Oleh

Ridho Frihadananta W G99161082

Safitri Tia Tampy G99152023

KEPANITERAAN KLINIK SMF ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNS/RSUD DR MOEWARDI
PATIENT STATUS
Identity of The Patient
 Name : Ms S
 Age : 35 years old
 Gender : Female
 Address : Matesih, Karangannyar
 Admission Date : October, 3th 2017
 Examination Date : February, 9th 2017
 MR Number : 013943XX
CHIEF COMPLAIN

Boiled water Burn Wound

PRESENT ILLNESS
 A patient came with her body burnt to boiled water since
3 hours before admitted to the hospital. The burn occured
one day earlier. She got the burn when she cooked in the
kitchen. Suddenly the patient has a seizure and
unconscious. At that moment the patient is in a position
holding a pot containing hot water. When the seizure
appears, accidentally boilled water is being spilled to the
patient’s body. Seizures occurred more than 15 minutes.
After the seizure stops, the patient regains consciousness
and complained of burns and painful, stiffness (-), nausea
(-), vomiting (-). Then the patient was taken by the family
to the nearest clinic. Then, patient was reffered to
Moewardi Hospital.
PAST HISTORY
 Allergy/Asthma : (+) drug, but
patient forgot
 Epileptic : (+) since 2005
 Kongenital anomali : denied
 Trauma : denied
 Operation history : denied
FAMILY HISTORY
 Alergy/asthma : denied
 Trauma : denied
 Mallignancy : denied
 SYSTEMIC ANAMNESIS

Head : wound (+), pain (+)

Eyes : no complaints
Mouth : no complaints
Respiratory system : no complaints
Cardiovascular system : no complaints
Gastrointestinal system : no complaints
Genitourinaria system : no complaints
Upper extremity : wound (-/-), pain (-/-)
Lower extremity : wound (+/-), pain (+/-)
 PRIMARY SURVEY

A. Airway : clear
B. Breathing : 20 times / min
 Palpation : normal
 Percussion : normal
 Auscultation : normal
C. Circulation : blood pressure 140/80, pulse 82 x / min
D. Disability : GCS E4V5M6, light reflex (+/+), isochoric
pupil
E. Exposure : temperature 36.7 ° C, injury (+) see local
examination
 Secondary Survey

Head : wound (+)

Eyes : normal
Ear : normal
Nose : wound (+)
Mouth : wound (+)
Neck : wound (+)
Thorax : wound (+)
Abdomen : normal
Genitourinaria : normal
Extremity : injury (+), see local physical examination
 LOCAL PHYSICAL EXAMINATION
REGIO INSPECTION
Regio Facialis Hiperpigmentasi (+) Bulla (-) Eritem (+) 3%

Regio Colli & Thoraks Hiperpigmentasi (+) Bulla (-) 3 %

Anterior

Regio Hip Dextra dan Hiperpigmentasi (+) Bulla (-) 3%

sinistra, femur dextra
anterior

Regio perineum Hiperpigmentasi (+) Bulla (-) 1%

Regio gluteus Hiperpigmentasi (+) Bulla (-) 3%

CLINICAL PHOTO
CLINICAL PHOTO
BlOOD EXAMINATION (10/11)

 Pemeriksaan Hasil Satuan Rujukan

HEMATOLOGI RUTIN (03/10/2017)

Hb 16.0 g/dl 12.1 – 17.6

Hct 48 % 33 – 45

AL 20.3 103/ L 4,5 – 11,0

AT 407 103 / L 150–450

AE 5.03 103/ L 4,50 – 5,90

KIMIA KLINIK (03/10/2017)

GDS 133 mg/dl 60-140

Creatinin 0.6 mg/dl 0.6-1.1

Ureum 26 mg/dl <50

ELEKTROLIT (03/10/2017)

Natrium darah 137 mmol/L 136 – 145

Kalium darah 3.5 mmol/L 3.3 – 5.1

Chlorida darah 106 mmol/L 98 – 106

SEROLOGI HEPATITIS (03/10/2017)

HbsAg Nonreactive Nonreactive

BlOOD EXAMINATION (10/11)



Pemeriksaan Hasil Satuan Rujukan

 RUTIN (06/10/2017)
HEMATOLOGI

Hb 13.8 g/dl 12.1 – 17.6

Hct 43 % 33 – 45

AL 7.2 103/ L 4,5 – 11,0

AT 292 103 / L 150–450

AE 4.49 103/ L 4,50 – 5,90

HEMOSTASIS (06/10/2017)S

PT 13.5 Detik 10,0 – 15,0

APTT 31.4 Detik 20,0 – 40,0

INR 1.100 -
ASSESSMENT
 BOILED WATER COMBUSTIOn GRADE II A-B 13%
 Seizure susp epilepsy
PLANNING
 RL infusion NS 1500cc/24 hours
 Ceftriaxone injection 1 g/12 hours
 Metamizole injection 1 g/8 hours
 Ranitidine injection 250 mg/12 hours
 Monitoring vital sign, general condition
 Balance Fluid
 Neurologic deaprtment consultation
LITERATURE REVIEW
INTRODUCTION

Burn wound is a tissue damaging or loss due

to extreme heat source, cold source, electric source,
chemical compounds, light, radiation, or friction.

Burns still constitute one of the main accidents in

homes and industry, and are also linked to social
and economic risk factors.
ETIOLOGY

Thermal
• Scald
• Flash
• Flam

Radiation BURNS Chemical

Electrical
ETIOLOGY

Thermal burns

• Flash and flame burns affected main population.

Flames produce deep burns especially if clothes
have been on fire and usually associated with
inhalational injury and trauma
• Scalds usually caused by spilling hot water or by
using too hot water for bathing. Scalds also caused
by grease or hot oils, which produce deeper burns
• Contact burns usually caused by hot metal, plastic,
glass and coal.
ETIOLOGY

Chemical Burns
• Sodium hypochloride : strong alkaline solution that
cause protein coagulation and when ingested
oesophageal constriction and perforation of
stomach.
• Phenol (carbolic acid): superficial burns caused by
phenol produce light grey lesion, deep burns
produce black lesion
• White phosphorous: produce painful thermal burn
• Sulphuric acid: Deep dermal burns have a bronzed
leathery appearance with deep ulceration
underneath.
ETIOLOGY

Electrical burns
• Electrical burns areclassified as high
voltage (≥1000V), low voltage (<1000V)
and those caused by lightning
• Low voltage: small partial thickness injury
• Hight voltage: large skin lessions with
necrosis at the contact point and even
deeper
ETIOLOGY

Radioactive burns
• Burn cause by exposed to radioactive
source
• Clinical symptomps: hair loss, burns,
desquamation, cutaneous necrosis and
ulseration
Layers of the Skin
 Epidermis  Dermis
 Outer layer  Inner
layer
 Body’s first line of  Composed of:
defense  Collagen fibers
 Composed of several  Elastin fibers

layers  Mucopolysaccharide gel

Layers of the Skin
Layers of the Skin
 Enclosed within the dermis are:
 Nerve endings
 Blood vessels

 Sweat glands

 Hair follicles
Layers of the Skin
 Beneath the dermis is the subcutaneous layer.
 Beneath the subcutaneous layer are the muscles,
tendons, bones, and vital organs.
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY

Zone of coagulation

• Cells in the immediate area of contact die and the

surrounding tissue coagulates and denatures.
• No blood circulation in this area.

Zone of stasis

• Blood perfusion is decreased

• Increased damage could occur because of prolonged
hypoperfusion
 PATHOPHYSIOLOGY

Zone of hyperaemia

• This is the outermost zone; perfusion

is increased and tissue here will
recover unless there is another insult
such as sepsis or hypoperfusion
DEGREES OF BURN
First degree
Second degree
Third degree
 DEGREES OF BURN

Depth of wounds are categorized in four parts:

Epidermal Superficial Deep partial Full thickness

partial thickness thickness
• only the • epidermis and • entire • the entire
epidermis is part of the epidermis and thickness of the
involved and papillary the papillary skin is lost,
sensation is still dermis is dermis is possibly with
intact damaged destroyed with deeper tissue
• Heal by itself • Heal for about part of the • They don’t heal
for about 7 14 days. reticular spontaneously;
days. • These take a skin graft is
about 14–21 needed if
days to heal depth exceeds
>1 cm.
DEGREES OF BURN
How to asses the degree of burn ?
How to measure burn area ?
How to measure burn area ?
 How to measure burn area ?
 Palmar surface—The surface area of a patient's
palm (including fingers) is roughly 0.8% of total
body surface area. Palmar surface are can be used
to estimate relatively small burns (< 15% of total
surface area) or very large burns (> 85%, when
unburnt skin is counted). For medium sized burns, it is
inaccurate.
 Wallace rule of nines—This is a good, quick way of
estimating medium to large burns in adults
SEVERITY OF BURN INJURY
MANAGEMENT
 MANAGEMENT

Emergent Phase
• Begins with the burn injury, assessing severity, initial care
and ends when the patient is stable and begins to diurese
and no longer requires fluid therapy
Acute Phase
• Return of fluid from the cells (intracellular fluid) and
between the cells (interstitial fluid) to the intravascular
space and continuous care of the wounds to promote
grafting, prevent infections, and promote healing (Weeks to
months)
 MANAGEMENT

Rehabilitation Phase
• Begins with the burn injury, assessing severity,
initial care and ends when the patient is stable
and begins to diurese and no longer requires
fluid therapy
• Helping the patient return to previous or
optiminal level of functioning. Many aspects of
rehabilitation begins at the time of emergent
care and continue through the phases.
MANAGEMENT
 MANAGEMENT OF BURN INJURY

drench the burn immerse the site in

thoroughly with cold water for 30
cool water minutes to reduce
pain and oedema

give Except in very

mercurochrome or small burns,
SSD or antibiotic debride all bullae
to the wound

Dress the burn with

gauze
 WOUND MANAGEMENT

Topical Oinments Wound Dressing Biological Wound Phsyological Wound

Dressing Dressing
• Silver sulfadiazine: • maximal support for • treatment of choice • Synthetic dressings
is the most common wound healing for excised burn are an excellent
ointment used. • „maximal protection wounds is an alternative for
• Mafenida : is against infection autograft covering burn
another ointment • „minimal pain during • cheaper alternative wounds
often used for full- dressing changes to this biological • Their function is to
thickness burns; it without anaesthesia dressing is a stimulate skin
has a bacteriostatic • „minimal cost. cultured epidermal regeneration and
action autograft in patients act as a barrier to
• Silver nitrate : An in whom a prevent infections.
alternative version • The most basic and considerable surface Therefore synthetic
of this compound common wound burn area is affected, dressings do not
(Acticoat) was dressing is gauze donor site may be work properly on
developed using covered with soft very limited. full-thickness burn
silver nanoparticles. paraffin injuries
WOUND MANAGEMENT BASED ON
DEGREEOF BURNS

First degree

• Drench the burn thoroughly with cool water

• Topical antibiotik
• Analgesic: NSAID (Ibuprofen, Acetaminophen)

Second Degree (Superficial)

• Need routine care of the wound

• Dress with antibiotic and gauze
• Temporary coverage: allograft or xenograft

Second Degree (Deep) dan Third Grade

• Early exicision and grafting

EARLY EXICISION AND GRAFTING
(E&G)
This technique is important because early excision and skin
grafting reduces the presence of necrotic and infected tissue

Eschar is removed operatively then the wound is covered with

skin graft (allograft or autograft)

Early excision and grafting can be done 3-7 days after the
injury
EARLY EXICISION AND GRAFTING
(E&G)
 ESCHAROTOMY

Third degree burn

Full- thickness circumferential and near-circumferential skin burns result in

the formation of tough and inelastic mass of burt tissue /eschar

Eschar cause vascularization disorder,

or burn induced compartment syndrome
Prevent

ischemia
ANTIMICROBIAL TERAPHY
 Burn >> remove barrier of skin >> infection
 Can be administered:
 Topically

 Systemically

 Topical teraphy: Silver sulfadiazine, Mafenide

acetate, Silver nitrate, Povidone-iodine, Bacitracin
(biasanya untuk luka bakar grade I), Neomycin,
Polymiyxin B, Nysatatin, mupirocin , Mebo.
THANK YOU