Burn and Bite/Sting Seok Joo Han, M.D. Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
General Aspect of Burn 1,200,000 burn/year in USA 50,000 (4%) urn/year required hospitalization 5,000 (0.4%)burn died per year-->10% mortaility Populations: Toddler: hot water (scalding burn) Young adults: flame burn Elderly Low social economic group Morbidity and mortality rates associated with burns are decreased. 50% decline in burn-related deaths and hospital admission in the United States over 20 years
Burn Unit Experienced burn surgeons Dedicated nursing personnel Physical and occupational therapists Social workers Dietitians Pharmacist Respiratory therapist Psychiatrists and clinical psychologists Prosthetists
Criteria for refer to burn center 1. Partial thickness burn greater than 10% TBSA 2. Burn involving the face, hands, feet, genitalia, perineum, or major joints 3. Any full-thickness burn 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burns in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect outcome. 8. Any patient with burns and concomitant trauma
Pathophysiology of Burn (I) Thermal injury coagulation necrosis of the epidermis and underlying tissue The depth of burn: the temperature and the duration of exposure Classification of Burn according to the causes Flame Scald Contact Chemical Electrical Coagulation necrosis from the transfer of the heat energy + Direct injury of cell membrane
Pathophysiology of Burn (II) Depth of Burn First degree: injury localized to the epidermis Superficial second degree: injury to the epidermis and superficial dermis Deep second degree: injury through the epidermis and deep into the dermis Third degree: full-thickness injury through the epidermis and dermis into the subcutaneous fat Fourth degree: injury through the skin and subcutaneous fat into underlying muscle or bone Normal Skin: physical barrier against bacterial invasion, important role for control of temperature, water and vitamin D production
Pathophysiology of Burn (III) Depth of Burn First degree: painful, erythematous, and blanch to the touch, sunburn or minor scalding burn, no scarring Superficial second degree: erythematous, painful, blanch to touch, and often blister, healing within 7-14 days with some slight discoloration Deep second degree: pale and mottled, do not blanch to touch, but remain painful to pinprick, healing in 14-35 days with severe scarring Third degree: hard leathery eschar, painless and black, white, or cherry red in color, healed by reepithelialization from the wound edges, skin graft
Pathophysiology of Burn (IV) Irreversible damage critical area
Pathophysiology of Burn (V) Zone of Burn Area Zone of coagulation: the necrotic area of burn where cell have been disrupted, irreversible damage Zone of stasis: the area immediately surrounding the zone of coagulation, moderate degree of insult with decreased tissue perfusion, either survive or go on to coagulation necrosis (possible reversible), associated with vascular damage and vessel leakage, thromboxane A 2 present in high concentration- local inhibitor: improve blood circulation Zone of hyperemia: vasodilatation from the inflammation surrounding the burn wound, clearly viable tissue, healing process, no risk for further necrosis
Pathophysiology of Burn (VI) The Rule of Nine Burn Size 1
For Example, 70 Kg male, Flame burn, Second degree
Solution Arm; 9% Anterior surface of right trunk: 9% Anterior surface of right lower limb; 9% = 27%
Pathophysiology of Burn (VI)
Treatment of Burn Initial first aid Fluid therapy Wound Care Rehabilitation
Initial Treatment Prehospital Removed from the source of injury Always suspect to have inhalation injury 100% Oxygen All ring, watches, jewelry and belt should be removed Room temperature water can be poured on the wound within 15 minutes of injury to decrease the depth of the wound Cold water should be avoided to preclude hypotherima Initial assessment: primary and secondary survey Initial wound care: only protection from the environment with clean dry dressing Intravenous small dose of narcotic agent after full assessment Transport
Fluid Resuscitation Rapid Calculation of Initial Fluid Rate; = (BSA X BWt/8)/ hr 80 Kg man with a 40 % of burn; = (40 X 80)/8 = 400ml/hr Formula Calculation for first 24 hours ½ amount The first 8 hrs
For Example, 70 Kg male, Flame burn, Second degree
Solution = 27% Fluid during transfer; (BSA x BWt/8)/ hrs =(27 x 70/8)/ hrs =236 cc/hr
Solution = 27% Fluid during first 24 hrs; = 4 cc/kg/bsa = 4 x 70 x 27 = 7560 cc/ 24 hrs The first 8hrs; = 7560/2 = 3780/8hrs = 472.5 cc/hr The next 16 hrs = 3780 cc/16 hrs = 236 cc/hr
Escharotomy
Wound care I
Wound care II
Wound care III
Wound care IV Excision and Skin Graft + Broad spectrum antibiotics
Snake Bite Snake: 3500 species in the world poisonous snake ; 10% In Korea, just three snakes have poison 살모사 ( ; agkistrodon blomhoffii brevicaudus) 까치살모사 ( agkistrodon saxatalis) 불독사 (agkistrodon calaginosus) 국내사교상환자 : 년간 409.6명 ( 심재한등 : 한국산독사의생태학적특성및독성, 고상빈도에관한조사연구. 환경생태의학회지 2:58-77, 1998)
살모사, 살무사 ( ) Agkistrodon blomhoffii brevicaudus
까치살모사 Agkistrodon saxatalis, Korean-Magpie-Viperine-Snake
불독사, 쇠살모사, 부독사 Agkistrodon calaginosus
Snake Bite In Korea, just three snakes have poison 살모사 ( ; agkistrodon blomhoffii brevicaudus) 까치살모사 ( agkistrodon saxatalis) 불독사 (agkistrodon calaginosus) 출현시기 : 4월하순 ~ 11월중순. 녹음기 골짜기풀밭, 돌무더기, 경작지 사독 : 효소계물질 : phospholipase A, protease, endonuclease, L- aminoacid oxidase, lecithinase, ATPase, DNPase, ribonuclease, deoxyribonuclease, phosphomonoenterase, cholinesterase, hyaluronidase, glycerophosphatase, 5-nucleotidase 비효소계물질 : crotoxin(neurotoxin), crotamine(cytolysin), proteolytic factor(hematoxin)
Snake Bite Phospholipase A: 세포막파괴, 용혈작용, 췌장염 Protease: 교상부위의조직괴사 Hyaluronidase: 확산효소 (spreading factor) Neurotoxin: Ach 유리억제, N-M junction 차단 호흡마비, 심근마비 Hematoxin: 적혈구세포막에직접작용하여용혈작용, 항응고작용 Cytolysin: 조직세포의파괴및기능억제 ( 뇌간세포에도작용 ), 혈관내피세포파괴, 신세뇨관의상피세포파괴, 백혈구적혈구의파괴
Snake Bite Identification of poisonous snake bite: 독사 : 1-2 개의독아자국, 비독사 : 한두줄의차아자국 국소반응 : 격심한통증및압통, 조직괴사및피하출혈, 수포형성
Snake Bite
Snake Bite
Snake Bite
Snake Bite
Snake Bite
Snake Bite 전신증상 : 발열, 오심, 구토, 호흡곤란, 복통, 시야혼탁, 의식장애, 안검하수, 설사, 현기증, 전신부종, 경부강직, 하혈, 두통, 언어장애 한국산독사의경우에는전신증상이심하지않음 빈혈이나황달은오래지속됨 국소치료 : First aid 독이전신으로퍼지기전에현장에서실시하는응급처치로한시간이내에시행함이좋음 Fixation: 사독의전신화를막기위하여교상부위를고정함 Tourniquet: 임파액의흐름만을막을정도로느슨하게장착 Incision and suction: 교사후 5분내의경우사독의 50% 가제거됨, 30 분후에는효과없음, 1 cm X 5 mm Excision: 교상후 2 시간이내에점상출혈이있는피하조직을광범위하게제거시대부분의독을제거할수있음. Cryotherapy: 조직의괴사만일으키며사독의비활성화의증거가없음
Snake Bite First Aids
Snake Bite First Aids
Snake Bite First Aids (immobilization)
Snake Bite 전신치료 Anitvenin treatment: Important for systemic toxicity But, no cross immunity: polyvalent antivenin (?) Anaphylactic shock and serum sickness due to horse serum of antivenin 전신독성이강하지않는한국산독사에서는꼭필요한지의문 Steroid treatment Traditional treatment, but effective? Report of decreased incidence of serum sickness in antivenin treatment Adequate antibiotic treatment Tetanus toxoid Conservative treatment for renal failure, respiratory failure, DIC, liver failure
Human Bite 구강내세균 : Staphylococcus, Streptococcus, Anaerobic streptococcus, gonococcus, Vincent s bacillus, fusiform bacillus, Spirochetes, Tetanus bacillus, Gas gangrene bacillus, Treponema pallidium 이러한균으로오염되었다고생각하고치료함
Human Bite 충분한세척및변연절제술 광벙위항생제치료 Delayed wound closure: 6 시간내에내원한안면부의경우에는충분한세척과변연절제술후봉합할수있다. 그러나완전히 avulsion된귀나코의조각은다시이어주는것은거의성공하지못한다.