COMBUSTION

Fajar Ari Nugroho

LUKA BAKAR
Merupakan luka yang disebabkan oleh panas, listrik, maupun bahan kimia Panas = - benda panas: padat, cair, udara (uap) - api - sengatan matahari atau sinar panas Listrik = aliran listrik tegangan tinggi Kimia = asam kuat, basa kuat

DIAGNOSIS LUKA BAKAR
Berdasar : 1. Luas luka bakar 2. Derajat (kedalaman) luka bakar 3. Lokalisasi 4. Penyebab

Penetapan Luas Luka Bakar 1. 2. Rumus 9 (Rule of Nine) Telapak tangan = 1% .

Rumus 9 (Rule of Nine) .

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oedema. nyeri Derajat II Epidermis dan dermis. lapisan basal masih baik. nyeri b (IIb) deep (dalam) : hampir mengenai seluruh lapisan kulit . oedematus. bagian dasar kulit masih baik b (IIa) superfisial (dangkal) : bulla. eritema.Derajat Luka Bakar Derajat I Mengenai epidermis. erithema.

Derajat Luka Bakar Derajat III seluruh lapisan kulit. jaringan putih. tidak nyeri. kecoklatan (nekrosis) . abuabu.

q tissue perfusion 2. q oxygen consumption 4. q body temperature .Fase Luka Bakar Ebb-phase response hypovolemic shock: 1. q metabolic rate 3. q blood pressure 5.

o catecholamin 4. o excretion of nitrogen 7.Fase Luka Bakar Flow-phase acute responses : 1. lipid mediators 5. o glucocorticoid 2. ooxygen consumption 9. o glucagon 3. Release of cytokines. Impaired use of fuels . o metabolic rate 8. Production of acute-phase proteins 6.

Hormonal response gradually disminishes 2. Wound healing depends in part on njutrient intake . Associated with recovery 4.Fase Luka Bakar Flow-phase adaptive response 1. q hyper metabolic rate 3. Potential with restoration of body protein 5.

2.MNT principal 1. will resume adequate oral food intake Must focus on laboratory data p not to define nutritional status. but for design the nutritional prescription . Because of difficulty in conducting a nutritional assessment in a critically ill patients (combust) p the ability to predict.

MNT principal 3. 10-15=moderate hyper metabolism (level 2). laboratory abnormalities. blood glucose. 4. specially electrolytes & acid-base balance p may impact enteral & parenteral formulation/diet order Urine Urea Nitrogen (UUN) excretion in grams/day has been evaluate the degree of hyper metabolism : 5=no stress. >15=severe hyper metabolism (level 3) . 5-10=mild hyper metabolism (level 1 stress). Should review indices of organ system function.

Pre injury nutritional status Type of trauma Extent of injury Surgical finding Gastrointestinal function Enteral access option . 4. 2. 3. 6. 5.Factor to consider 1.

maintaining circulatory volume Encourage fluid intake = juice (stump) To determined fluid & electrolyte needs: Lund & border chart Baxter/parkland 1. extent of the burn Early adequate fluid p preventing ischemia. 2. the calculate volume for first 24-h p given in first 8-h (the period of greatest intravascular loss).Fluid & electrolyte repletion The first 24-48 hour treatment p fluid & electrolyte replacement. . the volume of fluid needed p age & weight.

0-3. infus p >15%. ½ hasil perhit 8 jam pertama.1 mL/kg body weight per 24-h per %TBSA = fluid volume Baxter/parkland 4 cc x BB x % TBSA = RL volume Ket: TBSA p the percentage body surface area (luas permukaan luka bakar). RL p ringer laktat NB: <15%+grade 2 p oral.calculation Lund & browder 2. sisa ½ nya 16 jam berikutnya .

7 x BB)+(5 x TB) (6.8 x U) x AF x FS kebut energi (w) = 665 + (9.8 x TB) (4.Energy Adult 1.7 x U) x AF x FS Note: meningkatkan resiko morbiditas dan mortalitas. Harris benedict kebut energi (p) = 66+(13. terutama pada fase akut LB berat (overfeeding) .6 x BB) + (1.

Energy 2. biasanya menghasilkan perhitungan > actual energy expenditure . The curreri formula kebut energi = 24 Kcal x BBI + 40 Kcal x % TBSA burned (max 50% TBSA) Note: bila TBSA >50%-60% p minimal increases in energy expenditure occur. ketika formula ini digunakan hrs dipastikan penambahan kalori max 100% (2xREE).

Rule of thumb Kebut energi = 25 30 Kal/KgBB Note: merupakan metode perhitungan yang praktis dan dapat menghindari overfeeding .Energy 3.

Energy Pediatric 1.024265 .5378 x height (cm)0. Galveston formula Kebut energi = 1800 Kcal/m2 BSA+ 2200 Kcal/m2 BSA 2.3964 x 0. Polk formula Kebut energi = (60 Kcal x kg body weight) x (35 Kcal x % burn) Note: polk p children less then 3 yrs BSA = weight (kg)0.

indirect calorimetry is the most accurate methods of determining the energy needs .Considerable p energy needs Weight gain (severely underweight patient) p not feasible until after the acute illness Weight maintenance should be the goal p overweight patient For obese patient p more than calculation when using ideal body weight. less than calculation when using actual body weight.

o susceptibility to infection Diet high [-3 p increase immune response & tube feeding tolerance by: inhibit prostaglandin E2 & leucotrienes (immunosuppressive). slight in omega 3) (stump) MCT & structured lipids p under investigation . osmotic diuresis. stump) p recommended as the chief of energy source p excess : lipogenesis causes o oxygen consumption. 20% fat (2-4% essential amino acid. a reasonable approach 15%-20% (krause). o CO2 production.Energy sources Carbohydrate are excellent for protein-sparing (60%. respiratory difficulty Although lipids are a concentrate source of energy p excess: deleterious immunologic response. hyperglicemia.

3.0 g/kg BW for pediatric (pediatric: depend on renal function & fluid balance) BCAAs seem to have no beneficial effect. the conditional essential amino acids: arginine p may improve cell mediated immunity & wound healing. increased use in gluconeogenesis & wound healing 20-25% recommended for adult (krause)or 1.5-3 g/kg BW (stump). . (up to 2% of kcal) (stump).5.Protein Losses trough urine & wound. anabolic hormone production. 2. glutamine p o ability of neutrophils (krause).

3) basic nutritional assessment parameter Weight change trends can be identified after fluid gained during resuscitation period in 2 weeks Nitrogen balance is frequently used to evaluated the efficacy of nutrient regimen.Assessment of Energy & Protein Adequacy The best evaluated by: 1) wound healing. the first 4 weeks may be the most reflective measure in nutritional monitoring . 2) graft take. but it can t considered accurate without accounting for wound losses.

3.12 g nitrogen/kg/day Note: albumin levels remain depressed until major burn are healed. prealbumin.Assessment of Energy & Protein Adequacy 1. transferin p helping to assess protein status of patient . RBP. Formulas for predicting nitrogen losses: <10% open wound = 0.02 g nitrogen/kg/day 11-30% open wound = 0. 2.05 g nitrogen/kg/day >31 open wound = 0.

3. 2. 5-10 x RDA (stump) Vitamin A = 5000 IU/1000 calories of enteral nutrition (krause). . but exact requirement have not been establish Recommended: Vitamin C = 500 mg twice daily (krause). 2 x RDA (stump) Sodium/potassium are corrected by adjusting fluid therapy p restriction sodium free water : correct hyponatremia.Vitamin & mineral Vitamin needs increased. resuscitation & protein synthesis : hypokalemia (slightly o : inadequate rehydration ) 1.

6. Depression of calcium levels p may be seen in patient more than 30% TBSA (hypocalcemia : hypoalbuminemia) = supplement may necessary Hypophospathemia p large volume of resuscitation & large antacid = supplement via parenterally (prevent gastric irritation) Magnesium levels p loss from wound = supplement via parenterally (prevent gastric irritation) . 5.Vitamin & mineral 4.

8. Depressed zinc levels p unclear : total body zinc nutriture or an artifact of hypoalbuminemia = supplementation 220 mg zinc sulfate is appropriate (krause). 9. 10. 2 x RDA zinc sulfate (stump) Anemia p usually unrelated to iron deficiency (no history) = packed red blood cell Vitamin B-com 2-3 x RDA (stump) Vitamin B12 & K diberikan mingguan (stump) .Vitamin & mineral 7.

13. 12. high protein diet with 5-6 small meals & snack Avoid excesses of linoleic acid p depress immunocompetence Be careful iron & zinc excess in patient with sepsis Do not alter nutritional support because watery diarrhea p is likely occur for reason other than carbohydrate intolerance .Others 11. 14. Use high calorie.

10. 12. 8. 11. 9. 3. edema) BMI 6. 7. 4. Diet history Measured energy expenditure % body burned Burn (calsification) Edema BP temperature . Clinical/history Height Preburn weight Weight change Daily weight (beware of heavy exudates.Beware Clinical indicator 1. 2. 5.

Ability to chew 15. sugars 14. Ability to swallow 16. 15. low BP. 14. Albumin 2.Beware Clinical indicator Clinical/history 13. tachycardia. Chloride. decrease urinary output Lab 1. Transthyretin (q) 3. BUN. 5. Ca++. Creat Gluc. Na+. 13. O2 (PO2) Transferin. Mg++ Partial pressure of CO2 (PCO2). Urine aceton. cholesterol. Hypovolemic shock. K+. TG. CRP. 4. WBC Serum catecholamine (o) N balance .

diarrhea. potassium. magnesium. stomatitis.DNI Analgesic = GI function & appetite Antacid = change digestion process Antibiotic = leaching of sodium. abdominal pain Supportive therapy = no interaction . calcium & B-com Insulin = use for stress induce hyperglicemia Interferon gamma or alpha-2b = dry mouth. nausea & vomiting.

(2000). USA: Saunders company .E... (2008).Nutrition and Diagnosis-Related Care.Refference Stump. sixth edition. Philedelpia : lippincott Mahan. K. S. Krause·s Food nutrition & Diet Therapy.

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