Manajemen LUKA

BAKAR

Henni Kusuma
 Burn

Suhu

Kimia

Electrical
Derajat Burn

Epidermis
Dermis
Subcutaneous tissue
& fat
Muscle
Derajat 1

SUPERFICIAL
• Epidermal layer
• Pink, painful, and edematous
• Heals 3-5 days w/o scarring
Derajat 2

Epidermis & papillary

dermis
• Blisters, bullae, cairan
• tampak merah dan lembab
• nyeri,
• Edematous
• sembuh 7-28 hari dgn sedikt skar
minimal scarring
Derajat 2 dalam

Epidermis & reticular dermis

• Blisters, bullae, cairan serous
• agak pucat dan lembab
• nyeri
• Edematous
• sembuh 7-28 hari dgn skar
Derajat 3
Sampai jaringan subkutanous
• putih, kuning, hitam kecoklatan e
• thrombosed vessels, hilang
elastisitas, edema
• mungkin e escharotomy
• nyari bila sentuh
• perlu grafting
Derajat 4

Sampai ke otot
• hilang fungsi
• hitam, pucat
• kadang amputasi
• perlu escharotomy and
fasciotomy
 Capillary and fluid dynamics

The body´s fluids are composed of water,

electrolytes, proteins, and other substances
contained in the intracellular and extracellular compartments

The size of all cells is controlled by the

movement of water between the compartments
 Capillary and fluid dynamics

Since water is in motion, the pressure that is generated is

termed osmotic pressure

The osmotic activity that results is due to the number,

not the size, of non-diffusible particles

Water molecules, separated by a semipermeable

membrane, will move from the compartment with the
lesser number of nondiffusible particles to the
compartment with more
 Capillary and fluid dynamics
Because the hydrostatic pressure is higher at the arterial
end of a a capillary than at the venule end, fluid can move
out at the arterial end.

At the venule end of the capillary, the hydrostatic pressure

is lower.

The capillary colloid osmotic pressure is the dominant

pressure that pulls fluid back into the capillary at the
venule end
 Hydrostatic Pressure
Osmotic pressure is the hydrostatic pressure produced by a
solution in a space divided by a semipermeable membrane due
to adifferential in the concentrations of solute.

The principles of the equilibrium of fluids.

Relating to fluids at rest or to the pressures they exert or
transmit

This pressure drives fluid out of the capillary (i.e., filtration),

and is highest at the arteriolar end of the capillary and lowest
at the venular end.
 Capillary Plasma Oncotic
Pressure
Because the capillary barrier is readily permeable
to ions, the osmotic pressure within the capillary
is principally determined by plasma proteins that
are relatively impermeable.

Therefore, instead of speaking of "osmotic"

pressure, this pressure is referred to as the
"oncotic" pressure or "colloid osmotic" pressure
because it is generated by colloids.
 Capillary Plasma Oncotic
Pressure
Albumin generates about 70% of the oncotic pressure.
This pressure is typically 25-30 mmHg.

The oncotic pressure increases along the length of the

capillary, particularly in capillaries having high net
filtration (e.g., in renal glomerular capillaries), because
the filtering fluid leaves behind proteins leading to an
increase in protein concentration
 Capillary Plasma Oncotic
Pressure
Protein, the only ; dissolved particles in the plasma that
do not pass through the pores of the cell's
semipermiable membrane, are responsible for generating
the ' capillary colloid osmotic pressure.

Any disruption in the integrity of the capillary

membrane will lead to a reduction in the capillary
osmotic pressure and a loss of intracapillary water into
the interstitium
 ATHOPHYSIOLOGY AS A BASIS FOR
SIGNS AND SYMPTOMS

Skin and Soft tissue Injury

 Heat, or thermal energy, which the body

cannot
 dissipate,can burn the layer of the skin and

 underlyinng structures

 Severe burns on the skin present zones of

injury
Next...

 Zone of coagulation,The affected cells form an

area of coagulation at the center where the tissue
is not viable.
 Zone of stasis) Surrounding the zone of
coagulation is the area where capital occlusion,
diminished perfusion, and edema occur 24 to 48
hours after the burn.
Next..

 zone of hypoxemia (increased blow now) This

is the area around the zone of stasis. The
increased flow is one of the consequences of the
resulting inflammatory response
Area yang perlu diperhatikan

• Face
• Ears
• Hands
• Feet
• Joints
• Perineum
Manajemen
 Wound Care
• awal wound care
– Isolasi atau universal precautions
– luka bersih – blisters debrid
– cukr rambut ; cegah infeksi
• wound care setiap hari
– nyeri : analgetik
– Dressings
– angkat topical yang lama dan pelan cuci luka.
Debridement
– jangan agresif : menyebabkan perdarahan
– dapat terangkat oleh “coarse mesh gauze”
– Debrided dengan sedasi / analgesic
 Kaji infeksi
Disorientasi, menurun urin output, metabolic
acidosis, tachypnea, tachycardia, paralytic ileus,
hyperglycemia, hyper/hypothermia
kaji hamparan bakteri :
- Isolation
 Penanganan
TOPICAL AGENTS:
SSD [Silvadene - silver sulfadiazine
cream] ;
– larut air & non-toxic, bebas nyeri
– Bacterial spectrum gram + / - &
candida albicans
– eskar lembut
– beri 1 or 2 x/hari
Mafenide acetate krem - Sulfamylon
– Bacterial spectrum gram + / - &
anaerobes,
– dapat timbul metabolic acidosis
– Bacitracin or Petroleum ointments
– partial thickness burns – bibir & muka:
gram + & MRSA
Silver Nitrate [wet dressings]

Dakin's Solution [0.025% sodium

hypchlorite]

Bactroban [Mupericin] ointment

Biobrane
– Biosynthetic dressing (donor sites or
mesh autografts)
Xeroform
Utama donor sites
Acticoat
– steril, membunuh; Pseudomonas
aerginosa, Pseudo stutzeri, and E-Coli
– mengurangi imbalance electrolyte
– effektif untuk “bacterial penetration”
Temporary Grafts
– Heterograft > non-human
– Homograft > human [i.e. cadaver or live
donor]
– Allograft > non-human
– Autograft > human [sheet/mesh];
– Xenograft > non-human
DONOR SITES - autografting
– Dressings yang digunakan
• Conformant
• Xeroform
• Beta Glucan
• Acticoat
• Silvadene
• Biobrane
• Sulfamylon Solution
 Dressing lain
Untuk eskar lunak:
 hydroactive gel

 Sorbact gel
 General Management

2. In-hospital

 Emergency department (emergency room)

 Triage: patient selection (degree of severity)

1. Critical 2. Attention 3. Save 4. Dead

 Problem identification: ABC traumatology

 General Management

2. In-hospital

 Emergency department (emergency room)

 Triage: patient selection (degree of severity)

 Problem identification
 Resuscitation (life saving) and monitoring

 → Hemodynamic stability: perfusion

 Problem identification and Resuscitation

A. Deteriorated Airway : Inhalation injury

 Inflammation of upper respiratory tract mucosa due to exposure

to thermal source or inhaled toxic fumes lead to bronchial
obstruction followed by respiratory distress that is fatal. The
victim suffering respiratory distress (restless, increased
respiratory rate and hypoxic)
 Immediate endotracheal tube insertion or cricothyroidotomy is
mandatory to allow better oxygen input
 Inhalation therapy: oxygen delivery, humidification, positioning.
 Problem identification and Resuscitation

C. Deteriorated Circulation(hypovolemic shock, burn shock)

 Endothelial hyper-permeability lead to fluid flux lead to edema

formation (interstitial edema) and inadequacy of circulation
(hypovolemia); followed by hypo-perfusion. Unconsciousness,
restless, increased respiratory and heart rate, low to normal blood
pressure, decreased peripheral temperature, oliguria to anuria)
 Multiple intra venous access and rapid fluid administration is
mandatory
 Problem identification and Resuscitation

C. Deteriorated Circulation(hypovolemic shock, burn shock)

 Others:

 Lack of perfusion to extremities should be managed by

escharotomy and or fasciotomy
 General Management

2. In-hospital
 General Management

2. In-hospital

 Intensive Care Unit (ICU)

 Late resuscitation and Fluid management
 Reduce hypercatabolic state following shock let the administered
fluid and calorie meet the requirement
 Sedation, ventilated

 Close monitoring

 → Hemodynamic stability: perfusion

 General Management

2. In-hospital

 Intensive Care Unit (ICU)

 Fluid management
 To achieve better perfusion, in spite of fluid:
 Vasoactive: vasopressors, inotopics, etc
 Control of hyperglycemia: insulin
 Control of inflammation: low dose steroids
 Gut feeding (Enteral Nutrition) despite Parenteral Nutrition
 Homeostasis
 Continuous Renal Replacement Therapy
 General Management

2. In-hospital

 Wound management

 Shock phase : escharotomy, fasciotomy

 Stable hemodynamic
: escharectomy, necrotomy,
debridement, wound toilet
(source control)
skin grafting / other modalities
(definitive treatment)
Consensus Formula
Lactated Ringer’s solution (or other balanced saline solution): 2–4 mL
× kg body weight × % total body surface area (TBSA) burned. Half
to be given in first 8 hours; remaining half to be given over next 16
hours.
Evans Formula
1. Colloids: 1 mL × kg body weight × % TBSA burned
2. Electrolytes (saline): 1 mL × body weight × % TBSA burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over next 16
hours
Day 2: Half of previous day’s colloids and electrolytes; all of
insensible fluid replacement
Maximum of 10,000 mL over 24 hours. Second- and third-degree
(partial- and full-thickness) burns exceeding 50% TBSA are calculated
on the basis of 50% TBSA.
Brooke Army Formula
1. Colloids: 0.5 mL × kg body weight × % TBSA burned
2. Electrolytes (lactated Ringer’s solution): 1.5 mL × kg body
weight × % TBSA burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over next
16 hours
Day 2: Half of colloids; half of electrolytes; all of insensible fluid
replacement.
Second- and third-degree (partial- and full-thickness) burns exceeding
50% TBSA are calculated on the basis of 50% TBSA.
Parkland/Baxter Formula
Lactated Ringer’s solution: 4 mL × kg body weight × % TBSA burned
Day 1: Half to be given in first 8 hours; half to be given over next
16 hours
Day 2: Varies. Colloid is added.
Hypertonic Saline Solution
Concentrated solutions of sodium chloride (NaCl) and lactate with
concentration of 250–300 mEq of sodium per liter, administered at
a rate sufficient to maintain a desired volume of urinary output. Do
not increase the infusion rate during the first 8 postburn hours. Serum
sodium levels must be monitored closely. Goal: Increase serum
sodium level and osmolality to reduce edema and prevent pulmonary
complications