first management of burn injury
TRANSCRIPT
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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
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Mortality
(Hettiaratchy & Dziewulski, 2004)
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Etiology
(Hettiaratchy & Dziewulski, 2004)
Local response Systemic response
Pathophysology
(Jackson, 1947)
(Hettiaratchy & Dziewulski, 2004)
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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
Full-Thickness < 10%
TBSA
(none critical area)
10-20% TBSA
Full-Thickness < 10%
TBSA
(none critical area)
Severe >20% TBSA
Full-Thickness > 10%
TBSA
Critical areal*
Complicated burns**
>25% TBSA
Full-Thickness > 10%
TBSA
Critical area*
Complicated burns**
>20% TBSA
Full-Thickness > 10%
TBSA
Critical area*
Complicated burns**
(Singer, 2000)
Depth of burn wound
(Hettiaratchy & Dziewulski, 2004)
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Superficial Skin Burn
Superficial Skin Burn
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 Skin Burn
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 HaemorraghecontrolI.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)
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(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
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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)
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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
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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)
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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
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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)
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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:
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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
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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)
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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)
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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