BURN

 Concept
o Airway compromise
o Mechanical injury
o Hemodynamic stability
o Temperature control
o Removing patient from injuries environment
 Compromised :
o Airway and breathing
o Circulation
o Temperature
o Exposure
 Consequence of injury berkorelasi dengan derajat kerusakan/inflamasi; semakin
dalam burn nya  semakin keras inflamasinya
 Komplikasi:
o Rhabdomyolysis  cardiac dysrhythmia = electrical burn
o Compartment syndrome  following large volume resuscitation
 Primary survey and resuscitation of patient with burn
o Concept:
 Remove patient from burning environment
 Airway and breathing management
 IV access
o Stopping the burning process:  PAKE APD!
 Remove patient’s clothing, DO NOT peel adherent clothes!
 Take care of hypothermia
 Dry powder/solution di brush dari luka, irigasi dengan WARM NS yang
banyak
 Once the burning process sudah clear:
 Warm
 Dry
 Clean linen to prevent hypothermia!
o Establishing airway control
 Perhatikan:
 Increasing burn site and depth  be extra careful of child
patients!
 Burn pada area muka dan leher (fase and mouth)
 Inhalation injury
 Associated trauma and burn di dalam mulut
 Obstruksi terjadi bukan hanya direct injury (inhalation injury) tapi
karena massive edema dari burn injury
 Take note!  inhalation injury!
 Edema tidak terjadi secara cepat  lebih perlahan
 Biasanya tidak nampak dalam 24 jam pertama
 Jika ragu: cek orofaring dan tanda-tanda inflamasi
o Faring hiperemis
 o Mukosa erosi, eschar, bekas terbakar
 Indikasi early intubation:
 Signs of airway obstruction (hoarseness, stridor, accessory
muscle use, retraction)
 Extent of burn  > 40-50% BSA
 Extensive and deep facial burn
 Significant edema / risk of edema
 Difficulty swallowing
 Respiratory compromise : hiperesekresi, sulit ventilasi dan
poor oxygenation
 Penkes and  reflex airway
 Anticipated en route intubation = mau transport pasien
dengan large burn dan tidak ada personil yang bakal bisa
intubasi.
 Marker:
 Carboxyhemoglobin > 10% = suggest inhalation injury
 Patient’s neck circumferencial burn  intubasi!
 Stridor = indikasi intubasi ETT segera
o Ensure adequate ventilation:
 Breathing concerns (saluran nafas bawah)  hipoksia, CO poisoning,
smoke inhalation injury.
 Hypoxia:
 Inhalation injury
 Poor compliance karena circumferential burn
 Thoracal trauma ___ to thermal injury
  berikan oksigen dengan/tanpa intubasi
 CO:
 240x afinitas ketimbang oksigen
 Selalu periksa keracunan CO pada pasien dengan riwayat
terbakar pada ruangan tertutup:
o Ditegakkan dengan anamnesis + pemeriksaan fisik
o Pasien < HbCO 20% = tidak bergejala
 Headache  20-30%
 Confusion  30-40%
 Coma  40-60%
 Death  > 60%
 Diagnosis dan pemeriksaan penunjang:
o Obtain AGD  untuk menilai pulmonary status pasien  chest xray
o Cek HbCO baseline
o Oximeter dapat dilakukan namun tidak reliable  ga bisa bedain HbO2
dengan HbCO
 Tatalaksana:
o O2 100% via NRM  clearance half time CO menjadi 90 menit yang tadinya 4-
6 jam
o Hati-hati pada pasien dengan PPOK!
o Pasang ETT diameter internal 7.5 adult dan 4.5 anak-anak
 Intubasi juga pasien dengan significant burn injury (>20% TBSA in
adults or >10% TBSA in children < 10 yo or elderly > 50th)
 Jika kondisi pasien permit and no spunal cervical injury  elevasi
head and neck 300 to reduce neck and chest wall edema
 Full-thickness burn dari anterior and lateral chest wall will lead to
several restriction and chest wall edema  kadang perlu chest wall
escharotomy.
o American Burn Association for Inhalation injuries in Burn Patients:
 2 points:
 Exposure to combustible agents
 Signs of exposure to smoke in the lower airway below the
vocal cords, as seen on bronchoscopy.
  likelihood = injuries occur within and enclosed place and in cases of
prolonged exposure
o Manage circulation with burn shock resuscitation
 Resusitasi cairan  untuk replace the ongoing losses form capillary
leak due to inflammation
 Over:
o Edema
o Burn depth progression
o Extremity/abdominal compartment syndrome
 Under:
o Hypoperfusion
o End-organ perfusion
 Provide burn resuscitation fluids for deep partial and full-thickness
burns larger than 20% TBSA  hati2 risk of over resuscitation
 Upper extremities preferable than lower extremities  risiko infeksi
lebih besar  phlebitis and ___ phlebitis jika vena saphenous
digunakan  utamakan untuk unburned site > burned site  jika
tidak ada akses, ___ CV access/intraosseal infusion
 Pasang IV catheter 2 line (18G) pada unburned site, upper extremities
 Loading cairan warmed RL
 American burn association  2 mL x TBSA x weight in kgs for
2nd and 3rd degree burn
 ½ di 8 jam pertama
 ½ di 16 jam berikutnya
 Pasang indwelling cathether, hati-hati osmotic diuresis bikin rancu!
 Target dan kebutuhan cairan
Categories of Age and Adjustment Urine output
burn weight fluid rules
Flame or Scald Adult or older 2 ml RL x kg x 0.5 ml/kg/hr
children ( TBSA 30-50 ml/hr
14yo)
Children (<14 3 ml RL x kg x 1 ml/kg/hr
yo) TBSA
 Infants and 3 ml RL x kg x 1 ml/kg/hr
young TBSA pake
children (30 D5%RL
kgs)
Electrical burn All ages 4 ml RL x kg x 1-1.5 ml/kg/hr
TBSA sampe until urine
urine clears clears
(jernih)
 Untuk cairan:
 Jangan dibolus  titrasi untuk mencapai target urine output
 Tachycardia in burns is a poor predictor
 First signs:
 Cardiac dysrhythmia  sign of hypoxia and electrolyte
imbalance
 Acidosis  under or over resuscitation
o Patient Assessment
 AMPLE
 Allergies
 Meds currently used
 Past illness/pregnancy
 Last meal
 Event/environment related to the injury
 Assessment the size of body surface burned and the depth of the burn
injury
o History
 Injury history:
 Escape a fire / explosions / fractures
 Closed space
 LOC (anoxia cerebri)
 Tetanus immunization
 Allergies and drug sensitivity
 Body Surface Area
o Rule of nine
 Partial / full-thickness burns aja yg dihitung (2nd and 3rd degree burn)
 Palmar surface and finger approx. 1% of BSA
o Degree of Burn
 Superficial 1st degree burn:
 Erythema + pain
 No blister!
 No IV fluid resuscitation!
 Epidermis intact
 Partial-thickness burn:
 Superficial-partial
o Moist
o Most painful even to aircurrent  kena angin aja sakit
ngenes
 o Potentially blistered
o Homogenous pink
o Blanch to touch
 Deep-partial
o Drier
o Less painful
o Potentially blistered(?)
o Red or mottled appearance
o Do not blanch to touch
 Full thickness burn:
 Skin translucent or waxy white. Generally dry
 Appear leathery
 Painless to touch or pinprick
 Once epidermis is removed, the underlying dermis may be red
 Initially doesn’t blanch with pressure
 Dermis dry and doesn’t weep  less swollen
 Secondary survey and released adjuncts:
o Documentation
o Baseline trauma bloodwork  HbCO dan xrays
o Maintenance of peripheral circulation in circumferential extremity burns
o Gastric tube insertion
o Narcotic analgesic + sedation
o Wound care
o Tetanus immunization
 Documentation BSA
 Baseline determination for patient with major burns
o CBC + crossmatch
o Blood gas analysis + HbCO
o Serum glucose
o Serum electrolyte
o All female of childbearing age
o Obtain:
 Xray:
 Patient intubated  repeat __ as necessary
 Suspected inhalation injury  repeat __ as necessary
 Trauma as indicated
 Peripheral circulation in circumferential extremity burns:
o Goal utama: compartment syndrome!
o Compartment syndrome results from an increase in pressure within a
compartment that interferes with perfusion to the structure within
compartment
o Decrease skin elasticity + increased edema in the __ tissue = compartment
syndrome
o Pada extremity = Hati-hati muscle loss akibat anoxia
  A pressure of >30 mmHg within the compartment can lead to muscle
necrosis
 Can lead to muscle necrosis, when the pulse(?) is gone = it’s too late
o Sign = symptoms of compartment syndrome
 Pain greater than expected out of proportion to the stimulus or injury
 Pain on passive stretch of the affected muscle
 Tense swelling of the affected compartment
 Paresthesia or altered sensation distal to the affected compartment
o Compartment syndrome dapat terjadi pada chest and abdomen pada kasus
circumferential burn  leading to  peak inspiratory pressure and abdominal
compartment syndrome
o Tx:
 Remove patient’s jewelry / identification bands / allergic (?) bands
dari ekstremitas pasien
 Assess patient’s circulation status of distal circulation
 Cyanosis
 CRT
 Distal pulses
 Paresthesia/hyperesthesia
 Relieve circulatory compromise dengan escharotomy pada pasien:
 Circumferential burn
 Pada dinding dada yang terbakar sirkumferensial, lakukan
insisi di: anterior axillary line dengan cross incision pada
clavicular line and junction pada thorax dan abdomen
 Konsul SpB
 Biasanya tindakan tidak diperlukan apabila <6 jam
 Insisi hanya pada area kulit yang terbakar saja
 Fasciotomy jarang dilakukan
 Gastric tube insertion
o Pasang NGT. Pastikan teralir juka pasien mual, muntah, distensi abdomen
atau burn > 20% TBSA
 Narcotic, analgesic, sedative
o Pasien dengan luka bakar berat  may be restless and anxious from hypoxia
and hypovolemia than pain
o Oleh sebab itu  treat hypoxia and hypovolemia dulu sebelum masuk
sedative and narcotics karena bisa masking the condition (HYPOXIA and
HYPOVOLEMIA)
o Narcotic, analgesic, and sedative is given in low doses tapi namun sering,
secara IV
o Covering the __ will decrease the pain
 Antibiotics
o No indication for abx prophylaxis in every patient burn person
o Reserve only for tx of infection
 Tetanus
o Give sesuai indikasi
o Most people > 55 th tidak punya protective antibody
o Bergantung pada riwayat imunisasi pasien dan jenis luka, inkubasi teanus 1-2
hari hingga 7-21 hari
o Jenis luka yang dapat menciptakan lingkungan tumbuh tetanus
 Open fracture
 Deep penetrating wounds (>1 cm)
 Stellate atau luka avulsi, dsb
 Luka yang terdapat jaringan devaskularisasi
 Luka tembak
 Luka bakar atau frostbie
o Wounds:
 Dalam, > 1cm
 Stellate / avulsi
 Jaringan devaskularisasi
 Benda asing
 Luka ekstensif contusion/burns
 Kontaminasi tanah, tai kuda dan delay disinfeksi >4 hrs
 Wounds / burn delay > 6 hrs padahal butuh surgical intervention
 Wounds / burns yang associated dengan ___
 Luka bakar atau frost bite
 Luka tembak
o Treatment principles of Tetanus:
 Wound care surgical  lakukan debridement dan remove
devascularized tissue untuk segala macam luka
 Jangan dijahit bila  adekuasi pembersihan luka dipertanyakan dan
luka bersifat punktata – biarkan __ dan jangan jahit, tidak yakit dapat
bersih, luka penetrans.
 Active immunization  mainstay of therapy
 Prevensi:
 Pada pasien trauma  surgical wound care dan passive
immunization
 Passive = 250 unit hTIG IM
o Dosis ganda apabila luka >12 jam, BB > 90kg, atau luka
terkontaminasi berat
o HTIG is better karena perlindungan lebih panjang dan
fewer adverse reaction
 Tdap is preferred than TD pada pasien yg blm pernah dapet
Tdap karena ada chance herd immunity
 Td is preffered than TT pada px yg sudah dapet Tdap
sebelumnya, atau Tdap not available
 Sebaliknya jika TT dan TIG diberikan bersamaan, gunakan
tetanus toxoid yg adsorbed ketimbang __ untuk booste __
(fluid vaccine)
 Jika px sudah 3x inj. Toxoid, TIG tidak diindikasikan kecuali luka
tsb tetanus prone dan > 24 hrs
 Wound care:
 Cover wound with clean sheats
 Jangan break blister atau taruh antiseptic
  Jangan kasih cold water pada extensive burn > 10% TBSA
 Kriteria transfer pasien ke burn center:
o Partial thickness burn > 10% TBSA
o 3rd degree burn in any age group
o Electrical burn / lightning injury
o Inhalation burn
o Burn pada hands, feet, perineum, face, and other joints
o Pasien dengan komorbid seperti DM
o Chemical burn
o Pasien burn dengan trauma hebat
o Burn pasien anak tanpa fasilitas yang memadahi
o Burn pada pasien yang membutuhkan special treatment seperti gangguan
terapi, social, or rehab intervention

Burn injury yang lain

 Cemical
 Electrical
 Tar

Chemical burns
 Jenis:
o Acid  penetrasi dalam  coagulative necrosis
o Alkali  penetrasi lebih dalam > acid  liquefactive necrosis
o Petroleum
o Rapid removal of the chemical and immediate attention to wound care


 Dry powder = di brush dulu  kalo dikasi air, generalized heat (?)
 Paling baik diirigasi dengan air/shower in large amout selama 20-30 menit (alkali
lebih lama dibanding acid) ketimbang neutralizing agent karena bisa react terus
malah generates heat
 Alkali burn pada mata  irigasi dengan air for 8 hours

Electrical burns
 Luka dalam lebih parah dibandingkan luka di luar  akibat perbedaan heat loss
antara superficial and deep tissue
 Travel through blood vessels and nerves  resiko thrombosis
 Resiko kontraktur pada ekstremitas
 Mungkin membutuhkan fasciotomy
 Tatalaksana:
o Securing airway and ventilation + adequate oxygenation
o Placing IV line in uninvolved extremities 4 ml x kgBB x TBSA  50% 8 jam
pertama, 50% 16 jam selanjutnya
o Monitoring EKG (resiko cardiac arrhythmia)
 Prolong monitoring in:
 Patient with burn
 Loss of consciousness
 Paparan >1000 volts
 Cardiac rhythem abnormalities and arrhythmia evolution
 Examination patient muscle contraction  spine/fracture
 Pasang kateter  liat myoglobinuria, lanjutkan tx tanpa tunggu hasil,
asumsi jika merah  hemochromogen ada di urin  rhabdomyolysis
 Target UO:
 100 ml/hr in adults
 1-1.5 ml/kgBB/hrs in children < 30 kg
 Guyur tanpa __  __ __ ke 0.5 ml/kgBB/jam
 ! metabolic acidosis should be corrected by maintaining
adequate perfusion.