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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%

IT’S A CHALLENGE FOR US



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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
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ETIOLOGY
1. FIRE

2. SCALD

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
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DEPTH ASSESSMENT
1. 1
st
DEGREE
- EPIDERMIS

2. 2
nd
DEGREE
- SUPERFICIAL
- DEEP

3. 3
rd
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 ------------> 18%
 Lower extremities 18% -------> 36%
 Genital / perineum -------------> 1 %

 Total ----------------------------- 100%
ADULT
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9
14
9 9
18 18
18 18
9 9
18 18
16 16
9
18 18
14
10 14
18
15 yrs 5 yrs 0 – 1 yr
JUVENILE - CHILDREN
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SEVERITY CRITERIA
(AMERICAN BURN ASSOCIATION)
1. MILD
- 2
nd
DEGREE < 15%
- 2
nd
DEGREE < 10% IN JUVENILES
- 3
rd
DEGREE < 1%





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

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3. SEVERE
- 2
nd
DEGREE >25% IN ADULTS
- 2
nd
DEGREE >20% IN JUVENILES
- 3
rd
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

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


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FLUID RESUSCITATION
 EVANS’ FORMULA

 BROOKE’S FORMULA

 PARKLAND’S FORMULA

 BROOKE’S MODIFICATION

 MONAFO’S FORMULA

BAXTER’S 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

½ IN FIRST 8 HRS
½ NEXT 16 HRS

DAY 2 :

ADULT : MAINTENANCE
ALBUMIN (IF NECESSARY)

JUVENILE : MAINTENANCE

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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
• 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)
III. LABORATORY EXAMINATION


BURNS IMPAIR ORGAN FUNCTIONS

BASELINE LABORATORY TESTS
1. HAEMATOCRITE
2. COMPLETE BLOOD COUNT (Hb)
3. ALBUMIN
4. RFT & LFT
5. ELECTROLITE, Na, K, Cl, HCO
3

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

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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 - HCO
3
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. close wound as soon as possible
2. prevent infection
3. reduce scarring and contractures
4. provide for comfort
2. Wound cleaning + closed technique
3. Debridement, mechanical, surgical, enzymatic
4. Topical antibacterial therapy mafenide (sulfonamide)
sulfadiazine
5. 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. 3
rd
degree
4. Electric injury
5. Chemical injury
6. Inhalation injury
7. Juveniles
8. Associated with other traumas
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ACUTE BURN

A. Airway : inhalation injury
B. Breathing : fullthickness
circumferntial burn
C. Circulation : syok
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
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Fullthickness
circumferential
burns
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CLINITRON BED
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