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ARSURILE
CLINICA DE CHIRURGIE PLASTICA, MICROCHIRURGIE
RECONSTRUCTIVA SI CHIRURGIE ESTETICA
SPITALUL CINIC DE URGENTA "BAGDASAR ARSENI"
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DEFINITIE
Sens strict – efectele calduri asupra tesuturilor umaneIncluse in sens larg:
ElectrocutiileArsurile ElectriceArsurile chimiceEfectele traznetDegeraturi
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IMPORTANTA
Efecte dramatice asupra calitatii vietii, pierderi finaciare, suferinta fizica si psihologicaSUA - 1991
2 milioane de arsuri / an70000 arsuri majore – necesita
spitalizare5000 deceseROMANIA – greu de evaluat nu exista date centralizate –
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MECANISM DE PRODUCERE
Lichid fierbinte – oparire – varsare sau imersie
LichidGrasimeaburContact – cu corpuri solideFlacara flama / flacaraChimice – acizi / baze / exfolianti Electrice – flama / electrocutieRadiatie
Factor predictiv – asupra severitatii
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SUSCEPTIBILITATE
Arsuri minore – orice varsta – maxim la <5 ani si 20-29 aniCopii – oparire, flacaraAdulti – flacara si lichid67% din arsurile majore – barbatii Peste 70 ani contact cu suprafete incinse.
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ARSURILE PRIN FLACARA
Exista scenarii prestabilite
Consumul de alcoolImplicarea unui lichid inflamabilHaine inflamabileRaspunsul insotitorilor
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TEGUMENTUL
Epiderm
Superficial – celule moarte protectorProfund - MalpighianDermHipoderm
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TRANSFERUL DE CALDURA
Rata de transfer de la agentul cauzal la tesuturi severitatea arsurii. Capacitate calorica a agentului cauzal – agentul elibereaza – tegumentul si pielea preiau QTemperatura – diferenta apa fierbinte – aburDurata de contact – model logaritmic de crestere
la 44 grd – 6 ore80 de grade – aproximativ 2 secunde .Modalitatea de transfer – conductie, convectie, radiereConductivitate – material, suprafata,
temperatura.
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LEZIUNEA LOCALA DE ARSURA
3 zone concentrice de arsura – coagulare , staza si hiperemie – exista o interelatie , mediata de PG, BK si Histamina
Dezechilibrul vasomotor progresia leziunii.
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MODIFICARI GENERALERaspuns Inflamator Sistemic – la arsuri > 30% - - permeabilitate vasculara crescuta generalizata, vasoconstrictie splanhnica, hipovolemie = SIRS.
Disfunctie pulmonara – fara leziune – TxHemolizaSindrom hipermetabolic – pana la 1 an – scade rezistenta la infectii, procesele de vindecare etc
Raspuns cardiovascular – status hiperdinamic.
Scadere filtrare glomerulara.
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PRINCIPII TERAPEUTICE GENERALE.
SUPORT NUTRITIONAL – enteral de preferinta. COMBATEREA INFECTIEI – cauza majora de mortalitate. TRATAMENTUL SOCULUI POSTCOMBUSTIONAL.TRATAMENTUL CHIRURGICAL / NECHIRURGICAL AL LEZIUNII LOCALE DE ARSURA
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PRINCIPII TERAPEUTICE GENERALE.
SUPORT NUTRITIONAL – enteral de preferinta. COMBATEREA INFECTIEI – cauza majora de mortalitate. TRATAMENTUL SOCULUI POSTCOMBUSTIONAL.TRATAMENTUL CHIRURGICAL / NECHIRURGICAL AL LEZIUNII LOCALE DE ARSURA
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LEZIUNEA LOCALA DE ARSURA
ProfunzimeSuprafataRelatia grad / suprafata si varstaPrincipale categorii de arsi.
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PROFUNZIME -EVOLUTIVAABA – 3 grade
GRADUL 1
GRADUL 2
Superficiale – epiderm si derm superficial, flictene cu perete subtire, lichid clar, Roz, umede, extrem de dureroase la atingere, Vindecare in 2 maxim 3 S – din rezervele epiteliale.
GRADUL 3 – toata grosimea epiderm si derm – necesita grefare daca sunt mai mari de 1 cm diametru, Aspect alb sau de textura pielii tabacite, anestetica.
GRADUL 4 – implicarea grasimii, fascie , muschi , schelet, Necesita proceduri reconstructive complexe, dizabilitati pe perioada lunga.
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SUPRAFATA
Regula lui 9 – 9% cap gat si membre superioare, 18% trunchi ant si post, membre inferioare, 1% perineu.
Palma pacient – 1%
Schema Lund-Browder – corecteaza diferentele procentuale adult – copil.
Nu se includ ariile cu gradul 1.
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VARSTA SI SUPRAFATA
40% la 20 de ani – mortalitate de 8%
40% la 70 de ani – mortalitate de 94%
La fel la sub 1 an.
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CATEGORII DE ARSURA
ARSURI MINORE ARSURI MODERATE ARSURI MAJORE
Sub 15% la adulti
Sub 10% la copii si varstnici
Sub 2% TG la orice varsta – fara locatii functional importante
15-25% la adulti
10-20% la copii sau varstnici
2-10% Tg fara locatii importante functional
Peste 25% adulti
Peste 20% copii sau varstnici
Peste 10% TG
Implicarea TG fata, perineu, ochi, mana, picior Agenti caustici
Arsuri cu voltaj inalt
Leziuni inhalatorii sau politrauma.
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TRATAMENTUL ARSURILOR
Tratament prespitalicescTratament generalTratament local Recuperare si kinetoterapieReinsertie socioprofesionalaSechele
IDEAL – in sistem esalonat – locul accident, transport, unitate primara , unitate definitiva – organizat regional.
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NIVEL PRESPITALICESC
Extragerea victimei de sub actiunea agentului cauzalIndepartarea hainelor aprinseTransport cu asistare avansata a functiilor vitaleDaca exista semne de inhalare de fum oxigen umidifiat 10-12 l/ minutDaca nu respira – intubat si ventilat cu oxigen pur.Socul – elevarea membrelor si administrare de oxigen.Administrare de fluide iv Ringer lactat – daca se estimeaza peste 30 minute de trasnport sau exista semne de soc.Local – lavaj cu ser fiziologic sau apa rece – 1-5 grade – 30 minute, cele sub 5 si mai mult.Transport la Centru de Arsi – daca se ajunge in 30 minute / la Unitate de Urgenta daca dureaza peste 30 Minute
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TRATAMENT SPITALICESCEvaluare suprafata si profunzime leziuni
Status respirator si cardiovascular.Proceduri de REANIMARE
Respirator – 3 componente – leziuni inhalatorii CRS, IR acuta si intoxicatie CO.Asigurare cale respiratorie, ventilatie, adm oxigen, traheostomie, escarotomie trunchi etc.Ventilatie mecanicaCO – oxigen hiperbaric (afinitate 280X)
Profilaxie tetanica, administrare antialgice.
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TRATAMENT SPITALICESCRESUSCITARE LICHIDIANA
Functie de suprafata si gradMai multe formule – PARKLANDScop -= mentinere volum plasmatic, prevenirea ischemiei periferice, mentinerea perfuziei organelor vitale
Cantarit pacientulPierderile proteice – dupa 24 de ore Solutii hipertoneCateterizare – sonda urinara, sonda nasogastrica (nutritie precoce??) DECIZIA DE A NU RESUSCITASCOP – perfuzie tisulara/viscerala buna Diureza peste 1ml/kgc/ora
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CENTRU DE ARSI
Tratament antialgic – invers proportional cu profunzimea.
Morfina – are avantaje farmacologice – usor de titrat si de combatut efectul depresiv respirator – pana la 50mg/hPreventia eeroziunilor gastrice – preventiv antiH2 si antacidePreventie Insuficienta Renala – reanimare efectiva, combaterea infectiei locale sau generale.
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TRATAMENTUL LEZIUNII DE ARSURA
Toaleta
Lavaj abundent – ser, SUA poloxamer 188 Excizie flictenelor sparteAplicare de topic antibacterian localPansamente – zilnic sau 2x /ziSILVADENE, POLYSPORIN, BACITRACINPANSAMENTE OCLUZIVE – BIOBRANE< TRANSCYT – pentru leziuni intermediare
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TRATAMENT CHIRURGICAL
Indicatii – leziuni profunde sau extinse fara potential de vindecare in 21 de zile, complicatii ale celor intermediare, prevenirea complicatiilor leziunilor circumferentiale.ESCAROTOMII – pe aspectele lateral si medial ale membrelor, trunchi, penis etc.
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TRATAMENT CHIRURGICALLeziunile profunde – excizie grefare.
Excizia leziunii de arsura – tangential sau suprafascialAcoperire
Sub 30% - autogrefa normala sau expandata 1:1 sau 1:2 Peste 30%
Autogrefe expandate 1:3 sau 1:4AllogrefeXenogrefeArtificial – INTEGRA, DERMAGRAFT ALOGREFE prezervate in Glicerol
Minimalizarea pierderilor sangvineCAE – culturi epitelialeImobilizarea grefei – sutura , imobilizare.
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INFECTIA IN ARSURI
Celulita – str piogen de obicei –
Excizia escareiPenicilinaElevare membruSepsis – cu punct de plecare din plaga
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ARSURI MINORE
LavajFlictenele
ExcizateEvacuate sterilATPAATB – NUTratament deschis – la fata – bacitracinTratament inchis – pansamente sintetice de generatie 1 sau 2Elevarea segmentului afectat – mobilizarea activa precoceTratament antialgicControl la 2 zile.Obiectiv – vindecare in 10-14 zileInfectia – lavaj , dermazineNu expunere la soare, sunblockProfilaxia hipertrofiei.
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RASPUNSUL METABOLIC
Curreri formula
(25 kcal/kg+40 kcal/% TBSA)
Dublu fata de Harris-Benedict
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LOCALIZARI SPECIALE
Fata – expunere
Excizie precoceProfilaxia condriteiMaini – functionalPerineu
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REABILITAREA
Faza acuta
Preventia contracturilorPreventia diformitatilorFaza de recuperare imediata
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MANAGEMENTUL CICATRICILORMasajUnguente –
CONTRACTUBEX, KELOSOFTPresoterapieFolii de siliconInjectii cu steroizi – atentie la dozaPruritus – topice cu vit E, antihistaminice local sau general , dusuri reci
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RECONSTRUCTIA
Cat asteptam – cicatricea este matura la 2 ani – daca exista deficit functional mai repede.
Z plasty – baza reconstructiei Expandare tisulara Lambouri tisulare
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ARSURI ELECTRICE
Electricitate – flux de electroni intre atomiAmperaj – defineste nr de electroniVoltaj – campul de forta intre care se misca electroniiRezistenta corpului – variabila 1 milion ohm – pana la 100 ohmiCurentul alternativ / continuuArc electric – fenomen de descarcare – flama de pana la 4000 grade celsius.
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EFECTE
Cantitatea de curent 1 mA perceptibil, 10 mA contractii, 50-100 decesTraiectul urmat – fracturi, depresie nervoasa centralaDurata de contactAria de contactRezistenta corpuluiVoltaj - > 1000V = inalt voltaj
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PRIM AJUTOR
Inchiderea surseiIndepartarea de sursaCPR - ABC
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VOLTAJ NORMAL
Localizare – mana (adult) sau gura (copil)
Traseul calea de minima rezistentaSpitalizare Tratament local al arsurii, imobilizare
La 48-72 de ore – excizie grefare leziuni profunde.
Reconstructie.
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VOLTAJ INALT
Arc electric – nu trece prin corp dar are contact cu el complicat sau nu cu flama (leziuni suplimentare) Curent electric – pasajul prin corp
Rezistenta tesuturilor – tegument si schelet mare, restul scazutaTraseul curentului – aici – traseu unic prin toate tesuturile mai periculaos mana-mana decat mana-piciorLeziunile de intrare (escarificate, depresate) si iesire (explodate)Distructii tisulare profunde neaparente initialOsul – rezistenta mare – generator de Q
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MODIFICARI POSTINJURIE
Ischemie musculara – in 6-8 ore ireversibila – escarotomii si fasciotomii
Eliberare de mediatori in circulatia generala
Leziuni nervi periferici
Depresie miocardicaLeziuni vasculare
Insuficienta pulmonara acutaHipo K severa
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TRATAMENT
Depletia lichidiana – greu de estimatFactori predictivi – hematocrit si diurezaRinger lactat astfel incat sa avem 50-100 ml/h diureza.Daca exista Hb in urina - . 100 ml/h
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TRATAMENT
Individualizat pe regiuneDeschidere larga a traiectului cu aprecierea leziunilor profunde
EscarotomiiFasciotomiiExcizie grefareExcizii musculare – grefe, lambouri.
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ARSURI CHIMICE
Agenti cauzali:
AciziBazeCimentFenolExfoliantiNitratiFosforHidrocarburi
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MecanismReactii chimice locale
Exoterme – QDependent de agent –
Acid – denaturare proteine – leziuni uscateBaze – dizolva proteine si colagen – leziuni umedeOxidant, exfoliant.Concentratia, durata de actiuneEfecte sistemice
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TRATAMENT
Identificare agent cauzalIndepartarea agentului cauzalLavaj continuu cu apa – baze apoi hidroterapie.Acizi – neutralizare specifica functie de acid implicat.
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ACID FLUORHIDRIC
Fixeaza Ca – tulburari de ritm, dureri severe.Lavaj cu apa 30 minute.Infiltrare locala ca gluconate.Injectare intraarteriala.