BURN INJURIES & TREATMENT.pptx

7/23/2019 BURN INJURIES & TREATMENT.pptx

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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=19270


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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


= 1,5 ml FFP %TBSA Wt (kg)

volume during first 8 hr post injury volume next 16 hr post injury

Haifa Formula



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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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BURN INJURIES & TREATMENT.pptx

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