinErythema紅斑 (superficial redness of skin), if press→white (blanches)No blisters, painful, no chance of infectionSelf-heal in 3 to 6 days,Classification of burn: degree & exte

16、nt,Second degree (superficial)=superficial partial thicknessentire epidermis involvedHallmark: When pressure is applied to the reddened area, the area will blanch 發(fā)白but demonstrate a brisk 快速的 or rapid capillary refi

17、ll upon release of the pressure. May have blistering, red & moist under blisterChance of infectionpainfulheal within 3 weeksonly a change in skin color and pigmentation色素沉積 when healed,Classification of burn: de

18、gree & extent,Management of burns (small area/superficial burns)Immediate comfort, e.g. codeine, aspirin, morphinePrevent infection – cleansing – dressing – systemic antibiotics – topical

19、antibiotics for open wound, e.g. silver sulfadiazine cream; and antiseptic: e.g. silver nitrate solution, – tetanus prophylaxis – partial-thickness burns will heal by re-epithelialization 上皮再生from

20、dermal skin within 1 to 2 weeks,Classification of burn: degree & extent,Second degree (deep)=deep partial thicknessentire epidermis and large portion of dermis involved (hair follicles, sweat glands & sebaceou

21、s glands 皮脂腺spared)capillary refill may be absent or may be sluggish緩慢的 when pressure is releaseddry, ivory or pearly whiteproduce significant hypertrophic scar usually if not managed by skin graftinglonger than 3 we

22、eks to heal,Classification of burn: degree & extent,Third degree = full thicknessTotal destruction of skin (+ deeper tissues), e.g. subcutaneous fat, muscle etc) tan/fawn in color 棕褐色hard & dry inelasticthr

23、ombosed 形成血栓的vessels visible (blood clotted & aggregate on vessel wall → vascular obstruction ischaemia → necrosis)No painfulunable to heal spontaneously as no epithelial bed leftskin graftingsevere hypertrophy

24、scarmore complications,Classification of burn: degree & extent,Extent of burn: rules of nine,Classification of burn: degree & extent,Classification of burn: degree & extent,（2）輕度燒傷1）10歲到50歲的人群：淺二度以上燒傷占體表總面積

25、小于15%。2）年齡小于10歲大于50歲的人群：淺二度以上燒傷占體表總面積小于10%。3）三度或三度以上燒傷占體表總面積小于2%。（1）中度燒傷1）10歲到50歲的人群：淺二度以上燒傷占體表總面積在15%到25%之間。2）年齡小于10歲大于50歲的人群：淺二度以上燒傷占體表總面積在10%到20%之間。3）三度或三度以上燒傷占體表總面積在2%到10%之間。,Classification of burn: degree &a

26、mp; extent,（3）重度燒傷1）10歲到50歲的人群：淺二度以上燒傷占體表總面積大于25%。2）年齡小于10歲大于50歲的人群：淺二度以上燒傷占體表總面積大于20%。3）三度或三度以上燒傷占體表總面積大于10%。4）任何涉及到手部、面部、腳部或會陰部位的燒傷。5）燒傷覆蓋主要的關(guān)節(jié)部位。6）圍繞四肢任意部位一圈的燒傷。7）任何傷到呼吸道的燒傷。8）電燒傷。9）燒傷伴有骨折或其他外傷疊加的復(fù)合傷。10）嬰幼兒燒

27、傷。11）容易引起并發(fā)癥的高危人群發(fā)生燒傷。12）以上類型的燒傷需要將病人盡快送到專業(yè)的燒傷科。,Classification of burn: degree & extent,Classification of burn: degree & extent,Classification of burn: degree & extent,Medical Management,PART 02,Wound care

28、 Skin graftOperations,Medical Management,Acute Management of severe burns: ABCA = airwayB = breathingC = circulation,Acute Management of severe burns: ABC Life saving firstAdequate airway supply (inhalation

29、injury) – Inhalation injury: Damage is initiated by toxins and particulate debris 顆粒殘渣, which induce rapid local vasodilation and necrosis of the surface layer of the upper airway, which then separates from the tra

30、cheobronchial 氣管支氣管wall. Breathing difficulty – High dose of O2& secure airway passage ? Endotracheal氣管內(nèi) tube: a tube inserted into trachea & ? Tracheostomy氣管切開: a stoma (opening) into tra

31、chea especially for burn in face & neck ? Burns to chest may need escharotomy焦痂切開術(shù).Circulation: Intravenous fluid replacement – >10% surface area ? hypovolemic shock低血容量性休克: a severe reduction in

32、 circulating blood volume due to loss of blood into peripheral tissues by vasodilation → fluid loss from burnt body surface → hypoxemia低氧血癥 + fluid & electrolytic imbalance, renal failure → hypotensive state → shock

33、 ? shock: blood flow to peripheral tissues is inadequate to sustain life,Medical Management,Sub-acute Management of severe burns Saving the limbSurgery: Escharectomy 焦痂切除術(shù)Pain relief: codeine

34、, morphine 3. Wound Care & infection controlSystemic antibiotic: prevent sepsis, e.g. penicillin青霉素(some hospital would not provide prophylactic 預(yù)防性antibiotic as it may lead to infection with multiply-resistant

35、bacteria)Debridement清創(chuàng): removes necrotic tissue and reduces bacterial colonization, end point of debridement → healthy, bleeding, viable wound bed, granulation 肉芽notedBurn wound care: -- open/close method,Medica

36、l Management,Sub-acute Management of severe burns Observe septicemia5. Operation:Early excision: Escharectomy 焦痂切除術(shù)& escharotomy 焦痂切開術(shù)Grafting - Donor site: thigh, arm & head for skin

37、regeneration, full recovery of the area (usually 14 to 17 days); - When the skin is unable to heal after 17 to 21 days of local therapy → skin grafting 6. Prevent contracture by positioning & splinting,M

38、edical Management,1. Operation procedures Surgical excision? Escharotomy – Surgical incision through the eschar to relieve constriction 壓縮? Escharectomy – Removal of eschar to prepare for grafting? Eschar=&

39、gt; burned tissue,Medical Management,2. Local wound care: close methodDressings – occlusive – absorption – bulkyBiological dressings & skin substitutes替代物 – closing a wound / contamination

40、污染物 / reducing pain and fluid loss. Biologic products(e.g.human amnion羊膜) may deliver growth factors – biosynthetic生物合成wound dressing sheet (Biobrane) Topical antibiotics: most common: Silver sulfadiazine磺胺嘧啶銀(S

41、ilvadene),Prevent infection, promote removal of eschar +comfort,Prepare skin for grafting,Restore essential function of skin,Medical Management,Burn dressing: close methodDeeper burns typically are treated with silver s

42、ulfadiazine to help prevent wound dehydration脫水 and provide antimicrobial抗菌 protection,,Medical Management,3. Skin graftsWhen epidermal bed is so destroyed that spontaneous epithelial tissue re-growth is difficult or i

43、mpossible & where raw areas are more than 2.5 cm wide Skin graft: – Split skin graft – Full thickness / whole skin graft – Skin Flaps,Medical Management,Split skin grafts & whole skin/full thi

44、ckness skin graft,Medical Management,Types of grafts,Medical Management,Complications,PART 03,Hypertrophic scar & KeloidContractureManagement,Complication of burns,Complication of burns - Scar,Formation of hypertro

45、phic scarScar formation is a natural process in wound healing (Hunter, p.1269). But problems result when wound healing has gone beyond → Hypertrophic scar, keloid → contracture (by the contractile nature of the hypertr

46、ophic scar),Complication of burns - Scar,Major factors affecting formation of hypertrophic scar,,Complication of burns - Scar,Normal epidermis & hypertrophic scar,Complication of burns - Scar,Characteristics of hyper

47、trophic scars (early to mature phase) if untreated,Complication of burns - Scar,Complication of burns - Scar,Complication of burns - Scar,,Complications of hypertrophic scar Contracture,Complication of burns - Scar,Comp