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Tri Gunawan W, dr, Sp B, FICS, FInaCS

Skin Anatomy

Skin Constitution
 Epidermis
 Corium or

 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.

 Zone of stasis —
decreased tissue perfusion.
Potentially salvageable.

 Zone of hyperaemia —
tissue perfusion is
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 changes—Non-specific
down regulation of the immune response
occurs, affecting both cell mediated and
humoral pathways.
 Burn = Coagulative destruction of the skin or
mucous membrane
 Caused by heat, chemical or irradiation
 Thermal damage occurs above 48 ºC
 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

mediators hypovolemia

Interstitiel /

Burns can result in:
 Increased capillary permeability and fluid loss
 Hypovolaemia and shock
 Increased plasma viscosity and microthrombosis
 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
The question............??
How the oxygen
can be deliveried
to the cell?
 To allow oxygen
flow into the lung
 To allow carbon
dioxide flow out of
the lung
 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.
Important Consideration
1. Etiology
2. The depth of skin burn
3. Size and extent of the burn wound
1. Temperature
High ( Fire, Boiled Water, Steam, hot cloud, lava )
Low ( Frost Bite )
2. Electric
3. Chemical
Base – Acid
4. Radiation
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
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
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 Nine’s

• Prevent Heat Restore
• Electric injury  breaking
down the voltage
• Chemical 
decontamination / dilution
 Initial assessment should be by ATLS
 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 Airway

A: Look for signs of inhalation injury

Facial burns,
Soot in nostrils or sputum
Laryngoscope  edema, hyperemia
Acute phase
Rescusitation Breathing
B: Circumference Full thickness skin burn on the
chest wall  mechanical ventilation disturbance
Acute phase
• 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 15-
30 minutes
 Local :
Circumference Full thickness skin
burn on extremity  compartment
syndrome  5P  ESCHAROTOMY
Escharotomy on extremity
Acute phase
Disability (D)
 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


IVFD RL: 4 ml x BW (Kg) x BSA (%)

Patient with 50 Kg BW and 30% BSA

Fluid Needed : 4 x 50 Kg x 30 %
 6000 mL RL
First 8 hours 3000 mL  92 drops/mnt
Next 16 hours 3000 mL  46 drops/mnt
• Vital Sign
(Pulse rate, respiration rate, blood presure, temperature)
• Urin Output  Adult 30-50 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
 Analgesia
 Wound debridement
Controversy: Blister debridement
Maintenance Fluid Requirements
35 + %𝑏𝑢𝑟𝑛 𝑥 𝐵𝑆𝐴 𝑥 24 + 1500 𝑚𝐿 𝑥 𝐵𝑆𝐴

Body surface area (The Mosteller formula) =

body height cm x body weight (kg)

Hourly adjusted based on urine output

Patient with 50 kg BW, 160 cm BH,
and 30% BSA

 BSA = 1,5
 MFR = ((35+30)x1,5x24)+(1500x1,5)
= 2340 + 2250
= 4590 mL /24 hour  190 mL / hour

Hourly adjusment
Urine output < 1 mL/hour/Kg BW   10%
Urine output > 2 mL   10%
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)

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® /

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
 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)
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