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Total Care

on Burn Patient

Unit Luka Bakar RSUP Dr Sardjito
Sub-Bagian Bedah Plastik
Bagian Bedah, Fakultas Kedokteran
Universitas Gadjah Mada
Apakah bisa
memperbesar
otak juga?
Epidemiology of Burn
ABA 2,2 juta pasien terbakar di USA setiap tahun
5500 meninggal karena luka bakar
60,000 dirawat.
$1 milyar, beaya yang dihabiskan

(Mathes Plastic Surgery, 2007)

Indonesia? Tidak ada data
Epidemiology
(ABC Burn, 2006)
Mortality
(ABC Burn, 2006)
(ABC Burn, 2006)
Skin Anatomy
Skin Constitution
Epidermis
Corium or Dermis
Subcutis

The total skin area
of adult humans covers approx.
1 to 2 square meters
Epidermis
Composition of the Epidermis

(1) Horny scales
(2) Horny layer (stratum corneum)
(3) Clear layer (stratum lucidum)
(4) Granular layer (stratum granulosum)
(5) Prickle-cell layer (stratum basale)
(6) Basal layer (stratum basale)
(7) Connective tissue fibres
(8) Melanocyte
(9) Arterial branch of capillary
(10)Venous branch of capillary
(11)Initial lymph vessel
(12)Meissner`s corpuscle
(13)Free nerve ending
(14)Excretory duct of sweat gland

Renewal of the epidermis occurs within 27 days.
Anatomi kulit
1
2
3
4
5 5
6
7
8
9
10
Fungsi kulit
Protection
against cold,
heat, radiation
C Protection
against pressure
and friction
C Protection
against
chemicals
C Protection
against
microbes
C Absorption of
active agents
Regulation of
circulation and
temperature
C Protection against loss
of temperature and water
1 Sense of pressure, touch, pain
and temperature
Patofisiologi Luka Bakar
Destruksi lokal
Respon inflamasi sistemik (Systemic
inflamatory response)
Respon Lokal
Zone of
coagulation
Irreversible
Zone of stasis
Potensial
diselamatkan.
Zone of
hyperaemia
Biasanya sembuh
(ABC Burn, 2006)
Respon sistemik
LLB 20-30% pelepasan
faktor inflamasi sistemik
Peningkatan permeabilitas
kapiler
splanchnic vasoconstriction
Myocardial contractility
.
Fluid loss from the burn
wound hypoperfusion.
Respiratory changes
bronchoconstriction, ARDS
Metabolic changes.
Immunological
(ABC Burn, 2006)
Menyebabkan permeabilitas kapiler
, cairan pindah dari intravaskular
ke interstisial:
hypovolemia intravaskular
menyebabkan edema
Electron microscopic exam
Kebocoran kapiler
Tujuan resusitasi fase akut
Mempertahankan
perfusi oksigen di
perifer, terutama
organ vital (life
saving)
Mencegah
perburukan situasi
(meminimalkan
morbiditas)
1. Etiologi
2. Derajat luka bakar
3. Luas luka bakar
Yang perlu diperhatikan
ETIOLOGI / PENYEBAB
1. SUHU
PANAS ( API, UAP, AIR )
DINGIN ( FROST BITE )
2. LISTRIK (4). RADIASI
3. KIMIA (5). LASER
ASAM - BASA
KEDALAMAN LUKA BAKAR
DERAJAT SATU
Superficial Skin Burn
DERAJAT DUA
Partial Thickness Skin Burn
DERAJAT TIGA
Full Thickness Skin Burn
Derajat 1
Superficial Skin Burn
KEDALAMAN LUKA BAKAR
Luka Bakar
Derajat Satu
Derajat 2 Partial Thickness Skin Burn
Derajat Dua
Derajat 3 Full Thickness Skin Burn
Derajat tiga
Luas luka bakar
Rule of Nines
TABEL
LUND &
BROWDER
PENANGANAN
PRE HOSPITAL
STOP - DROP - ROLL
Hilangkan Heat Restore
(Masih Efektif bila < 2 menit)
Luka bakar listrik putuskan
sumber listrik
Luka bakar kimia dilusi dengan air
mengalir
Assessment
Initial assessment ATLS
Managemen awal yang baik
mencegah morbiditas dan mortalitas
Primary Survey
A Airway
B Breathing
C Circulation / C-spine / Cardiac
status
D Disability / Neurologic Deficit
E Exposure and Examination
F Fluid Resuscitation



Fase Akut Cari Masalah ABC
RESUSITASI Airway
A: Curiga Trauma Inhalasi
* Bila kejadian di ruang tertutup
* Bulu hidung terbakar
* Laryngoscope edema, hiperemis
ET LEBIH BAIK DARIPADA
TRACHEOSTOMY
Fase Akut
RESUSITASI A - B - C
B: Luka Bakar Derajat 3 Melingkar Dinding Dada
ESCHAROTOMY
Fase akut
Rescusitation Breathing
Waspada intoksikasi karbonmonoksida (CO)
'pink' (cherry red) with a normal pulse
oximeter berikan 100% Oxygen
intubasi and ventilator (bila perlu)
Smoke injury jelaga di lubang hidunfg dan
sputuum Nebulizer
intubasi and ventilator (bila perlu)
Fase akut
Rescusitation Circulation (C)
Sistemik :
jika datang dg syok infus 2 jalur
IVFD RL 20 ml/Kg BW in 15-30
minutes (bisa sampai 2000 cc pada
dewasa)
Lokal:
Eskar melingkar di ekstremitas
compartment syndrome 5P
ESCHAROTOMY
Escharotomy pada
ekstremitas
Fase akut
Disability (D)
GCS
Lateral Sign

CO intoxication
Hipovolemic shock
Fase Akut
Exposure (E)
Luas luka bakar(% TBSA)
Derajat luka bakar
Trauma lain
Cegah hipothermia
Acute phase
Fluid Resucitation (F)
(Mathes, 2006)
(Mathes, 2006)
Fase Akut
RESUSITASI Circulation (C)
Sistemik :
Pelepasan mediator inflamasi vasodilatasi +
kebocoran intravaskuler Hipovolemik
FORMULA BAXTER / PARKLAND
Infus RL: 4 cc x BB (Kg) x LUAS LB (%)


Kasus
Pasien dg BB 50 Kg dan 30% BSA
Cairan yang dibutuhkan : 4 x 50 Kg x 30 %
6000 cc RL
8 jam pertama 3000 ml 92 tetes/mnt
16 jam berikutnya 3000 ml 46 tetes/mnt
Emergency
burn
pathway
(ABC Burn, 2006)
MONITORING
Vital Sign (TD, HR, RR, temp)
Urin Output Dewasa 30 ml / J am
Anak 1-2 ml / Kg / J am
Suara Nafas Waspadai edema pulmo
Pada LB berat (>40%) pasang CVP
Produk NGT Waspadai stress ulcer
Hb, WBC, Plt, Hematocrit, Elektrolit, Albumin,
GDR,
Fungsi ginjal, Fungsi live, BGA (AGD)
EKG, Thorax X-ray
INDIKASI RAWAT INAP
LB Derajat II > 15% Dewasa
> 10% Anak / Geriatri
LB Derajat III > 5% Dewasa
Trauma Inhalasi
Listrik / Kimia
LB di daerah muka, tangan, genital, perineal
LB dengan kelainan lain / trauma lain yang
berat
Nutrisi
Metabolisme basal 2-3 x:
Produksi glukosa ,
insulin resistance,
lipolysis,
Katabolisme protein otot.
Tanpa nutrisi yang adekuat
penyembuhan luka ,
Fungis imunitas ,
Penurunan berat badan
(Mathes, 2006)
(Mathes, 2006)
Pemberian Nutrisi
Enteral
Oral
Nasogastric
Nasoduodenal
Parenteral
Partial
Total
Pemberian Nutrisi
Enteral vs Parenteral
Oral vs Tube

Penggunaan tube sering lebih
menguntungkan dibandingkan dengan
intake oral regular
Pengendalian Nyeri
Nyeri yang berat dampak negatif
dalam penyembuhan
Dressing, regular bedside
debridement memerlukan sedatif
dan opiat dosis tinggi
Tujuan merawat luka
Cegah konversi luka
Buang jaringan mati
Siapkan granulasi sehat
Minimalkan infeksi
Siap untuk autografting
Cegah kelainan parut dan kontraktur
WOUND CARE FOR THE ADULT BURN PATIENT
By Judy Knighton, RN, BScN, MScN
General Principles of Daily Care
If conversion is going to occur, it is typically several days (sometimes weeks) post-
burn

Continue monitoring if indicated
Avoid hypothermia
- warm room
- warm water
- do not expose entire body at once

Avoid Cross-Contamination
- Wear caps, masks, gown, gloves wash hands before and after
- Expose, clean, and rewrap less infected areas first
- Look for sources of bacteria in equipment used

Assure Adequate Control of Pain, Anxiety, Fever
- Pre-indication with narcotics and short-acting sedative
- Use intravenous route
- Consider antipyretic pre-treatment pre-burn care

Wound Dressing
- Use comfortable but no immobilizing dressing, as muscle activity is important!
(exception: new grafts)
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Perawatan awal
Hentikan proses kontak dg sumber
panas
Bersihkan luka
Tutup dengan balutan bersih, lembab,
dan tidak lengket
Analgesia
Debridement luka

Controversy: Blister debridement
Moist concept in wound
healing
Exposed method Moist method
PERAWATAN LUKA / SUB-AKUT
Derajat Satu
Derajat Dua Cuci NaCl + Savlon
500 cc 5 cc
Dressing Moist dan Non Adherent
Tulle + Kassa Steril
(Biarkan Satu Minggu)
MEBO (4 6 x / hari)
PERAWATAN LUKA / SUB AKUT
Derajat Tiga Bahaya kolonisasi kuman
di bawah eskar sepsis
Cuci NaCl 500 cc + Savlon 5 cc
Debridement tiap hari
Dermazin / Burnazin
(Silver Sulfadiazin) tiap hari
K/P Escharectomy + Skin Graft
Burn Tank
Terapi bedah
Eksisi serial
Membuang jar nekrotik/debris harian
Escharectomy
Membuang eskar yang nyata (>10 hari)
Eksisi tangensial
Shaving the eschar dg pisau graft + skin
Biasanya 48-72 jam post burn subtitute
Eksisi primer
Eksisi sampai level fasia secepatnya
Biasanya 48-72 jam post burn
(Achauer, 1987)
Skin Subtitutes
Autograft (beda lokasi sama individu)
Isograft (dari spesias yang genetically identical)
Biological dressing
Allograft (dari spesies yang sama=homograft)
Xenograft (heterograft, dari spesies lain)
Amnion
Kulit sintetik (silicone polymers / composite
membranes)
Kultur kulit (provide coverage, albeit fragile, for
large wounds)
Kombinasi
Skin Subtitutes
Ideal Properties

1. Menempel kuat
2. Aman (sterile, hypoallergenic, nontoxic,
nonpyrogenic)
3. Mampu mengontrol kehilangan cairan
4. Fleksibel
5. Tahan lama
6. Mampu menjadi barier kuman
7. Mudah digunakan dan dilepas
8. Availability mudah disimpan
9. Murah
10. Hemostatic
(Woodroof, 1984)
Problem
Bagaimana menutup
luka yang luas?
Grafting Technique
Hand dermatome
require most skill to use
(Watson, Cobbett)
Electric dermatom,
relatively can be use by
inexperienced surgeon
(Padgett, Reese)
Drum dermatome
usually yield a wider graft
(Brown)
Expanding graft by meshing (Tanner
mesher)
Postage stamp secured by nylon
netting
Mesh graft stapled, covered with
nylon netting, antibiotic dressing,
synthetic skin, xenograft,or allograft

(Achauer, 1987)

Skin Expansion 1
Tanner Mesher
Combination between large sheet of allograft and
small pieces of autografts (used in China)
Alexander et al widely mesh graft covered with
allograft
Application of strips of autograft (3-4 mm wide
alternating with strips of allograft (15-22 mm
wide)

Alternative for alternating autograft: xenograft,
synthetic skin, amnion, cultured epithelium
(Achauer, 1987)
Skin Expansion 2
Luka bakar listrik
Waspadai gangguan irama jantung
Waspadai kerusakan lebih berat dari
tampilan yang ada kerusakan otot
(Rhabdomyolisis)
Ancaman ekstremitas fasiotomi
Waspadai Gagal ginjal high urine output
fluid therapy 100 cc/hour (Manitol)
Tx: 2 amp Manitol (25 g) followed
immediately 2 amp bicarbonate, IV push

Luka bakar kimia
Reaksi tetap berjalan
Waspadai kerusakan yang progresif
Waspadai cedera organ selain kulit
(mata, daun telinga, dll)
Prinsip dilusi 30 60 menit
Jangan menetralkan
Komplikasi
Sub-akut infeksi SIRS
SEPSIS MODS Death
Stress ulcer
Ulkus dekubitus

Lanjut kontraktur

Sumber infeksi
(ABC Burn, 2006)
Inflammatory trigger-
Uncontrolled inflammatory response
Severe Shock
MODS- (Lungs fail first)
MODS Multi Organ Dysfunction Syndrome
SIRS
Risk for
ALI/ARDS
Sepsis, Infection (i.e. Pneumonia)
Uncontrolled Inflammation
Uncontrolled Inflammation
Death
Terapi non bedah
Antibiotic prophylactic?
Sistemic vs Local
ATS Tetagam? 3
rd O
, large burn size
GIT protector
Antidecubital bed / care
Splinting
Antioxidant
Imunomodulator
Inotropic (if needed)
Bagaimana memilih agen topikal
Efikasi klinis
Antibacterial spectrum luas
Minimal Toksisitas, absorption baik
Kejadian superinfeksi
Mudah dan fleksibel digunakan
Murah
Diterima oleh pasien dan staf
Agen Topikal
Silver sulphadiazine 1% (Flamazine )
Silver sulphadiazine 1% chlorhexidine digluconate
0.2% (Flamazine C)
Mafenide acetate 2% (Sulfamylon)
Silver nitrate 0.5%
Povidone iodine 10% (Betadine)
Nitrofurazone (Furacin)
Gentamycin sulphate (Garamycin)
Bactracin with polymyxin B (Polysporin)
Normal saline 0.9%
Acetic Acid 0.5%
Hydrogen peroxide, half-strength

MEBO
Fisioterapi & Splinting
Fase akut
Fase bedah
Fase rehabilitasi
Fase akut
Tujuan:
Menjaga paru tetap bersih
Mempertahankan fungsi
Meminimalkan udema
Menggunakan
Fisioterapi dada
Latihan pasif
Splinting
Ilustration
Fase Bedah
Tujuan:
Meningkatkan kekuatan
Menggunakan:
Latihan motor aktif
Fisioterapi dada
mobilisasi
Rehabilitasi
Tujuan: mengembalikan pasien ke
tempat kerja
Menggunakan:
Latihan lebih menguatkan
Tugas2 yang spesifik
Case 1, Boy, 15 y.o.
Electric Burn
Case 2, Male, 30 y.o.
Chemical burn
Case 3, 1 year finger contracture
Release + FTSG
Case 4, 10 years axilla contracture
Local Skin Flap + STSG
Case 5, Arm electrical injury
LD MC Flap + Skin Graft
Case 6, Scalp electrical injury
LD Free Flap + STSG
TERIMA KASIH
Terima kasih