BURN INJURIES & TREATMENT

dr. Neng Sari Rubiyanti dr. Raymond. Adiwicaksana

Burns
 A burn is an injury to the skin or other organic

tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals, as well as respiratory damage resulting from smoke inhalation, are also considered to be burn
World Health Organization http://www.who.int/violence_injury_prevention/other_injury/burns/en/index.html

American burn association
 a burn is defined as an injury to the skin or other

organic tissue primarily caused by thermal or other acute trauma. It occurs when some or all of the cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissues due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns.

Initial evaluation
 1. airway management

 2. evaluation of other injuries
 3. estimation of burn size  4. diagnosis of carbon monoxide & cyanide

poisoning

Mechanism of burn  Thermal injury  Electrical injury  Chemical injury .

zone of coagulation  severe  Center of the wound  Tissue coagulated &frankly necrotic grafting  Need excision &  2.PATHOPHYSIOLOGY Three zones of tissue injury ( jackson )  1. zone of statis  Vasocontriction & resultant ischemia  Need excision & skin grafting  3. zone o hyperemia  Heal with minimal/ no scarring .

result in systemic hypotension and end organ hypoperfusion. Myocardial contractility is decreased. British medical journal www.com/content/328/7453/1427 .Pathophysiology  Systemic response  The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% of total body surface area. leading to loss of intravascular proteins and fluids into the interstitial compartment. Peripheral and splanchnic vasoconstriction occurs. These changes. possibly due to release of tumour necrosis factor α. coupled with fluid loss from the burn wound.bmj.  Cardiovascular changes—Capillary permeability is increased.

affecting both cell mediated and humoral pathways.  Metabolic changes—The basal metabolic rate increases up to three times its original rate. and in severe burns adult respiratory distress syndrome can occur. This. coupled with splanchnic hypoperfusion.com/content/328/7453/1427 . Respiratory changes—Inflammatory mediators cause bronchoconstriction.  Immunological changes—Non-specific down regulation of the immune response occurs. necessitates early and aggressive enteral feeding to decrease catabolism and maintain gut integrity.​ British medical journal www.bmj.

partial thickness ( 2nd degree)  3. superficial ( 1st degree)  2. full thickness ( 3rd degree) .Classification of burn wounds  1.

Classification of burn wounds 1st degree  Painfull  Do not blister 2nd degree  Dermal envolvement  Extremely painfull  Weeping  blister 3rd degree  Hard  Painless  blanching .

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feet. or perineum Burns complicated by fractures or other trauma Burns complicated by inhalation injury Burns crossing major joints Burns extending completely around the circumference of a limb Electrical burns Full-thickness burns of greater than 10% body surface area in any risk group Partial-thickness burns more than 20% body surface area in the higher-risk group Partial-thickness burns more than 25% of the body surface area in the low-risk group .Major-Minor Criteria ( American Burn Association ) Major Burns          Any burns in infants or the elderly Any burns involving the hands. face.

 Moderate Burns These include: Partial-thickness burns of 15 to 25% body surface area in the low-risk group  Partial-thickness burns of 10-20% body surface area in the higher-risk group  Full-thickness burns of at least 10% body surface area or less in others  Minor Burns Minor burns must be: Less than 15% body surface area in the low-risk group  Less than 10% body surface area in the higher-risk group  Full-thickness burns that are less than 2% body surface area in others .

Coexistent trauma .Inhalation injury .Burn size (persent TBSA) .pneumonia .Prognosis (mortality )  The baux score Mortality =age + percent TBSA .Age .

Rule of nine .

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5%)  Groin = 1  Each leg = 18% total (front = 9%.5%.Rule of nine  Head = 9%  Chest (front) = 9%  Abdomen (front) = 9%  Upper/mid/low back and buttocks = 18%  Each arm = 9% (front = 4. back = 4. back = 9%) .

reactive bronchocontriction.  obstruction of the lower airways.edema.  Injury to epithelium & pulmonary alveolar macrophage release prostaglandin & chemokines migration of of neutrophil and inflamatory mediators tracheobronchial blood flow  increase capillary permeability  lead to ARDS .Inhalation injury and ventilator management ARDS : Adult Respiratory Distress Syndrome  Smoke inhalation :  heat injury  upper airway (swelling)  Combution products  lower airway  Direct mucosal injury  mucosal sloughing.

large-bore peripheral IV catheters should be placed and fluid resuscitation should be initiated .  Concurrently with the primary survey.Think first!!!  Burn patients should be first considered trauma patients.  A primary survey should be conducted in accordance with advanced trauma life support guidelines. especially when details of the injury are unclear.

Breathing. Exposure) harus selesai dilakukan dalam 2 . Circulation.5 menit.ABCDE DALAM TRAUMA  Survei ABCDE (Airway.  Tujuannya: segera mengenali cedera yang mengancam jiwa seperti : • Obstruksi jalan nafas • Cedera dada dengan kesukaran bernafas • Perdarahan berat eksternal dan internal • Cedera abdomen . Disability.

 Jika ada tanda gagal nafas (seperti : serak.Airway + C Spine Control  Menilai jalan nafas. mengi atau stridor) atau obstruksi. maka lakukan :  Chin lift / jaw thrust  Suction  Guedel airway / nasopharyngeal airway  Intubasi endotrakheal . adanya trauma inhalasi (smoke inhalation) dan menjaga imobilisasi cervikal pada pasien dengan kecurigaan adanya fraktur cervikal.

Sementara itu nilai ulang apakah jalan nafas bebas.  Jika pernafasan tidak memadai:  Oksigen harus diberikan pada semua kasus  Monitoring dengan pulse oximetry  Monitoring serial BGA  Ventilator  Evaluasi adanya trauma thorax akibat pasien meloncat /jatuh dari ketinggian .Breathing + Ventilation  Menilai pernafasan cukup.

death  Administration of 100% oxygen is the gold standard for treatment of CO poisoning . atau jika pasien tidak sadar  The affinity of CO for hemoglobin is approximately 200–250 times more than that of O2  decreases the levels of normal oxygenated hemoglobin and can quickly lead  hipoksemia.carbon monoxide (CO) poisoning  Harus dicurigai pada pasien luka bakar karena api pada ruang tertutup. anoxia.

Hydrogen cyanide toxicity  May also be a component of smoke inhalation injury  Cyanide inhibits cytochrome oxidase.  Treatment consists of sodium thiosulfate. hydroxocobalamin. which in turn inhibits cellular oxygenation. and 100% oxygen. In the majority of patients. the lactic acidosis will resolve with ventilation and sodium thiosulfate treatment becomes unnecessary. .

Sementara itu nilai ulang apakah jalan nafas bebas dan pernafasan cukup.Circulation  Menilai sirkulasi / peredaran darah. . terutama bila luas luka bakar > 40 % luas permukaan tubuh  Berikan infus cairan  Pada anak  akses intra osseous (darurat)  Tekanan darah tidak selalu merupakan indikator yang baik terhadap status sirkulasi.  Resusitasi cairan IV dipengaruhi oleh luasnya luka bakar terhadap luas permukaan tubuh.  Frekuensi nadi dan produksi urin adalah indikator yang lebih baik. Jika sirkulasi tidak memadai:  Hentikan perdarahan eksternal  Segera pasang dua jalur infus dengan jarum besar (14 - 16 G).

monitoring UOP tiap jam Produksi urin:30 ml/jam pada dewasa.Penanganan Pada Pertolongan Awal          Tidak memberikan Antibiotik Pemberian Oksigen dan Analgetik opiat dan Anxiolytic (Benzodiazepine) Resusitasi cairan intravena → luas luka bakar > 20% TBSA (> 15% TBSA pada anak ) Awal: Ringer lactat 1000 ml/jam pada dewasa dan 20 ml/kg BB/jam pada anak Target MAP > 60 mmHg Pasang kateter Foley. 1-1.5 ml/kg BB/jam pada anak Setelah penentuan luasnya luka bakar → Parkland formula Early enteral feeding .

RESUCITATION .

over 8 hrs ( for > 30% burn)  Children : 3ml R.5 ml /kg /%TBSA of 5% albumin in RL 24 hrs after injury .45%) .L.× %TBSA × Wt + maintainance (G/S 0.Baxter / Parkland Formula = 4 ml Ringer Lactate × %TBSA × Wt (kg)  half over 8 hrs  half over 16 hrs  0.

Modified Brooke Formula = 2 ml Ringer Lactate × %TBSA × Wt (kg) Haifa Formula = 1 ml Ringer Lactate × %TBSA × Wt (kg) = 1.5 ml FFP × %TBSA × Wt (kg)  ½ volume during first 8 hr post injury  ½ volume next 16 hr post injury .

atau dengan trauma inhalasi → pasang CVP  Pasien Anak pada kondisi emergency perlu akses Intraosseous .In Emergency Room  Luas luka bakar > 40% TBSA → 2 jalur intravena dengan kateter berukuran besar  Lebih dianjurkan pada ekstremitas atas  Pasien dengan Luka Bakar Berat/ memiliki penyakit penyerta / usia yang ekstrem.

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Silver nitrate. topical ointments (bacitracin. mupirocin→methicillinresistant S. Mafenide acetate. neomycin. and polymyxin B).Treatment of the Burn Wound  topical therapies : silver sulfadiazine. aureus  Silver-impregnated dressings (Acticoat and Aquacel Ag)  Biologic membranes .

http://www.burnsjournal.com/article/S0305-4179%2809%29004136/abstract .

& result in more efficient protein metabolism. slow the hypermetabolic response. ↑ catabolism of muscle proteins and ↓ lean body mass → delay functional recovery.  Metoclopramide  Glutamine . gastric ileus can often be avoided.  Early enteral feeding → prevent loss of lean body mass.Nutrition  Not only such as immune responsiveness→ the hypermetabolic respone( ± 200%).

4.7 x BB) + (5 x TB .7 x Umur)  BEE = BMR + 10%  Curreri Formula  25 kcal/kg/day + 40 kcal/%TSBA/day .6 x BB) + (1.7 x TB .Nutrition  The Haris – Benedict formula  BMR  Laki-laki = 66 + (13.6.8 x Umur)  Perempuan = 655 + (9.

Modifying the hypermetabolic response  Beta blocker  The anabolic steroid oxandrolone  Insulin  metformin .

bloodstream infections → catheter-related infections .Complications in Burn Care  postinjury pneumonia  subglottic stenosis → in burn patients with     prolonged endotracheal intubation Abdominal Compartment Syndrome (ACS) Deep vein thrombosis (DVT) & fatal pulmonary embolus. arterial thrombosis→ heparin prophylaxis → prevent thrombotic complications. HIT → thrombocytopenic burn patients → the platelet counts drop in hospital days 7 to 10.

com/acssurgery/secured/figTabPopup.acssurgery. Eschar is tangentially excised until healthy. http://www.action?bookId=ACS&li nkId=part07_ch15_fig8&type=fig .Surgery  Escharotomies  Fasiotomi  Eksisi  Grafting Tangential excision of the burn wound is carried out with a Watson knife (as shown here) or a Weck/Goulian blade. bleeding tissue that is suitable for skin grafting is reached.

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Surgery  Full-thickness burns with a rigid eschar →a tourniquet effect  The resulting compartment syndrome is most common in     circumferential extremity burns. Inadequate perfusion despite proper escharotomies may indicate the need for fasciotomy Thoracic escharotomies should be placed along the anterior axillary lines with bilateral subcostal and subclavicular extensions. . Extremity incisions are made on the lateral and medial aspects of the limbs in an anatomic position and may extend onto thenar and hypothenar eminences of the hand. but abdominal and thoracic compartment syndromes also occur Escharotomies are rarely needed within the first 8 hours following injury and should not be performed unless indicated because of the terrible aesthetic sequelae. Extension of the anterior axillary incisions down the lateral abdomen typically will allow adequate release of abdominal eschar.

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. and compresses soaked in a dilute epinephrine solution are necessary adjuncts after excision. Pneumatic tourniquets are helpful in extremity burns.Surgery  Early excision and grafting in burned patients revolutionized      survival outcomes in burn care. It is appropriate to leave healthy dermis. which will appear white with punctate areas of bleeding. Excision is performed with repeated tangential slices using a Watson or Goulian blade until only nonburned tissue remains. Excision to fat or fascia may be necessary in deeper burns. The downside of tangential excision is a high blood loss. though this may be ameliorated using techniques such as instillation of an epinephrine clysis solution underneath the burn. attention should be turned to excising the burn wound. After the initial resuscitation is complete and the patient is hemodynamically stable.

. and the inner layer becomes vascularized. AlloDerm (LifeCell Corporation. Meshing of autografted skin provides a larger area of wound coverage. TX) is another dermal substitute consisting of cryopreserved acellular human dermis. This must also be used in combination with thin split-thickness skin grafts. the silastic layer is removed and a thin autograft placed over the neodermis. This results in faster healing of the more superficial donor sites. This also allows drainage of blood and serous fluid to prevent accumulation under the skin graft with subsequent graft loss. and hands should be grafted with nonmeshed sheet grafts to ensure optimal appearance. At approximately 2 weeks. creating an artificial neodermis. and seems to have less hypertrophic scarring and improved joint function. Integra (Integra LifeSciences Corporation. The Woodlands. The silastic barrier helps prevent fluid loss and infection. Plainsboro. Areas of cosmetic importance such as the face. neck. NJ) is a bilayer product with a porous collagen-chondroitin 6-sulphate inner layer that is attached to an outer sheet of silastic.Wound Coverage  Full-thickness grafts are impractical for most burn wounds  split-thickness sheet autografts harvested with a power dermatome     make the most durable wound coverings and have a decent cosmetic appearance.

The buttocks. and cost. Silvadene . infection control.Wound Coverage  Epidermal skin substitutes such as cultured epithelial autografts are an option in patients with massive burns and very limited donor sites  Convenient anatomic donor sites. Thighs.The scalp. . The thicker skin of the back . for both hemostasis of this hypervascular area and also to create a smooth surface for harvesting. comfort. the skin  Epinephrine clysis is necessary for harvesting the scalp.  Principles behind choosing a dressing should balance ease of care.

and persists in http://www.htm severity long after discharge .Rehabilitation  Immediate and ongoing physical and occupational therapy is mandatory to prevent loss of physical function.burntherapist.com/History.  passive ROM at least twice a day  Psychological rehabilitation is equally important in the burn patient → Psychological distress occurs in as many as 34% of burn patients.

Prevention  community-based interventions  Smoke alarms  Regulation of hot water heater temperatures  community-based programs emphasizing education and in-home inspections .

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