醫療團隊 燒傷外科手術介紹 翁立窈物理治療師 2015/08/09 整體性醫療 (Total care) 以病患及家屬為中心, 期使病患得到 身心靈 三方面的 整體性醫治, 建議燙傷聯合治療小組員包括 : 整形外科或燒燙傷專科醫師 燒燙傷專科護理師 復健科醫師 職能治療師 物理治療師 營養師 呼吸治療師 社工師 心理師 各專科會診醫師 : 如內科 麻醉科 小兒科 眼科 耳鼻喉科 精神科醫師等 1 2 Escharotomy Indications Full-thickness skin burns Circumferential, tough, inelastic mass of burnt tissue/eschar+ accumulation of fluid underlying the eschar 3 4 圖片來源 : http://gog.net.nz/burns.html Vedio http://sydneyhems.com/2014/08/30/build-yourown-escharotomy-man/ 5 6 1
Fasciotomy Indications electrical burn injury; four degree of burn injury etc. Fasciotomy is a clinical procedure indicated once the clinical diagnosis of compartment syndrome is made 7 8 圖片來源 :http://www.hughston.com/hha/a_17_2_1.htm PT after Escharotomy PT after Fasciotomy 需考慮組織的健康情況及損傷程度, 包含 : 神經 肌肉 肌腱 韌帶及關節等 圖片來源 :http://rachelanthropus.tumblr.com/ 9 10 Burn Wound Classification Superficial Burn 11 12 2
Superficial Partical-thickness Burn Deep Partial-thickness Burn 13 14 Full-thickness Burn Phases of Wound Healing Inflammatory phase ( 發炎期 ) Proliferative phase( 增生期 ) 表皮化 (Epithelialization) (picture) 上皮細胞移行覆蓋於肉芽組織上 倘若傷口表層一直無表皮細胞覆蓋, 則傷口會持續在發炎期 肉芽組織增生及上皮細胞形成 肉芽組織 由巨嗜細胞和纖維母細胞構成 結構紅色 結實發亮的顆粒狀外觀 Mature phase (Remodeling)( 重塑期 ) 15 16 成熟期的疤痕組織 (Mature phase of scar) 疤痕成熟 (Scar maturation) The number of vascularity of the wound decrease to the point where a mature wound is dominated by collagen fibers and little else Resolution of inflammation The scar become less erythematous flattens The final phase ends when the wound becomes pale 肉芽組織 由巨嗜細胞和纖維母細胞構成 結構紅色 結實發亮的顆粒狀外觀 17 18 3
上皮細胞移行覆蓋於肉芽組織上 過程中張力逐漸增強 19 20 燙傷傷口治療原則 希望在二到三週內達成傷口癒合的目標 對於淺層燒燙傷病患 ( 一度 淺二度 ), 可以使用生物敷料覆蓋於燒燙傷傷口上,, 直到皮膚再生, 一般約需一至二星期, 使其逐漸脫落 暫時性覆蓋, 多採用生物敷料 異種異體 : 常見為豬皮, 約 7-8 天排斥反應 同種異體 : 屍皮, 約兩周產生排斥反應 對於深層燒燙傷病患 ( 深二度 三度以上 ) 則需要使用植皮修補法, 可能的選擇包括自體皮膚移植甚至皮瓣手術重建來達成傷口癒合的目標 部分深層傷口, 需反覆多次清創, 直到存留組織為乾淨後, 方能執行自體皮膚移植手術 21 22 植皮修復法 深度燒燙傷傷口經焦痂切開及清瘡處理後, 必須及早對傷口進行覆蓋, 以防止傷口發生感染及細菌侵入組織, 同時防止體液及電解質流失, 及減輕病患痛苦 暫時性覆蓋多採用動物性的人工敷料 異種異體 : 常見為豬皮, 約 7-8 天排斥反應 同種異體 : 屍皮, 約兩周產生排斥反應 自體皮膚移植 所謂自體皮膚移植, 是由病患自己身上未受燒燙傷的部位, 取下部分皮層的皮膚, 移植到受傷的傷口上 移植後的皮膚尚不穩定, 通常肢體需禁止活動數日 頭皮或大腿為常用供皮區 植皮的部位必須固定一至二星期, 使移植皮膚重新獲得血流供應而生長於被移植的部位 23 24 4
清創 (Debridement) Indication 深二度以上燙傷傷口 25 26 深二度燙傷傷口清創 三到四度燙傷傷口清創 27 28 生物敷料 自體皮膚移植 (Skin Graft) 深二度以上傷口需自體皮膚移植 29 30 5
Skin Graft Split Thickness Skin Graft (STSG) Partial dermis Full Thickness Skin Graft (FTSG) Entire dermis Thickness of Skin Graft Donor: 大腿或頭皮 31 http://medicinembbs.blogspot.tw/2014/05/principles-of-skin-cover-grafts-and.html 32 wisconsinfootandankleinstitute.com/research/versajet-hydrosurgery-technique-for-the-prep Split Thickness Skin Graft http://openi.nlm.nih.gov/detailedresult.php?img=2742389_eplasty09e33_fig1&req=4 http://www.burnsurvivorsttw.org/burns/grafts.html 33 http://veterinarymedicine.dvm360.com/skills-laboratory-wound-repair-techniques-strip-skin 34 Donor site Mesh skin graft MEEK skin graft 7 days after surgery 35 36 6
Mesh Skin Graft 37 38 MEEK MEEK Video https://www.youtube.com/watch?v=wwdylz51cw4 http://hungvuongmed.com/san-pham/dao-khia-da-tem-thu/ 39 http://www.humeca.com/product/meek-micrograft/local-therapy/ 40 Full Thickness Skin Graft Video https://www.youtube.com/watch?v=hixknuewdbk 41 42 7
Donor site Artificial Dermis 43 44 http://www.intechopen.com/books/skin-grafts/treatment-of-legchronic-wounds-with-dermal-substitutes-and-thin-skin-grafts 45 46 Flap Flaps involve transferring tissue that contains its own blood supply. Effective in covering area that are relatively avascular (over bone and tendon), where skin grafts are ineffective 47 48 8
Local Flap Local flap involves moving tissue to a neighboring. 49 http://z0mbie.host.sk/soft-tissue-coverage.html 50 Regional Flap Regional flaps are based on a named artery and can be larger and can consist of more than one type of tissue pectoralis major flap, latissimus dorsi flap, and deltopectoral flap Regional flaps should be considered for the reconstruction of extensive burned contracture on the movable areas such as the anterior neck, axilla, and joints to prevent recontracture by grafted skin. Regional Flap Reconstruction of the neck with a regional latissimus dorsi flap 51 http://www.ro-journal.com/content/6/1/109/figure/f3 52 Distant Flap Distant flaps are used when the donor site is far from the defect. Groin flap Free Flap Free flaps were used in burn reconstruction when there was exposed bone, tendon, or cartilage present and local or regional flaps were inadequate. 53 http://z0mbie.host.sk/soft-tissue-coverage.htm 54 9
Thanks! 55 10