*

Rosadi Seswandhana
Plastic Surgery
DR Sardjito General Hospital
Faculty of Medicine, Gadjah Mada University

* Worldwide, burns cause significant morbidity

and mortality

* Dramatic decrease in the case fatality rate of

burns over the past 50 years

* Majority of burns are not life-threatening and

can be managed in the ED and primary care
settings

* Early appropriate assessment is needed to

provide adequate treatment

* Firstly, to determine whether situations are

life-threatening or not

* In disaster event, triage is the most important

to make several priority level

* If the victim is pediatric, sign of abuse is

mandatory to be looked for

* One of the most important aspects of burn care

is determination of the extent and depth of the

injury

* PRE-HOSPITAL MANAGEMENT

STOP - DROP - ROLL

Prevent Heat Restore

Electric injury breaking

down the voltage

Chemical dilution

*Burn mass casualty triage is similar to

typical mass incident triage.

*In the face of limited resources, patients

who are the most salvageable should
receive priority; Not the most severely
injured

* severity of injury can be determined rapidly by

1. considering total extent of burn,

2. age of patient and
3. the presence or absence of inhalation
injury or

4. associated severe mechanical trauma

*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

*
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
applied.
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

*
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 burns have a relatively
characteristic clinical appearance.
Little discomfort for the patient.
They may be of almost any color
because of the breakdown of
hemoglobin.
The appearance of the skin may be
waxy and translucent.
Visible thrombosed vessels beneath
translucent skin are pathognomonic
for full thickness injury.

Rule of Nines

TABEL
LUND &
BROWDER

* A Airway
* B Breathing
* C Circulation / C-spine / Cardiac status
* D Disability / Neurologic Deficit
* E Exposure and Examination
* F Fluid Resuscitation
(Modified ATLS)

A:

Look for signs of inhalation injury

*Facial burns,
*Soot in nostrils or sputum
*Laryngoscope edema, hyperemia

*ET Better than tracheostomy

(later if prolonged ET)

* Breathing (B)
B:

Circumference Full thickness skin burn on the chest

wall mechanical ventilation disturbance

ESCHAROTOMY

* Breathing

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)
(merapi eruption material volcano ash)

* Circulation (C)
Systemic :
If patient arrived with shock condition
2 IV-line
Drirectly IVFD RL 20 ml/Kg BW
combine with colloid (fast drip)
Local :
Circumference Full thickness skin
burn on extremity compartment
syndrome 5P ESCHAROTOMY

* Disability (D)

GCS

Lateral Sign
CO intoxication
Hipovolemic shock

* Exposure (E)

Burn Size (% TBSA)

Depth of Burn Wound

Other trauma

* Fluid Resucitation (F)

(Mathes, 2006)

(Mathes, 2006)

* 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

BAXTER / PARKLAND FORMULA

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

* Vital Sign
* (Pulse rate, respiration rate, blood presure, temperature)
* Urin Output
Adult 0.5 - 1 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, RBG,
* Kidney Function, Liver Function, BGA
* ECG, Thorax X-ray

*MONITORING

* Monitoring of urinary production is important

to evaluate the adequacy of resuscitation.

* Wardhana in 2011, defined that volume fluid

resuscitation should be adjustable regarding
urinary output per kilogram bodyweight per
hour.

* If urine production 1 ml/kg BW/hour + 10%

* If urine production = 1 ml/kg BW/hour
* If urine production 1 ml/kg BW/hour - 10%

 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

*Criteria for burn

center referral

*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 (Manitol)
* Tx: 2 amp Manitol (25 g) followed immediately 2 amp
bicarbonate, IV push

*Electrical 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

*Chemical injury

* After the initial resuscitation, up to 75% of

mortality in burns patients is related to

infection.
* Gram positive organisms colonised with large
numbers within 48 hours. Gram negative
bacteria appear from three to 21 days after the
injury. Invasive fungal infection is seen later
* Preventing infection, recognizing it when it
occurs, and treating it successfully present
considerable challenges

* Destruction of the skin or mucosal surface

barrier allows microbial access

* Presence of necrotic tissue and serosanguinous

exudates provides a medium to support growth

of microorganisms

* Invasive monitoring provides portals for

bacterial entry

* Impaired immune function allows microbial

proliferation

(ABC Burn, 2006)

Uncontrolled Inflammation
Inflammatory trigger-

Sepsis, Infection (i.e. Pneumonia)

SIRS
Uncontrolled inflammatory response
Severe Shock

Risk for
ALI/ARDS

MODS- (Lungs fail first)

Death
MODS Multi Organ Dysfunction Syndrome

* To this end, aggressive surgery and the use of

topical antimicrobial agents are effective.

* silver sulfadiazine is the most frequently used

* Early closure of the burn wound by surgical
techniques

* Prophylactic use of systemic antibiotics is

controversial

* Surface swabs and cultures cannot distinguish

wound infection from colonisation

* Wound biopsy, followed by histological

examination and quantitative culture, is the

definitive method

* relies heavily on clinical parameters, with the

aid of blood, surface, or tissue cultures to
identify likely pathogens

* haemolytic streptococci to
* resistant Gram negative organisms including
pseudomonas,

* resistant Gram positive organisms,

* and fungi

*When invasive infection of a burn wound is

suspected, empirical systemic antimicrobial

treatment must be started

*Topical treatment alone is not sufficient

*Antibiotic depend on culture and sensitivity
*surgical excision

*Avoid wound conversion

*Remove devitalized tissue
*Bed granulation preparation
*Minimal level of infection
*Autografting preparation
*Scar abnormality and contrature prevention

*
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)
http://www.burnsurgery.org/Modules/

*
* Stop the burning process
* Clean the wound
* Cover. Clean, moist, nonadherent dressing
* Analgesia
* Wound debridement
Controversy: Blister debridement

Exposed method

Moist method

*
*1st O
*2nd O

no specific treatment

Cleansed with NaCl + Savlon

500 ml
5 ml
Tule + sterile thick gauze
or Biological dressing
(Observation in one week)
MEBO
Sponge derivate dressing (Allevyn, Wundress)
Silver impragnated dressing (Acticoat, Mepilex-Ag)
Controversy: Usage of Silver Sulfadiazin
(Deep 2nd O)

*
*3rd O
Cleansed with NaCl 500 ml + Savlon 5 ml
Daily debridement
Daily Silver Sulfadiazin (Dermazin /
Burnazin)
Silver impragnated dressing
Plus Surgical Treatment

*
* Sequential excision
Daily removal of loose debris
* Escharectomy
Excise the obvious full thickness burn
About 10 days post-burn
* Tangential excision
Shaving the eschar with skin graft knives
Usually done 48 to 72 hours post-burn
* Primary excision
Excision to the fascial level acutely
Usually done 48 to 72 hours post-burn

+ skin subtitute

(Achauer, 1987)

*
*Autograft (different location within the same individual)
*Isograft (from a genetically identical donor to the

recipient)
Biological dressing
*Allograft (homograft in older terminology)
*Xenograft (heterograft in older terminology)
*Amnion
*Synthetic skin (silicone polymers / composite
membranes)
*Cultured epithelium (provide coverage, albeit fragile,
for large wounds)
Combination

*
Ideal Properties
1. Adherence
2. Safety (sterile, hypoallergenic, nontoxic,
nonpyrogenic)
3. Controls evaporative water loss
4. Flexible
5. Durable
6. Bacterial barrier
7. Ease of application and removal
8. Availability easy to store
9. Cost effective
10.Hemostatic
(Woodroof, 1984)

How to resurface wide

area of skin burn ?

*
*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)

*
*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)

*
*Prevent contracture
Splinting

*Prevent pseudosyndatily
individual dressing on
every-finger

*To develop good scar

pressure garment,
moisturize the new skin

Wach TL and McQueen KAK, Burn Management in disaster and humanitarian crises. In Herndon DN [Ed]:
Total Burn Care. Third Edition. 2007. p43-66.

*
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Young DM. Burn and Electrical Injury. In Mathes SJ [Ed]: Plastic Surgery. 2nd Edition. 2006. P811-833

Stewart C. Wang. Michigans Plan for Burn Mass-Casualty Incidents. Director, U of Michigan Burn Center
Director, State of Michigan Burn Coordinating Center. File presentation.

Smith S, Duncan M, Mobley J, et al. Emergency room management of minor burn injuries: a quality
management evaluation. J Burn Care Rehabil 1997;18:76-80. (Retrospective;791 patients)

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Hettiaratchy S, Dziewulski P. ABC of burns. BMJ 2004;329:5046

Singer AJ. Thermal Burns: Rapid Assessment And Treatment. Emerg.Med.Pract. Sep 2000. Vol 2[9]
Dale S.Vincent, Benjamin W. Berg, Keiichi Ikegami, Mass-Casualty Triage Training for International
Healthcare Workers in the Asia-Pacific Region Using Manikin-Based Simulations. Prehospital and Disaster
Medicine. May June 2009. http://pdm.medicine.wisc.edu

Wardhana A. Adjustable volume of fluid resuscitation for burn injury. Plastic Annual Meeting. 2011
Burn Injuries. HDM Course. Society of Critical Care Medicine, 2007
Judy Knighton, WOUND CARE FOR THE ADULT BURN PATIENT
Preuss S. Breuing KH, Eriksson E. Plastic Surgery Techniques. In [eds] Achauer BM et al. PLASTIC
SURGERY Indications, Operations, and Outcomes. Mosby. 2000:147-162