09/02/2014

First management of
Burn Injury:
GP Must Do and Dont
Rosadi Seswandhana
Plastic Surgery Division, Dept of Surgery, GMU
Burn Unit DR Sardjito General Hospital

Problems

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Mortality

(Hettiaratchy & Dziewulski, 2004)

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Etiology

(Hettiaratchy & Dziewulski, 2004)

Pathophysology

Local response Systemic response

(Jackson, 1947)
(Hettiaratchy & Dziewulski, 2004)

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Severity of Burns

Age
Children Adult Older
Severity
Mild < 10% TBSA < 15% TBSA < 10% TBSA
Full-Thickness < 2% Full-Thickness < 2% Full-Thickness < 2%
TBSA TBSA TBSA
Moderate 10-20% TBSA 15-25% TBSA 10-20% TBSA
Full-Thickness < 10% Full-Thickness < 10% Full-Thickness < 10%
TBSA TBSA TBSA
(none critical area) (none critical area) (none critical area)

Severe >20% TBSA >25% TBSA >20% TBSA

Full-Thickness > 10% Full-Thickness > 10% Full-Thickness > 10%
TBSA TBSA TBSA
Critical areal* Critical area* Critical area*
Complicated burns** Complicated burns** Complicated burns**

(Singer, 2000)

Depth of burn wound

(Hettiaratchy & Dziewulski, 2004)

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Superficial Skin Burn

Superficial Skin Burn

Superficial Skin Burn

The prototype is a sunburn with erythema
and mild edema.
The area involved is tender and warm.
There is rapid capillary refill after pressure is
applied.
All layers of the epidermis and dermis are
intact; no topical antimicrobial is necessary.
Uncomplicated healing is expected within
five to seven days.

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Partial Thickness Skin Burn

Partial Thickness Skin Burn

Initially they may be quite difficult to
diagnose accurately
The hallmark of the partial-thickness
burn is blister formation and pain.
Confusion may result, however, when
partial-thickness burns are examined
after blisters have been ruptured and
uncovered pin prick test

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Full Thickness Skin Burn

Full Thickness Skin Burn

Full Thickness Skin Burn

Full-thickness burns have a relatively

characteristic clinical appearance.
Little discomfort for the patient.
They may be of almost any color
because of the breakdown of
hemoglobin.
The appearance of the skin may be
waxy and translucent.
Visible thrombosed vessels beneath
translucent skin are pathognomonic
for full thickness injury.

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Size and extent of the burn wound

Adult and Children > 10 y.o Children < 10 y.o

(ANZBA, 2013)

Lund and Browder table

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Management

Assessment for the first time

Mild
Moderate
Severe Complicated

Unconscious patient severe trauma

(ANZBA, 2013)

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First aid
Stop burning
process
Cooling
treatment

Severe / Complicated burns

ATLS
ABLS
ESBM
Goals:
Life-saving
Limb/organ saving

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EMSB Structure
L A B C D E FLUIDS AM PLE
O I R I I X History
O R E R S P
K W A C A O ANALGESIA Head to Toe
A Examination
H U B S
Y I L I U
TESTS Tetanus
N A L R
G T I E Document &
I T TUBES Transfer
O Y
N Support
D Haemorraghe Environmental
C O2 control
AVPU control
O & Pupils
spine I.V.
Secondary
Primary Survey First Aid
Survey

(ANZBA, 2013)

Acute phase Initial assessment

Rescusitation Airway
A: Look for signs of inhalation injury
Facial burns,
Soot in nostrils or sputum
Laryngoscope edema, hyperemia
ET Better than TRACHEOSTOMY
Do not forget: C-Spine control

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Acute phase
Rescusitation Breathing
Do not forget: Give O2 100% 15 L/minute (NRM)
B: Circumference Full thickness skin burn on the
chest wall mechanical ventilation disturbance
ESCHAROTOMY

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Acute phase
Rescusitation Breathing
Be aware of carbon monoxide poisoning
Patient may appear 'pink' (cherry red) with a normal
pulse oximeter reading
administere 100% Oxygen
Perform intubation and artificial ventilation
(if needed)
(Do not believe pulse oxymetri saturation)
Smoke injury Soot in nostrils or sputum
Nebulizer
Perform intubation, artificial ventilation and
bronchial toilet (if needed)

Acute phase
Rescusitation Circulation (C)
Examine:
Central pressure
Blood pressure
Central and periphery capillary refill
Systemic :
If patient arrived with shock condition 2 IV-line
First IVFD RL 20 ml/Kg BW in 15-30 minutes
(Do not forget blood test sample complete
blood count, blood group, chemical analysis,
BGA, and -HCG for pregnant woman)

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Escharotomy on extremity
Local :
Circumference Full thickness skin
burn on extremity compartment
syndrome 5P ESCHAROTOMY

(Remember: escharotomy should be performed

after life-threatening was managed)

Acute phase
Disability (D)
GCS
Lateral Sign

CO intoxication
Hipovolemic shock

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Acute phase
Exposure and Environmental control
Log Roll Manuver
Burn Size (% TBSA)
Depth of Burn Wound
temperature
Other trauma

Beware : Hypothermia blanket

Acute phase
Fluid Resucitation (F)

(Mathes, 2006)

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(Mathes, 2006)

Acute phase
Fluid Resucitation (F)
Systemic :
The release of cytokines and other inflammatory mediators
Increase of capillary permeability let the intravascular fluid shifted
to the interstitial space hypovolemia

BAXTER / PARKLAND FORMULA

IVFD RL: 4 ml x BW (Kg) x BSA (%)

ANZBA IVFD RL: 3-4 ml x BW (Kg) x BSA (%)

for children, + maintenance

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Case

Patient with 50 Kg BW and 30% BSA

Fluid Needed : 4 x 50 Kg x 30 %
6000 mL RL
First 8 hours 3000 mL 92 drops/mnt
Next 16 hours 3000 mL 46 drops/mnt

MONITORING
Vital Sign
(Pulse rate, respiration rate, blood presure, temperature)
Urin Output Adult 0,5-1,0 mL / Kg BW/ hour
Child 1,0-2,0 mL / Kg BW/ hour
Breathing sound
Severe burn (>40%) apply Central Venous Catheter

Fluid theraphy adjustment hourly

Deficiency add 10%
Overload reduce 10%

Beware: myoglobinuria (haemochromogens)

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Analgetic
Burns is painfull need adequate analgetic
Morphine : 0,05 0,1 mg/Kg BW (ANZBA, 2013)
Fenthanyl : 1 g/Kg BW

Continue with maintenance dose

(better using syringe pump)

Test
ECG, Lateral Cervical, Thorax , Pelvical X-ray
Hb, WBC, Plt, Hematocrit, Electrolite, Albumin, GDS
Kidney Function, Liver Function, BGA

Tube
Nasogastric tube production beware of stress
ulcer
Indweiling catheter urine monitoring
Central venous catheter

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Secondary survey
History : A M P L E

Head to toe examination

Electrical injury
Beware of cardiac rythm abnormality closed ECG
evaluation in the first 2 days
Beware of extensive rhabdomyolisis
Beware compartment syndrome need fasciotomy

Beware of renal failure high urine output fluid

therapy (100 cc/hour)
Tx: 2 amp Manitol (25 g) followed immediately 2 amp bicarbonate, IV push,
continue 12,5 g manitol every 1 L fluid which was given
(Hettiaratchy & Dziewulski, 2004 and ANZBA, 2013)

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Chemical injury

Beware of Progresive Destruction

Beware of organ injury (eye, ear etc)
Principle dilution
Do not try neutralized acid with base,
even in vice versa

Wound Care
1st O no spesific treatment

2nd O Cleansed with NaCl + Savlon

500 ml 5 ml
Film transparan
Foam
Silver impregnated foam
Calcium alginate
Cellulosa

Antibiotic ointment
MEBO
Controversy: Usage of Silver Sulfadiazin

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Conservative wound care

Wound Care
3rd O
Cleansed with NaCl 500 ml + Savlon 5 ml
Daily debridement
Daily Silver Sulfadiazin (Dermazin / Burnazin) ,
Silver contained dressing (Acticoat / Mepilex-Ag)

Plus Surgical Treatment

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Surgical wound treatment

Non Surgical Treatment

Antibiotic prophylactic? Sistemic vs Local
ATS Tetagam? 3rd O, large burn size
GIT protector
Nutrition
Antioxidant
Imunomodulator
Inotropic (if needed)
Bath sower burn tank
Antidecubital bed / care
Splinting & Rehabilitation

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Referral criteria

American Burn Association -

Advance Burn Life Support Course:
1. Partial thickness burns greater than 10% total body surface area (TBSA).
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
3. Third degree burns in any age group.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Inhalation injury.
7. Burn injury in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality.
8. Any patient with burns and concomitant trauma (such as fractures) in which the
burn injury poses the greatest risk of morbidity or mortality. In such cases, if
the trauma poses the greater immediate risk, the patient may be initially
stabilized in a trauma center before being transferred to a burn unit. Physician
judgment will be necessary in such situations and should be in concert with the
regional medical control plan and triage protocols.
9. Burned children in hospitals without qualified personnel or equipment for the
care of children.
10. Burn injury in patients who will require special social, emotional, or
rehabilitative intervention (ABA-ABLS, www.ameriburn.org)

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Australian and New Zealand Burn Association:

1. Mid to deep dermal burns in adults >10% TBSA (total body
surface area)
2. Full thickness burns in adults >5% TBSA
3. Mid-dermal, deep dermal or full thickness burns in children >5%
TBSA
4. Burns to the face, hands, feet, genitalia, perineum and major joints
5. Chemical burns
6. Electrical burns including lightning injuries
7. Burns with concomitant trauma
8. Burns with associated inhalation injury
9. Circumferential burns of the limbs or chest
10. Burns in patients with pre-existing medical conditions that could
adversely affect patient care and outcome
11. Suspected non-accidental injury including children, assault or self-
inflicted
12. Pregnancy with cutaneous burns
13. Burns at the extremes of age infants and frail elderly
(ANZBA, 2013)

Modifikasi kriteria rujukan menurut Asosiasi Luka

Bakar Indonesia:
1. Luas luka bakar derajat 2-3 > 15% untuk dewasa
2. Luas luka bakar derajat 2-3 > 10% untuk anak-anak dan usia
lanjut
3. Luas luka bakar derajat 3 > 5%
4. Luka bakar listrik
5. Luka bakar kimia
6. Luka bakar pada daerah khusus seperti wajah, tangan,
genital, perineal dan persendian
7. Pasien luka bakar yang mempunyai komorbid sistemik yang
dapat membuat tata-laksana pasien menjadi rumit, seperti
stroke dan lainnya.
8. Pasien luka bakar yang disertai dengan trauma multipel,
seperti akibat kecelakaan atau pasien melompat/terjatuh dari
ketinggiaan saat kejadian.
9. Luka bakar minor yang tidak sembuh dalam 3 minggu
10.Luka bakar yang dicurigai bukan karena kecelakaan

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Pathway for access to Burn Injury services

(Fiona wood, 2009)

Fluid Maintenance
Maintenance Fluid Requirements
=
35 + % 24 + 1500

Body surface area (The Mosteller formula) =

body height cm x body weight (kg)
3600

Hourly adjusted based on urine output

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Nutrition

Burn injury can increase the basal metabolic rate

50% to 100% of the normal resting rate. The main
features include:
increased glucose production,
insulin resistance,
lipolysis,
and muscle protein catabolism.
Without adequate nutritional support, patients have
delayed wound healing, decreased immune
function, and generalized weight loss
(Mathes, 2006)

(Mathes, 2006)

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Splinting

Document & Transfer

Diagnosis (Type/Depth of Wound, Extent, Etiology)
Inhalation trauma? Intubation
Other major trauma?
Other co-morbid?
Onset
Theraphy which was already given
Fluid (Type of fluid, amount)
Drugs
Surgical treatment (escharotomy, tracheostomy)

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Thank you

Peate WF. Outpatient management of burns. Am Fam Physician 1992;45:1321-1330. (Review)

Young DM. Burn and Electrical Injury. In Mathes SJ [Ed]: Plastic Surgery. 2nd Edition. 2006. P811-
833
Australia and New Zealand Burn Association, Emergency Severe Burn Management: Course
Manual, 17th Edition, Feb 2013
Seswandhana MR, 2011, Pengalaman menghadapi erupsi Gunung Merapi, presentasi ilmiah,
Pertemuan Ilmiah Tahunan Perhimpunan Ahli Bedah Indonesia (PABI), Medan, 2011
Hettiaratchy S, Dziewulski P. ABC of burns. BMJ 2004;329:5046
Singer AJ. Thermal Burns: Rapid Assessment And Treatment. Emerg.Med.Pract. Sep 2000. Vol
2[9]
Wardhana A. Adjustable volume of fluid resuscitation for burn injury. Plastic Annual Meeting. 2011
Bessey, PQ.Wound Care.in Herndon DN [ed]: Total Burn Care. 3rd Edition. 2007. Elsevier. Printed
in China
Hirsch T,Ashkar W,Schumacher O,Steinstraesser L,Ingianni G,Ceolidi CC.Moist Expossed Burn
Ointment(MEBO) in partial thickness burns a randomized,comperative open mono-center study
on the efficacy of dermaheal (MEBO) ointment on thermal 2nd degree burns compared to
conventional therapy .Eur J Med Res .2008 Nov 24;13(11):505-10
Prasetyono TOH, Rendy L. Merujuk Pasien Luka Bakar: Petunjuk Praktis. Maj Kedokt Indon,
Volum: 58, Nomor: 6, Juni 2008; p 216-24
American Burn Association, ABLS at www.ameriburn.org
Wood F, Burn Injury Model of Care, 2009

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