enanganan

egawatdaruratan pada
uka Bakar
ditya Wardhana, SpBP-RE(K)
 DEFINISI LUKA BAKAR
• Kerusakan kulit (dapat disertai jaringan di bawahnya) yang disebabkan oleh cedera
panas atau dingin
• Penyebab: api, air panas, listrik, bahan kimia, radiasi, frost bite
 FISIOLOGI KULIT
•Proteksi
•Termoregulasi
•Permukaan sensoris
•Respon imun
•Sebagai reservoir darah
•Pengontrol kehilangan cairan
•Fungsi metabolik
•Fungsi psikososial
 KEDALAMAN LUKA
SKETSA KULIT
NORMAL
Luka Bakar
Luka Bakar
Epidermal
Superficial
Dermal

Partial-Thickness Burn
Superficial Burn

Luka Bakar Deep-

Dermal

Luka Bakar Full

Thickness

Deep-Partial Thickness Burn Full Thickness Burn

 KLASIFIKASI LUKA BAKAR
I IIA IIB III
Superficial Partial Deep Partial Full thickness burn
Burn Thickness Thickness burn
Red, painful, dry burnblistered
Red/ pink, White/ red, pain with White/ grey/ brown/ black/
(+), swollen, painful , pressure, blister (+/-), dark red, pain (-), blister (-),
needs skin graft needs skin graft
 PATOFISIOLOGI
(JACKSON BURN WOUND MODEL)
LOKAL
 PATOFISIOLOGI
Zone of Hyp

Zone of Stasis
Zone of Hyperemia
Zone of Stasis
Zone of Coagul
(Necrosis)
Zone of Coagulation
(Necrosis)
PATOFISIOLOGI

Zone of Hyperemia

Zone of Stasis

Zone of Coagulation
(Necrosis)
 DINAMIKA LUKA BAKAR

Zone of Necrosis

Zone of Hyperemia

Zone of Stasis

Zone of Necrosis

Post Burn Day 1 Post Burn Day 3

 DINAMIKA LUKA BAKAR

Zona Koagulasi (Nekrosis) muncul dan semakin jelas terlihat

Post Burn Day 1 Post Burn Day 3

 DINAMIKA LUKA BAKAR

Zona Koagulasi (Nekrosis) muncul dan semakin jelas terlihat

Post Burn Day 3 Post Burn Day 7
ATOFISIOLOGI
ay 2nd post burn day 3rd post burn day 13th post burn day

Necrosis
Stasis

Hyperemia

st burn day 1 year post burn day

A. Central area was white and analgesic, and the surrounding area was pink
B. Three zones of hyperaemia, stasis and coagulation were present and marked
C. Two zones were evident – hyperaemia, and the rest which was white with red nodules
D. Epithelizationhad spread centrally to the ’white line’, and dense speckling has appeared
the deepest central area
E. The translucent epithelium of the speckled zone had become opaque, but the deep cen
remained unhealed till the end of fourth week
F. Texture of all healed skin was normal. The area within the white line was pigmented at
but paler than normal at a year

*Jackson, D. M., et al. The Diagnosis of the Depth of B

PATOFISIOLOGI

Necrosis
Stasis

Hyperemia

A. Central area was white and analgesic, and the surrounding area was pink
B. Three zones of hyperaemia, stasis and coagulation were present and marked
C. Two zones were evident – hyperaemia, and the rest which was white with red nodules
D. Epithelization had spread centrally to the ’white line’, and dense speckling has appeared except in the deepe
area
E. The translucent epithelium of the speckled zone had become opaque, but the deep central area remained un
the end of fourth week
F. Texture of all healed skin was normal. The area within the white line was pigmented at 3 months but paler
at a year

*Jackson, D. M., et al. The Diagnosis of the Dept

 PATOFISIOLOGI
ISTEMIK
• Pembengkakan tubuh
• Gelisah hingga penurunan kesadaran
• Peningkatan denyut nadi
• Sesak nafas sampai gagal nafas akut
• Penurunan fungsi ginjal dan produksi urin, dapat sampai gagal ginjal
• Gangguan pencernaan, bahkan sampai perdarahan, dan risiko infeksi kuman
• Penurunan fungsi sistem imunitas tubuh
• Infeksi merupakan faktor penyebab tertinggi kematian pada luka bakar
CALCULATE TBSA: RULE OF NINE

Paediatric <1 yea

CALCULATE TBSA: PAEDIATRIC RULE
OF NINE AND ADJUST FOR AGE

Untuk setiap pertambahan tahun,

ambil 1% dari kepala dan tambahkan ke tiap kaki 0,5%
CALCULATE TBSA: PALMAR
METHOD
CALCULATE TBSA IN BURN
UNIT:
LUND AND BROWDER CHART
 FIRST AID IN BURN ALAT PEMADAM API RINGAN

JATUHKAN BADAN KE BERGULING DI LANTAI

BAWAH HINGGA API REDA

STOP SEMUA TINDAKAN

JANGAN PANIK
 FIRST AID IN BURN
▹ Alirkan dengan air dingin selama 20 menit (Jika Luka
Bakar Kimia alirkan 1-2 jam) STOP jika suhu
JANGAN BERIKAN
tubuh pasien <350 C
▹ Lepaskan semua perhiasan, jam tangan, pakaian yang • Pasta Gigi
menempel di badan • Mentega
▹ Posisikan sisi yang terbakar menghadap ke atas • Kecap
▹ Tutup dengan kain katun tebal yang bersih • Air es
▹ Minum obat anti nyeri jika perlu • Bahan lainnya selain air
▹ Segera bawa ke rumah sakit terdekat untuk
RKAN DENGAN AIR
perawatan lebih lanjut
IN SELAMA 20 MENIT

YA EFEKTIF SAMPAI 3
SETELAH KEJADIAN
 PRIMARY & SECONDARY SURVEY
IN BURN
STRUCTURE OF EMSB
L A B C D E AMPLE History
O I R I I X Fluids
O R E R S P Head to Toe
K W A C A O Analgesia Examination
A T U B S
Y H L I U Tests Tetanus
I A L R
N T I E Tubes Documentation &
G I T Transfer
O Y
N Support
C-SPINE O2 Hemorrhage AVPU & Environmental
D Control Pupils Control

O
Primary Survey First Aid Secondary Survey
CHECKLIST OF PRIMARY SURVEY OF SEVERE BURN
Airway
eathing and ventilation
ulation with hemorrhage
control
bility: Neurological states
Check Do
Patent or not patent airway  Speak to the patient
 Clear the airway of foreign material
 Chin lift, jaw thrust
 Never hyperflex or hyperextend the head and neck
 Control cervical spine, best with rigid collar
 Sign of hypoxia and hyperventilation or hypoventilation  Expose the chest, ensure the expansion is adequate and equal
 Beware of carbon monoxide intoxication. Cherry pink and non  Always provide supplementation oxygen 100%, 15 L/min via non rebrea
breathing patient mask
 Beware circumferential chest burn (is an escharotomy  If required ventilate via bag and mask or intubate if necessary
required?)
 Sign of shock Apply pressure to point of hemorrhage if present
 Check the central pulse Insert 2 large bore IV line, preferably through unburned tissue
 Check the blood pressure If the patient is shock, give bolus of ringer lactate to attain radial pulse
 Check capillary refill (normal return ≤ 2 seconds) Take blood sample (Full Blood Count, Arterial Blood Gas Analysis)
 Check the circumferential burn on the limb (need for Find and treat the other clinical sign of shock due to another cause
escharotomy?)
Level of unconsciousness  Check the level of consciousness
A: Alert  Check the pupil response to light (brisk and equal)
V: Response to verbal stimuli  Beware that hypoxemia and shock can cause restlessness and decreas
P: Response to pain stimuli of consciousness
U: unresponsive
CHECKLIST OF PRIMARY SURVEY OF SEVERE BURN
Check Do
Exposure with environmental control  Remove all clothing and jewelry
 Log roll the patient to visualize posterior surface
Exposure  Keep the patient warm
 Estimate TBSA with Rule of Nine or Palmar Surface Area

Adequate fluid resuscitation and monitoring  Parkland Formula: 3-4 ml x weight (kg) x % burn TBSA (+
maintenance for children)
 Use Hartmann solution (Ringer Lactate)
 Half of calculated fluid is given in the first 8 hours, the rest is gi
uid resuscitation on the next 16 hours
 Measure urine output hourly
 Check ECG, pulse, blood pressure, respiratory rate, pulse oxim
arterial blood gas analysis
 Adjust resuscitation fluid as indicated
Pain management Give intravenous IV morphine 0,05 – 0,1 mg/kg
Analgesia Titrate to effect
Exclude other trauma  X-Ray:
o Lateral cervical
Test o Chest
o Pelvis
o Other
 Avoid gastroparesis  Insert nasogastric tube (>10% children, >20% adults)
Tubes  Decompress stomach  Insert urinary catheter
 FLUID RESUSCITATION
Cairan inisial diberikan 24 jam pertama pasca trauma dengan modifikasi Parkland Formula :
Dewasa : 3-4mls x BB pasien x % TBSA
½ jumlah volume pertama dalam 8 jam, ½ jumlah volume sisanya dalam 16 jam.

Anak: 3-4mls x BB pasien x % TBSA

+
Rumatan Cairan Darrow
100ml/kg : untuk 10kg pertama
50ml/kg : untuk 10 kg kedua
20ml/kg : untuk tiap kilogram diatas 20 kg

nak : Infus RL untuk cairan resusitasi dan infus D5% dalam 0.45% (1/2 normal saline) untuk cairan rumatan. Semua diberikan bersamaan

Cairan Koloid Tidak dipergunakan dalam 24 jam pertama resusitasi pasca trauma
 FLUID RESUSCITATION

If urine output <0.5ml/kg/hr increase IV fluids by 1/3 of current IV fluid amount. E.g. Last hrs urine = 20ml, received 1200ml/hr, increase IV
to 1600ml/hr.

If urine output >1ml/hr for adults or >2ml/kg/hr for children decrease IV fluids by 1/3 of current IV fluid amount. E.g. Last hrs urine = 100ml,
received 1600ml/hr, decrease IV to 1065ml.
 DIFFERENCES IN CHILDREN
• Limited physiological reserve
• IV Fluid required at lower % TBSA
• Greater surface area to mass ratio
• Need higher volume per kilogram
• Tendency to hypoglycaemia
• Increased requirement (add dextrose)
= normal daily maintenance

Emergency Medicine of Severe Burn, Australia New Zealand Burn Association

 CHALLENGES IN CHILDREN
Hypoglycaemia
Dilutional hyponatraemia
Less margin for error
• Over or under fluid resuscitation occurs easily
• Careful titration to urine output required

Emergency Medicine of Severe Burn, Australia New Zealand Burn Association

 DRESSING
perficial • Film dressing
Partial • Foam dressing
ckness • Vaseline impregnated gauze

• Antibiotic cream (SSD) Parafin gauze

p Partial • Silver based dressing
ckness • Early excision and skin grafting

Silver Sulfadiazine cream

Full
ckness • Early excision and skin grafting
Burns Opsite
 CONTOH TRANSPARANT FILM
DRESSING
A B C

D E F

A. Transparent + Foam Dressing B. Transparent + Foam Dressing C. Transparent + Kassa

B. Transparent Dressing E. Transparent Dressing F. Transparent Dressing
 BEFORE REFERRING

*dikutip dari : The Royal Children’s Hospital melbourne Guidelines of initial management of severe burn. Burn injuries >20% TBSA or who
meet criteria of Victorian State Burn Service transfer criteria. 2012.
 REFERRAL CRITERIA
American Burn Association
• Luka bakar > 10% TBSA
• Luka bakar > 5% TBSA pada anak
• Luka bakar full thickness > 5% TBSA
• Luka bakar pada area khusus (wajah,
tangan, kaki, genitalia, perineum, sendi
utama, dan luka bakar sirkuler pada
ekstremitas dan dada)
• Luka bakar dengan trauma inhalasi
• Luka bakar listrik
• Luka bakar karena zat kimia
• Luka bakar dengan penyakit yang
menyertai sebelumnya
• Luka bakar yang disertai trauma mayor
• Luka bakar pada usia ekstrim (anak sanga
muda dan orang tua)
• Luka bakar pada wanita hamil
• Luka bakar bukan karena kecelakaan
Alur Rujukan Pasien Luka Bakar
BURN UNIT IN JAKARTA

1 Type B Hospital Burn Unit

• RSUD Koja

3 Type A Hospital Burn Unit

• RSUPN Cipto Mangunkusumo
• RSPAD Gatot Soebroto
• RSUD Tarakan

2 Type B Hospital Burn Unit

• RS Islam Jakarta
• RS Yarsi

2 Type A Hospital Burn Unit

• RS Pusat Pertamina
• RSUP Fatmawati

Populasi Jakarta: 10.2 Juta Jiwa

34
Pada jam sibuk 30 Juta Jiwa (dari DeTaB
Terima Kasih