First Management of Burn Injury _Clinup

8/12/2019 First Management of Burn Injury _Clinup

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09/02/20

First management of

Burn In jury:

GP Must Do and Don’t Rosadi Seswandhana

Plastic Surgery Division, Dept of Surgery, GMU

Burn Unit – DR Sardjito General Hospital

Problems



09/02/20

Mortality

(Hettiaratchy & Dziewulski, 2004)



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Etiology


Local response Systemic response

Pathophysology

(Jackson, 1947)




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Severity of Burns

Age

SeverityChildren Adult Older

Mild < 10% TBSA

Full-Thickness < 2%

TBSA

< 15% TBSA

Full-Thickness < 2%

TBSA

< 10% TBSA

Full-Thickness < 2%

TBSA

Moderate 10-20% TBSA

Full-Thickness < 10%

TBSA

(none critical area)

15-25% TBSA


TBSA


10-20% TBSA


TBSA


Severe >20% TBSA

Full-Thickness > 10%

TBSA

Critical areal*

Complicated burns**

>25% TBSA


TBSA

Critical area*

Complicated burns**

>20% TBSA


TBSA

Critical area*

Complicated burns**

(Singer, 2000)

Depth of burn wound




09/02/20

Superficial Skin Burn



The prototype is a sunburn with erythema

and mild edema.

The area involved is tender and warm.

There is rapid capillary refill after pressure is

applied.

All layers of the epidermis and dermis are

intact; no topical antimicrobial is necessary.

Uncomplicated healing is expected within

five to seven days.



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Partial Thickness Skin Burn

Partial Thickness Skin Burn

Initially they may be quite difficult to

diagnose accurately

The hallmark of the partial-thickness

burn is blister formation and pain.

Confusion may result, however, when

partial-thickness burns are examined

after blisters have been ruptured anduncovered pin prick test



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Full Thickness Skin Burn



Full-thickness burns have a relatively

characteristic clinical appearance.

Little discomfort for the patient.

They may be of almost any color

because of the breakdown ofhemoglobin.

The appearance of the skin may be

waxy and translucent.

Visible thrombosed vessels beneath

translucent skin are pathognomonic

for full thickness injury.



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Adult and Children > 10 y.o Children < 10 y.o

Size and extent of the burn w ound

(ANZBA, 2013)

Lund and Browder table



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Management

Assessment for the first time

Mild

Moderate

Severe Complicated

Unconscious patient severe trauma

(ANZBA, 2013)



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First aid

Stop burning

process

Cooling

treatment

Severe / Complicated burns

ATLS ©

ABLS ©

ESBM ©

Goals:

Life-saving

Limb/organ saving



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EMSB Structure

LO

O

K

D

O

AI

R

W

A

Y

BR

E

A

H

I

N

G

CI

R

C

U

L

A

T

I

O

N

DI

S

A

B

I

L

I

T

Y

EX

P

O

S

U

R

E

FLUIDS

ANALGESIA

TESTS

TUBES

A M P L EHistory

Head to Toe

Examination

Tetanus

Document &

Transfer

Support

Cspine

O2 Haemorraghecontrol

I.V. A V P U& Pupils

Environmentalcontrol

Primary Survey First AidSecondary

Survey

(ANZBA, 2013)

Acute phase Initial assessment

Rescusitation Airway

A: Look for s igns of inhalation in jury

Facial bur ns ,

Soot in nost r i ls or sputum

Laryngoscope edema, hyperemia

ET Better than TRACHEOSTOMY

Do not forget : C-Spine control



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Acute phase Rescusi tat ion Breathing

Do not forget: Give O2 100% 15 L/minute (NRM)

B: Circumference Ful l th ickness skin burn on the

chest wal l mech anical vent i lation disturb ance

ESCHAROTOMY



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Acute phase

Rescusi tat ion Breathing

• Be aware of carbon monoxide poisoning

Patient may appear 'pink' (cherry red) with a normal

pulse oximeter reading

administere 100% Oxygen

Perform intubation and artificial ventilation

(if needed)

(Do not believe pulse oxymetri saturation)

• Smoke injury Soot in nostrils or sputum

NebulizerPerform intubation, artificial ventilation and

bronchial toilet (if needed)

Acute phase

Rescusi tat ion Circu lation (C)

Examine:

Central press ure

Blood p ressure

Central and periphery c api l lary ref i l l

Systemic :

If pat ient arr ived with sho ck condit ion 2 IV-l ine

First IVFD RL 20 m l/Kg BW in 15-30 m inu tes

( Do not forget bloo d test samp le com plete

blood c oun t, bloo d group , chem ical analysis,

BGA, and β-HCG for pregnant wom an )



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Escharotomy on extremity

(Remember: escharotom y shou ld be performed

after l i fe-threatening was managed)

Local :

Circumference Ful l th ickness skin

burn on extremity comp artment

syndrome 5P ESCHAROTOMY

Acute phase

Disabil i ty (D)

GCS

Lateral Sign

CO intoxic at ion

Hipovolemic shock



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Acute phase Exposu re and Environmental control

Log Rol l Manuver

Bu rn Size (% TBSA )

Depth of Burn Wound

temperature

Other trauma

Beware : Hypothermia blanket

Acute phase

Fluid Resu citat ion (F)

(Mathes, 2006)



09/02/20

(Mathes, 2006)

Acute phase

Fluid Resu citat ion (F)

Systemic :

The release of cytokines and other inflammatory mediators

Increase of capillary permeability let the intravascular fluid shifted

to the interstitial space hypovolemia

BAXTER / PARKLAND FORMULA

IVFD RL: 4 ml x BW (Kg) x BSA (%)

ANZBA IVFD RL: 3-4 m l x BW (Kg) x BSA (%)

for ch i ldren, + maintenance



09/02/20

Case

Patient with 50 Kg BW and 30% BSA

Fluid Needed : 4 x 50 Kg x 30 %

6000 mL RL

First 8 hours 3000 mL 92 drops/mn t

Next 16 hours 3000 mL 46 drops/mn t

MONITORING • Vital Sign

(Puls e rate, resp iration rate, blood presu re, temp erature)

• Urin Output Adult 0,5-1,0 mL / Kg BW/ hou r

Child 1,0-2,0 mL / Kg BW/ hou r

• Breath ing soun d

• Severe burn (>40%) apply Central Venous Catheter

• Flu id theraphy adjustment h our ly

• Defic iency add 10%

• Overload reduce 10%

Beware: myoglobinuria (haemochromogens)



09/02/20

Analgetic Burns is painfull need adequate analgetic

Morphine : 0,05 – 0,1 mg/Kg BW (ANZBA, 2013)

Fenthanyl : 1 μg/Kg BW

Continue with maintenance dose

(better using syringe pump)

• Nasogastr ic tube prod uct ion beware of stressulcer

• Indw ei l ing catheter ur ine monitor ing

• Central venous catheter

Test• ECG, Lateral Cervic al, Thorax , Pelvic al X-ray

• Hb, WBC, Plt, Hematoc rit , Electro l i te, Alb um in, GDS

• Kidn ey Func t ion, Liver Funct ion , BGA

Tube



09/02/20

Secondary survey History : A – M – P – L – E

Head to toe examination

Electrical injury

Beware of cardiac rythm abnormality closed ECG

evaluation in the first 2 days

Beware of extensive rhabdomyolisis

Beware compartment syndrome need fasciotomy

Beware of renal failure high urine output fluid

therapy (100 cc/hour)Tx: 2 amp Manitol (25 g) followed immediately 2 amp bicarbonate, IV push,

continue 12,5 g manitol every 1 L fluid which was given

(Hettiaratchy & Dziewulski, 2004 and ANZBA, 2013)



09/02/20

Chemical injury

Beware of Progresive Destruction

Beware of organ injury (eye, ear etc)

Principle dilution

Do not try neutralized acid with base,

even in vice versa

Wound Care1 st O no spesi f ic treatment

2 nd O Cleansed with NaCl + Savlon

500 ml 5 ml

Film transparan

Foam

Silver impregnated foam Calcium alginate

Cellulosa

Antibiotic ointment

MEBO

Controv ersy: Usage of Si lver Sulfadiazin



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Conservative wound care

Wound Care 3 rd O

Cleansed with NaCl 500 ml + Savlon 5 ml

Daily debr idement

Dai ly Si lver Sulfadiazin (Dermazin® / Bu rnazin®) ,

Si lver contained d ressing (Act ico at® / Mepi lex-Ag® )

Plus Surgic al Treatment



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Surgical wound treatment

Non Surgical Treatment

Antibiotic prophylactic? Sistemic vs Local

ATS – Tetagam? 3rd O, large burn size

GIT protector

Nutrition

Antioxidant

Imunomodulator

Inotropic (if needed)

Bath sower burn tank

Antidecubital bed / care

Splinting & Rehabilitation



09/02/20

Referral criteria

1. Partial thickness burns greater than 10% total body surface area (TBSA).

2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.

3. Third degree burns in any age group.

4. Electrical burns, including lightning injury.

5. Chemical burns.

6. Inhalation injury.

7. Burn injury in patients with preexisting medical disorders that could complicate

management, prolong recovery, or affect mortality.

8. Any patient with burns and concomitant trauma (such as fractures) in which the

burn injury poses the greatest risk of morbidity or mortality. In such cases, if

the trauma poses the greater immediate risk, the patient may be initially

stabilized in a trauma center before being transferred to a burn unit. Physician

judgment will be necessary in such situations and should be in concert with the

regional medical control plan and triage protocols.

9. Burned children in hospitals without qualified personnel or equipment for the

care of children.

10.Burn injury in patients who will require special social, emotional, or

rehabilitative intervention

Amer ican Bu rn Asso ciation -

Advance Burn Li fe Suppor t Course :

(ABA-ABLS, www.ameriburn.org)



09/02/20

1. Mid to deep dermal burns in adults >10% TBSA (total body

surface area)2. Full thickness burns in adults >5% TBSA

3. Mid-dermal, deep dermal or full thickness burns in children >5%

TBSA

4. Burns to the face, hands, feet, genitalia, perineum and major joints

5. Chemical burns

6. Electrical burns including lightning injuries

7. Burns with concomitant trauma

8. Burns with associated inhalation injury

9. Circumferential burns of the limbs or chest

10.Burns in patients with pre-existing medical conditions that could

adversely affect patient care and outcome11.Suspected non-accidental injury including children, assault or self-

inflicted

12.Pregnancy with cutaneous burns

13.Burns at the extremes of age – infants and frail elderly

Austral ian and New Zealand Burn As soc iat ion:

(ANZBA, 2013)

1. Luas luka bakar derajat 2-3 > 15% untuk dewasa

2. Luas luka bakar derajat 2-3 > 10% untuk anak-anak dan usia

lanjut

3. Luas luka bakar derajat 3 > 5%

4. Luka bakar listrik

5. Luka bakar kimia

6. Luka bakar pada daerah khusus seperti wajah, tangan,

genital, perineal dan persendian

7. Pasien luka bakar yang mempunyai komorbid sistemik yangdapat membuat tata-laksana pasien menjadi rumit, seperti

stroke dan lainnya.

8. Pasien luka bakar yang disertai dengan trauma multipel,

seperti akibat kecelakaan atau pasien melompat/terjatuh dari

ketinggiaan saat kejadian.

9. Luka bakar minor yang tidak sembuh dalam 3 minggu

10.Luka bakar yang dicurigai bukan karena kecelakaan

Modifikasi kriteria rujukan menurut Asosiasi Luka

Bakar Indonesia:



09/02/20

Pathway for access to Burn Injury services

(Fiona wood, 2009)

Fluid Maintenance

Maintenance Fluid Requirements =

35 + % 24 + 1500

Body surface area (The Mosteller formula) =

body height cm x body weight (kg)

6

Hourly adjusted based on urine output



09/02/20

Nutrition

Burn injury can increase the basal metabolic rate50% to 100% of the normal resting rate. The mainfeatures include: increased glucose production,

insulin resistance,

lipolysis,

and muscle protein catabolism.

Without adequate nutritional support, patients havedelayed wound healing, decreased immunefunction, and generalized weight loss

(Mathes, 2006)

(Mathes, 2006)



09/02/20

Splinting

Document & Transfer

Diagnosis (Type/Depth of Wound, Extent, Etiology)

Inhalation trauma? Intubation

Other major trauma?

Other co-morbid?

Onset

Theraphy which was already given

Fluid (Type of fluid, amount)

Drugs

Surgical treatment (escharotomy, tracheostomy)



09/02/20

Thank you

• Peate WF. Outpatient management of burns. Am Fam Physician 1992;45:1321-1330. (Review)

• Young DM. Burn and Electrical Injury. In Mathes SJ [Ed]: Plastic Surgery. 2nd Edition. 2006. P811-

833

• Australia and New Zealand Burn Association, Emergency Severe Burn Management: Course

Manual, 17th Edition, Feb 2013

• Seswandhana MR, 2011, Pengalaman menghadapi erupsi Gunung Merapi, presentasi ilmiah,

Pertemuan Ilmiah Tahunan Perhimpunan Ahli Bedah Indonesia (PABI), Medan, 2011

• Hettiaratchy S, Dziewulski P. ABC of burns. BMJ 2004;329:504 –6

• Singer AJ. Thermal Burns: Rapid Assessment And Treatment. Emerg.Med.Pract. Sep 2000. Vol

2[9]• Wardhana A. Adjustable volume of fluid resuscitation for burn injury. Plastic Annual Meeting. 2011

• Bessey, PQ.Wound Care.in Herndon DN [ed]: Total Burn Care. 3rd Edition. 2007. Elsevier. Printed

in China

• Hirsch T,Ashkar W,Schumacher O,Steinstraesser L,Ingianni G,Ceolidi CC.Moist Expossed Burn

Ointment(MEBO) in partial thickness burns – a randomized,comperative open mono-center study

on the efficacy of dermaheal (MEBO) ointment on thermal 2nd degree burns compared to

conventional therapy .Eur J Med Res .2008 Nov 24;13(11):505-10

• Prasetyono TOH, Rendy L. Merujuk Pasien Luka Bakar: Petunjuk Praktis. Maj Kedokt Indon,

Volum: 58, Nomor: 6, Juni 2008; p 216-24

• American Burn Association, ABLS at www.ameriburn.org

• Wood F, Burn Injury Model of Care, 2009

First Management of Burn Injury _Clinup

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