Post on 11-Feb-2018
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dr. Neng Sari Rubiyanti
dr. Raymond. Adiwicaksana
BURN INJURIES &
TREATMENT
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BurnsA 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 orchemicals, 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
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American burn association
a burn is defined as an injury to the skin or otherorganic 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.
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Initial evaluation
1. airway management
2. evaluation of other injuries
3. estimation of burn size
4. diagnosis of carbon monoxide & cyanidepoisoning
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Mechanism of burn
Thermal injury
Electrical injury
Chemical injury
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Three zones of tissue injury ( jackson
)
1. zone of coagulation severe
Center of the wound
Tissue coagulated &frankly necrotic grafting
Need excision &
2. zone of statis
Vasocontriction & resultant ischemia
Need excision & skin grafting 3. zone o hyperemia
Heal with minimal/ no scarring
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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.
Cardiovascular changesCapillary permeability is increased,
leading to loss of intravascular proteins and fluids into the
interstitial compartment. Peripheral and splanchnic
vasoconstriction occurs. Myocardial contractility is decreased,
possibly due to release of tumournecrosis factor . These
changes, coupled with fluid loss from the burn wound, result in
systemic hypotension and end organ hypoperfusion.
British medical journal
www.bmj.com/content/328/7453/1427
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Respiratory changesInflammatory mediators causebronchoconstriction, and in severe burns adult respiratory
distress syndrome can occur.
Metabolic changesThe basal metabolic rate increases up to
three times its original rate. This, coupled with splanchnic
hypoperfusion, necessitates early and aggressive enteral feedingto decrease catabolism and maintain gut integrity.
Immunological changesNon-specific down regulation of the
immune response occurs, affecting both cell mediated and
humoral pathways.
British medical journal
www.bmj.com/content/328/7453/1427
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Classification of burn wounds
1. superficial ( 1st degree)
2. partial thickness ( 2nd degree)
3. full thickness ( 3rd degree)
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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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Major-Minor Criteria ( American
Burn Association )
Major BurnsAny burns in infants or the elderly
Any burns involving the hands, face, 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 inany risk group
Partial-thickness burns more than 20% body surface area in thehigher-risk group
Partial-thickness burns more than 25% of the body surface areain the low-risk group
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Moderate BurnsThese include:Partial-thickness burns of 15 to 25% body surface area inthe 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 surfacearea in others
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Prognosis (mortality )
The baux scoreMortality =age + percent TBSA
- Age
- Burn size (persent TBSA)
- Inhalation injury
- Coexistent trauma
- pneumonia
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Rule of nine
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Rule of nine
Head = 9%
Chest (front) = 9%
Abdomen (front) = 9%
Upper/mid/low back and buttocks = 18% Each arm = 9% (front = 4.5%, back = 4.5%)
Groin = 1
Each leg = 18% total (front = 9%, back = 9%)
http://www.emedicinehealth.com/script/main/art.asp?articlekey=19270http://www.emedicinehealth.com/script/main/art.asp?articlekey=2081http://www.emedicinehealth.com/script/main/art.asp?articlekey=3637http://www.emedicinehealth.com/script/main/art.asp?articlekey=3637http://www.emedicinehealth.com/script/main/art.asp?articlekey=2081http://www.emedicinehealth.com/script/main/art.asp?articlekey=192707/23/2019 BURN INJURIES & TREATMENT.pptx
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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,edema,
reactive bronchocontriction, obstruction of the
lower airways.
Injury to epithelium & pulmonary alveolar
macrophage release prostaglandin & chemokinesmigration of of neutrophil and inflamatory
mediators tracheobronchial blood flow
increase capillary permeability lead to ARDS
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Think first!!!
Burn patients should be first considered traumapatients, especially when details of the injury
are unclear.
A primary survey should be conducted in
accordance with advanced trauma life supportguidelines.
Concurrently with the primary survey, large-bore
peripheral IV catheters should be placed and fluid
resuscitation should be initiated
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ABCDE DALAM TRAUMA Survei ABCDE (Airway, Breathing, Circulation,
Disability, Exposure) harus selesai dilakukandalam 2 - 5 menit.
Tujuannya: segera mengenali cedera yang
mengancam jiwa seperti : Obstruksi jalan nafas
Cedera dada dengan kesukaran bernafas
Perdarahan berat eksternal dan internal
Cedera abdomen
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Menilai jalan nafas, adanya trauma inhalasi(smoke inhalation) dan menjaga imobilisasi
cervikal pada pasien dengan kecurigaan
adanya fraktur cervikal.
Jika ada tanda gagal nafas (seperti : serak,
mengi atau stridor) atau obstruksi, maka
lakukan :
Chin lift / jaw thrust Suction
Guedel airway / nasopharyngeal airway
Intubasi endotrakheal
Airway + C Spine Control
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Breathing + Ventilation
Menilai pernafasan cukup. Sementara itu nilaiulang 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 pasienmeloncat /jatuh dari ketinggian
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carbon monoxide (CO) poisoning
Harus dicurigai padapasien luka bakar karenaapi pada ruang tertutup,atau jika pasien tidaksadar
The affinity of CO for
hemoglobin isapproximately 200250times more than that ofO2
decreases the levels ofnormal oxygenated
hemoglobin and canquickly leadhipoksemia, anoxia,death
Administration of 100%oxygen is the gold
standard for treatment ofCO poisoning
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Hydrogen cyanide toxicity
May also be a component of smoke inhalationinjury
Cyanide inhibits cytochrome oxidase, which in
turn inhibits cellular oxygenation.
Treatment consists of sodium thiosulfate,
hydroxocobalamin, and 100% oxygen. In the
majority of patients, the lactic acidosis will resolve
with ventilation and sodium thiosulfate treatment
becomes unnecessary.
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Circulation Menilai sirkulasi / peredaran darah. Sementara itunilai ulang apakah jalan nafas bebas dan pernafasan
cukup. Jika sirkulasi tidak memadai: Hentikan perdarahan eksternal Segera pasang dua jalur infus dengan jarum besar (14 -
16 G), terutama bila luas luka bakar > 40 % luaspermukaan tubuh Berikan infus cairan Pada anak akses intra osseous (darurat)
Tekanan darah tidak selalu merupakan indikator yangbaik terhadap status sirkulasi.
Frekuensi nadi dan produksi urin adalah indikatoryang lebih baik.
Resusitasi cairan IV dipengaruhi oleh luasnya lukabakar terhadap luas permukaan tubuh.
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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 dan20 ml/kg BB/jam pada anak
Target MAP > 60 mmHg
Pasang kateter Foley, monitoring UOP tiap jam
Produksi urin:30 ml/jam pada dewasa,1-1,5 ml/kg BB/jam pada anak
Setelah penentuan luasnya luka bakar Parklandformula
Early enteral feeding
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RESUCITATION
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Baxter / Parkland Formula
= 4 ml Ringer Lactate %TBSA Wt (kg)
half over 8 hrs
half over 16 hrs 0.5 ml /kg /%TBSA of 5% albumin in RL
24 hrs after injury , over 8 hrs ( for > 30% burn)
Children : 3ml R.L. %TBSA Wt
+ maintainance (G/S 0.45%)
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Modified Brooke Formula
= 1 ml Ringer Lactate %TBSA Wt (kg)
= 1,5 ml FFP %TBSA Wt (kg)
volume during first 8 hr post injury volume next 16 hr post injury
Haifa Formula
= 2 ml Ringer Lactate %TBSA Wt (kg)
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In Emergency Room
Luas luka bakar > 40% TBSA 2jalur intravenadengan kateter berukuran besar
Lebih dianjurkan pada ekstremitas atas
Pasien dengan Luka Bakar Berat/ memiliki
penyakit penyerta / usia yang ekstrem, ataudengan trauma inhalasi pasang CVP
Pasien Anak pada kondisi emergency perlu akses
Intraosseous
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Treatment of the Burn Wound
topical therapies : silversulfadiazine, Mafenide
acetate, Silver nitrate,
topical ointments
(bacitracin, neomycin,and polymyxin B),
mupirocinmethicillin-
resistant S. aureus
Silver-impregnateddressings (Acticoat and
Aquacel Ag)
Biologic membranes
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http://www.burnsjournal.com/article/S0305-4179%2809%2900413-6/abstract
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Nutrition
Not only such as immune responsiveness thehypermetabolic respone( 200%), catabolism
of muscle proteins and lean body mass delay
functional recovery.
Early enteral feeding prevent loss of lean bodymass, slow the hypermetabolic response, & result
in more efficient protein metabolism, gastric ileus
can often be avoided.
Metoclopramide
Glutamine
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Nutrition
The Haris Benedict formula BMR
Laki-laki = 66 + (13,7 x BB) + (5 x TB - 6,8 x Umur)
Perempuan = 655 + (9,6 x BB) + (1,7 x TB - 4,7 x Umur)
BEE = BMR + 10%
Curreri Formula
25 kcal/kg/day + 40 kcal/%TSBA/day
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Modifying the hypermetabolic
response
Beta blocker The anabolic steroid oxandrolone
Insulin
metformin
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Complications in Burn Care
postinjury pneumonia subglottic stenosis in burn patients with
prolonged endotracheal intubation
Abdominal Compartment Syndrome (ACS)
Deep vein thrombosis (DVT) & fatalpulmonary embolus, arterial thrombosisheparin prophylaxis prevent thromboticcomplications.
HIT thrombocytopenic burn patients theplatelet counts drop in hospital days 7 to 10.
bloodstream infections catheter-relatedinfections
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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.
Eschar is tangentially excised until
healthy, bleeding tissue that is suitable
for skin grafting is reached.
http://www.acssurgery.com/acssurgery/secured/figTabPopup.action?bookId=ACS&li
nkId=part07_ch15_fig8&type=fig
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Surgery
Full-thickness burns with a rigid eschara tourniquet effect The resulting compartment syndrome is most common in
circumferential extremity burns, but abdominal and thoraciccompartment syndromes also occur
Escharotomies are rarely needed within the first 8 hoursfollowing injury and should not be performed unless indicated
because of the terrible aesthetic sequelae. Extremity incisions are made on the lateral and medial aspects
of the limbs in an anatomic position and may extend onto thenarand hypothenar eminences of the hand.
Inadequate perfusion despite proper escharotomies mayindicate the need for fasciotomy
Thoracic escharotomies should be placed along the anterioraxillary lines with bilateral subcostal and subclavicularextensions. Extension of the anterior axillary incisions down thelateral abdomen typically will allow adequate release ofabdominal eschar.
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Surgery
Early excision and grafting in burned patients revolutionizedsurvival outcomes in burn care.
After the initial resuscitation is complete and the patient ishemodynamically stable, attention should be turned to excisingthe burn wound.
Excision is performed with repeated tangential slices using a
Watson or Goulian blade until only nonburned tissue remains. Itis appropriate to leave healthy dermis, which will appear whitewith punctate areas of bleeding.
Excision to fat or fascia may be necessary in deeper burns.
The downside of tangential excision is a high blood loss, thoughthis may be ameliorated using techniques such as instillation of
an epinephrine clysis solution underneath the burn. Pneumatic tourniquets are helpful in extremity burns, and
compresses soaked in a dilute epinephrine solution arenecessary adjuncts after excision.
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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 cosmeticappearance.
Meshing of autografted skin provides a larger area of wound coverage.This also allows drainage of blood and serous fluid to preventaccumulation under the skin graft with subsequent graft loss. Areas of
cosmetic importance such as the face, neck, and hands should begrafted with nonmeshed sheet grafts to ensure optimal appearance.
Integra (Integra LifeSciences Corporation, Plainsboro, NJ) is a bilayerproduct with a porous collagen-chondroitin 6-sulphate inner layer that isattached to an outer sheet of silastic.
The silastic barrier helps prevent fluid loss and infection, and the innerlayer becomes vascularized, creating an artificial neodermis. Atapproximately 2 weeks, the silastic layer is removed and a thin autograftplaced over the neodermis. This results in faster healing of the moresuperficial donor sites, and seems to have less hypertrophic scarringand improved joint function.
AlloDerm (LifeCell Corporation, The Woodlands, TX) is another dermalsubstitute consisting of cryopreserved acellular human dermis. Thismust also be used in combination with thin split-thickness skin grafts.
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Wound Coverage
Epidermal skin substitutes such as culturedepithelial autografts are an option in patients with
massive burns and very limited donor sites
Convenient anatomic donor sites, Thighs, The
thicker skin of the back , The buttocks, Silvadene,The scalp, the skin
Epinephrine clysis is necessary for harvesting the
scalp, for both hemostasis of this hypervascular
area and also to create a smooth surface forharvesting.
Principles behind choosing a dressing should
balance ease of care, comfort, infection control,
and cost.
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Rehabilitation
Immediate and ongoingphysical and occupationaltherapy is mandatory toprevent loss of physicalfunction.
passive ROM at leasttwice a day
Psychologicalrehabilitation is equally
important in the burnpatientPsychologicaldistress occurs in asmany as 34% of burnpatients, and persists in
severity long afterdischar ehttp://www.burntherapist.com/History.htm
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Prevention
community-basedinterventions
Smoke alarms
Regulation of hot water
heater temperatures
community-based
programs emphasizing
education and in-home
inspections
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