Acute Burn Management

8/10/2019 Acute Burn Management

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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 : 107MORTALITY RATE : 37,78%

DR. SOETOMO HOSPITAL (1999 - 2005)

ADMISSION NUMBER : 739MORTALITY RATE : 29,8%

ITSA 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 PHASEMANAGEMENT


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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 forcechange

Fluid and protein shift

Total blood volume have been lost

Burn shock


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DEPTH ASSESSMENT

1. 1stDEGREE

- EPIDERMIS

2. 2ndDEGREE

- SUPERFICIAL

- DEEP

3. 3rdDEGREE

- 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%


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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- 2ndDEGREE < 15%- 2ndDEGREE < 10% IN JUVENILES- 3rdDEGREE < 1%


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2. MODERATE

- 2ndDEGREE 15-25% IN ADULTS

- 2ndDEGREE 10-20% IN JUVENILES

- 3rdDEGREE < 10%


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3. SEVERE

-2ndDEGREE >25% IN ADULTS

- 2ndDEGREE >20% IN JUVENILES

- 3rdDEGREE >10%

- AFFECTED HANDS, FACE, EARS, EYES, FEET, AND

GENITAL / PERINEUM

- INHALATION INJURY, ELECTRICAL INJURY, OR ASSOCIATED WITHOTHER 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


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II. SECONDARY SURVEY :

A.HISTORY TAKINGB.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


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7. PERFUSSION ASSESSMENT

8. CONTINUED VENTILATORY ASSESSMENT

9. PAIN MANAGEMENT

10.PSYCHOSOCIAL ASSESSMENT11.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

BROOKES FORMULA

PARKLANDS FORMULA

BROOKES MODIFICATION

MONAFOS FORMULA


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BAXTERSFORMULADR. 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 CC1-3 YRS : BW X 75 CC

3-5 YRS : BW X 50 CC

IN FIRST 8 HRS

NEXT 16 HRS


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DAY 2 :

ADULT : MAINTENANCEALBUMIN (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. OLIGURIAASSOCIATED 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 EXAMINATIONBURNS 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-RAY9. 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 statebegins at the onset of burn and lasts for the first 48hours - 72 hours

Rapid fluid shifts - from the vascular compartmentsinto the interstitial spaces

Capillary permeability with burns increases withvasodilation

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 itmoves back into the cell or is excreted in urine withthe diuresis

Fluid overload can occur due to increasedintravascular volume

Metabolic acidosis - HCO3loss in urine, increase infat metabolism


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SIGNS OF ADEQUATEFLUID RESUSCITATION :

Clear sensorium

Pulse < 120 beats per minute

Urine output for adults 30 - 50cc/hour

Systolic blood pressure > 100 mm Hg

Blood pH within normal range 7.35 -7.45


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Organisms that usuallyinfect burns are:

a. Staphylococcus aureus

b. Pseudomonas Infection is usuallythe cause of any deterioration


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Signs of Sepsis:

a. Change in sensorium

b. Fever

c. Tachyapnead. 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 incontact with patient


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WOUND CARE PRINCIPLES

1. GOALS1. close wound as soon as possible2. prevent infection3. reduce scarring and contractures4. provide for comfort

2. Wound cleaning + closed technique3. Debridement, mechanical, surgical, enzymatic4. Topical antibacterial therapy mafenide (sulfonamide)

sulfadiazine5. 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

joints3. 3rddegree

4. Electric injury

5. Chemical injury

6. Inhalation injury7. Juveniles

8. Associated with other traumas


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ACUTE BURN

A. Airway : inhalation injury

B. Breathing : fullthickness

circumferntial burn

C. Circulation : syok


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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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INHALATION INJURY


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INHALATION INJURY


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INHALATIONINJURY


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Fullthickness

circumferentialburns
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Acute Burn Management

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