Height: 168cm, Body Weight: 85.3kg.
Vital sign: relatively stable.
TBSA(total burn surface area): 20%, 2nd degree superficial to deep.
Q: How to approach?
1. Diagnosis (怎麼燒傷？電傷跟化學灼傷、火焰燒傷的處理有所差異)
a. Causes Zones,
b. depth & estimation of burned area(BA) (二度以上會有scar，往往要補皮) ,
BA: rule of nine, or pt’s palm=1%.
c. Burn center referral criteria
2. Resuscitation (body fluid怎麼給？Parkland or Modified Brooke formula)
a. Burn shock
b. Initial fluid resuscitation & maintainance fluids
3. Treatment strategies (Abx, pain control, and?)
a. Surgical Treatment
b. Burn wound treatment
[U.S Burn Depth Categories]
所以這個pt 是從左臉左上軀幹以及左上臂前臂估計達20%的淺、深二度燒傷。一開始建立兩條IV-line, Fluid resuscitation, pain control(Depain, Morphine), covered Abx(Cephazolin). 清洗傷口後用betadine消毒、wetdressing即轉入燒傷加護中心monitor. 另外這個病人因為有面部燒傷，鼻毛呈黑色，有無inhale injury? 有無on endo的必要？
Reference: (Rosen’s Emergency Medicine, 6th/e)
Fires usually emit smoke, which victims may inhale, especially in closed spaces. Smoke inhalation can cause both pulmonary parenchymal damage and CO and other toxic poisoning, which may have lifethreatening consequences. The prehospital care provider should look for signs of inhalation injury (e.g., dyspnea, burns of mouth and nose, singed nasal hairs, sooty sputum, brassy cough). If one or more of these signs are present, humidified oxygen should be administered with a nonrebreathing reservoir mask at a rate of 10 to 12 L/min. The patient who has airway involvement should be intubated early in the course because edema can develop and make intubation increasingly difficult.
經判斷後，病人的SpO2 100%, N/C: 2L/min，加上只有臉部灼傷、鼻毛燒焦，沒有明顯stridor，非密閉空間。所以先密切觀察，沒有on endo.
Q：What’s Parkland or Modified Brooke Formula
Parkland: 4c.c./ %TBSA/ kg ,
Modified Brooke: 2c.c/ %TBSA/ kg (Lactate Ringer)
= amount should be infused in 1st 24hr.
Half amount calculated above in 1st 8hr, and then the other half in continuous 16hrs. (And then f/u U/O 0.5-1c.c/kg for decided the amount of L.R)
所以這個病人85.3kg * 二度以上範圍 20% * 4 c.c = 6824 c.c.
Q：為什麼要L.R？而盡量不要N/S？
減少高氯酸血症的發生機率。（不過按Rosen所說，如果沒有L.R也可以用N/S)
Q：為什麼後續要依照U/O 來決定infusion的量？
學長說波灣戰爭之後發現overhydration有可能造成Abdominal Compartment Syndrome. (一來因為Burn injury之後血管的permeability 增加) 一旦發生mortality近100%。 也因此有Modified Brooke for 大範圍燒傷。
Reference:
Q: 學長teaching的其他Fluid Maintain公式。（目前還沒找到出處）
Total daily maintenance fluid requirements=
Basal (1500 cc/m2) + evaporative water loss [(25+%burn) × m2 × 24]
IV route or enteral feeding
IV fluid: 50% N/S + K+ (120 mEq/day) Children needs more fluid than adults
UOP is unreliable after 48 hr of resuscitation:
Adult: 1500-2000 cc/d child: 3-4 cc/Kg/hr
Q: 後續Care…
這個pt隔天跟家屬談到自費的含銀敷料Acticoat後進去op room debride加貼敷料。（目前使用後幾乎沒有wound infection)據學長說是因為滲透壓的關係，在貼的那瞬間病人也會有痛楚感。標準一片可用3天，不過其實可以持續到1 week。外層用pad吸附discharge即可。一個禮拜後再進op debride即更換。兩三個禮拜後tissue生長到一個程度，necrosis的地方就用skin graft去補。（其他以前共筆均有，不贅述）
唯因病人有nightmare，consult psych後加上stilnox CR 6.25 1# HS, setine 20mg 1# QN, mood stable, kept OBS.
Q: 常用的topical agent
Antibacterial ointment (neomycin, bacitracin)
這個病人眼睛我們用erythromycin, 其他部位用neomycin。Erythromycin軟膏對眼睛的結膜刺激較小。
Silver salfadiazide （ex: Acticoat）
Clean 2nd-3rd degree burn wound
S. aureus, E. coli, Klebsiella, P. aeruginosa, Proteus, Candida
Pseudoeschar formation
Transient leukopenia (無其他infection sign不需擔心，2-3wks會恢復)
歡迎討論及補充
