ACUTE BURN MANAGEMENT

dr. Iqmal Perlianta, SpBP-RE

0821 799 13501

FK UNSRI MADANG
Palembang, 17 Sept 2014
1
HIGH MORBIDITY AND MORTALITY RATE

U.S : 2 3 MILLION / YEAR
MORTALITY RATE : 5 6 THOUSAND / YEAR

CIPTO MANGUNKUSUMO HOSPITAL (1998)
ADMISSION NUMBER : 107
MORTALITY RATE : 37,78%

DR. SOETOMO HOSPITAL (1999 - 2005)
ADMISSION NUMBER : 739
MORTALITY RATE : 29,8%

ITS A CHALLENGE FOR US



3
BURN PHASES
1. ACUTE / SHOCK / EARLY PHASE
- IMMEDIATE / EMERGENCY ROOM
- AIRWAY & FLUID PROBLEM
- WOUND

2. SUBACUTE PHASE
- DURING ADMISSION
- WOUND, INFECTION, SEPSIS PROBLEM

3. LATE PHASE
- AFTER DISCHARGED
- SCAR & CONTRACTURE PROBLEMS
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ACUTE PHASE
MANAGEMENT
5
ETIOLOGY
1. FIRE

2. SCALD

3. CHEMICAL SUBSTANCES

4. ELECTRIC & RADIATION

5. SUNBURN

6. STOVE / GAS EXPLOSION

7. BOMB EXPLOSION
6
7
8
9
10
Burn
Capillary permeability and osmotic force
change
Fluid and protein shift
Total blood volume have been lost
Burn shock
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DEPTH ASSESSMENT
1. 1
st
DEGREE
- EPIDERMIS

2. 2
nd
DEGREE
- SUPERFICIAL
- DEEP

3. 3
rd
DEGREE
- EXTENSION TO MUSCLE / BONE
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15
16
17

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WOUND EXTENT
WALLACE
RULE OF NINE
Head & neck 9% --------> 9%
Upper extremities 9% --------> 18%
Anterior of the body --------------> 18%
Posterior of the body ------------> 18%
Lower extremities 18% -------> 36%
Genital / perineum -------------> 1 %

Total ----------------------------- 100%
ADULT
21
9
14
9 9
18 18
18 18
9 9
18 18
16 16
9
18 18
14
10 14
18
15 yrs 5 yrs 0 1 yr
JUVENILE - CHILDREN
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SEVERITY CRITERIA
(AMERICAN BURN ASSOCIATION)
1. MILD
- 2
nd
DEGREE < 15%
- 2
nd
DEGREE < 10% IN JUVENILES
- 3
rd
DEGREE < 1%





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2. MODERATE
- 2
nd
DEGREE 15-25% IN ADULTS
- 2
nd
DEGREE 10-20% IN JUVENILES
- 3
rd
DEGREE < 10%

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3. SEVERE
- 2
nd
DEGREE >25% IN ADULTS
- 2
nd
DEGREE >20% IN JUVENILES
- 3
rd
DEGREE >10%
- AFFECTED HANDS, FACE, EARS, EYES, FEET, AND
GENITAL / PERINEUM
- INHALATION INJURY, ELECTRICAL INJURY, OR ASSOCIATED WITH
OTHER TRAUMAS


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I. PRIMARY SURVEY
II. SECONDARY SURVEY
III.INITIAL CARE OF THE BURN WOUND
IV. INITIAL LABORATORY STUDIES
V. BURN CENTER REFERRAL
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I. PRIMARY SURVEY :
LIKE ANY OTHER TRAUMA




A. AIRWAY & CERVICAL SPINE PROTECTION
B. BREATHING & VENTILATION
C. CIRCULATION & HEMORRHAGE CONTROL
D. DISABILITY NEUROLOGICAL EXAMINATION
E. EXPOSURE

II. SECONDARY SURVEY :

A. HISTORY TAKING
B. PHYSICAL EXAMINATION /
HEAD TO TOE EXAMINATION
C. PRINCIPALS :
1. STOP THE PROCESS CAUSING BURN WOUNDS
2. UNIVERSAL PRECAUTION, HIV, HEPATITIS
3. FLUID RESUSCITATION : 2-4 CC RL X KG BW X
%WOUND SURFACE
4. VITAL SIGN
5. NASOGASTRIC TUBE / IF NECESSARY
6. URINARY CATHETER / IF NECESSARY
7. PERFUSSION ASSESSMENT
8. CONTINUED VENTILATORY ASSESSMENT
9. PAIN MANAGEMENT
10.PSYCHOSOCIAL ASSESSMENT
11.TETANUS TOXOID PROFILAXIS
12.MEASURING BODY WEIGHT
13.WOUND CLEANSING (OPERATING THEATRE, GENERAL
ANAESTHESIA)
14.ESCHAROTOMY & FASCIOTOMY


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FLUID RESUSCITATION
EVANS FORMULA

BROOKES FORMULA

PARKLANDS FORMULA

BROOKES MODIFICATION

MONAFOS FORMULA

BAXTERS FORMULA
DR. SOETOMO GENERAL HOSPITAL

DAY 1 :
ADULT: RL 4 CC X KG BW X %WOUND SURFACE / 24 HRS
ANAK : RL : DEXTRAN = 17 : 3
2 CC X KG BW X %WOUND SURFACE +
MAINTENANCE

MAINTENANCE :
< 1 YR : BW X 100 CC
1-3 YRS : BW X 75 CC
3-5 YRS : BW X 50 CC

IN FIRST 8 HRS
NEXT 16 HRS

DAY 2 :

ADULT : MAINTENANCE
ALBUMIN (IF NECESSARY)

JUVENILE : MAINTENANCE

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MONITORING FLUID RESUSCITATION
1. URINARY PRODUCTION PER HOUR
ADULT : 0,5 CC/BW/HR (30-50 CC/HR)
JUVENILE : 1 CC/BW/HR
2. OLIGURIA
ASSOCIATED WITH SYSTEMIC VASCULAR RESISTANCE &
CARDIAC OUTPUT RECUCTION
3. HAEMOCHROMOGENURIA (RED PIGMENTED URINE)
4. BLOOD PRESSURE
5. HEART RATE
6. HAEMATOCRITE & HAEMOGLOBIN
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CLOSED WOUND MANAGEMENT
WOUND CLEANSING, DEBRIDEMENT, & DESINFECTION WITH
SAVLON 1 : 30
TULLE
TOPICAL SILVER SULFADIAZINE (SSD)
THICK STERILE GAUZE / ELASTIC BANDAGE
OPEN THE WOUND DRESSINGS AT DAY 5 UNLESS THERE IS
ANY SIGN OF INFECTION
PERFORM UNDER GENERAL ANAESTHESIA (IN THE OPERATING
THEATRE)
III. LABORATORY EXAMINATION


BURNS IMPAIR ORGAN FUNCTIONS

BASELINE LABORATORY TESTS
1. HAEMATOCRITE
2. COMPLETE BLOOD COUNT (Hb)
3. ALBUMIN
4. RFT & LFT
5. ELECTROLITE, Na, K, Cl, HCO
3

6. BLOOD UREA NITROGEN
7. URINALYSIS
8. CHEST X-RAY
9. ARTERIAL BLOOD GAS (INHALATION INJURY)
10. CARBOXY HAEMOGLOBIN
11. ECG (ELECTRIC INJURY)

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Functions of the skin
Protection
intact skin is the first line of defense against
bacterial and foreign-substance invasion
Heat regulation
Sensory preception
Excretion
Vitamin D production
Expression
important with body image - fear of disfigurement


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STAGES OF BURNS
Hypovolemic state
begins at the onset of burn and lasts for the first 48
hours - 72 hours
Rapid fluid shifts - from the vascular compartments
into the interstitial spaces
Capillary permeability with burns increases with
vasodilation
Fluid loss deep in wounds
Initially Sodium and H2O
Protein loss - hypoproteninemia
Hemoconcentration - Hct increases
Low blood volume, oliguria
Hyponatremia - loss of sodium with fluid
Hyperkalemia - damaged cells release K, oliguria
Metabolic acidosis

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STAGES OF BURNS
Diuretic Stage
begins 48 - 72 hours after burn injury:
Capillary membrane integrity returns
Edema fluid shifts back into vessels - blood volume
increases
Increase in renal blood flow - result in diuresis
(unless renal damage)
Hemodilution - low Hct, decreased potassium as it
moves back into the cell or is excreted in urine with
the diuresis
Fluid overload can occur due to increased
intravascular volume
Metabolic acidosis - HCO
3
loss in urine, increase in
fat metabolism

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SIGNS OF ADEQUATE
FLUID RESUSCITATION :
Clear sensorium
Pulse < 120 beats per minute
Urine output for adults 30 - 50
cc/hour
Systolic blood pressure > 100 mm Hg
Blood pH within normal range 7.35 -
7.45

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Organisms that usually
infect burns are:
a. Staphylococcus aureus

b. Pseudomonas Infection is usually
the cause of any deterioration

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Signs of Sepsis:
a. Change in sensorium
b. Fever
c. Tachyapnea
d. Paralytic ileus
e. Abdominal distention
f. Oliguria

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Ways to prevent infection:

a. Gowns, masks, gloves

b. Sterile linen

c. Persons with URI should not come in
contact with patient

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WOUND CARE PRINCIPLES
1. GOALS
1. close wound as soon as possible
2. prevent infection
3. reduce scarring and contractures
4. provide for comfort
2. Wound cleaning + closed technique
3. Debridement, mechanical, surgical, enzymatic
4. Topical antibacterial therapy mafenide (sulfonamide)
sulfadiazine
5. Biological dressing
- Homograft (cadaver skin )
- Heterograft
- Autograft
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IV. BURN CENTER REFERRAL
REFERRAL CRITERIA
1. 2nd degree >10%
2. Affecting face, hands, genital, perineum, & main
joints
3. 3
rd
degree
4. Electric injury
5. Chemical injury
6. Inhalation injury
7. Juveniles
8. Associated with other traumas
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ACUTE BURN

A. Airway : inhalation injury
B. Breathing : fullthickness
circumferntial burn
C. Circulation : syok
Carbon monoxide poisoning
Inhalation injury above the glottis
Inhalation below the glottis
Any victim, burned in a closed area, like a
house fire, should be presumed to have an
inhalation injury until proven otherwise
INHALATION INJURY

INHALATION INJURY
INHALATION
INJURY
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Fullthickness
circumferential
burns
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CLINITRON BED
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