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ACUTE

BURN
MANAGEMENT

Dr. Abda Arif, SpBP


Sub Dep Bedah Plastik
RSMH

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%
ITS A CHALLENGE FOR US
HIGH MORBIDITY AND MORTALITY RATE

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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ETIOLOGY
1.

FIRE

2.

SCALD

3.

CHEMICAL SUBSTANCES

4.

ELECTRIC & RADIATION

5.

SUNBURN

6.

STOVE / GAS EXPLOSION

7.

BOMB EXPLOSION
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DEPTH ASSESSMENT
1. 1st DEGREE
- EPIDERMIS
2. 2nd DEGREE
- SUPERFICIAL
- DEEP

3. 3rd DEGREE
- EXTENSION TO
MUSCLE / BONE
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Second A
caused; hot liquid or
solid
appearance; red,
moist blebs
surface; wet,
sensation; very painful

Second B
caused; hot liquid,
flash flame to clothing
appearance; red,
blebs, edematous
surface; wet
sensation; hipoesthesi

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13

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WOUND EXTENT
WALLACE
RULE OF NINE
Head & neck

----------9%

Upper extremities 9%

---------- 18%

Anterior of the body

---------- 18%

Posterior of the body

---------- 18%

Lower extremities 18%

-----------36%

Genital / perineum

-----------1 %

Total

---------- 100%

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ADULT

ANAK ANAK
10
9

14
9

18 18

18

18 18

18

15 tahun

18

16

18 18

16

5 tahun

14

14

0 1 tahun

SEVERITY CRITERIA
(AMERICAN BURN ASSOCIATION)

1. MILD
- 2nd DEGREE < 15%
- 2nd DEGREE < 10% IN JUVENILES
- 3rd DEGREE < 1%

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

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3. SEVERE
- 2nd Degree >25% IN ADULTS
- 2nd Degree >20% IN JUVENILES
- 3rd 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 examanation
E. Exposure

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II. SECONDARY SURVEY :


A. History taking
B. Physical examanation/ head to toe examanation
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 assesment
8. Continoued ventilatory assesment
9. Pain management
10. Psychosocial assesment
11. Tetanus toxoid profilaxis
12. Measuring body weight
13. Wound cleansing (operating theatre, general anaesthesia)
14. Escaharotomy & fasciotomy

FLUID RESUSCITATION

EVANS FORMULA

BROOKES FORMULA

PARKLANDS FORMULA

BROOKES MODIFICATION

MONAFOS FORMULA
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BAXTERS FORMULA
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

IN FIRST 8 HRS
NEXT 16 HRS

DAY 2 :
ADULT

: MAINTENANCE
ALBUMIN (IF NECESSARY)

JUVENILE

: MAINTENANCE

MONITORING FLUID RESUSCITATION


1.

2.

URINARY PRODUCTION PER HOUR


ADULT

: 0,5 CC/BW/HR (30-50 CC/HR)

JUVENILE

: 1 CC/BW/HR

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)

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III. LABORATORY EXAMINATION


BURNS IMPAIR ORGAN FUNCTIONS

BASELINE LABORATORY TESTS


1.
2.
3.
4.

HAEMATOCRITE
COMPLETE BLOOD COUNT (Hb)
ALBUMIN
RFT & LFT

5. ELECTROLITE, Na, K, Cl, HCO3


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

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 - HCO3 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.
b.
c.
d.
e.
f.

Change in sensorium
Fever
Tachyapnea
Paralytic ileus
Abdominal distention
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.
2.
3.
4.

2.
3.
4.
5.

close wound as soon as possible


prevent infection
reduce scarring and contractures
provide for comfort

Wound cleaning + closed technique


Debridement, mechanical, surgical, enzymatic
Topical antibacterial therapy mafenide (sulfonamide)
sulfadiazine
Biological dressing
- Homograft (cadaver skin )
- Heterograft
- Autograft

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IV. BURN CENTER REFERRAL

REFERRAL CRITERIA
1.
2.
3.
4.
5.
6.
7.
8.

2nd degree >10%


Affecting face, hands, genital, perineum, & main joints
3rd degree
Electric injury
Chemical injury
Inhalation injury
Juveniles
Associated with other traumas

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V. SPECIFIC BURN MANAGEMENT


A. INHALATION INJURY
B. ELECTRIC INJURY
C. CHEMICAL INJURY
D. BURNS IN PREGNANCY

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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

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Scene
Survey

Cause of burns may still be active eg explosive, live


wires, chemical agents
Fires in enclosed spaces increases risk of inhalational
injury, smoke may contain toxic gases CO, cyanide
Stop ongoing burning process, remove clothes if
possible, rinse copiously with water

Patient
Assessmt

Primary survey as for trauma patient, ABCs


Signs of A/w burns
Note %BSA and depth quickly
Assess RR, chest wall, auscultation, neurological

Critical
Interventn

Oxygen
Cooling
Stop Bleeding
Ventolin nebulization if pt is wheezing

Identify
LOAD &
GO

Inhalational injury
>= 20% BSA second degree burns
Send to burns centre

NOTIFY

Inform the receiving hospital early so that they


are prepared to receive patient

Secondary
Survey

IV Fluids
Wound care

Start fluid management


Cover burns sites with dry sterila nonstick
dressing
Cooling body sites with water ( 10mins at least)

Analgesia

Entonox contraindicated in inhalational injury


Cooling and evacuate ASAP

Signs of inhalational injury


Signs of shock
Extent and depth of burns
Arrhythmia
Cause of burns if not elicited earlier

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CLINITRON BED
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THANK
YOU