燒燙傷治療燒燙傷治療燒燙傷治療燒燙傷治療

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報告者: 李秋月2015.08.12

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INTRODUCTIONINTRODUCTION

IntroductionIntroduction�根據國防醫學院公共衛生系暨研究所所發表燒燙傷流行病學統計

�燒燙傷不論是發生、住院及死亡均以男性高於女性

住院病患年齡以五歲以內的小孩居多

教育程度則以高中（職）居多

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� 大部份的燒燙傷是意外所致

發生的季節並無太大差異，但以冬天月份稍高

一天內發生的時間以10~12點及16~18點為兩個高峰

發生地點則以住家較多，並以廚房的比例最高

發生燒燙傷時則以從事給薪工作較高

燒燙傷的種類以燙傷的比例最高

部位則以頭部及四肢較高

平均燒燙傷總面積約15%

平均住院天數約為18天

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1. Heat burns (thermal burns)火焰灼傷、燙傷、接觸性灼傷

2. Electrical burns電流熱灼傷、電弧灼傷電流導致心律不整或心臟停止、肌肉僵直性收縮

3. Chemical burns強酸、強鹼經皮膚吸收產生中毒症狀

4. Radiation burnsUV 、放射線

●● CausesCauses

http://firstaid.webmd.com/tc/burns-topic-overview

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●● Depth of InjuryDepth of Injury

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1078.htm

� The depth of the thermal injuryvaries from inconsequentialinjuries of the superficial epidermis to deep injuries involving muscle and bone.

� The depth of injury determines the homeostatic response and thenecessary treatment.

Depth of InjuryDepth of Injury

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� The rule of nines assesses the percentage of burn and is used to help guidetreatment decisions including fluid resuscitation and becomes part of theuidelines to determine transfer to a burn unit.

As an example:If both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen were burned?

TBSA= 55%

●● Total body surface area (TBSA)Total body surface area (TBSA)

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●● Total body surface area (TBSA)Total body surface area (TBSA)

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� R-Baux score: (TBSA + age+[17×R])

� {R =1 if patient has inhalation injury and R = 0 if not}

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燒燙傷死亡率計算

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Complications併發症� acute respiratory distress syndrome

� ventilator associated pneumonia

� wound infection

� sepsis

� multi organ failure syndrome

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16http://www.ahrq.gov/clinic/tp/heparntp.htm

Burns

Frist

Second Third

TBSA

Flame Scald

chemicalContact Smoke

Inhalation Electrical

Clinical Outcomes

Early (e.g. pain, length of stay,scarring, bleeding,

Infection, thrombosis…)

Late (e.g. quality of life, psychiatric, adjustment, mortality…)

Degree

Type

Fourth

依病患的年齡﹑面積﹑部位及深度將嚴重度歸為三大類

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目前健保住院標準�二度燒傷，燒傷面積成人大於全身20%，兒童大於10%

�三度燒傷，燒傷面積成人大於全身10%，兒童大於5%　可住入燒傷加護病房

�其餘較輕微之傷害可住於燒傷病房、一般病房或門診治療

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TREATMENTTREATMENT

燒燙燒的緊急處理

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燒燙燒的緊急處理

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Fluid resuscitation�病人被送至急診時，除了檢視傷口及相關外傷外，第一件要做的事就是輸液的給予（fluid resuscitation）。其之所以緊急與重要處在於大面積的燒燙傷會導致缺水性休克（hypovolemic shock）。

�要給予正確的輸液量，就要詳細的詢問病史。一定要知道受傷的時間，因為那是開始產生生理變化的起點，也是輸液治療的基準點。

22burns 36 (2010) 1242–1247

輸液治療其適應症：

� 成人：Total body surface area（TBSA）> 20%

小孩：TBSA > 10%

� Inhalation injury 呼吸性灼傷

� Electrical injury 電燒傷

� Pre-existing medical problems, i.e., cardiac, pulmonary or renal disease 合併其他疾病的燒傷

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Parkland Formula (成人及大於成人及大於成人及大於成人及大於30公斤的孩童公斤的孩童公斤的孩童公斤的孩童)

�第一個24小時：4ml/ kg/ % TBSA bouned給予 Lactate Ringer’s solution

在前八個小時輸入總量的一半在前八個小時輸入總量的一半在前八個小時輸入總量的一半在前八個小時輸入總量的一半

在後十六個小時補充另外一半在後十六個小時補充另外一半在後十六個小時補充另外一半在後十六個小時補充另外一半

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兒童�第一個24小時

3 ml/kg/%TBSA +維持量的 Ringer‘s Lactatesolution

維持量：

小於 10 kg： 100ml/kg/24hr10至 20 kg： (1000ml + 50ml/kg)/24hr20至 30 kg： (1500ml + 20ml/kg)/24hr

�頭二十四小時內原則上不給含蛋白膠質的輸液，但大面積燒燙傷（ >50%TBSA）的幼兒可考慮在受傷後十六小時起給膠質輸液。

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�第二個二十四小時：(1)以葡萄糖液（ D5W）維持適量的尿量。(2)補充蛋白膠質（新鮮冷凍血漿或白蛋白輸液），以維持血漿中的白蛋白濃度高於3gm/dl。

�後續的體液治療：三至五日間為利尿期，要減少輸液量以減輕心臟負擔。

�監視參考值為尿量(1) 成人成人成人成人：：：：0.5-1 ml/kg/hr(2) 小孩小孩小孩小孩：：：：1-2 ml/kg/hr(3)電燒傷的病人則需提高一倍電燒傷的病人則需提高一倍電燒傷的病人則需提高一倍電燒傷的病人則需提高一倍：：：：1-2 ml/kg/hr

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antibiotic � Systemic antimicrobial therapy

在 sepsis or septic shock

� empiric antimicrobial therapy

pipercillin/tazobactam or carbapenem

+/- vancomycin

methicillin-resistant Staphylococcus aureus (MRSA)

+/- aminoglycoside

multidrug resistant Pseudomonas aeruginosa

� burn wound cellulitis

intravenous Cefazolin or Clindamycin or Vancomycin (if MRSA)

+/- oral Fluoroquinolone

for burns involving the lower extremity or feet or burns in patients with diabetes.

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PAIN TREATMENTSPAIN TREATMENTS

疼痛評估

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�減少外界刺激

�解除緊張焦慮沮喪

�可用輕度鎮靜劑如 Oxazolam，鎮靜劑如Diazepine，安眠藥如Triazolam，抗組織胺藥如Cetirizine、Cyproheptadine或肌肉鬆弛劑如Chlormezanone等幫忙。

�有時需精神科醫師會診或用藥

� 催眠（Hypnosis）

� 遊戲治療（Playing therapy)

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疼痛分為兩種─

� Backgrond pain

一直都感覺到的疼痛，疼痛程度變化不大，病人較容易適應。針對這種疼痛，可選擇給予類鴉片類點滴、

鎮靜劑、 Acetaminophen 、NSAIDs。

� Procedure pain

幫患者做治療(換藥、清洗、復健)時會引起的強烈疼痛，可選擇類Opioid藥物，Morphine類自控式止痛裝置。

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Anxiolytics

� Benzodiazepine治療改善燒傷病人術後疼痛評分

� Antipsychotic medications也可用於與燒傷疼痛和治療相關的焦慮和激動管理。

�第一代抗精神病藥物（如haloperidol）是輔助地用於危重病人的治療或預防過度活躍的譫妄和躁動。

�第二代抗精神病藥物（例如，Quetiapine）被越來越多地用於治療各種焦慮症和可能的組合有用與benzodiazepine用於管理焦慮和改善燒傷患者的睡眠。

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Opioid analgesics for Pain

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Drug 途徑途徑途徑途徑 Dose(mg) 須減半須減半須減半須減半Dose Duration(hr)

Codeine PO 200 30-60 Q6-8hr 4-6

Fentanyl IV/SC 100mcg (單一)250mcg(之後)

25-50mcg Q 1-2hr 0.5-1 IV1-2 SC

patch 20-100mcg 12-25mcg Q72hr 48-72 per patch

Hydrocodone PO 30 5-10 Q6hr 4-8

Hydromorphone IV/IM/SC

1.5 0.3-1IV Q2-4hr0.3-1SC/IMQ3-4hr

3-4

PO 7.5 2-4Q3-4hr 3-6

Morphine IV/IM/SC

10 2-5IVQ2-4hr2-10IMQ3-4hr

3-4

PO 20-30 10-30Q4hr 3-6

Drug 途徑途徑途徑途徑 Dose(mg) 須減半須減半須減半須減半Dose Duration(hr)

Methadone IV/IM/SC

10 1.5-2.5 Q4-8hr 3-4(initially)6-8

oral immediate-release

20 2.5-10Q4-8hr

Oxymorphone IV/SC/IM 1 0.5IVQ4-6hr0.5-1.5SC/IMQ4-6hr

3-6

oral immediate-release

15 5-10Q4-6hr 3-6

Tramadol PO 50-100Q4-6hr(immediate release)100 QD(extended release)

4-6(initially)3-11

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Opioid analgesics for ues in Children for painDurg Equianalgesic dose Oral dose and

frequencyIV dose and frequency

Oral(mg) IV(mg)

Morphine 30 10 0.3mg/kg Q3-4hr 0.1mg/kg Q2-4hr

Hydromorphone

7.5 1.5 0.04-0.08mg/kg Q3-4hr

0.015mg/kg Q2-4hr

Oxycodone 20 N/A 0.1-0.2mg/kg Q3-4hr N/A

Fentanyl N/A 0.1(100mcg) N/A 0. 5-1mcg/kg Q1-2hr

Methadone 0.1 mg/kg Q8-12hr 0.1-0.5mg/kg Q8-12hr

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PCA dosingDrug

General PCA dosing

Morphine Hydromorphone Fentanyl

Standard concentration

1 mg/ml 1 mg/ml 1 0 mcg/ml

PCA dose 1.5 mg 0.2mg 20mcg

Lockout Interval 7 7 7

4 hour Dose Limit 30mg 3 mg 300mcg

High risk General PCA dosing

Standard concentration

1 mg/ml 1 mg/ml 1 0 mcg/ml

PCA dose 1 mg 0.1 mg 15 mg

Lockout Interval 7 7 7

4 hour Dose Limit 30mg 3 mg 300mcg

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NSAIDs:usual dosing for adults with pain or

inflammationDrug Loading dose Usual analgesic

dose(oral)Maximum dose per day (mg)

Acetaminophan none 325-650mg Q4-6hr 3000

Naproxen 500mg 250-500mg Q12hr 1250(acute)1000(chronic)

Ibuprofen 1600mg 400mgQ4-6hr 3200(acute)2400(chronic)

Diclofenac 75-100mg 50mg Q8H 150

Indomethacin 75mg 25-50mg Q8-12H 150

Sulindac 300mg 150-200 mg Q12H 400

Meloxicam 7.5mg 7.5-15 mgQD 15

Mefenamic acid 500mg 250mg Q6H 1000

Celecoxib 400mg 200mgQD 400

Etoricoxib none 30-60mgQD 120(acute)60(chronic)

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Pharmacology of benzodiazepinesDrug Adult oral total

daily dose(mg)Potency(mg) Onset(hour)

Alprazolam 0.5-6 0.5 1

Chlordiazepoxide 5-100 10 1

Clonazepam 0.5-4 0.25-0.5 0.5-1

Diazepam 4-40 5 0.25-0.5

Lorazepam 0.5-6 1 0.5-1

Estazolam 1-2 0.3 0.5-1

Flurazepam 15-30 5 0.5-1

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therapeutic dose ranges for commonly used adjuvant

analgesicscategory base on conventional use

Class Drugs Usual starting dose

Usual effective dose range

Multipurposeanalgesics

Corticosteroids Dexamethasone varies 1-2mg BID,POorIV

Prednisone varies 5-10mg BID

Antidepressants Duloxetine 20-30 QD 60-120 QD

Bupropion 75mg BID 300-450mg QD

Venlafaxine 75mg QD 150-225mg QD

Alpha-2adrenergicagonists

Tizanidine 1-2mg HS 2-8mgBID

Used forneuropathicpain

Anticonvulsants Gabapentin 100-300mg BID 300-1200mgTID

Pregabalin 25-75mg BID 150-300mgBID

GABA agonist CLonazepam 0.5HS 0.5-3mg QD40

NONPHARMACOLOGIC TREATMENT

OPTIONS 非藥物治療方法

� Avoidance techniques-目的是分散病人的痛苦，轉移注意力而減輕疼痛。

� include distraction, guided imagery, hypnotic analgesia, and virtual reality

� Approach technique —Relaxation techniques, Deep breathing

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復健

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SUMMARYSUMMARY

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� Burns are one of the most common injuries encountered.

� In terms of injury factors in burns the prognosis depends primarily on the burn surface area (% TBSA) and the age of the person. The presence of smoke inhalation injury, other significant injuries such as long bone fractures and serious co-morbidities (heart disease, diabetes, psychiatric illness, suicidal intent etc.) will also adversely influence prognosis.

� Further research and understanding of the pathophysiology of burns will likely be followed by the development of improved treatments to limit burn progression, enhance wound healing, and limit scarring

●● SummarySummary

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Thank youThank you