Dr. Mirza Koeshardiandi ABC of Burn

8/18/2019 Dr. Mirza Koeshardiandi ABC of Burn

1/35

of urn

- Managing Burn Cases Made

Mirza Koeshardiandi

Ponorogo, 2 /1 /2015


2/35

Terus Aku Kudu Piye Jum ????


3/35

What is Burn ?

•

A burn is an injury to the skin or other organic tissue primarily cheat or due to radiation, radioactivity, electricity, friction or with chemicals.

• Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals,

respiratory damage resulting from smoke inhalation, are alsconsidered to be burns.


4/35

Skin Function

1. Protectiona barrier from mechanical impacts andpressure, variations in temperature,

micro-organisms, radiation and chemicals

2. RegulationBody temperature, peripheral circulation,

vitamin D synthesis, balance of water and

electrolyte

3. SensationSensation as alarm of danger from “outside”

to prevent further damage.


5/35

Degree of burn


6/35

Degree of burn


7/35

Type of burn (severity)

• Minor Burn• Partial thickness :

• Adult : < 10 % of BSA

• Children : < 5 % of BSA

• Full thickness < 1% of BSA

• NO smoke inhalation

• NO other comorbidities

•Metabolic problems

• Trauma / injured

• Suitable for outpatient management

• Major Burn• Total burn > 25% of BSA

• Partial thickness :

• Adult : > 10 % of BSA

• Children : > 5 % of BSA

• Full thickness > 1% of BSA

• ± smoke inhalation

•± comorbidities

• Hospitalized

• Resuscitation

• ICU/Burn Unit


8/35

Minor Burn

First Aid :

•

A : Avoid from burning source, remove clothing(heat retention)

• B : Bath , water irrigation-cleaning(hypothermia in children-monitored body

temperature)

• C : Cure the pain, give analgesia, antihistamine,cooling water, no routine antibiotics

• D : Dressing, aseptic, change in 48 hrs , /3 days


9/35

Major Burn

• A major burn is defined as a burn covering 25% or more of total body su

any injury over more than 10% should be treated similarly.

• 7R of Care in major burn (Rescue, Resuscitate, Retrieve, ResurfacRehabilitate, Reconstruct, Review)

• Rapid assessment is vital

In the Resuscitation phase ,

Burn surface area is more important than degree / depth of bur


10/35

7R

, Care of Major Burn Injury Holistic approach

1. RESCUE get the individual away from the source of the injury & provide first aiddone by non-professionals—friends, relatives, bystanders, etc.

2. RESUSCITATE Immediate support for any failing organ system. Administeringmaintain the circulatory system but may also involve supportincardiac, renal, and respiratory systems.

3. RETRIEVE patients with serious burns may need transfer to a specialist burns unifurther care.

4. RESURFACE This can be achieved by various means, from simple dressings toaggressive surgical debridement and skin grafting.


11/35

5. REHABILITATE return patients, as far as is possible, to their pre-injury lephysical, emotional, and psychological wellbeing.

6. RECONSTRUCT The operations needed to do this are often complex and maneed repeating as a patient grows or the scars re-form.

7. REVIEW Burn patients, especially children, require regular review for many problems can be identified early and solutions provided.

7R

,Care of Major Burn Injury


12/35

What possibly happen….to the victims?

Always assume multiple trauma / injury until it is prove

• Hea

• Che

• Abd• Pelv

• Extr

• Inha

• Tox


13/35

R

escue

• Call for help, professional help from Fire department, others

• Take away individual from sources of injury.

• Rescuer safety is priority, use special anti fire garment/gear/devices ono harm.

• Principle of transportation


14/35

•

Primary Survey

• Secondary Survey

• Referal

R

esuscitation

Airway with C-Spine Controland susp. laryngeal

Breathing with attention to tension penumothorhematothoraks, and Inhalation trauma

Circulation with Bleeding Control and

Disability with ICP control and hypoxemia,hyper

Exposure with temperature control

Fluid resuscitation with periodic ballance

Give analgesia with titration

History taking and mechanism of injury


15/35

R

esuscitation

Airway• Compromised or is at risk of compromise.

• The cervical spine should be protected unless it is definitely not injured.

• Inhalation of hot gases burn above the vocal cords

• Fluid resuscitation Airway oedema

• Patent airway on arrival occlude after admission Esp. in small children

• Senior anaesthetist airway then intubation is the safest policy.

• Unnecessary intubation and sedation worsen

• Decision to intubate should be made carefully.


16/35

Signs of inhalational injury

• History of flame burns or burns in an enclosed space

• Full thickness or deep dermal burns to face, neck, orupper torso

• Singed nasal hair

• Carbonaceous sputum or carbon particles inoropharynx

R

esuscitation

Airway


17/35

R

esuscitation

Airway

Indication of Intubation

• Erythema or swelling of oropharynx on directvisualisation

• Change in voice, with hoarseness or harsh cough

• Stridor, tachypnoea, or dyspnoea

Circular Third degree / full

Circular full thickness burn in :- Neck Strangulation, edema Prior Intubation

- Chest Disturbance of chest wall movement

Dyspneu HypoventilationMechanical Ventilation


18/35

• Breathing problems affect the respiratory system below vocal cord

• Tx :100% oxygen through a humidified non-rebreathing mask on presentation.

• Tx according to the cause of respiratory compromise :

1. Mechanical restriction of breathing (Eschar) Escharotomi

2. Blast Injury ( Pneumothorax, Hemothorax, Flail chest, Contusio Pulmonum) --

analgesia, mechanical ventilation3. Smoke Inhalation (bronkospasm, inflammation, bronchorrhoea) PEEP, Oks

toilete, Bronchodilator, mech. Ventilation.

4. CO-hb , Carboxy hemoglobinemia O2 100 % + if necessary mech. ventilati

R

esuscitation

Breathing


19/35

•Minimal double I.V line / large bore

• Blood sample and Laboratory investigation

• Parkland formula + Maintenance

• If profound hypotension not normal assume as syok

• Elicit : cardiogenic problem, occult bleeding (thorax, abdomen, pelvis)

• Electrical injury common cardiac arrythmias

• If syok treat as syok :

• Syok position , syok fluid replacement, bleeding control

R

esuscitation

Circulation


20/35

• Burn with syok (hypovolemic syok)• Syok : 20 ml/kg body weight in 20-30 minutes, kristaloid (RL,Na

No colloids for syok treatment

• Transfusion (Hb


21/35

•Degree of consciousness GCS periodically

• Patient confused hypoxia, hypovolemia and neurotrauma

• Routine examination pupil diameter, light reflexes elicit intracranial pr

R

esuscitation

Disability

• Examine whole patient estimate total burn area (incl. the back)• Concomitant injuries

• Avoid hypothermia esp. children hypoperfusion and deepening the

• Thermoregulation

Exposure


22/35

Exposure


23/35

• Parkland formula :

• Add Maintenance ( for children) :Children receive maintenance fluid in addition, at hourly rate of

4 ml/kg for first 10 kg of body weight plus

2 ml/kg for second 10 kg of body weight plus

1 ml/kg for > 20 kg of body weight

R

esuscitation

Fluid Replacement (1st - 24 hours)

4 ml x Burn Area (%) x Body weight (kg)

50% given in 8 hours 50% given in 16 hours

4 – 2 – 1


24/35

• Parkland formula for high tension electrical injury :

• Target end points of Fluid replacement :

Urine output of 0.5-1.0 ml/kg/hour in adults

Urine output of 1.0-1.5 ml/kg/hour in children

Urine output of 1.5-2.0 ml/kg/hour in adults with electrical injur

R

esuscitation

Fluid Replacement (1st - 24 hours)

9 ml x Burn Area (%) x Body weight (kg)

50% given in 8 hours 50% given in 16 hours


25/35

• Coloid infusion :

• Add Maintenance ( for Adult ) :

Cristaloid (Dekstrose – Saline)

•

Add Maintenance ( for children) :Children receive maintenance fluid in addition, at hourly rate of

4 ml/kg for first 10 kg of body weight plus

2 ml/kg for second 10 kg of body weight plus

1 ml/kg for > 20 kg of body weight

R

esuscitation

Fluid Replacement (After 24 hours)

0,5ml x Burn Area (%) x Body wei

4 – 2 – 1

1,5ml x Burn Area (%) x Body wei


26/35

Case 1. A 25 year old man weighing 70 kg with a 30% flame

admitted at 4 pm. His burn occurred at 3 pm.

• Total fluid requirement for first 24 hours4 ml × (30% total burn surface area) × (70 kg) = 8400 ml in 24 hours

(4 pm – 1 1 pm) (11pm - 3pm next day)

• Kristaloid (RL, RA, PZ)

• After 24 hours• Koloid : 0.5 ml x 30% x 70 kg = 1050 ml /24 hours (HES, Gelatine) = 14 dpm

• Maintenance : 1.5 ml x 30% x 70 kg = 3150 ml / 24 hours (D5 ½ NS) = 44 dpm

• Target end points : urine 35 – 70 ml / hour

4200 ml in 8 hours

600 ml/hour = 200 dpm

4200 ml in 16 hours


7 hours


27/35

Case 2. A 4 year boy weighing 15 kg with a 40 % flame burn was

admitted at 4 pm. His burn occurred at 3 pm. During transhe received 500 ml RL.

• Total fluid requirement for first 24 hours4 ml × (40% total burn surface area) × (15 kg) = 2400 ml in 24 hours

• Maintenance• 4 ml x 10 kg = 40 ml

• 2 ml x 5 kg = 10 ml

maintenance 50 ml / hour D5 ½ NS

• Target end points : urine 15 ml – 22 ml / hour

950 ml in 7 hours


1900 ml for 23 hours500 ml in 1 hours

during transport

950 ml in 16 hour

60 ml/hour = 20 dp


28/35

• Superficial burns can be extremely painful.

• large burns intravenous morphine at a dose /kg Body weight .

• 0.1 mg/kg body weight slow i.v. injection

• titrated against pain and respiratory – cardiovascular depression.

• The need for further doses should be assessed within 30 minutes.

• If in doubt consultation should be made to burn specialist, intensivist,

• Avoid NSAID

R

esuscitation

Give Analgesia


29/35

R

esuscitation

History takingKey points of a burn history

Exact mechanism

• Type of burn agent (scald, flame, electrical, chemical)

• How did it come into contact with patient?

• What first aid was performed?

• What treatment has been started?

• Is there risk of concomitant injuries (such as fall from height, road traffic crash, ex

• Is there risk of inhalational injuries (did burn occur in an enclosed space)?

Exact timings

• When did the injury occur?

• How long was patient exposed to energy source?

• How long was cooling applied?

• When was fluid resuscitation started?


30/35

R

esuscitation

History takingKey points of a burn history

Exact injury

Scalds

What was the liquid? Was it boiling or recently boiled? If tea or coffee, was milk in it?

Was a solute in the liquid? (Raises boiling temperature and causes worse injury, such

Electrocutioninjuries

What was the voltage (domestic or industrial)?

Was there a flash or arcing? Contact time

Chemicalinjuries

What was the chemical?

Is there any suspicion of non-accidental injury?


31/35

R

esuscitation

Investigation (Laboratory, Radiograph etc)Investigations for major burns

General

Full blood count, packed cell volume, urea and electrolyte concentration, clotting screeBlood group, and save or crossmatch serum

Electrical injuries

12 lead electrocardiography

Cardiac enzymes (for high tension injuries)

Inhalational injuries

Chest x ray

Arterial blood gas analysisCan be useful in any burn, as the base excess is predictive of the amount of fluid resuscitation required Helpf

success of fluid resuscitation and essential with inhalational injuries or exposure to carbon monoxide

*Any concomitant trauma will have its own investigations

Indications


32/35

A+B

C


33/35

• Primary Survey


• Referal

R

esuscitation

Airway with C-Spine Control and susp. laryngeal




Exposure with temperature controlFluid resuscitation with periodic ballance


History taking and mechanism of injuryHead to Toe Examination


34/35

• Primary Survey


• Referal

R

esuscitation

Airway with C-Spine Control and susp. laryngeal




Exposure with temperature controlFluid resuscitation with periodic ballance


History taking and mechanism of injuryHead to Toe Examination


35/35

?Terima Kasih

Dr. Mirza Koeshardiandi ABC of Burn

Documents