Ambulatory Management of Burns

8/20/2019 Ambulatory Management of Burns

1/49

Ambulatory Management of Burns

ERIC D. MORGAN, MAJ, MC, USA, Esen!o"er Army Me#$al Center, %ort Gor#on,

Georga

SCO&& C. B'EDSOE, C(&, MC, USA, )ee# Army Communty *os+tal, %ort Ir"n,

Calforna

JANE BARER, C(&, MC, USA, Mon$ref Army Communty *os+tal, %ort Ja$-son,

Sout! Carolna

Am %am (!ys$an. /// No0 1234567/189/3.

See relate# +atent nformaton !an#outs on ta-ng $are of burns an#+re0entng burns, "rtten by t!e aut!ors of t!s art$le.

Burns often !a++en une:+e$te#ly an# !a0e t!e +otental to $ause #eat!, lfelong

#s;gurement an# #ysfun$ton. A $rt$al +art of burn management s assessng

t!e #e+t! an# e:tent of n


2/49

!os+tal@aton an# m+lementng measures to +romote !ealng, +re0ent nfe$ton

an# rele0e +an. Durng follo"9u+ $are, t!e fo$us s!fts to lmtng #s;gurement

from s$arrng an# #ysfun$ton from $ontra$tures. Alt!oug! most +atents "t!

burns $an be manage# by famly +!ys$ans, some re?ure surg$al referral for

s-n graftng an# s$ar re!abltaton.

A$ute Management of Burns

It s of +aramount m+ortan$e to #etermne "!et!er a +atent "t! a burn n


3/49

%IGURE .

Dee+ +artal9t!$-ness burns on t!e trun- an# e:tremtes of a young $!l#. &!ese

burns are ty+;e# by easly unroofe# blsters t!at !a0e a "a:y a++earan$e an#

#o not blan$! "t! +ressure.

e" 'arge

%IGURE .

%ull9t!$-ness burn on a "omans left Fan-. Burn areas of t!s ty+e are

$!ara$terst$ally nsensate an# "a:y "!te or leat!ery gray n $olor.

e" 'arge

&AB'E 1 Class;$aton of Burns Base# on De+t!

e" &able

Derentatng a #ee+ +artal9t!$-ness burn from a full9t!$-ness burn $an be

?ute #H$ult ntally.,8,3 Re0sons of burn9#e+t! estmatons are often

ne$essary n t!e ;rst to !ours8 an# may be re?ure# t!roug! t!e ;rst t"o

or t!ree "ee-s. %or nstan$e, alt!oug! a full9t!$-ness burn ty+$ally !as a "!te

or $!arre# a++earan$e, t $an be re# after a s$al# n s a++ro+rate for use n all a#ults an# "!en a ?u$- assessment s

nee#e# for a $!l#.


4/49

More a$$urate met!o#s are re?ure# for #e;nt0e estmaton of t!e e:tent of

burns n $!l#ren. &!e 'un# an# Bro"#er met!o# $o0ers all age grou+s an# s

$ons#ere# t!e most a$$urate met!o# to use n +e#atr$ +atents 4%gure 86.,K

C!art for Estmatng Area of Burns

%IGURE 8.

Mo#;e# 'un# an# Bro"#er $!art for estmatng t!e area of burns. &!s a++roa$!

s $ons#ere# t!e most a$$urate for use n +e#atr$ +atents. &!e ;gures $an be

$olore# n "t! re# for full9t!$-ness burns an# blue for +artal9t!$-ness burns.

4n# L se$on#9#egree burn2 r# L t!r#9#egree burn2 &BSA L total +er$entage of

bo#y surfa$e area6

A#a+te# "t! +ermsson from Mertens DM, Jen-ns ME, )ar#en GD. Out+atent

burn management. Nurs Cln Nort! Am 155273, an# 'un# C, Bro"#er N.

&!e estmaton of areas of burns. Surg Gyne$ol Obstet 152578K.

e" 'arge

&!e surfa$e area of a +atents +alm $an also be use# to estmate t!e e:tent of

small or +at$!y burns. Class$ally, t!e +alm !as been $ons#ere# to re+resent 1

+er$ent of t!e &BSA.,3 *o"e0er, a re$ent stu#y #emonstrate# t!at t!e +alm

more a$$urately re+resents /. +er$ent of t!e &BSA, an# t!e entre !an#

re+resents /.K +er$ent of t!e &BSA.5

IN(A&IEN& &REA&MEN& AND BURN UNI& RE%ERRA'

(atents $ons#ere# to !a0e mo#erate burns base# on t!e gra#ng system

#e0elo+e# by t!e Amer$an Burn Asso$aton 4ABA6 s!oul# be a#mtte# for

ntra0enous !y#raton an# surg$al $are of t!er "oun#s 4&able 6.3,1/ Be$ause

of t!e ntal #H$ultes n #erentatng #ee+ +artal9t!$-ness burns from full9

t!$-ness burns, famly +!ys$ans s!oul# strongly $ons#er obtanng a surg$al

$onsultaton for "!at a++ears to be a #ee+ +artal9t!$-ness burn ae$tng more

t!an +er$ent &BSA.

&AB'E Amer$an Burn Asso$atons Gra#ng System for Burn Se0erty an#

Ds+oston of (atents

e" &able

(ulmonary nsuH$en$y s res+onsble for more t!an 8 +er$ent of ;re9relate#

#eat!s.1 Be$ause of t!e +ossblty of +rogress0e e#ema, +atents "t!sus+e$te# n!alaton n


5/49

*stor$al or +!ys$al ;n#ngs t!at rase $on$ern about n!alaton n


6/49

Management of Burns

%gure 3.

Algort!m for t!e management of +atents "t! burns.

A#a+te# from (eate )%. Out+atent management of burns. Am %am (!ys$an

15528713.

e" 'arge

A systemat$ a++roa$! to t!e ambulatory management of burns s

$on$e+tual@e# by t!e s: =Cs>7 $lot!ng, $oolng, $leanng, $!emo+ro+!yla:s,

$o0erng an# $omfortng 4.e., +an relef6.

Clot!ng. Any $lot!ng t!at s !ot or burne# s!oul# be remo0e# mme#ately from

t!e +atents bo#y. Clot!ng t!at !as been e:+ose# to $!em$als s!oul# also be

remo0e# to a0o# e:+osng t!e s-n to $ontnue# burn nsult. If $lot!ng #oes not

remo0e easly, nona#!erent materal s!oul# be $ut a"ay, "t! a#!erent $lot!ng

left for remo0al n t!e $leanng +!ase.

Coolng. I#eally, burns s!oul# be $oole# mme#ately after t!ey o$$ur. Alt!oug!

most tssue !as alrea#y $oole# by t!e tme +atents "t! burns +resent to a+!ys$an, furt!er $oolng #urng t!e ;rst se0eral !ours after n


7/49

&ar an# as+!alt res#ues s!oul# ne0er be #ebr#e#82 nstea#, t!ey $an be

remo0e# "t! a m:ture of $ool "ater an# mneral ol. A++lyng $o+ous

amounts of +olymy:n Bba$tra$n @n$ ontment 4(olys+orn6 o0er se0eral #ays

s!oul# emulsfy an# remo0e res#ual tar.18 Embe##e# bts of $lot!ng or ot!er

materals s!oul# be remo0e# by $o+ous rrgaton usng a large9gauge syrnge.

&o mnm@e nfe$ton, ne$rot$ tssue from +artal9 an# full9t!$-ness burns s!oul#

be remo0e# manually or "t! "!rl+ool #ebr#ement. &!e latter met!o# ten#s to

be better tolerate# by +atents. &!e yello" es$!ar $!ara$terst$ of +artal9

t!$-ness burns nee# not be remo0e#.

Ru+ture# blsters s!oul# be remo0e#. Many e:+erts re$ommen# unroo;ng

blsters f t!ey $ontan $lou#y Fu# or are l-ely to ru+ture mmnently 4e.g.,blsters lo$ate# o0er


8/49

use# to +re0ent burn nfe$tons. &!s agent s!oul# ne0er be use# on t!e fa$e or

n +atents "t! sulfonam#e !y+ersenst0ty. Be$ause of t!e rs- of sulfonam#e

-ern$terus, sl0er sulfa#a@ne s!oul# not be use# n +regnant "omen, ne"borns

or nursng mot!ers "t! nfants younger t!an t"o mont!s of age.

Ba$tra$n s an alternat0e to+$al +ro+!yla$t$ antbot$. &!s agent s!oul#

al"ays be use# aroun# mu$ous membranes. Be$ause of t!e #e$rease# $ost,

se0eral aut!ors fa0or usng ba$tra$n rat!er t!an sl0er sulfa#a@ne for any

su+er;$al +artal9t!$-ness burn. No stu#es $om+arng t!e eH$a$es of

ba$tra$n an# sl0er sulfa#a@ne !a0e yet been +ubls!e#.

Alternat0es to to+$al antbot$s n$lu#e bolog$ #ressngs 4+gs-n, !uman

allograft6 an# bsmut!9m+regnate# +etroleum gau@e or Bobrane #ressngs. &!ea#0antage of t!ese #ressngs s t!at t!ey are a++le# only on$e. As a result,

+atents are s+are# t!e +an t!at ty+$ally a$$om+anes #ressng $!anges.

Bolog$ #ressngs are asso$ate# "t! lo"er nfe$ton rates an# faster !ealng

rates t!an sl0er sulfa#a@ne. *o"e0er, t!ese #ressngs are e:+ens0e, #H$ult to

a++ly an# not al"ays rea#ly a0alable.1 If use#, bolog$ #ressngs s!oul# be

a++le# "t!n t!e ;rst s: !ours after t!e burn s sustane#. &!e ntal

a++l$aton may loosen by t!e follo"ng #ay, ne$esstatng rea++l$aton.

&!ereafter, t!ese #ressngs gra#ually +eel o as s-n e+t!elal@es un#erneat!t!em. Early se+araton of t!e #ressng from t!e s-n n#$ates t!e +resen$e of a

#ee+er "oun# 4re?urng surg$al treatment6 or an nfe$ton.8

Bsmut!9m+regnate# +etroleum gau@e an# Bobrane #ressngs a++ear to be

a#0antageous treatments an# are a$$e+table for use n young $!l#ren "t!

su+er;$al +artal9t!$-ness burns.1,8 Bot! of t!ese #ressngs are a++le# as a

sngle layer o0er t!e burn an# are t!en $o0ere# "t! a bul-y #ressng. &!e bul-y

#ressng s!oul# be $!ange# e0ery ot!er #ay, ty+$ally n a +!ys$ans oH$e, "t!

$lose assessment of t!e "oun# for sgns of nfe$ton.

Co0erng. Dogmat$ re$ommen#atons regar#ng t!e ty+e an# #uraton of

#ressng $annot be ma#e be$ause of t!e +au$ty of stu#es on t!e sub


9/49

Su+er;$al burns #o not re?ure "oun# #ressngs. Use of a sm+le s-n lubr$ant

4e.g., aloe 0era $ream6 s suH$ent, an# +atents s!oul# be nstru$te# to see t!er

+!ys$an f any blsters #e0elo+.

All +artal9 an# full9t!$-ness burns s!oul# be $o0ere# "t! sterle #ressngs. A

;ne mes! gau@e 4e.g., &elfa6 s!oul# be a++le# after t!e burn !as been $leane#

an# a t!n layer of to+$al antbot$ !as been a++le#. Cr$ulatory m+arment s

mnm@e# by a++lyng t!s nona#!erent #ressng n su$$ess0e str+s, rat!er

t!an "ra++ng t aroun# t!e "oun#.13 &!e #ressng s !el# n +la$e "t! a

tubular net ban#age or lg!tly a++le# gau@e "ra+s. &ubular net ban#ages $ome

n a 0arety of s@es. &!s ban#age s e:$ellent for use on e:tremtes, an# t $an

be mo#;e# to ;t t!e trun- of a younger $!l#.

Re$ommen#e# fre?uen$es for #ressng $!anges range from t"$e #aly to on$e a

"ee-.3 Dressngs s!oul# be $!ange# "!ene0er t!ey be$ome soa-e# "t!

e:$ess0e e:u#ate or ot!er Fu#s.8 At ea$! #ressng $!ange, t!e to+$al

antbot$ s!oul# be remo0e# as $om+letely as +ossble usng gentle "as!ngs.

S$rubbng an# s!ar+ #ebr#ement are not ne$essary.8

Comfortng. Analges$s s!oul# be g0en aroun# t!e $lo$- to $ontrol =ba$-groun#>

+an. A$etamno+!en 4&ylenol6 an# nonstero#al ant9nFammatory #rugs 4alone

or n $ombnaton "t! o+o#s6 are often a++ro+rate for use n +atents "t!small burn "oun#s.3 As+rn +ro#u$ts s!oul# be a0o#e# be$ause of +latelet

n!bton an# t!e rs- for blee#ng.

(atents "t! burns often re?ure a =res$ue> me#$aton 4e.g., a$etamno+!en

"t! $o#ene &ylenol ) Co#eneP or a stronger nar$ot$ e.g., mor+!neP6 before

#ressng $!anges an# #urng n$rease# +!ys$al a$t0ty.3 Nar$ot$ me#$atons

$an be use# n $!l#ren as "ell as a#ults.1,13,

A +atents "orst +an s$ore s!oul# be less t!an 8 4on a s$ale of @ero to 1/6.

S$ores of 8 or !g!er nterfere "t! slee+, a$t0ty an# moo#.K

%ollo"9U+ Care for Burns

%ollo"9u+ $are n0ol0es sur0eyng +atents "t! burns for sgns of nfe$ton,

s$arrng an# $ontra$ture. &o mnm@e furt!er #amage, nfe$ton s best manage#

n a !os+tal. S$arrng an# $ontra$tures $onnote long9term #s;gurement an##sablty, bot! of "!$! are n#$atons for s+e$al@e# $are.


10/49

%O''O)9U( IN&ERA'S

(atents "t! burns "!o are beng manage# as out+atents s!oul# be seen agan

on t!e #ay after n &!s s not ne$essarly t!e $ase

"t! burns. Alt!oug! t!e t!reat of nfe$ton an# t!e magntu#e of +an #mns!

"t! tme, t!e +ros+e$ts for long9term s$arrng an# #sablty often be$ome more

a++arent. *y+ertro+!$ s$arrng s t!oug!t to be ne0table "!en e+t!elal@aton

ta-es longer t!an t"o "ee-s n bla$-s an# young $!l#ren, or longer t!an t!ree

"ee-s n all ot!er +atents.5

A++l$aton of +ressure to burn "oun#s s generally re$ommen#e# to mnm@e

!y+ertro+!$ s$arrng, alt!oug! o+tmal +ressure an# #uraton !a0e not yet been

#etermne# n $ontrolle# trals./ A 0arety of te$!n?ues are use#, but all are

$om+le: an# $ostly. &!erefore, famly +!ys$ans often refer +atents at rs- for

s$arrng to a burn s+e$alst. Be$ause +ressure +re0ents s$ars but #oes not treat

t!em on$e t!ey #e0elo+, referral s!oul# be ntate# +rom+tly at t!e ;rst sgn of

!y+ertro+!$ s$arrng or f a "oun# msses $ertan e+t!elal@aton mlestones

4&able 6.1


11/49

&AB'E )oun# E+t!elal@aton Mlestones

e" &able

Alt!oug! +ressure #oes lttle to remo#el e:stng !y+ertro+!$ s$ars, t!e

a++l$aton of sl$one gel s!eetng !as been foun# to sgn;$antly re#u$e

establs!e# s$ars as late as 1 years after n


12/49

It$!ng s a $ommon +roblem #urng t!e !ealng +ro$ess. (rurtus s often

trggere# or "orsene# by en0ronmental e:tremes 4es+e$ally !eat6, +!ys$al

a$t0ty an# stress.3 &!e t$!ng usually #mns!es gra#ually an# e0entually

sto+s after $om+lete "oun# !ealng.3 Untl t!en, a number of measures $an be

em+loye# to $ontrol t$!ng. System$ ant!stamnes are usually tre# ;rst, "t!

#+!en!y#ramne 4Bena#ryl6 use# most fre?uently.8,3 Cy+ro!e+ta#ne 4(era$tn6

an# !y#ro:y@ne 4Atara:6 are alternat0es.3 'o$al measures n$lu#e b$arbonate

of so#a bat!s an# mostur@ng lotons.8 Many +atents +refer to "ear loose, soft,

$otton $lot!ng.3

In a##ton to !el+ng +atents $o+e "t! long9term +!ys$al #s$omfort, famly

+!ys$ans s!oul# be alert for +sy$!olog$ ssues. (atents "!o !a0e sustane#

burns are at n$rease# rs- for an:ety, #e+resson an# +ost9traumat$ stress

#sor#er. %amly #ynam$s $an also $!ange #ramat$ally. %amly members may be

str$-en "t! gult, an# +atents are sus$e+tble to #e+en#en$y ssues be$ause of

t!e a##tonal !el+ re?ure# for #aly a$t0tes "!le !ealng s o$$urrng. If a

+sy$!olog$ ssue s not$e#, a++ro+rate treatment s!oul# be m+lemente#.

&!e Aut!ors

ERIC D. MORGAN, MAJ, MC, USA, s res#en$y #re$tor for t!e De+artment of

%amly an# Communty Me#$ne at Esen!o"er Army Me#$al Center, %ort

Gor#on, Ga. *e re$e0e# !s me#$al #egree from 'oma 'n#a 4Calf.6 Un0ersty

S$!ool of Me#$ne an# $om+lete# a famly +ra$t$e res#en$y at &r+ler Army

Me#$al Center, *onolulu. *e also earne# a master of +ubl$ !ealt! #egree from

t!e Un0ersty of )as!ngton, Seattle, an# $om+lete# a fa$ulty #e0elo+ment

fello"s!+ at Ma#gan Army Me#$al Center, %ort 'e"s, )as!.

SCO&& C. B'EDSOE, C(&, MC, USA, s a sta +!ys$an at t!e %amly (ra$t$e

Cln$, )ee# Army Communty *os+tal, %ort Ir"n, Calf. *e gra#uate# from

r-s0lle 4Mo.6 College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly

+ra$t$e res#en$y at Esen!o"er Army Me#$al Center.

JANE BARER, C(&, MC, USA, s a sta famly +!ys$an at t!e %amly *ealt!

Center, Mon$ref Army Communty *os+tal, %ort Ja$-son, S.C. S!e gra#uate#

from r-s0lle College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly


A##ress $orres+on#en$e to Er$ D. Morgan, MAJ, MC, USA, Res#en$y Dre$tor,

De+artment of %amly an# Communty Me#$ne, Esen!o"er Army Me#$al


13/49

Center, %ort Gor#on, GA /5/89838/ 4e9mal a##ress7

Er$.MorganQse.ame##.army.ml6. Re+rnts are not a0alable from t!e aut!ors.

&!e o+nons an# assertons $ontane# !eren are t!e +r0ate 0e"s of t!e

aut!ors an# are not to be $onstrue# as oH$al or as reFe$tng t!e 0e"s of t!e

Army Me#$al De+artment or t!e Army Ser0$e at large.

&!e +!otogra+!s n ;gures 1 t!roug! "ere +ro0#e# by Ste0e Bra$$ of t!e

Jose+! M. Stll Burn Center at Do$tors *os+tal, Augusta, Ga.

&!s art$le s #e#$ate# to Elsabet! Morgan, t!e #aug!ter of Dr. Er$ D. Morgan.

Elsabet! sustane# a se0ere s$al# n


14/49

3. *artfor# CE. Care of out+atent burns. In7 *ern#on DN, e#. &otal burn $are.

(!la#el+!a7 Saun#ers, 155371K/.

. *emba$! D, Mann R, Engra0 '. E0aluaton of t!e burn "oun#. Management

#e$sons. In7 *ern#on DN, e#. &otal burn $are. (!la#el+!a7 Saun#ers, 15537K1

.

K. 'un# C, Bro"#er N. &!e estmaton of areas of burns. Surg Gyne$ol Obstet.

152578K.

5. (erry RJ, Moore CA, Morgan DB, (lummer D'. Determnng t!e a++ro:mate

area of a burn7 an n$onssten$y n0estgate# an# re9e0aluate#. BMJ.15532171K.

1/. *os+tal an# +re!os+tal resour$es for o+tmal $are of +atents "t! burn

n


15/49

1. (us!-ar NS, San#ormns-y B(. Col# treatment of burns. Burns In$l &!erm In


16/49

K. Cleelan# CS, Ryan M. (an assessment7 global use of t!e Bref (an

In0entory. Ann A$a# Me# Snga+ore. 1552715K.

5. Det$! EA, )!eela!an &M, Rose M(, Clot!er J, Cotter J. *y+ertro+!$ burn

s$ars7 analyss of 0arables. J &rauma. 15K27K58K.

/. Muller MJ, *ern#on DN. &!e $!allenge of burns. 'an$et. 1552713/.

1. Carr9Collns JA. (ressure te$!n?ues for t!e +re0enton of !y+ertro+!$ s$ar.

Cln (last Surg. 1552157.

. A!n S&, Monafo )), Mustoe &A. &o+$al sl$one gel for t!e +re0enton an#

treatment of !y+ertro+!$ s$ar. Ar$! Surg. 15512137558/.

. unn J. Sl$one gel n s$ar treatment. Burns In$l &!erm In


17/49

Mana


18/49

'u-a ba-ar #a+at meng!an$ur-an lu-a yang menga-bat-an -ematan atau lu-a

seumur !#u+, $a$at #an #sfungs. 'u-a ba-ar a#ala! +enyebab utama -etga

-ematan -arena -e$ela-aan # Amer-a Ser-at 4setela! ns#en yang melbat-an

-en#araan bermotor #an sen


19/49

Gambar 1.

'u-a ba-ar su+er;sal +a#a batang #an lengan -anan #ar ana- mu#a. Basanya,

n a#ala! lu-a ba-ar mera! yang memut!-an #engan te-anan.

'!at besar

Gambar .

Su+er;$al +artal9t!$-ness memba-ar lutut -anan +ra. &er- lu-a yang

memut!-an #engan te-anan meru+a-an -ara-terst- #ang-al +arsal9-etebalan

lu-a ba-ar. 'u-a n


20/49

'UAS A BURN

'uasnya lu-a ba-ar #nyata-an sebaga +ersentase total luas +ermu-aan tubu!

4&BSA6 ter-ena $e#era. Estmas a-urat #ar &BSA #ar lu-a ba-ar sangat +entng

untu- membmbng mana


21/49

(asen #angga+ meml- lu-a ba-ar mo#erat ber#asar-an sstem +enlaan yang

#-embang-an ole! Amer$an Asso$aton Ba-ar 4ABA6 !arus #a-u untu- !#ras

ntra0ena #an +era"atan be#a! lu-a mere-a 4&abel 6 .3,1/ arena -esultan

a"al #alam membe#a-an +artal9 #alam -etebalan lu-a ba-ar #ar full9t!$-ness

lu-a ba-ar, #o-ter -eluarga !arus mem+ertmbang-an men#a+at-an -onsultas

be#a! untu- a+a yang tam+a-nya men


22/49

ba-ar Immerson a#ala! lu-a ba-ar -las- #alam +ele$e!an ana-, teta+

+ele$e!an !arus #$urga #engan $e#era mele+u!, terutama


23/49

ba-ar saat !a#r untu- #o-ter, +en#ngnan leb! lan


24/49

emo+ro;la-ss. Imunsas tetanus !arus #+erbaru +a#a +asen #engan lu-a

leb! #alam #ar burn. +arsal9-etebalan #ang-al

Men#agnoss nfe-s +a#a +asen #engan lu-a ba-ar menantang. 'u-a ba-ar

menmbul-an +era#angan, yang meng!asl-an rngan ertema, e#ema, rasa sa-t

#an nyer. J-a tan#a9tan#a n ter


25/49

Dressng bologs ber!ubungan #engan tng-at nfe-s yang leb! ren#a! #an

tng-at +enyembu!an leb! $e+at #ar sulfa#a@n +era-. Namun, #ressng n

ma!al, sult untu- menera+-an #an t#a- selalu mu#a! a0alable.1 J-a

#guna-an, #ressng bologs !arus #tera+-an #alam enam


26/49

#engan e-su#at yang berleb!an atau Fu#s.8 lannya (a#a seta+ +eruba!an

ras, antbot- to+-al !arus #!a+us seleng-a+ mung-n mengguna-an

+embasu!an lembut. S$rubbng #an #ebr#ement ta


27/49

$m, +asen !arus #ru


28/49

ontra-tur S$ar menyebab-an $a$at #an $a$at. J-a ter#ete-s #n, $ontra$ture

#a+at #obat #engan ss+an sl-on #an te-anan. J-a $ontra$ture leb! ma


29/49

Selan membantu +asen mengatas -et#a-nyamanan ;s-


30/49

%oto9foto #alam ang-a 1 sam+a yang #se#a-an ole! Ste0e Bra$$ #ar Jose+!

M. Mas! Burn Center # Ruma! Sa-t Do-ter, Augusta, Ga.

Art-el n ##e#-as-an untu- Elsabet! Morgan, +utr Dr Er$ D. Morgan.

Elsabet! mengalam $e#era +ara! mele+u! lama setela! ulang ta!un

+ertamanya. Mes-+un -ult Elsabet! +ermanen men$ermn-an trage#

-e$ela-aan #an tela! selamanya +e-a aya! #o-ternya #engan -engeran lu-a

ba-ar, -euletan nya, 0taltas #an su-a$ta bag -e!#u+an a#ala! bu-t

-emam+uan -e!en#a- manusa #an -e+rba#an untu- men


31/49

K 'un# C, Bro"#er N. Estmas #aera! lu-a ba-ar. Surg Gyne$ol Obstet. 152 57

89K.

5. (erry RJ, Moore CA, Morgan DB, (lummer D'. Menentu-an ta-sran luas lu-a

ba-ar7 n-onsstens #sel#- #an re9e0aluas. BMJ. 15532 17 1K.

1/ Ruma! Sa-t #an sumber #aya +ra9ruma! sa-t untu- +era"atan o+tmal

+asen #engan lu-a ba-ar7 +e#oman untu- +engembangan #an +engo+erasan

+usat lu-a ba-ar. Amer-a Ba-ar Asso$aton. J Ba-ar (era"atan Re!abl. 155/2

117 5K91/.

11. Monafo )). Mana


32/49

1K. All"oo# JS. Mana


33/49

5. Det$! EA, )!eela!an &M, Rose M(, Clot!er J, Cotter J. *y+ertro+!$ be-as

lu-a ba-ar7 analss 0arabel. J &rauma. 15K2 7 K589K.

/. Muller MJ, *ern#on DN. &antangan lu-a ba-ar. 'an$et. 1552 7 139/.

1. Carr9Collns JA. &e-n- te-anan untu- +en$ega!an +arut !+ertro;-. Cln (last

Surg. 1552 157 9.

. A!n S&, Monafo )), Mustoe &A. Gel sl-on to+-al untu- +en$ega!an #an

+engobatan be-as lu-a !+ertro;-. Ar$! Surg. 15512 137 5598/.

. unn J. Gel sl-on #alam +engobatan be-as lu-a. &ermasu- lu-a ba-ar

&!erm In


34/49

See relate# +atent nformaton !an#outs on ta-ng $are of burns an#

+re0entng burns, "rtten by t!e aut!ors of t!s art$le.

Burns often !a++en une:+e$te#ly an# !a0e t!e +otental to $ause #eat!, lfelong

#s;gurement an# #ysfun$ton. A $rt$al +art of burn management s assessng

t!e #e+t! an# e:tent of n


35/49

a$$urate #etermnaton of t!e #e+t! an# e:tent of t!e "oun#4s6, as "ell as

$ons#eraton of $rt$al ssues su$! as s-n t!$-ness, burn lo$aton an#

$omorb# $on#tons.

DE(&* O% A BURN

&!e tra#tonal $lass;$aton of burns as ;rst, se$on# or t!r# #egree s beng

re+la$e# by t!e #esgnatons of su+er;$al 4%gure 16, su+er;$al +artal t!$-ness

4%gure 6, #ee+ +artal t!$-ness 4%gure 6 an# full t!$-ness 4%gure 6. Burn

#e+t! !as an m+a$t on !ealng tme, t!e nee# for !os+tal@aton an# surg$al

nter0enton, an# t!e +otental for s$ar #e0elo+ment. Alt!oug! a$$urate

$lass;$aton s not al"ays +ossble ntally, t!e $auses an# +!ys$al

$!ara$terst$s of burns are !el+ful n $ategor@ng t!er #e+t! 4&able 16.

Gambar 1.

Su+er;$al burns on t!e trun- an# rg!t arm of a young $!l#. &y+$ally, t!ese are

re# burns t!at blan$! "t! +ressure.

'!at besar

%IGURE .

Su+er;$al +artal9t!$-ness burn on a mans rg!t -nee. Blsterng "oun#s t!at

blan$! "t! +ressure are $!ara$terst$ of su+er;$al +artal9t!$-ness burns.

&!ese "oun#s are also ty+$ally most an# "ee+ng.

'!at besar

%IGURE .

Dee+ +artal9t!$-ness burns on t!e trun- an# e:tremtes of a young $!l#. &!ese

burns are ty+;e# by easly unroofe# blsters t!at !a0e a "a:y a++earan$e an#

#o not blan$! "t! +ressure.

'!at besar

%IGURE .

%ull9t!$-ness burn on a "omans left Fan-. Burn areas of t!s ty+e are$!ara$terst$ally nsensate an# "a:y "!te or leat!ery gray n $olor.


36/49

'!at besar

&AB'E 1 Class;$aton of Burns Base# on De+t!

'!at &abel

Derentatng a #ee+ +artal9t!$-ness burn from a full9t!$-ness burn $an be

?ute #H$ult ntally.,8,3 Re0sons of burn9#e+t! estmatons are often

ne$essary n t!e ;rst to !ours8 an# may be re?ure# t!roug! t!e ;rst t"o

or t!ree "ee-s. %or nstan$e, alt!oug! a full9t!$-ness burn ty+$ally !as a "!te

or $!arre# a++earan$e, t $an be re# after a s$al# n s a++ro+rate for use n all a#ults an# "!en a ?u$- assessment s

nee#e# for a $!l#.

More a$$urate met!o#s are re?ure# for #e;nt0e estmaton of t!e e:tent of

burns n $!l#ren. &!e 'un# an# Bro"#er met!o# $o0ers all age grou+s an# s

$ons#ere# t!e most a$$urate met!o# to use n +e#atr$ +atents 4%gure 86.,K

C!art for Estmatng Area of Burns

%IGURE 8.

Mo#;e# 'un# an# Bro"#er $!art for estmatng t!e area of burns. &!s a++roa$!

s $ons#ere# t!e most a$$urate for use n +e#atr$ +atents. &!e ;gures $an be

$olore# n "t! re# for full9t!$-ness burns an# blue for +artal9t!$-ness burns.


37/49

4n# L se$on#9#egree burn2 r# L t!r#9#egree burn2 &BSA L total +er$entage of

bo#y surfa$e area6

A#a+te# "t! +ermsson from Mertens DM, Jen-ns ME, )ar#en GD. Out+atent

burn management. Nurs Cln Nort! Am 155273, an# 'un# C, Bro"#er N.

&!e estmaton of areas of burns. Surg Gyne$ol Obstet 152578K.

'!at besar

&!e surfa$e area of a +atents +alm $an also be use# to estmate t!e e:tent of

small or +at$!y burns. Class$ally, t!e +alm !as been $ons#ere# to re+resent 1

+er$ent of t!e &BSA.,3 *o"e0er, a re$ent stu#y #emonstrate# t!at t!e +alm

more a$$urately re+resents /. +er$ent of t!e &BSA, an# t!e entre !an#

re+resents /.K +er$ent of t!e &BSA.5

IN(A&IEN& &REA&MEN& AND BURN UNI& RE%ERRA'

(atents $ons#ere# to !a0e mo#erate burns base# on t!e gra#ng system

#e0elo+e# by t!e Amer$an Burn Asso$aton 4ABA6 s!oul# be a#mtte# for

ntra0enous !y#raton an# surg$al $are of t!er "oun#s 4&able 6.3,1/ Be$ause

of t!e ntal #H$ultes n #erentatng #ee+ +artal9t!$-ness burns from full9

t!$-ness burns, famly +!ys$ans s!oul# strongly $ons#er obtanng a surg$al

$onsultaton for "!at a++ears to be a #ee+ +artal9t!$-ness burn ae$tng more

t!an +er$ent &BSA.

&AB'E Amer$an Burn Asso$atons Gra#ng System for Burn Se0erty an#

Ds+oston of (atents

'!at &abel

(ulmonary nsuH$en$y s res+onsble for more t!an 8 +er$ent of ;re9relate#

#eat!s.1 Be$ause of t!e +ossblty of +rogress0e e#ema, +atents "t!

sus+e$te# n!alaton n


38/49

*os+tal a#msson s ne$essary for +atents "!o !a0e $r$umferental +artal9

t!$-ness or full9t!$-ness burns, +atents "!o !a0e burn n


39/49

A systemat$ a++roa$! to t!e ambulatory management of burns s

$on$e+tual@e# by t!e s: =Cs>7 $lot!ng, $oolng, $leanng, $!emo+ro+!yla:s,

$o0erng an# $omfortng 4.e., +an relef6.

Clot!ng. Any $lot!ng t!at s !ot or burne# s!oul# be remo0e# mme#ately from

t!e +atents bo#y. Clot!ng t!at !as been e:+ose# to $!em$als s!oul# also be

remo0e# to a0o# e:+osng t!e s-n to $ontnue# burn nsult. If $lot!ng #oes not

remo0e easly, nona#!erent materal s!oul# be $ut a"ay, "t! a#!erent $lot!ng

left for remo0al n t!e $leanng +!ase.

(en#ngn.I#eally, burns s!oul# be $oole# mme#ately after t!ey o$$ur.Alt!oug!

most tssue !as alrea#y $oole# by t!e tme +atents "t! burns +resent to a

+!ys$an, furt!er $oolng #urng t!e ;rst se0eral !ours after n


40/49

be better tolerate# by +atents. &!e yello" es$!ar $!ara$terst$ of +artal9

t!$-ness burns nee# not be remo0e#.

Ru+ture# blsters s!oul# be remo0e#. Many e:+erts re$ommen# unroo;ng

blsters f t!ey $ontan $lou#y Fu# or are l-ely to ru+ture mmnently 4e.g.,

blsters lo$ate# o0er


41/49

su+er;$al +artal9t!$-ness burn. No stu#es $om+arng t!e eH$a$es of

ba$tra$n an# sl0er sulfa#a@ne !a0e yet been +ubls!e#.

Alternat0es to to+$al antbot$s n$lu#e bolog$ #ressngs 4+gs-n, !uman

allograft6 an# bsmut!9m+regnate# +etroleum gau@e or Bobrane #ressngs. &!e

a#0antage of t!ese #ressngs s t!at t!ey are a++le# only on$e. As a result,

+atents are s+are# t!e +an t!at ty+$ally a$$om+anes #ressng $!anges.

Bolog$ #ressngs are asso$ate# "t! lo"er nfe$ton rates an# faster !ealng

rates t!an sl0er sulfa#a@ne. *o"e0er, t!ese #ressngs are e:+ens0e, #H$ult to

a++ly an# not al"ays rea#ly a0alable.1 If use#, bolog$ #ressngs s!oul# be

a++le# "t!n t!e ;rst s: !ours after t!e burn s sustane#. &!e ntal

a++l$aton may loosen by t!e follo"ng #ay, ne$esstatng rea++l$aton. &!ereafter, t!ese #ressngs gra#ually +eel o as s-n e+t!elal@es un#erneat!

t!em. Early se+araton of t!e #ressng from t!e s-n n#$ates t!e +resen$e of a

#ee+er "oun# 4re?urng surg$al treatment6 or an nfe$ton.8

Bsmut!9m+regnate# +etroleum gau@e an# Bobrane #ressngs a++ear to be

a#0antageous treatments an# are a$$e+table for use n young $!l#ren "t!

su+er;$al +artal9t!$-ness burns.1,8 Bot! of t!ese #ressngs are a++le# as a

sngle layer o0er t!e burn an# are t!en $o0ere# "t! a bul-y #ressng. &!e bul-y

#ressng s!oul# be $!ange# e0ery ot!er #ay, ty+$ally n a +!ys$ans oH$e, "t!$lose assessment of t!e "oun# for sgns of nfe$ton.

Co0erng. Dogmat$ re$ommen#atons regar#ng t!e ty+e an# #uraton of

#ressng $annot be ma#e be$ause of t!e +au$ty of stu#es on t!e sub


42/49

tubular net ban#age or lg!tly a++le# gau@e "ra+s. &ubular net ban#ages $ome

n a 0arety of s@es. &!s ban#age s e:$ellent for use on e:tremtes, an# t $an

be mo#;e# to ;t t!e trun- of a younger $!l#.

Re$ommen#e# fre?uen$es for #ressng $!anges range from t"$e #aly to on$e a

"ee-.3 Dressngs s!oul# be $!ange# "!ene0er t!ey be$ome soa-e# "t!

e:$ess0e e:u#ate or ot!er Fu#s.8 At ea$! #ressng $!ange, t!e to+$al

antbot$ s!oul# be remo0e# as $om+letely as +ossble usng gentle "as!ngs.

S$rubbng an# s!ar+ #ebr#ement are not ne$essary.8

Comfortng. Analges$s s!oul# be g0en aroun# t!e $lo$- to $ontrol =ba$-groun#>

+an. A$etamno+!en 4&ylenol6 an# nonstero#al ant9nFammatory #rugs 4alone

or n $ombnaton "t! o+o#s6 are often a++ro+rate for use n +atents "t!small burn "oun#s.3 As+rn +ro#u$ts s!oul# be a0o#e# be$ause of +latelet

n!bton an# t!e rs- for blee#ng.

(atents "t! burns often re?ure a =res$ue> me#$aton 4e.g., a$etamno+!en

"t! $o#ene &ylenol ) Co#eneP or a stronger nar$ot$ e.g., mor+!neP6 before

#ressng $!anges an# #urng n$rease# +!ys$al a$t0ty.3 Nar$ot$ me#$atons

$an be use# n $!l#ren as "ell as a#ults.1,13,

A +atents "orst +an s$ore s!oul# be less t!an 8 4on a s$ale of @ero to 1/6.

S$ores of 8 or !g!er nterfere "t! slee+, a$t0ty an# moo#.K

%ollo"9U+ Care for Burns

%ollo"9u+ $are n0ol0es sur0eyng +atents "t! burns for sgns of nfe$ton,

s$arrng an# $ontra$ture. &o mnm@e furt!er #amage, nfe$ton s best manage#

n a !os+tal. S$arrng an# $ontra$tures $onnote long9term #s;gurement an#

#sablty, bot! of "!$! are n#$atons for s+e$al@e# $are.

%O''O)9U( IN&ERA'S

(atents "t! burns "!o are beng manage# as out+atents s!oul# be seen agan

on t!e #ay after n


43/49

to +ro0#e +ro+er "oun# $are, t!e +atent s!oul# be seen on a #aly bass untl

$om+lete e+t!elal@aton o$$urs.,3

If "oun# e+t!elal@aton !as not begun after t"o "ee-s or f subse?uent

e0aluatons re0eal t!e +resen$e of a full9t!$-ness burn more t!an $m n

#ameter, t!e +atent s!oul# be referre# to a surgeon "t! e:+ertse n burn

$are.,3,18 &ny o+ales$ent slan#s of e+t!elum t!roug!out t!e "oun# n#$ate

e+t!elal@aton, "t! t!e "oun# ty+$ally !ealng $om+letely n se0en to 1/

#ays.3

After e+t!elal@aton !as o$$urre#, +atents are seen e0ery four to s: "ee-s to

assess for e0#en$e of !y+ertro+!$ s$ar formaton an# to montor $o+ng

me$!ansms.

*(ER&RO(*IC SCARRING AND CON&RAC&URES

It !as been sa# t!at =tme !eals all "oun#s.> &!s s not ne$essarly t!e $ase

"t! burns. Alt!oug! t!e t!reat of nfe$ton an# t!e magntu#e of +an #mns!

"t! tme, t!e +ros+e$ts for long9term s$arrng an# #sablty often be$ome more

a++arent. *y+ertro+!$ s$arrng s t!oug!t to be ne0table "!en e+t!elal@aton

ta-es longer t!an t"o "ee-s n bla$-s an# young $!l#ren, or longer t!an t!ree

"ee-s n all ot!er +atents.5

A++l$aton of +ressure to burn "oun#s s generally re$ommen#e# to mnm@e

!y+ertro+!$ s$arrng, alt!oug! o+tmal +ressure an# #uraton !a0e not yet been

#etermne# n $ontrolle# trals./ A 0arety of te$!n?ues are use#, but all are

$om+le: an# $ostly. &!erefore, famly +!ys$ans often refer +atents at rs- for

s$arrng to a burn s+e$alst. Be$ause +ressure +re0ents s$ars but #oes not treat

t!em on$e t!ey #e0elo+, referral s!oul# be ntate# +rom+tly at t!e ;rst sgn of

!y+ertro+!$ s$arrng or f a "oun# msses $ertan e+t!elal@aton mlestones

4&able 6.1

&AB'E )oun# E+t!elal@aton Mlestones

'!at &abel

Alt!oug! +ressure #oes lttle to remo#el e:stng !y+ertro+!$ s$ars, t!e

a++l$aton of sl$one gel s!eetng !as been foun# to sgn;$antly re#u$e

establs!e# s$ars as late as 1 years after n


44/49

res+on#ers from nonres+on#ers. S#e ee$ts of +rurtus an# ras! $an be

mnm@e# by "as!ng t!e s$ar an# a++lyng sl$on gel #aly.

S$ar $ontra$tures result n #s;gurement an# #sablty. If #ete$te# early, a

$ontra$ture $an be treate# "t! sl$one nserts an# +ressure. If t!e $ontra$ture s

more #e0elo+e#, a $ontnuously "orn stat$ s+lnt s a##e# to mantan sustane#

stret$!. On$e full range of moton s a$!e0e#, s+lntng $an be re#u$e# to

ng!ttme use untl t!e s$ar fully matures. Surg$al nter0enton s!oul# be

$ons#ere# f t!e $ontra$ture s not $om+letely re#u$e#.1

RO'E O% SURGER

Surg$al e:$son an# s-n graftng begnnng less t!an !ours after n


45/49

of so#a bat!s an# mostur@ng lotons.8 Many +atents +refer to "ear loose, soft,

$otton $lot!ng.3

In a##ton to !el+ng +atents $o+e "t! long9term +!ys$al #s$omfort, famly

+!ys$ans s!oul# be alert for +sy$!olog$ ssues. (atents "!o !a0e sustane#

burns are at n$rease# rs- for an:ety, #e+resson an# +ost9traumat$ stress

#sor#er. %amly #ynam$s $an also $!ange #ramat$ally. %amly members may be

str$-en "t! gult, an# +atents are sus$e+tble to #e+en#en$y ssues be$ause of

t!e a##tonal !el+ re?ure# for #aly a$t0tes "!le !ealng s o$$urrng. If a

+sy$!olog$ ssue s not$e#, a++ro+rate treatment s!oul# be m+lemente#.

&!e Aut!ors

ERIC D. MORGAN, MAJ, MC, USA, s res#en$y #re$tor for t!e De+artment of


Gor#on, Ga. *e re$e0e# !s me#$al #egree from 'oma 'n#a 4Calf.6 Un0ersty

S$!ool of Me#$ne an# $om+lete# a famly +ra$t$e res#en$y at &r+ler Army

Me#$al Center, *onolulu. *e also earne# a master of +ubl$ !ealt! #egree from

t!e Un0ersty of )as!ngton, Seattle, an# $om+lete# a fa$ulty #e0elo+ment

fello"s!+ at Ma#gan Army Me#$al Center, %ort 'e"s, )as!.

SCO&& C. B'EDSOE, C(&, MC, USA, s a sta +!ys$an at t!e %amly (ra$t$eCln$, )ee# Army Communty *os+tal, %ort Ir"n, Calf. *e gra#uate# from

r-s0lle 4Mo.6 College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly


JANE BARER, C(&, MC, USA, s a sta famly +!ys$an at t!e %amly *ealt!

Center, Mon$ref Army Communty *os+tal, %ort Ja$-son, S.C. S!e gra#uate#

from r-s0lle College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly


A##ress $orres+on#en$e to Er$ D. Morgan, MAJ, MC, USA, Res#en$y Dre$tor,

De+artment of %amly an# Communty Me#$ne, Esen!o"er Army Me#$al

Center, %ort Gor#on, GA /5/89838/ 4e9mal a##ress7

Er$.MorganQse.ame##.army.ml6. Re+rnts are not a0alable from t!e aut!ors.

&!e o+nons an# assertons $ontane# !eren are t!e +r0ate 0e"s of t!e

aut!ors an# are not to be $onstrue# as oH$al or as reFe$tng t!e 0e"s of t!eArmy Me#$al De+artment or t!e Army Ser0$e at large.


46/49

&!e +!otogra+!s n ;gures 1 t!roug! "ere +ro0#e# by Ste0e Bra$$ of t!e

Jose+! M. Stll Burn Center at Do$tors *os+tal, Augusta, Ga.

&!s art$le s #e#$ate# to Elsabet! Morgan, t!e #aug!ter of Dr. Er$ D. Morgan.

Elsabet! sustane# a se0ere s$al# n


47/49

K. 'un# C, Bro"#er N. &!e estmaton of areas of burns. Surg Gyne$ol

Obstet.152578K.

5. (erry RJ, Moore CA, Morgan DB, (lummer D'.Determnng t!e a++ro:mate

area of a burn7 an n$onssten$y n0estgate# an# re9e0aluate#.

BMJ.15532171K.

1/. *os+tal an# +re!os+tal resour$es for o+tmal $are of +atents "t! burn

n


48/49

15. (ur#ue G%, 'ayton &R, Co+elan# CE. Col# n


49/49

/. Muller MJ, *ern#on DN.&!e $!allenge of burns. 'an$et.1552713/.

1. Carr9Collns JA. (ressure te$!n?ues for t!e +re0enton of !y+ertro+!$ s$ar.

Cln (last Surg. 1552157.

. A!n S&, Monafo )), Mustoe &A. &o+$al sl$one gel for t!e +re0enton an#

treatment of !y+ertro+!$ s$ar. Ar$! Surg. 15512137558/.

. unn J. Sl$one gel n s$ar treatment. Burns In$l &!erm In &!s art$le s one n a seres $oor#nate# by t!e De+artment of


Gor#on, Ga. Guest e#tor of t!e seres s &e# D. E++erly, CO', MC, USA

Ambulatory Management of Burns

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