dr. Anang P.

Atmojo
TBM ALERT VI

Total Care
on Burn Patient
Rosadi Seswandhana
Plastic Surgeon
Dept of Surgery, Faculty of Medicine
Gadjah Mada University

Diberikan dalam rangka

Rangkaian pelatihan internal TBM ALERT
SIMULASI GAWAT DARURAT BENCANA
12 - 22 Februari 2015
Epidemiology

(ABC Burn, 2006)

Mortality

(ABC Burn, 2006)

Skin Anatomy the total skin area
of adult humans covers approx.
1 to 2 square meters
 Function of the skin
Protection
against cold, Absorption Regulation of
Protection of active
heat, against circulation and
radiation Protection agents temperature
chemicals Protection
against against
pressure and microbes
friction

7 9
2 3
1 4 6 8
10

5 5

Protection against Sense of pressure, touch,

loss of temperature pain and temperature
and water
 Pathophysiology of Burn
Local tissue destruction
Systemic inflamatory response
Burn = Coagulative destruction of the skin or mucous
membrane
Caused by heat, chemical or irradiation
Thermal damage occurs above 48 C
Extent of necrosis is related to temperature and duration of
contact
Burns can result in:
Increased capillary permeability and fluid loss
Hypovolaemia and shock
Increased plasma viscosity and microthrombosis formation
Haemoglobinuria and renal damage
Increased metabolic rate and energy metabolism
3 Zones of Thermal Injury
Hyperemia

Stasis

Coagulation
 Local response
Zone of coagulation This
occurs at the point of
maximum damage.
Irreversible
Zone of stasisThe
surrounding zone of stasis is
characterised by decreased
tissue perfusion. Potentially
salvageable.
Zone of hyperaemiaIn this
outermost zone tissue
perfusion is increased.
Usually Recover

(ABC Burn, 2006)

 Systemic response
The release of cytokines and
other inflammatory mediators at
the site of injury has a systemic
effect once the burn reaches 20-
30% of total body surface area
Cardiovascular changes
Capillary permeability is
increased. Peripheral and
splanchnic vasoconstriction
occurs. Myocardial contractility
is decreased. Fluid loss from the
burn wound hypoperfusion.
Respiratory changes
Inflammatory mediators cause
bronchoconstriction, ARDS
Metabolic changesBMR
increases >3x. Splanchnic
hypoperfusion
Immunological changesNon-specific
down regulation of the immune response
occurs, affecting both cell mediated and
humoral pathways.
(ABC Burn, 2006)
The capillary leakage
Increase of capillary permeability let
the intravascular fluid shifted to the
interstitial space:
hypovolemia
the edema formation

Electron microscopic exam

The Goals in the acute situation
To maintain oxygen perfusion to the vital
organs; acutely, heart and brain (life
saving)
To prevent a worsening of the situation
(minimize morbidity)
Important Consideration
1. Etiology
2. The depth of skin burn
3. Size and extent of the burn
wound
 Etiology
1. Temperature
High ( Fire, Boiled Water, Steam )
Low ( Frost Bite )
2. Electric
3. Chemical
Base Acid
4. Radiation
5. LASER
 The Depth of Burn
Wound
Superficial Skin Burn (1st O)
Pain, Erythema, epidermal slough 1-4 days later
Partial Thickness Skin Burn (2nd O)
Pain, Blisters within 1-6 hours, erythema,
tenderness, good capillary refill
Full Thickness Skin Burn (3rd O)
Insensate, leathery, thrombosed vessels, no
capillary refill
 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.
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
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.
Size and extent of the
burn wound Rule of Nines
TABEL
LUND &
BROWDER
Management

PRE HOSPITAL
STOP - DROP - ROLL
Prevent Heat Restore
Electric injury breaking
down the voltage
Chemical dilution
 Assessment
Initial assessment should be by ATLS
principles
Good early management is required to
prevent morbidity or mortality
 Primary Survey
A Airway
B Breathing
C Circulation / C-spine / Cardiac status
D Disability / Neurologic Deficit
E Exposure and Examination
F Fluid Resuscitation
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
Acute phase
Rescusitation Breathing
B: Circumference Full thickness skin burn on the
chest wall mechanical ventilation disturbance
ESCHAROTOMY

(ABC Burn, 2006)

Escharotomy
Komplit eskarotomi
 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)
Smoke injury Soot in nostrils or sputum
Nebulizer
Perform intubation, artificial
ventilation and bronchial toilet (if needed)
Acute phase
Rescusitation Circulation (C)
Systemic :
If patient arrived with shock condition
2 line
First IVFD RL 20 ml/Kg BW in 15-30
minutes
Local :
Circumference Full thickness skin
burn on extremity compartment
syndrome 5P ESCHAROTOMY
Escharotomy on extremity
Acute phase
Disability (D)
GCS
Lateral Sign
CO intoxication
Hipovolemic shock

Exposure (E)
Burn Size (% TBSA)
Depth of Burn Wound
Other trauma
Acute phase
Fluid Resucitation (F)

(Mathes, 2006)
(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 (%)
 Case

Patient with 50 Kg BW and 30% BSA

Fluid Needed : 4 x 50 Kg x 30 %
6000 cc 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 30 ml / hour
Child 1-2 ml / Kg / hour
Breathing sound
Severe burn (>40%) apply Central Venous Catheter
Nasogastric tube production beware of stress ulcer
Hb, WBC, Plt, Hematocrit, Electrolite, Albumin, GDR,
Kidney Function, Liver Function, BGA
ECG, Thorax X-ray
Emergency
burn
pathway

(ABC Burn, 2006)

(Mathes, 2006)
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
Criteria for burn center referral
2nd Degree Burn> 15% Adult
> 10% Child
3rd Degree Burn> 5%
Electric/Chemical
Burn Wound on the face, hand, genital
and perineal
Other trauma or sistemic disease
 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)
 Method of feeding
Enteral
Oral
Nasogastric
Nasoduodenal
Parenteral
Partial
Enteral vs Parenteral
Total Oral vs Tube

Tube feeding has advantages

over than regular oral intake
 Pain Control
Severe pain negative impact
Dressing, regular bedside debridement
need high dose of opiates and sedatives
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)
Objective of Wound Care
Avoid wound conversion
Remove devitalized tissue
Bed granulation preparation
Minimal level of infection
Autografting preparation
Scar abnormality and contrature
prevention

WOUND CARE FOR THE ADULT BURN PATIENT

By Judy Knighton, RN, BScN, MScN
General Principles of Daily Care
If conversion is going to occur, it is typically several days (sometimes weeks) post-burn

Continue monitoring if indicated

Avoid hypothermia

- warm room
- warm water
- do not expose entire body at once

Avoid Cross-Contamination

- Wear caps, masks, gown, gloves wash hands before and after
- Expose, clean, and rewrap less infected areas first
- Look for sources of bacteria in equipment used

Assure Adequate Control of Pain, Anxiety, Fever

- Pre-indication with narcotics and short-acting sedative

- Use intravenous route
- Consider antipyretic pre-treatment pre-burn care

Wound Dressing

- Use comfortable but no immobilizing dressing, as muscle activity is important! (exception: new grafts)

http://www.burnsurgery.org/Modules/
 Initial wound care
Stop the burning process
Clean the wound
Cover. Clean, moist, nonadherent
dressing
Analgesia
Wound debridement
Controversy: Blister debridement
Moist concept in wound
healing

Exposed method Moist method

 Wound Care
1st O no spesific treatment

2nd O
Cleansed with NaCl + Savlon
500 ml 5 ml
Tule + sterile thick gauze
or Biological dressing
(Observation in one week)
MEBO
Controversy: Usage of Silver Sulfadiazin
(Deep 2nd O)
 Latest
Salep mata kloramfenikol 1% utk
gr.1 dan gr.2 kelembaban
didapat utk reepitelisasi
Mebo Sibro Masbro ? -,-
Mebo merangsang hipergranulasi
Sofratul sebelum balut kassa
 Wound Care
3rd O
Cleansed with NaCl 500 ml + Savlon 5 ml
Daily debridement
Daily Silver Sulfadiazin (Dermazin /
Burnazin)

Plus Surgical Treatment

 Latest
Debridement 1x/2hari untuk epitelisasi
maksimal tiap hari bila sangat produktif
Bioplacenton X
Dressing Sofratul+kassa kering atau
kassa lembab bila tdk ada sofratul
Absorben dressing pd kasus debris dan
nanah yg sangat produktif
 Kontroversi
Tdk ada antibiotik yg bisa menyerap
masuk ke jaringan nekrotik pada gr.3
SS mebuat jar.nekrotik lebih
lembek mudah debridement atau
eksisi jar.nekrotik
Burn Tank
 Surgical Treatment
Sequential excision
Daily removal of loose debris
Escharectomy
Excise the obvious full thickness burn
About 10 days post-burn
Tangential excision
Shaving the eschar with skin graft knives + skin subtitute
Usually done 48 to 72 hours post-burn
Primary excision
Excision to the fascial level acutely
Usually done 48 to 72 hours post-burn
(Achauer, 1987)
 Pisau
Diatermi
 Skin Subtitutes
Autograft (different location within the same
individual)
Isograft (from a genetically identical donor to the
recipient)
Biological dressing
Allograft (homograft in older terminology)
Xenograft (heterograft in older terminology)
Amnion
Synthetic skin (silicone polymers / composite
membranes)
Cultured epithelium (provide coverage, albeit fragile,
for large wounds)
Combination
 Complication
Sub-acute infection SIRS
MODS Death
Stress ulcer
Pressure sore

Late contracture
Risk of infection

(ABC Burn, 2006)

 Non Surgical Treatment
Antibiotic prophylactic?
Sistemic vs Local
ATS Tetagam? 3rd O, large burn size
GIT protector
Antidecubital bed / care
Splinting
Antioxidant
Imunomodulator
Inotropic (if needed)
How to choose topical agent
Clinical efficacy
Wide antibacterial spectrum
Toxicity, absorption
Frequency of superinfection
Ease and flexibility of use
Cost
Acceptance by patients and staff
 Topical agent
Silver sulphadiazine 1% (Flamazine )
Silver sulphadiazine 1% chlorhexidine digluconate 0.2% (Flamazine C)
Mafenide acetate 2% (Sulfamylon)
Silver nitrate 0.5%
Povidone iodine 10% (Betadine)
Nitrofurazone (Furacin)
Gentamycin sulphate (Garamycin)
Bactracin with polymyxin B (Polysporin)
Normal saline 0.9%
Acetic Acid 0.5%
Hydrogen peroxide, half-strength

MEBO (SIBRO)
Physiotherapy & Splinting
Acute phase
Surgical phase
Rehabilitation phase
 Acute phase
Objective:
Keep lungs clear
Preserve function
Minimise swelling
Using
Chest Physio
Passive exercise
Splinting
Ilustration
 Surgical Phase
Objective:
Increase strength
Using:
Active motor exercise
Chest physio
mobilisation
 Rehabilitation
Objective: to get the patient back to
work
Using:
More strengthing exercise
Task specific goals
Case 1, Boy, 15 y.o.
Electric Burn
Case 2, Male, 30 y.o.
Chemical burn
Case 3, 1 year finger contracture
Release + FTSG
Case 4, 10 years axilla contracture
Local Skin Flap + STSG
Case 5, Arm electrical injury
LD MC Flap + Skin Graft
Case 6, Scalp electrical injury
LD Free Flap + STSG
 Electrical injury
Beware of cardiac rythm abnormality
closed ECG evaluation in the first 2 days
Beware of extensive rhabdomyolisis
Beware compartment syndrome fasciotomy
Beware of renal failure high urine output
fluid therapy 100 cc/hour (Manitol)
Tx: 2 amp Manitol (25 g) followed
immediately 2 amp bicarbonate, IV push
 Shock Severity
Severity of the shock depends
on:
Path of current through the body
Amount of current flowing
through the body (amps)
Duration of the shocking current
through the body,

LOW VOLTAGE DOES NOT

MEAN LOW HAZARD
88
PRINCIPLES OF ELECTRICITY
Electricity is the flow of electrons (the
negatively charged outer particles of an
atom) through a conductor.

when the electrons flow away from this

object through a conductor, they create an
electric current, which is measured in
Amperes (I).

The force that causes the electrons to flow is

the voltage, and it is measured in Volts (V).

Anything that impedes the flow of electrons

through a conductor creates resistance,
which is measured in Ohms (R).
 Resistance of Body Tissues
Least
Nerves
Blood
Mucous membranes
Muscle

Intermediate
Dry skin

Most
Tendon
Fat
Bone
Immediate death may occur from:

1) Current-induced ventricular fibrillation

2) Asystole

3) Respiratory arrest secondary to:

Paralysis of the central respiratory control system
Paralysis of the respiratory muscles
 Cutaneous Injuries & Burns
Extensive flash and flame burns

Hemodynamic, autonomic, cardiopulmonary,

renal, metabolic and neuroendocrine responses
Management of Electrical and
Lightning Injuries

Overall fluid management should be

judicious unless: SIADH
 Patient Monitoring
Most severe cardiac complications present
acutely

Very unlikely for a patient to develop a

serious or life-threatening dysrhythmia
hours or days later

Asymptomatic normal ECG do not need

cardiac monitoring
 Preexisting heart disease: monitor such
patients for 24 hrs after the injury

Criteria for cardiac monitoring:

Exposure to high voltage
Loss of consciousness
Abnormal ECG at admission
 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
Thank you
TERIMA KASIH