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%

IT’S 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 • Second B
caused; hot liquid or caused; hot liquid,
solid flash flame to clothing
appearance; red, appearance; red,
moist blebs blebs, edematous
surface; wet, surface; wet
sensation; very painful sensation; hipoesthesi

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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 14 18

9 9 9 9 9 9

18 18 18 18 18 18

18 18 16 16 14 14

15 tahun 5 tahun 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

 BROOKE’S FORMULA

 PARKLAND’S FORMULA

 BROOKE’S MODIFICATION

 MONAFO’S FORMULA

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BAXTER’S 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

½ IN FIRST 8 HRS
½ NEXT 16 HRS
DAY 2 :

ADULT : MAINTENANCE
ALBUMIN (IF NECESSARY)

JUVENILE : MAINTENANCE
 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)

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 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, 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. 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. 3rd degree
4. Electric injury
5. Chemical injury
6. Inhalation injury
7. Juveniles
8. 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 • Cause of burns may still be active eg explosive, live
wires, chemical agents
Survey • 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 • Primary survey as for trauma patient, ABCs
• Signs of A/w burns
Assessmt
• Note %BSA and depth quickly
• Assess RR, chest wall, auscultation, neurological
Critical • Oxygen
• Cooling
Interventn
• Stop Bleeding
• Ventolin nebulization if pt is wheezing
Identify • Inhalational injury
• >= 20% BSA second degree burns
LOAD &
• Send to burns centre
GO
NOTIFY • Inform the receiving hospital early so that they
are prepared to receive patient

Secondary • Signs of inhalational injury

• Signs of shock
Survey
• Extent and depth of burns
• Arrhythmia
• Cause of burns if not elicited earlier
IV Fluids • Start fluid management
• Cover burns sites with dry sterila nonstick
Wound care
dressing
• Cooling body sites with water ( 10mins at least)

Analgesia • Entonox contraindicated in inhalational injury

• Cooling and evacuate ASAP
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CLINITRON BED
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THANK
YOU