Rosadi Seswandhana

Plastic Surgeon
Dept of Surgery, Faculty of Medicine
Gadjah Mada University

Emergency

A sudden unforeseen crisis (usually involving

danger) that requires immediate action

An emergency is a situation which poses an

immediate risk to health, life, property or
environment
Most emergencies require urgent intervention to
prevent a worsening of the situation
(Wikipedia)

Epidemiology of Burn

According to the most recent statistics compiled by the

American Burn Association, approximately 2.2 million people
are burned in the United States every year;
5500 deaths result from burn injury, and
60,000 people are admitted to the hospital for care.
The cost to treat these patients exceeds $1 billion, and the
cost to society in terms of lost wages, vocational
rehabilitation, and need for long-term care is staggering
(Mathes Plastic Surgery, 2007)

Indonesia? We have no national data

Epidemiology

Mortality

Skin Anatomy

Skin Constitution
Epidermis
Corium or
Dermis
Subcutis

The total skin area

of adult humans
covers approx. 1 to
2 square meters

Pathophysiology of Burn
Local tissue destruction
Systemic inflamatory response

Local response

Zone of coagulation
maximum damage.
Irreversible

Zone of stasis
decreased tissue perfusion.
Potentially salvageable.

Zone of hyperaemia
tissue perfusion is
increased.
Usually Recover

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
Capillary permeability
Splanchnic vasoconstriction
Myocardial contractility
Fluid loss
Respiratory changes
Bronchoconstriction, ARDS
Metabolic changes, BMR 3x

Immunological changesNon-specific
down regulation of the immune response
occurs, affecting both cell mediated and
humoral pathways.

Pathophysiology
Burn = Coagulative destruction of the skin or
mucous membrane
Caused by heat, chemical or irradiation
Thermal damage occurs above 48 C
Extent of necrosis is related to temperature and
duration of contact

Intravascular fluid shifting

Local and systemic inflammatory reaction

Normal capillary barrier is disrupted by a host of
mediators, including

histamine,
serotonin,
prostaglandins,
platelet products,
complement components,
and members of the kinin family.

The margination of neutrophils, macrophages,

and lymphocytes

Capillary leakage
Burn
Tissue

inflammatory
mediators

intravascular
hypovolemia

Interstitiel /
extravascular
edema

Electron microscopic exam

The capillary leakage

Arterioale dilatation and venulle
constriction Increase of capillary
permeability let the intravascular
fluid shifted to the interstitial space:
hypovolemia
the edema formation

Burns can result in:

Increased capillary permeability and fluid loss
Hypovolaemia and shock
Increased plasma viscosity and microthrombosis
formation
Haemoglobinuria and renal damage
Increased metabolic rate and energy metabolism

The Goals in the acute situation

To maintain oxygen
perfusion to the
vital organs;
acutely, heart and
brain (life saving)
To prevent a
worsening of the
situation (minimize
morbidity)

The question............??
How the oxygen
can be deliveried
to the cell?

Breathing
To allow oxygen
flow into the lung
To allow carbon
dioxide flow out of
the lung

Pass through the

patent airway

Circulation
To distribute
oxygen rich blood
from the lung to the
peripheral tissue
To collect oxygen
poor blood from
peripheral tissue to
the lung

Cell metabolism

Cell metabolism is the

process (or really the
sum of many ongoing
individual processes)
by which living cells
process nutrient
molecules and
maintain a living state.

Utility of the ATP

To maintain milieu intrieur,

(the environment within the
cell)
NA-K pump

Activity of the cell, tissue,

and organ
Muscle contractility
Gland secretion
etc

Important Consideration
1.
2.
3.

Etiology
The depth of skin burn
Size and extent of the burn wound

Etiology
1. Temperature
High ( Fire, Boiled Water, Steam, hot cloud, lava )
Low ( Frost Bite )
2. Electric
3. Chemical
Base Acid
4. Radiation
5. LASER

The Depth of Burn Wound

Superficial Skin Burn (1st O)

Pain, Erythema, epidermal slough 1-4 days later

Partial Thickness Skin Burn (2nd O)

Pain, Blisters within 1-6 hours, erythema,

tenderness, good capillary refill

Full Thickness Skin Burn (3rd O)

Insensate, leathery, thrombosed vessels, no

capillary refill

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.

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 and
uncovered pin prick test

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 of
hemoglobin.
The appearance of the skin may be
waxy and translucent.

Visible thrombosed vessels beneath

translucent skin are pathognomonic
for full thickness injury.

Size and extent of the burn wound

Rule of Nines

TABEL
LUND &
BROWDER

Management
PRE HOSPITAL

STOP - DROP - ROLL

Prevent Heat Restore

Electric injury breaking

down the voltage

Chemical
decontamination / dilution

Assessment
Initial assessment should be by ATLS
principles
Good early management is required to
prevent morbidity or mortality

Primary Survey
A Airway
B Breathing
C Circulation / C-spine / Cardiac status
D Disability / Neurologic Deficit
E Exposure and Examination
F Fluid Resuscitation

Acute phase Initial assessment

Rescusitation

A:

Airway

Look for signs of inhalation injury

Facial burns,
Soot in nostrils or sputum
Laryngoscope edema, hyperemia
ET Better than TRACHEOSTOMY

Acute phase
Rescusitation
B:

Breathing

Circumference Full thickness skin burn on the

chest wall mechanical ventilation disturbance

ESCHAROTOMY

Escharotomy

Acute phase
Rescusitation
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)
Smoke injury Soot in nostrils or sputum

Nebulizer
Perform intubation, artificial ventilation and
bronchial toilet (if needed)

Acute phase
Rescusitation

Circulation (C)

Systemic :
If patient arrived with shock
condition 2 IV-line
First IVFD RL 20 ml/Kg BW in 1530 minutes
Local :

Circumference Full thickness skin

burn on extremity compartment
syndrome 5P ESCHAROTOMY

Escharotomy on extremity

Acute phase
Disability (D)

GCS

Lateral Sign
CO intoxication
Hipovolemic shock

Acute phase
Exposure (E)

Burn Size (% TBSA)

Depth of Burn Wound

Other trauma

Acute phase
Fluid Resucitation (F)

(Mathes, 2006)

(Mathes, 2006)

Acute phase
Fluid Resucitation (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 (%)

Case
Patient with 50 Kg BW and 30% BSA
Fluid Needed : 4 x 50 Kg x 30 %

6000 cc RL
First 8 hours 3000 ml 92 drops/mnt

Next 16 hours 3000 ml 46 drops/mnt

Emergency
burn
pathway

MONITORING

Vital Sign

(Pulse rate, respiration rate, blood presure, temperature)

Urin Output Adult 30 ml / hour

Child 1-2 ml / Kg / hour

Breathing sound

Severe burn (>40%) apply Central Venous Catheter

Nasogastric tube production beware of stress ulcer

Hb, WBC, Plt, Hematocrit, Electrolite, Albumin, GDR,

Kidney Function, Liver Function, BGA

ECG, Thorax X-ray

Criteria for burn center referral

2nd Degree Burn> 15% Adult

> 10% Child

3rd Degree Burn> 5%

Electric/Chemical
Burn Wound on the face, hand, genital
and perineal
Other trauma or sistemic disease

Initial wound care

Stop the burning process
Clean the wound
Cover. Clean, moist, nonadherent
dressing
Analgesia
Wound debridement

Controversy: Blister debridement

Moist concept in wound healing

Exposed method

Moist method

Wound Care

1st O no spesific treatment

2nd O
Cleansed with NaCl + Savlon
500 ml
5 ml
Tule + sterile thick gauze
or Biological dressing
(Observation in one week)
MEBO
Controversy: Usage of Silver Sulfadiazin

Conservative wound care

Wound Care

3rd O
Cleansed with NaCl 500 ml + Savlon 5 ml
Daily debridement
Daily Silver Sulfadiazin (Dermazin /
Burnazin) ,
Silver contained dressing (Acticoat /
Mepilex-Ag)

Plus Surgical Treatment

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

Bathing

Nutrition

Burn injury can increase the basal metabolic rate

50% to 100% of the normal resting rate. The main
features include:

increased glucose production,

insulin resistance,
lipolysis,
and muscle protein catabolism.

Without adequate nutritional support, patients

have delayed wound healing, decreased immune
function, and generalized weight loss

(Mathes, 2006)

(Mathes, 2006)

Physiotherapy & Splinting

Pressure garment

Electric Burn Injury

Chemical Burn Injury

Electrical injury

Beware of cardiac rythm abnormality closed

ECG evaluation in the first 2 days
Beware of extensive rhabdomyolisis
Beware compartment syndrome 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

Case, Male, 15 years old

Electric Burn Injury

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

Case, Male, 30 years old

Chemical burn injury

Thank you