Acute Burn

Management
in Emergency
Department
Dr. dr. Aditya Wardhana, Sp.B.P.R.E., Subsp.L.B.L(K)
 • Kerusakan kulit (dapat disertai jaringan di bawahnya) yang disebabkan
oleh cedera panas atau dingin
• Penyebab: api, air panas, listrik, bahan kimia, radiasi, frost bite

Neligan P, Gurtner G. Plastic surgery: Principles. 4th ed Vol.4. Canada: ELSEVIER; 2018.
 Fase Luka Bakar
1. Akut (0-5 Hari), pada 0-
48 jam terjadi angiogenesis
2. Subakut (6 Hari-21
Hari), dapat memanjang
(luka kronik)
3. Lanjut (>21 Hari)
Tata laksana disiplin bidang lain menyesuaikan dengan masalah pasien yang ditemukan
Problem Tatalaksana Bedah
Resusitasi, eksisi tangensial dini,
Syok Hipovolemik (dewasa >15% TBSA,
eskarotomi, fasiotomi, amputasi (khusus
anak >10% TBSA)
luka bakar listrik)
Eksisi lanjutan, skin graft, eskarotomi,
Hipometabolik, ARDS, Sepsis, Risiko
fasiotomi, amputasi (khusus luka bakar
kematian tinggi
listrik)
Luka Kronik, Malnutrisi, Parut Hipertrofik
Eksisi lanjutan, skin graft, flap
& Kontraktur, Risiko kecacatan tinggi
 EMERGENCY MANAGEMENT OF SEVERE BURN
• Burn injury  emergency  based on EMSB and ATLS
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
 Check Do
Patent or not patent airway  Speak to the patient
 Clear the airway of foreign material
 Chin lift, jaw thrust
Airway  Never hyperflex or hyperextend the head and neck
 Control cervical spine, best with rigid collar

 Sign of hypoxia and hyperventilation or
hypoventilation
 Beware of carbon monoxide intoxication. Cherry
pink and non breathing patient
 Beware circumferential chest burn (is an
Breathing and ventilation escharotomy required?)
 Expose the chest, ensure the expansion is adequate and equal
 Always provide supplementation oxygen 100%, 15 L/min via non
rebreathing mask
 If required ventilate via bag and mask or intubate if necessary

 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)
Circulation with  Check the circumferential burn on the limb (need Find and treat the other clinical sign of shock due to another cause
hemorrhage control for escharotomy?)

Level of unconsciousness  Check the level of consciousness

A: Alert  Check the pupil response to light (brisk and equal)
Disability: Neurological V: Response to verbal stimuli  Beware that hypoxemia and shock can cause restlessness and
states P: Response to pain stimuli decrease level of consciousness
U: unresponsive
 Check Do
Exposure with environmental control  Remove all clothing and jewelry
 Log roll the patient to visualize posterior surface
 Keep the patient warm
Exposure  Estimate TBSA with Rule of Nine or Palmar Surface Area

Adequate fluid resuscitation and monitoring
(target urine output: 0,5-1 cc/kgBB)
Fluid resuscitation
 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 given on the next 16 hours
 Measure urine output hourly
 Check ECG, pulse, blood pressure, respiratory rate, pulse
oximetry, 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
 • Airway: clear / tidak
• Tanda ancaman: leher bengkak, mulut dan lidah bengkak, wajah
bengkak
• Breathing: pemberian suplementasi oksigen

Neligan P, Gurtner G. Plastic surgery: Principles. 4th ed Vol.4. Canada: ELSEVIER; 2018.
 - Anamnesis
Diagnostik klinis belum tentu - Pajanan terhadap api, asap, atau bahan kimia
trauma Inhalasi - Durasi pajanan
- Pajanan diruang tertutup
- Penurunan Kesadaran
Gold standard Diagnostik: - Pemeriksaan Fisik
- Look: Luka bakar pada wajah, bulu hidung
Bronkoskopi dan Pemeriksaan CO Dar
terbakar, sputum berjelaga, cuping hidung
ah
membesar, sesak nafas, retraksi trakea,
retraksi supraklavikula, retraksi intercostal
Indikasi intubasi: - Listen: suara sesak, batuk kasar, stridor
inspiratori, batuk produktif
• Difficulty of breathing
• Penurunan Kesadaran
•  Segera rujuk pasien untuk tindakan bronkos
kopi apabila ada kecurigaan kearah trauma inha
lasi
Neligan P, Gurtner G. Plastic surgery: Principles. 4th ed Vol.4. Canada: ELSEVIER; 2018.
 - Syok pada luka bakar berbeda dengan syok perdarahan

- Pastikan akses intravena terpasang dengan baik

- Pastikan apakah ada perdarahan ditempat lain?

- Jika vena kolaps, sulit untuk pasang akses intravena  kanulasi vena dalam / venous

cutdown

Neligan P, Gurtner G. Plastic surgery: Principles. 4th ed Vol.4. Canada: ELSEVIER; 2018.
 • 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

*Anak : 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

Neligan P, Gurtner G. Plastic surgery: Principles. 4th ed Vol.4. Canada: ELSEVIER; 2018.
 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.

Neligan P, Gurtner G. Plastic surgery: Principles. 4th ed Vol.4. Canada: ELSEVIER; 2018.
 I IIA IIB III
Superficial Partial Thickness Deep Partial Full thickness burn
Burn burn Thickness burn
Red, painful, Red/ pink, blistered White/ red, pain with White/ grey/ brown/
dry (+), swollen, pressure, blister (+/-), black/ dark red, pain (-),
painful , needs skin graft blister (-), needs skin
graft

12
Jackson, D. M., et al. The Diagnosis of the Depth of Burning. 1953
 Paediatric <1 years old 13
Jackson, D. M., et al. The Diagnosis of the Depth of Burning. 1953
 Untuk setiap pertambahan tahun,
ambil 1% dari kepala dan tambahkan ke tiap kaki 0,5%
14
Jackson, D. M., et al. The Diagnosis of the Depth of Burning. 1953
 Superficial • Film dressing
Partial • Foam dressing
Thickness • Vaseline impregnated gauze

• Antibiotic cream
Deep Partial • Silver based dressing Parafin gauze
Thickness • Early excision and skin grafting
Silver Sulfadiazine
Full cream
thickness • Early excision and skin grafting
Burns

Opsite

American Burn Association. Advanced Burn Life Support Course Provider Manual 2018 Update
 Eksisi Tangensial

• Membuang jaringan nekrotik pada luka

bakar deep-partial thickness dan full-
thickness
• Menjaga jaringan viabel sebanyak mungkin

Split Thickness Skin Graft

• Minimalisasi terjadinya kehilangan cairan

• Mengurangi kebutuhan metabolik
• Melindungi kulit dari paparan organisme
infeksius

American Burn Association. Advanced Burn Life Support Course Provider Manual 2018 Update
 • Escharotomy dilakukan bila ada eschar khususnya
pada luka bakar deep burn atau full-thickness untuk
mengurangi komplikasi
• Escharotomy ekstrimitas pada anak sama prinsipnya
dengan dewasa

Lee JO, Dibildox M, Jimenez CJ, Gallagher JJ, Sayeed S, Sheridan RL, et al. Operative Wound Management. In:
Herndon DN. Total Burn Care. 4th ed. USA: Elsevier Saunders; 2012. P. 157-161.
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 sangat muda dan orang tua)
• Luka bakar pada wanita hamil
• Luka bakar bukan karena kecelakaan 19
• Jackson, D. M., et al. The Diagnosis of the Depth of Burning. 1953
• Neligan P, Gurtner G. Plastic surgery: Principles. 4th ed Vol.4. Canada:
ELSEVIER; 2018.
• Lee JO, Dibildox M, Jimenez CJ, Gallagher JJ, Sayeed S, Sheridan RL, et
al. Operative Wound Management. In: Herndon DN. Total Burn Care.
4th ed. USA: Elsevier Saunders; 2012. P. 157-161.
• American Burn Association. Advanced Burn Life Support Course
Provider Manual 2018 Update.
TERIMA KASIH