ACUTE BURN MANAGEMENT

dr. Iqmal Perlianta, SpBP-RE

0821 799 13501
FK UNSRI MADANG
Palembang, 17 Sept 2014
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HIGH MORBIDITY AND MORTALITY RATE

U.S : 2 3 MILLION / YEAR
MORTALITY RATE : 5 6 THOUSAND / YEAR
CIPTO MANGUNKUSUMO HOSPITAL (1998)
ADMISSION NUMBER : 107
MORTALITY RATE : 37,78%
DR. SOETOMO HOSPITAL (1999 - 2005)
ADMISSION NUMBER : 739
MORTALITY RATE : 29,8%
ITS A CHALLENGE FOR US

BURN PHASES
1. ACUTE / SHOCK / EARLY PHASE
- IMMEDIATE / EMERGENCY ROOM
- AIRWAY & FLUID PROBLEM
- WOUND
2. SUBACUTE PHASE
- DURING ADMISSION
- WOUND, INFECTION, SEPSIS PROBLEM
3. LATE PHASE
- AFTER DISCHARGED
- SCAR & CONTRACTURE PROBLEMS
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ACUTE PHASE
MANAGEMENT

ETIOLOGY
1.

FIRE

2.

SCALD: air mendidih

3.

CHEMICAL SUBSTANCES

4.

ELECTRIC & RADIATION

5.

SUNBURN

6.

STOVE / GAS EXPLOSION

7.

BOMB EXPLOSION
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Burn
Capillary permeability and osmotic
force change
Fluid and protein shift
Total blood volume have been lost
Burn shock

DEPTH ASSESSMENT
1. 1st DEGREE
- EPIDERMIS
2. 2nd DEGREE
- SUPERFICIAL
- DEEP

3. 3rd DEGREE
- EXTENSION TO MUSCLE / BONE
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WOUND EXTENT

WALLACE

RULE OF NINE

Head & neck

9% --------> 9%

Upper extremities

9% --------> 18%

Anterior of the body --------------> 18%

Posterior of the body ------------>

Lower extremities

Genital / perineum

Total

18%

18% -------> 36%

------------->

1%

----------------------------- 100%
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ADULT

JUVENILE - CHILDREN
10
9

14
9

18 18

18

18 18

18
15 yrs

18

16

18 18

16 14
5 yrs

14
0 1 yr

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SEVERITY CRITERIA
(AMERICAN BURN ASSOCIATION)

1. MILD
- 2nd DEGREE < 15%
- 2nd DEGREE < 10% IN JUVENILES
- 3rd DEGREE < 1%

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2. MODERATE
- 2nd DEGREE 15-25% IN ADULTS
- 2nd DEGREE 10-20% IN JUVENILES
- 3rd DEGREE < 10%

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3. SEVERE
- 2nd DEGREE >25% IN ADULTS
- 2nd DEGREE >20% IN JUVENILES
- 3rd DEGREE >10%
- AFFECTED HANDS, FACE, EARS, EYES, FEET, AND
GENITAL / PERINEUM
- INHALATION INJURY, ELECTRICAL INJURY, OR ASSOCIATED WITH
OTHER TRAUMAS

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I. PRIMARY SURVEY
II. SECONDARY SURVEY
III.INITIAL CARE OF THE BURN WOUND
IV. INITIAL LABORATORY STUDIES
V. BURN CENTER REFERRAL
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I.

PRIMARY SURVEY :
LIKE ANY OTHER TRAUMA

A. AIRWAY & CERVICAL SPINE PROTECTION

B. BREATHING & VENTILATION
C. CIRCULATION & HEMORRHAGE CONTROL
D. DISABILITY NEUROLOGICAL EXAMINATION
E. EXPOSURE

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II. SECONDARY SURVEY :

A. HISTORY TAKING
B. PHYSICAL EXAMINATION /
HEAD TO TOE EXAMINATION
C. PRINCIPALS :
1.

STOP THE PROCESS CAUSING BURN WOUNDS

2.

UNIVERSAL PRECAUTION, HIV, HEPATITIS

3.

FLUID RESUSCITATION : 2-4 CC RL X KG BW X %WOUND

SURFACE

4.

VITAL SIGN

5.

NASOGASTRIC TUBE / IF NECESSARY

6.

URINARY CATHETER / IF NECESSARY

7. PERFUSSION ASSESSMENT
8. CONTINUED VENTILATORY ASSESSMENT
9. PAIN MANAGEMENT
10.PSYCHOSOCIAL ASSESSMENT
11.TETANUS TOXOID PROFILAXIS
12.MEASURING BODY WEIGHT
13.WOUND CLEANSING (OPERATING THEATRE, GENERAL
ANAESTHESIA)
14.ESCHAROTOMY & FASCIOTOMY

FLUID RESUSCITATION
EVANS FORMULA
BROOKES FORMULA
PARKLANDS FORMULA
BROOKES MODIFICATION
MONAFOS FORMULA
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BAXTERS FORMULA
DR. SOETOMO GENERAL HOSPITAL
DAY 1 :
ADULT:

RL 4 CC X KG BW X %WOUND SURFACE / 24 HRS

ANAK :

RL : DEXTRAN = 17 : 3
2 CC X KG BW X %WOUND SURFACE +
MAINTENANCE
MAINTENANCE :
< 1 YR
: BW X 100 CC
1-3 YRS : BW X 75 CC
3-5 YRS : BW X 50 CC
IN FIRST 8 HRS
NEXT 16 HRS

DAY 2 :
ADULT

: MAINTENANCE
ALBUMIN (IF NECESSARY)

JUVENILE : MAINTENANCE

MONITORING FLUID RESUSCITATION

1.

URINARY PRODUCTION PER HOUR

ADULT

: 0,5 CC/BW/HR (30-50 CC/HR)

JUVENILE : 1 CC/BW/HR
2.

OLIGURIA
ASSOCIATED WITH SYSTEMIC VASCULAR RESISTANCE &
CARDIAC OUTPUT RECUCTION

3.

HAEMOCHROMOGENURIA (RED PIGMENTED URINE)

4.

BLOOD PRESSURE

5.

HEART RATE

6.

HAEMATOCRITE & HAEMOGLOBIN

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CLOSED WOUND MANAGEMENT

WOUND CLEANSING, DEBRIDEMENT, & DESINFECTION WITH

SAVLON 1 : 30

TULLE Sofra-Tulle(framycetin): Luka karena panas, trauma,

ulserasi, infeksi sekunder & elektif pd kulit., framycetin.

TOPICAL SILVER SULFADIAZINE (SSD)

THICK STERILE GAUZE / ELASTIC BANDAGE

OPEN THE WOUND DRESSINGS AT DAY 5 UNLESS THERE IS

ANY SIGN OF INFECTION

PERFORM UNDER GENERAL ANAESTHESIA (IN THE OPERATING

THEATRE)

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III. LABORATORY EXAMINATION

BURNS IMPAIR ORGAN FUNCTIONS

BASELINE LABORATORY TESTS

1.
2.
3.
4.

HAEMATOCRITE
COMPLETE BLOOD COUNT (Hb)
ALBUMIN
RFT & LFT

5. ELECTROLITE, Na, K, Cl, HCO3

6. BLOOD UREA NITROGEN
7. URINALYSIS
8. CHEST X-RAY
9. ARTERIAL BLOOD GAS (INHALATION INJURY)
10. CARBOXY HAEMOGLOBIN
11. ECG (ELECTRIC INJURY)

Functions of the skin

Protection
intact skin is the first line of defense against
bacterial and foreign-substance invasion

Heat regulation
Sensory preception
Excretion
Vitamin D production
Expression
important with body image - fear of disfigurement
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STAGES OF BURNS
Hypovolemic state
begins at the onset of burn and lasts for the first 48
hours - 72 hours
Rapid fluid shifts - from the vascular compartments
into the interstitial spaces
Capillary permeability with burns increases with
vasodilation
Fluid loss deep in wounds

Initially Sodium and H2O

Protein loss - hypoproteninemia

Hemoconcentration - Hct increases

Low blood volume, oliguria
Hyponatremia - loss of sodium with fluid
Hyperkalemia - damaged cells release K, oliguria
Metabolic acidosis
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STAGES OF BURNS
Diuretic Stage
begins 48 - 72 hours after burn injury:
Capillary membrane integrity returns
Edema fluid shifts back into vessels - blood volume
increases
Increase in renal blood flow - result in diuresis (unless
renal damage)
Hemodilution - low Hct, decreased potassium as it
moves back into the cell or is excreted in urine with
the diuresis
Fluid overload can occur due to increased
intravascular volume
Metabolic acidosis - HCO3 loss in urine, increase in fat
metabolism
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SIGNS OF ADEQUATE
FLUID RESUSCITATION :
Clear sensorium
Pulse < 120 beats per minute
Urine output for adults 30 - 50
cc/hour
Systolic blood pressure > 100 mm Hg
Blood pH within normal range 7.35 7.45
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Organisms that usually

infect burns are:
a. Staphylococcus aureus
b. Pseudomonas Infection is usually
the cause of any deterioration

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Signs of Sepsis:
a. Change in sensorium
b. Fever
c. Tachyapnea
d. Paralytic ileus
e. Abdominal distention
f. Oliguria

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Ways to prevent infection:

a. Gowns, masks, gloves
b. Sterile linen
c. Persons with URI should not come in
contact with patient
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WOUND CARE PRINCIPLES

1.

GOALS
1.
2.
3.
4.

2.
3.
4.
5.

close wound as soon as possible

prevent infection
reduce scarring and contractures
provide for comfort

Wound cleaning + closed technique

Debridement, mechanical, surgical, enzymatic
Topical antibacterial therapy mafenide (sulfonamide)
sulfadiazine
Biological dressing
- Homograft (cadaver skin )
- Heterograft
- Autograft
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IV. BURN CENTER REFERRAL

REFERRAL CRITERIA
1. 2nd degree >10%
2. Affecting face, hands, genital, perineum, & main
joints
3. 3rd degree
4. Electric injury
5. Chemical injury
6. Inhalation injury
7. Juveniles
8. Associated with other traumas
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ACUTE BURN

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Carbon monoxide poisoning

Inhalation injury above the glottis
Inhalation below the glottis
Any victim, burned in a closed area, like a
house fire, should be presumed to have an
inhalation injury until proven otherwise

INHALATION INJURY

INHALATION INJURY

INHALATION
INJURY

Fullthickness
circumferential
burns

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CLINITRON BED
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