Burn Ulcer Management

Salafudin Yusra
Advanced Certified Wound Care Clinician
 The BURNS
patient has the
same priorities as
all other
TRAUMA patients
Skin Functions
Maintains fluid and
electrolyte balance

Protects body from invasion

bacteria.

Regulates body temperature

Sensation

Appearance (Estetika)
Types of Burn
Thermal
– Stop, drop, and roll

Chemical
– Dilute chemicals
– Remove clothing
– Alkalis worse than acids

Electrical
– Remove from source
 Phatopisiology
Local response
The local response to a burn injury
consists of inflammation,
regeneration and repair.
A burn may be divided into three
zones
Systemic response
In complex burns of more than
20–30% TBSA, there is also a
systemic response due to the
extensive release of
inflammatory mediators at the
injury site.
The effects are far reaching
and include systemic hypoten-
sion, bronchoconstriction, a
threefold increase in basal
metabolic rate and a reduced
immune response
Zones of a Burn Injury

Zone of Hyperaemia
Viable tissue

Zone of stasis
Decreased tissue perfusion
Obliteration of microcirculation, release of
mediators — TXA, anti-O2 ischaemic
reperfusion injury, increase in local vascular
permeability

Central zone of necrosis

Coagulative necrosis
 ZONES OF INJURY

Zone of Zone of Zone of Hyperaemia

Coagulation Stasis

Jackson 1953
 ZONES OF INJURY
Zone of
coagulation/necrosis :
 Di area luka yg terbakar

 No tissue perfusion

 Kerusakan jaringan yg
permanen dan terjadinya
kuagulasi protein.
 ZONES OF INJURY
Zone of stasis :
 Area sekitar
terjadinya kerusakan
jaringan
 Penurunan perfusi
jaringan.
 Kemungkinan bisa
pulih dgn baik dengan
per.yg tepat &
kemungkinan
jaringan hancur
menjadi zona 1
 ZONES OF INJURY
Zone of hyperaemia
 At the periphery of the wound.

 Good tissue perfusion.

 Tissue recovery likely.

Zona Aman & perlu

diwaspadai hyperemia yg berlanjut
dapat menjadi zona 2
 PROSES BURN INJURY

0-48 (72) JAM FASE S/D 21 (32) S/D 8-12

FASE HARI FASE
DETERIORASI SUB BULAN
AKUT ABC SIRS & MODS
LANJUT REHABILITASI
AKUT

Ket: A: Airway, B: Breathing, C: Circulation, SIRS: Systemic inflammatory

response syndrome, mods: multi-system organ dysfungsion syndrome
 Sistemic Inflammatory Response Syndrome (SIRS),
Multi-system Organ Dysfunction Syndrome (MODS) dan Sepsis
PENCETUS

Respon Lokal

Sitokin Tahap I

Makrofag Sel Endotel

Respon Sistemik
Tahap II
Hilangnya Homeostasis
Tahap III
SIRS

Hematologi Hati Ginjal Usus

Endokrin/Metabolik Serebral Jantung Paru

MODS
 Emergency management pathway for burns

Stop burning process

FIRST AID
Remove jewellery or hot clothing
Cool the burn
Place under running cool tap water for 20 minutes or
apply hydrogel

Provide analgesia according to pain protocol —

superficial and partial thickness dermal burns are very INITIAL
painful

Check for trauma and any life-threatening injuries

Check tetanus status and provide immunisation if

indicated according to local protocols PRIMARY SURVEY
Assess burn size SECONDARY SURVEY
Assess burn depth

Ensure burn is covered and prepare

Does patient require admission to burns unit? YES patient for transfer

Contact burns unit for advice. Use

UNSURE
telemedicine if appropriate

NO Debride blisters and remove all

loose burned tissue
Follow protocols for local wound
management, with review at
10–14 days (p15)
If poor progress, refer to burns unit
for specialist advice
 Assessment Depth of Burns
FIRST DEGREE
(SUPERFICIAL)
Epidermal layer

Pink, painful, and edematous

Heals 3-5 days w/o scarring

Causes:

Flame , Sun, Flash from explosion

 Assessment Depth of Burns
SUPERFICIAL SECOND
DEGREE
Epidermis and papillary region of
dermis

Blisters/bullae, serous fluid

Cherry red moist appearing
Painful, sensation intact
Edematous

Heals in 7-28 days with minimal

scarring
Cause: flame, flash, scald contact
 Assessment Depth of Burns
DEEP SECOND DEGREE
Epidermis and reticular region of
dermis

Blisters, bullae, serous fluid

Pale ivory moist appearing

Painful, sensation intact

Edematous

Heals in 7-28 days with variable

scarring

Cause: flame, flash, scald contact

 Assessment Depth of Burns
THIRD DEGREE (FULL THICKNESS)
Extends into subcutaneous tissue

White, yellow, brown leathery appearance

Thrombosed vessels, loss of elasticity, marked

edema

Possible escharotomy

Painless to touch

Requires grafting

Causes: flame, electricity, chemicals, prolonged

exposure

May take 2-3 days to fully present true depth

 Assessment Depth of Burns
FOURTH DEGREE
Extends to muscle

Loss of function

Black, charred appearance

May require amputation

May require escharotomy and

fasciotomy

Causes: very prolonged

exposure to flame, chemicals,
and high voltage
Escharatomy
Full thickness,
circumferential burns
Loss of circulation

Loss of movement

Performed medial and lateral

sides

Relieves pressure
Wallace’s Rule of Nines
 Lund & Browder Chart
0-1 1–4 5–9 10 – 14 15
Area tahun tahun tahun tahun tahun
Dewasa

Kepala 19 17 13 11 9 7
Leher 2 2 2 2 2 2
Badan bagian depan 13 13 13 13 13 13
Badan bagian belakang 13 13 13 13 13 13
Pantat kanan 2.5 2.5 2.5 2.5 2.5 2.5
Pantat kiri 2.5 2.5 2.5 2.5 2.5 2.5
Genitalia (kemaluan) 1 1 1 1 1 1
Lengan kanan atas 4 4 4 4 4 4
lengan kiri atas 4 4 4 4 4 4
Lengan bawah kanan 3 3 3 3 3 3
Lengan bawah kiri 3 3 3 3 3 3
Tangan kanan (telapak & punggung) 2.5 2.5 2.5 2.5 2.5 2.5
Tangan kiri (telapak & punggung) 2.5 2.5 2.5 2.5 2.5 2.5
Paha kanan 5.5 6.5 8 8.5 9 9.5
Paha kiri 5.5 6.5 8 8.5 9 9.5
Betis kanan 5 5 5.5 6 6.5 7
Betis kiri 5 5 5.5 6 6.5 7
Kaki kanan (telapak & punggung) 3.5 3.5 3.5 3.5 3.5 3.5
Kaki kiri (telapak & punggung) 3.5 3.5 3.5 3.5 3.5 3.5
Total 100 % 100 % 100 % 100 % 100 % 100 %
 Palmar Surface

Adults : 1 % Children : 1,25 %

TABLE : American Burn Association's Grading System for Burn Severity and
Disposition of Patients
Type of burn
Minor Moderate Major
Criteria: <10 percent 10 to 20 percent TBSA >20 percent TBSA burn in
TBSA burn burn in adult adult
in adult 5 to 10 percent TBSA >10 percent TBSA burn in
<5 percent burn in young or old young or old
TBSA burn 2 to 5 percent full- >5 percent full-thickness
in young or thickness burn burn
old High-voltage injury High-voltage burn
<2 percent Suspected inhalation Known inhalation injury
full- injury Any significant burn to
thickness Circumferential burn face, eyes, ears, genitalia
burn Concomitant medical or joints
problem predisposing Significant associated
the patient to infection injuries (e.g., fracture,
(e.g., diabetes, sickle other major trauma)
cell disease)
Disposition Outpatient Hospital admission Referral to burn center
: management
 AREA OF SPECIAL CONCERN

Face
Ears
Hands
Feet
Joints
Perineum
Hipersekresi
Pathology of the lumen

Lumen
Sloughing Mucosa Obstruction

Edema laring
ASSESSMENT — PRIMARY SURVEY
A. Airway maintenance with cervical spine control

B. Breathing and ventilation

C. Circulation with haemorrhage control

D. Disability — neurological assessment

E. Exposure — preventing hypothermia

F. Fluid resuscitation
 Resusitasi cairan
DEWASA (BAXTER FORMULA)
4 CC X % LBB X Kg BB = ….Lar.RL
Diberikan :
- ½ bagian 8 jam pertama
- ½ bagian 16 jam berikutnya.
- Berikan lar.koloid 500-1000 cc
pd jam ke 18-24
Anak2 modifikasi baxter.
2 CC x % LLB x Kg BB = …lar.RL
Diberikan :
- ½ bagian 8 jam pertama
- ½ bagian 16 jam berikutnya
 Next..
Fluid resuscitation :
Effective fluid resuscitation is the corner- stone of management in
major burns. If the burn area is over 15% in adults or 10% in
children, intravenous fluids should be started as soon as
possible on scene (e.g. using the rule of 10)
BURN-SPECIFIC EVALUATION — SECONDARY
SURVEY :
Approximate wound size

Approximate wound depth

Location of burn injury (including any involvement of the face,

eyes, ears, hands, genitals or feet)

Presence of an inhalation injury

Presence of a circumferential deep dermal burn injury

The cause of the burn injury (thermal, electrical or chemical)

Suspicion of abusive injury.

 Wound Care
Debridement
 Remove dead tissue to get
between dead and viable
tissue

 Not so aggressive as to cause

bleeding

 Some removed with coarse

mesh gauze

 Debrided with sedation /

analgesic / conscious sedation
or general anesthesia
 Cleansing And Debridement
A new burn is essentially sterile
and it is important to keep it
clean and moist to promote
the development of healthy
granulation tissue.
Irrigation is the preferred method
for cleansing wounds, and various
solutions can be used, including
normal saline or warm
tap water. Mild soap
may also be used.
Topical wound irrigation
solutions containing topical
antiseptics (e.g.
polyhexamethylene
biguanide [PHMB]) can
be considered to
maintain a low bacterial
load, reducing the risk
of infection
 Next..
Debridement of the wound
and wound edges to remove
necrotic tissue can
reduce the
risk of infection and
encourage epithelialisation. This
may be a one-off debridement or
ongoing for maintenance
 Managing Blisters
The general consensus is that
blisters greater than 1cm2
should be deroofed,
while smaller blisters should be
left intact

Blisters on the palm of the hand

should be left intact (as
deroofing is painful here) unless
they restrict movement
 Burn Wound Dressing
The characteristics of a good burn wound
dressing have been described :

Maintains a moist wound environment

Contours easily
Non-adherent to protect delicate skin

Retains close contact with the wound

bed

Easy to apply and remove

Painless on application and removal

Protects against infection

Cost-effective.
MEMILIH DRESSING (PRIMARY DRESSING)

HYDRO
HYDRO CALCIUM HYDRO FOBIC ZINC
FOAM
GEL ALGINATE COLOID & CREAM
SILVER
SECONDARY DRESSING
GAUZE/KASSA

ORTHOPEDIC WOOL

COHESIVE BANDAGE

CREPE BANDAGE

STOCKINET
 HYDROGEL

 CMC = Carboxyl Metyl Celulosa

 Menciptakan suasana lembab (rehidrasi)
 Support Autolisis Dedridement
 Memberi efek dingin pada luka
Zinc Cream; METCOVAZIN

 Chitosan
 Menciptakan
suasana lembab
 Support Autolisis
Dedridement
 Support Granulasi
& Epitelisasi

BALUTAN DARI TITRASI NANO PROTEIN KULIT UDANG

Case Study ; 3 hari
Pusat Perawatan Luka Jepara

Cindara Wound Care Center

Jl. Gotri Welahan Gg VI Bakalan 14/2 Kalinyamatan Jepara
081228281976 – 08122816064 (WA) – 085655556064
ulilalul@gmail.com
Terima Kasih