EMERGENCY MEDICINE BLOCK

CASE 2

Ronald Chrisbianto Gani

405090223
Faculty of Medicine
Tarumanagara University

THERMAL BURNS

THERMAL BURNS
Injuries to the skin resulting from
contact with heat, electrical current,
radiation, or chemical agents
Less than 44oC well tolerated
Above 60oC denaturation of
protein

Rosens Emergency Medicine 7th E

EPIDEMIOLOGY
American Burn Association
500.000 burn injuries, 40.000 admissions
4.000 deaths
Caused by : Fire (46%), scalds (32%), hot
objects (8%), electricity (4%), chemical agents
(3%)
38% >10% TBSA, 10% >30% TBSA
Age 19-44
Location : UE (41%), LE (26%), Head & Neck
(17%)
<5% full thickness

Rosens Emergency Medicine 7th E

PATHOPHYSIOLOGY
Three concentric zone
Zone of irreversible coagulative necrosis
Zone of ischemia
Zone of hyperemia

Regeneration comes from

Basal layer of cells
Dermal skin appendages (hair follicles
and sebaceous glands)

Rosens Emergency Medicine 7th E

PATHOPHYSIOLOGY
Clotting inflammatory cells
recruitment (B2-integrins, CD11b, CD18) cells
marginate to vessel walls (ICAM-1)
release of mediators and cytokines
(cytotoxic reactive oxygen and nitrogen species) lipid
peroxidation accumulation of
leukocytes, RBC, platelet
microthrombi reduce local
perfusion

Rosens Emergency Medicine 7th E

PATHOPHYSIOLOGY
Inhalation injury
Caused by steam, aldehydes, oxides of sulfur
and nitrogen, PVC, Hydrochloric Acid, CO
Airway edema & de-epithelization of injured
mucosa necrotic lining
pseudomembranous cast airway obstruction
Edema & congestion of pulmonary
parenchyma bronchospasm, inflammation,
destruction decreased lung compliance
microatelectasis progressive hypoxemia
ARDS

Rosens Emergency Medicine 7th E

CLASSIFICATION

1st degree epidermis

2nd degree superficial papilary dermis
2nd degree deep reticular dermis
3rd degree full thickness
4rd degree subcutaneous or deeper

Rosens Emergency Medicine 7th E

CLASSIFICATION
Percentage of TBSA involved
Rules of nine : 18% front trunk, 18%
back trunk, 18% each LE, 9% each UE,
9% head & neck, 1% perineal

Rosens Emergency Medicine 7th E

CLASSIFICATION
LUND-BROWDER CHART

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1ST & 2ND DEGREE BURN

INJURY

Rosens Emergency Medicine 7th Ed

1st degree
Fitzpatricks Dermatology in General Medicine 7th Ed

3RD
DEGREE
BURN
INJURY

Rosens Emergency Medicine 7th Ed

patricks Dermatology in General Medicine 7th Ed

4TH DEGREE BURN INJURY

Fitzpatricks Dermatology in General Medicine 7th

MANAGEMENT
Prior to ED arrival
Stop burning process, extinguish flame,
chemical injury tap water wash
Protect from additional injury
Adequacy of airway and ventilation intubation
CO poisoning 100% oxygen
Extensive burns IV fluid LR, Parkland Formula
Morphine sulfate 2-4mg IV bolus
Cover burns with clean dressing
Prevent hypotermia

Rosens Emergency Medicine 7th E

INPATIENT / OUTPATIENT

Fitzpatricks Dermatology in General Medicine 7th

MANAGEMENT
At Emergency Department (ABC!!)
Airway
Check for upper airway edema fiberoptic
laryngoscopy
Endotracheal intubation or crycothyrotomi if
needed
Escharotomies if needed
Maintain PO2 >92%
Urethral catheter monitor urine output
and eval for rhabdomiolysis and
myoglobinuria
NGT prevent gastric distention

Rosens Emergency Medicine 7th E

MANAGEMENT
Inhalation Injury

Fiberoptic laryngoscope & bronchoscopy

soot, charring, inflammation, edema,
necrosis
Injury to parenchyma xenon ventilation
(RARE)
Other : CO and cyanides
Treatment : mechanical ventilation,
aleveolar lavage, PO2 >92%, airway
pressure <35cm H2O, pH >7,25
Bronchospasm bronchodilators +
suctioning
N-acetylsistein with/without
heparin
Rosens
Emergency Medicine 7th E

Rosens Emergency Medicine 7th E

MANAGEMENT
Circulation and Fluid Resuscitation

Burn injury activate PG, Histamine, LT

Intravascular fluid extravasation fluid
depletion + soft tissue edema
Small burns oral fluid, Large burns IV
fluids
Volume Parkland Formula + adjustment
as needed
Adjustment criteria : HR, BP, Conciousness,
Capilarry Refill, urine output.
Additional fluid : inhalation injury, electrical
burn
Excessive fluid pneumonia,
sepsis,
ARDS,
Rosens
Emergency
Medicine 7th E

RESUSCITATION FORMULAS

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MANAGEMENT
Local Wound Care
Cleansing with soap + water, removal of
debris and necrotic tissue, TT booster
Cooling : tap water 10o-25o C up to
30mins after injury, avoid hypothermia,
ice/ice water contraindicated
Burn Blisters : Fluid confined by necrotic
skin heal faster less infection, 2nd
degree debridement + intact less
scaring, heal faster

Rosens Emergency Medicine 7th E

MANAGEMENT
Burn dressing
Open method : antimicrobial topical until
skin is re-epithelialized. Used on exudative
burn. Mostly used silver sulfadiazine and
mafenide acetate. Daily removed
Closed method : moist wound healing
environment heal faster. Mostly used :
Nanocrystalline silver.
At home : washing, apply topicals. Occlusive
should not be opened unless saturated or
malodorous go to ER. If swelling of fever
go to ER

Rosens Emergency Medicine 7th E

BURN DRESSINGS

Rosens Emergency Medicine 7th E

MANAGEMENT
Escharotomy
Releasing constriction of burn eschar
with scalpel
Eschar constriction interrupts
arterial outflow pain, loss of
sensation, delayed capilarry refill.
Indication: Doppler Signal & Pulse
oximetry <90%
Avoid to cut underlying vessels and
nerves

Rosens Emergency Medicine 7th E

MANAGEMENT
Pain Types and Management
3 phases of burn recovery
Emergency / Resuscitative Phase
Healing Phase
Rehabilitative Phase

In Emergency Phase, there are 3 kinds

of pain
Background Pain
Breakthrough Pain
Procedural Pain

Rosens Emergency Medicine 7th E

MANAGEMENT
Non pharmacologic
Cooling, tap water 10o-25oC
Moist occlusive dressing

Pharmacologic

Morphine Sulfate (0,05-0,1mg/kg) titrated

Acetaminophen (1g adults, 15mg/kg child) /4-6h
Ibuprofen (400-800mg adults, 10mg/kg child) / 6-8h
Fentanyl 0,5-1mg/kg
Lidocaine
Anxyolytics : benzodiazepin (Lorazepam)
Others : gabapentin, stimulants, B-Blockers,
antidepressants

Rosens Emergency Medicine 7th E

COMPLICATION

Fitzpatricks Dermatology in General Medicine 7th

COMPLICATION
Streptococcal Cellulitis

Fitzpatricks Dermatology in General Medicine 7th

HYPERTROPHIC SCAR
BEFORE SURGERY

AFTER SURGERY

Fitzpatricks Dermatology in General Medicine 7th

BURN PREVENTION

Rosens Emergency Medicine 7th E

SEPSIS SYNDROMES

DEFINITIONS
Activated Inflammatory cascade
cause the bodyd defenses and
regulatory system become
overwhelmed leading to disruption of
hemeostasis
Systemic Inflammatory Response
Syndrome (SIRS) 2 or more :
tachycardia, tachypnea,
hyperthermia or hypothermia, high
or low WBC count, bandemia.

Rosens Emergency Medicine 7th E

DEFINITIONS

Sepsis : SIRS + infection

Severe Sepsis : Sepsis + Organ
Dysfunction
Septic Shock : Severe Sepsis +
hypotension which is not responsive
to fluid challange
Approach : PIRO (predisposition,
infection source, response of host,
organ dysfuntion)
Bacteremia is not obligatory
in
Rosens Emergency
Medicine 7th E

EPIDEMIOLOGY
In United States :
10th most common
cause of death
571.000 cases of
severe sepsis
Mortality rate 2050%
Incidence

Rosens Emergency Medicine 7th E

PATHOPHYSIOLOGY
Infection host response
neutrophil and macrophage
mobilization to injury site release
cytokines inflammatory cascade
synthesis is not well regulated
sepsis
Ongoing toxin persistent
inflammatory response mediator
activation cellular hypoxia, tissue
injury, shock, Multi-Organ Failure,

Rosens Emergency Medicine 7th E

PATHOPHYSIOLOGY
Mediators of Sepsis
Proinflammatory : IL-1, IL8, TNF
Anti-inflammatory IL-10, IL-6 TGF B,
IL-1ra
Growth promoting

Arachidonat acid pathway

peripheral dilation, vasocontriction,
leukocyte and platelet aggregation
PG fever

Rosens Emergency Medicine 7th E

PATHOPHYSIOLOGY
Vasopressin release in stress
condition, cause vasoconstriction,
osmoregulation, maintenance of
normovolemia
NO Regulating vascular tone,
platelet adhesion, insulin secretion,
neurotransmission, tissue injurt,
inflammation and cytotoxicity

Rosens Emergency Medicine 7th E

ORGAN SYSTEM DYSFUNCTION

AND DEATH

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ORGAN SYSTEM
DYSFUNCTION
Neurologic
Altered mental status and lethargy septic
encephalopathy

Cardiovascular
Myocardial depression : killed organism /
bacteria
Distributive shock : toxic mediators
Early sepsis : Cardiac output , vascular
resistance
Reversible cardiac function usually in 10 days

Rosens Emergency Medicine 7th E

ORGAN SYSTEM
DYSFUNCTION
Pulmonary
Right-to-left shunting, arterial
hypoxemia, intractable hypoxemia
Sepsis : High catabolic state + airway
resistance ARDS

Gastrointestinal
Ileus hypoperfusion. splanchnic blood
flow.
Aminotransferase + bilirubin
hepatic failure (rare)

Rosens Emergency Medicine 7th E

ORGAN SYSTEM
DYSFUNCTION
Endocrine
Adrenal insufficiency
IL-1 & IL-6 activate hypothalamicpituitary axis
TNF-A & corticostatin, depressed bloow
flow, depress pituitary function and
secretion

Hematologic

DIC, fibrin deposition, microvascular

thrombi
Associated with Protein CRosens Emergency Medicine 7th E

CLINICAL SIGNS &

SYMPTOMS
Identify systemic infection and the source
Altered conciousness intubation
Systemic Infection : tachycardia,
tachypnea, hypo/hyperthermia,
hypotension (severe)
Flushed/warm skin while in vasodilation
state
Hypoperfused mottled and cyanotic
Shock exclude other shock etiologies
Use MEDS score for risk stratification

Rosens Emergency Medicine 7th E

MEDS
SCORE

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SOURCE OF INFECTIONS
Respiratory (most common) : cough, fever,
chills, throat and ear pain, pneumonia, etc
GI (2nd most common) : abdominal pain,
Murphy sign, McBurney Sign, etc
Neurologic : meningitis
Genitourinary :Flank pain,dysuria,polyuria,
etc
Musculoskeletal
IV drug abuse, artificial heart valve,
endocarditis

Rosens Emergency Medicine 7th E

DIAGNOSTIC FEATURES
Hematology
Leukocytosis
Febrile neutropenic admission, isolation,
empirical IV antimicrobial
Bandemiarelease of immature cell from
marrow
Ht >30%, Hb >10g/dL
Acute phase platelet
Low platelet shock
Thrombocytopenia, pTT & aPTT , fibrinogen
, DIC & severe sepsis syndrome

Rosens Emergency Medicine 7th E

DIAGNOSTIC FEATURES
Chemistry
bicarbonate acidosis & inadequate
perfusion
serum creatinine ARF
Lactate inadequate perfusion, shock
Arterial blood gas detect acid base
disturbance
Metabolic acidosis inadequate perfusion
Bilirubin source from gallbladder
Amilase & Lipase pancreatitis

Rosens Emergency Medicine 7th E

DIAGNOSTIC FEATURES
Microbiology
Culture from blood, sputum, urine, CSF, tissue
Obtained before/soon after AB administration
Start with empirical therapy

Radiology
Chest pneumonia, ARDS
Bowel perforation free air aunder
diaphragm
Pneumomediastinum esophageal
perforation, mediastinitis

Rosens Emergency Medicine 7th E

DIAGNOSTIC FEATURES
Ct-Scan diverticulitis, appendicitis,
necrotizing pancreatitis,
microperforation, intra-abdominal
abscess
Head CT septic emboli
Abdominal USG Cholycystitis
Pelvic USG endometritis
Transesophageal USG --> endocaditis
MRI soft tissue

Rosens Emergency Medicine 7th E

DIFFERENTIAL DIAGNOSIS

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MANAGEMENT
Principles
AB therapy
Maintenance of adequate tissue
perfusion

Rosens Emergency Medicine 7th E

MANAGEMENT
Respiratory Support
Airway protection, intubation,
mechanical ventilatory support if
needed

Cardiovascular support

Initial therapy 2L of isotonic

crystalloid
Normal Saline/ LR.
Maintain MAP >65mmHg, but 75mmHg
in patient ith history of severe
hypertensive patient
Rosens Emergency Medicine 7th E

MANAGEMENT
Drugs : Vasopresin, Norepinephrine,
Dopamine, Phenylephrine, Epinephrine.
Inotropic agents : Dobutamine,
Bicarbonate, AB

Novel Therapies
Activated Protein C
Steroid Therapy

Rosens Emergency Medicine 7th E

MANAGEMENT

Rosens Emergency Medicine 7th E

Rosens Emergency Medicine 7th E

REFERENCES
Marx JA, Hockberger RS, Walls RM,
Adams JG, editors. Rosens
Emergency Medicine Concepts and
Clinical Practice. 7th Ed. Philadelpia :
Mosby Elsevier, 2010
Wolff K, Goldsmith LA, Katz SI,
Gilchrest BA, editors. Fitzpatricks
Dermatology in General Medicine.
7th Ed. New York : McGraw-Hill, 2008