BURN INJURIES & TREATMENT

dr. Neng Sari Rubiyanti dr. Raymond. Adiwicaksana

Burns
A burn is an injury to the skin or other organic

tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals, as well as respiratory damage resulting from smoke inhalation, are also considered to be burn
World Health Organization http://www.who.int/violence_injury_prevention/other_injury/burns/en/index.html

American burn association

a burn is defined as an injury to the skin or other

organic tissue primarily caused by thermal or other acute trauma. It occurs when some or all of the cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissues due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns.

Initial evaluation
1. airway management

2. evaluation of other injuries

3. estimation of burn size 4. diagnosis of carbon monoxide & cyanide

poisoning

Mechanism of burn
Thermal injury

Electrical injury
Chemical injury

PATHOPHYSIOLOGY
Three zones of tissue injury ( jackson )
1. zone of coagulation
severe Center of the wound Tissue coagulated &frankly necrotic grafting Need excision &

2. zone of statis
Vasocontriction & resultant ischemia Need excision & skin grafting

3. zone o hyperemia
Heal with minimal/ no scarring

Pathophysiology
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. Cardiovascular changesCapillary permeability is increased, leading to loss of intravascular proteins and fluids into the interstitial compartment. Peripheral and splanchnic vasoconstriction occurs. Myocardial contractility is decreased, possibly due to release of tumour necrosis factor . These changes, coupled with fluid loss from the burn wound, result in systemic hypotension and end organ hypoperfusion.
British medical journal www.bmj.com/content/328/7453/1427

 Respiratory changesInflammatory mediators cause

bronchoconstriction, and in severe burns adult respiratory distress syndrome can occur. Metabolic changesThe basal metabolic rate increases up to three times its original rate. This, coupled with splanchnic hypoperfusion, necessitates early and aggressive enteral feeding to decrease catabolism and maintain gut integrity. Immunological changesNon-specific down regulation of the immune response occurs, affecting both cell mediated and humoral pathways.
British medical journal www.bmj.com/content/328/7453/1427

Classification of burn wounds

1. superficial ( 1st degree)

2. partial thickness ( 2nd degree)

3. full thickness ( 3rd degree)

Classification of burn wounds

1st degree Painfull Do not blister 2nd degree Dermal envolvement Extremely painfull Weeping blister 3rd degree Hard Painless blanching

Major-Minor Criteria ( American Burn Association )

Major Burns

Any burns in infants or the elderly Any burns involving the hands, face, feet, or perineum Burns complicated by fractures or other trauma Burns complicated by inhalation injury Burns crossing major joints Burns extending completely around the circumference of a limb Electrical burns Full-thickness burns of greater than 10% body surface area in any risk group Partial-thickness burns more than 20% body surface area in the higher-risk group Partial-thickness burns more than 25% of the body surface area in the low-risk group

 Moderate Burns

These include: Partial-thickness burns of 15 to 25% body surface area in the low-risk group Partial-thickness burns of 10-20% body surface area in the higher-risk group Full-thickness burns of at least 10% body surface area or less in others

Minor Burns Minor burns must be: Less than 15% body surface area in the low-risk group Less than 10% body surface area in the higher-risk group Full-thickness burns that are less than 2% body surface area in others

Prognosis (mortality )
The baux score

Mortality =age + percent TBSA

- Age - Burn size (persent TBSA)

- Inhalation injury
- Coexistent trauma - pneumonia

Rule of nine

Rule of nine
Head = 9%

Chest (front) = 9%
Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% (front = 4.5%, back = 4.5%) Groin = 1 Each leg = 18% total (front = 9%, back = 9%)

Inhalation injury and ventilator management

ARDS : Adult Respiratory Distress Syndrome
Smoke inhalation :
heat injury upper airway (swelling) Combution products lower airway Direct mucosal injury mucosal sloughing,edema,

reactive bronchocontriction, obstruction of the lower airways. Injury to epithelium & pulmonary alveolar macrophage release prostaglandin & chemokines migration of of neutrophil and inflamatory mediators tracheobronchial blood flow increase capillary permeability lead to ARDS

Think first!!!
Burn patients should be first considered trauma

patients, especially when details of the injury are unclear. A primary survey should be conducted in accordance with advanced trauma life support guidelines. Concurrently with the primary survey, large-bore peripheral IV catheters should be placed and fluid resuscitation should be initiated

ABCDE DALAM TRAUMA

Survei ABCDE (Airway, Breathing, Circulation,

Disability, Exposure) harus selesai dilakukan dalam 2 - 5 menit. Tujuannya: segera mengenali cedera yang mengancam jiwa seperti :
Obstruksi jalan nafas Cedera dada dengan kesukaran bernafas Perdarahan berat eksternal dan internal Cedera abdomen

Airway + C Spine Control

Menilai jalan nafas, adanya trauma inhalasi

(smoke inhalation) dan menjaga imobilisasi cervikal pada pasien dengan kecurigaan adanya fraktur cervikal. Jika ada tanda gagal nafas (seperti : serak, mengi atau stridor) atau obstruksi, maka lakukan :
Chin lift / jaw thrust

Suction
Guedel airway / nasopharyngeal airway Intubasi endotrakheal

Breathing + Ventilation
Menilai pernafasan cukup. Sementara itu nilai

ulang apakah jalan nafas bebas. Jika pernafasan tidak memadai:

Oksigen harus diberikan pada semua kasus Monitoring dengan pulse oximetry Monitoring serial BGA Ventilator

Evaluasi adanya trauma thorax akibat pasien

meloncat /jatuh dari ketinggian

carbon monoxide (CO) poisoning

Harus dicurigai pada

pasien luka bakar karena api pada ruang tertutup, atau jika pasien tidak sadar The affinity of CO for hemoglobin is approximately 200250 times more than that of O2 decreases the levels of normal oxygenated hemoglobin and can quickly lead hipoksemia, anoxia, death Administration of 100% oxygen is the gold standard for treatment of CO poisoning

Hydrogen cyanide toxicity

May also be a component of smoke inhalation

injury Cyanide inhibits cytochrome oxidase, which in turn inhibits cellular oxygenation. Treatment consists of sodium thiosulfate, hydroxocobalamin, and 100% oxygen. In the majority of patients, the lactic acidosis will resolve with ventilation and sodium thiosulfate treatment becomes unnecessary.

Circulation
Menilai sirkulasi / peredaran darah. Sementara itu

nilai ulang apakah jalan nafas bebas dan pernafasan cukup. Jika sirkulasi tidak memadai:
Hentikan perdarahan eksternal Segera pasang dua jalur infus dengan jarum besar (14 -

16 G), terutama bila luas luka bakar > 40 % luas permukaan tubuh Berikan infus cairan Pada anak akses intra osseous (darurat)
Tekanan darah tidak selalu merupakan indikator yang

baik terhadap status sirkulasi. Frekuensi nadi dan produksi urin adalah indikator yang lebih baik. Resusitasi cairan IV dipengaruhi oleh luasnya luka bakar terhadap luas permukaan tubuh.

Penanganan Pada Pertolongan Awal

Tidak memberikan Antibiotik Pemberian Oksigen dan Analgetik opiat dan Anxiolytic (Benzodiazepine) Resusitasi cairan intravena luas luka bakar > 20% TBSA (> 15% TBSA pada anak ) Awal: Ringer lactat 1000 ml/jam pada dewasa dan 20 ml/kg BB/jam pada anak Target MAP > 60 mmHg Pasang kateter Foley, monitoring UOP tiap jam Produksi urin:30 ml/jam pada dewasa, 1-1,5 ml/kg BB/jam pada anak Setelah penentuan luasnya luka bakar Parkland formula Early enteral feeding

RESUCITATION

Baxter / Parkland Formula

= 4 ml Ringer Lactate %TBSA Wt (kg)
half over 8 hrs half over 16 hrs
0.5 ml /kg /%TBSA of 5% albumin in RL

24 hrs after injury , over 8 hrs ( for > 30% burn) Children : 3ml R.L. %TBSA Wt + maintainance (G/S 0.45%)

Modified Brooke Formula

= 2 ml Ringer Lactate %TBSA Wt (kg)

Haifa Formula
= 1 ml Ringer Lactate %TBSA Wt (kg) = 1,5 ml FFP %TBSA Wt (kg)
volume during first 8 hr post injury volume next 16 hr post injury

In Emergency Room
Luas luka bakar > 40% TBSA 2 jalur intravena

dengan kateter berukuran besar

Lebih dianjurkan pada ekstremitas atas

Pasien dengan Luka Bakar Berat/ memiliki

penyakit penyerta / usia yang ekstrem, atau dengan trauma inhalasi pasang CVP Pasien Anak pada kondisi emergency perlu akses Intraosseous

Treatment of the Burn Wound

topical therapies : silver

sulfadiazine, Mafenide acetate, Silver nitrate, topical ointments (bacitracin, neomycin, and polymyxin B), mupirocinmethicillinresistant S. aureus Silver-impregnated dressings (Acticoat and Aquacel Ag)
Biologic membranes

http://www.burnsjournal.com/article/S0305-4179%2809%29004136/abstract

Nutrition
Not only such as immune responsiveness the

hypermetabolic respone( 200%), catabolism of muscle proteins and lean body mass delay functional recovery. Early enteral feeding prevent loss of lean body mass, slow the hypermetabolic response, & result in more efficient protein metabolism, gastric ileus can often be avoided. Metoclopramide Glutamine

Nutrition
The Haris Benedict formula
BMR Laki-laki = 66 + (13,7 x BB) + (5 x TB - 6,8 x Umur) Perempuan = 655 + (9,6 x BB) + (1,7 x TB - 4,7 x Umur) BEE = BMR + 10%

Curreri Formula
25 kcal/kg/day + 40 kcal/%TSBA/day

Modifying the hypermetabolic response

Beta blocker

The anabolic steroid oxandrolone

Insulin metformin

Complications in Burn Care

postinjury pneumonia

subglottic stenosis in burn patients with

prolonged endotracheal intubation Abdominal Compartment Syndrome (ACS) Deep vein thrombosis (DVT) & fatal pulmonary embolus, arterial thrombosis heparin prophylaxis prevent thrombotic complications. HIT thrombocytopenic burn patients the platelet counts drop in hospital days 7 to 10. bloodstream infections catheter-related infections

Surgery
Escharotomies

Fasiotomi
Eksisi Grafting

Tangential excision of the burn wound is carried out with a Watson knife (as shown here) or a Weck/Goulian blade. Eschar is tangentially excised until healthy, bleeding tissue that is suitable for skin grafting is reached. http://www.acssurgery.com/acssurgery/secured/figTabPopup.action?bookId=ACS&li nkId=part07_ch15_fig8&type=fig

Surgery
Full-thickness burns with a rigid eschar a tourniquet effect The resulting compartment syndrome is most common in

circumferential extremity burns, but abdominal and thoracic compartment syndromes also occur Escharotomies are rarely needed within the first 8 hours following injury and should not be performed unless indicated because of the terrible aesthetic sequelae. Extremity incisions are made on the lateral and medial aspects of the limbs in an anatomic position and may extend onto thenar and hypothenar eminences of the hand. Inadequate perfusion despite proper escharotomies may indicate the need for fasciotomy Thoracic escharotomies should be placed along the anterior axillary lines with bilateral subcostal and subclavicular extensions. Extension of the anterior axillary incisions down the lateral abdomen typically will allow adequate release of abdominal eschar.

Surgery
Early excision and grafting in burned patients revolutionized

survival outcomes in burn care. After the initial resuscitation is complete and the patient is hemodynamically stable, attention should be turned to excising the burn wound. Excision is performed with repeated tangential slices using a Watson or Goulian blade until only nonburned tissue remains. It is appropriate to leave healthy dermis, which will appear white with punctate areas of bleeding. Excision to fat or fascia may be necessary in deeper burns. The downside of tangential excision is a high blood loss, though this may be ameliorated using techniques such as instillation of an epinephrine clysis solution underneath the burn. Pneumatic tourniquets are helpful in extremity burns, and compresses soaked in a dilute epinephrine solution are necessary adjuncts after excision.

Wound Coverage
Full-thickness grafts are impractical for most burn wounds split-thickness sheet autografts harvested with a power dermatome

make the most durable wound coverings and have a decent cosmetic appearance. Meshing of autografted skin provides a larger area of wound coverage. This also allows drainage of blood and serous fluid to prevent accumulation under the skin graft with subsequent graft loss. Areas of cosmetic importance such as the face, neck, and hands should be grafted with nonmeshed sheet grafts to ensure optimal appearance. Integra (Integra LifeSciences Corporation, Plainsboro, NJ) is a bilayer product with a porous collagen-chondroitin 6-sulphate inner layer that is attached to an outer sheet of silastic. The silastic barrier helps prevent fluid loss and infection, and the inner layer becomes vascularized, creating an artificial neodermis. At approximately 2 weeks, the silastic layer is removed and a thin autograft placed over the neodermis. This results in faster healing of the more superficial donor sites, and seems to have less hypertrophic scarring and improved joint function. AlloDerm (LifeCell Corporation, The Woodlands, TX) is another dermal substitute consisting of cryopreserved acellular human dermis. This must also be used in combination with thin split-thickness skin grafts.

Wound Coverage
Epidermal skin substitutes such as cultured

epithelial autografts are an option in patients with massive burns and very limited donor sites Convenient anatomic donor sites, Thighs, The thicker skin of the back , The buttocks, Silvadene ,The scalp, the skin Epinephrine clysis is necessary for harvesting the scalp, for both hemostasis of this hypervascular area and also to create a smooth surface for harvesting. Principles behind choosing a dressing should balance ease of care, comfort, infection control, and cost.

Rehabilitation
Immediate and ongoing

physical and occupational therapy is mandatory to prevent loss of physical function. passive ROM at least twice a day Psychological rehabilitation is equally important in the burn patient Psychological distress occurs in as many as 34% of burn patients, and persists in http://www.burntherapist.com/History.htm severity long after discharge

Prevention
community-based

interventions Smoke alarms Regulation of hot water heater temperatures community-based programs emphasizing education and in-home inspections