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Emergency Management

of
Severe Burns
THE EDUCATION COMMITTEE OF
AUSTRALIA AND NEW ZEALAND BURN ASSOCIATION LTD

Published by : KOLEGIUM ILMU BEDAH INDONESIA

Translated by : DR Yefta Moenadjat, dr, SpBP(K)


The Education Committee
of

The Australian and


New Zealand Burn Association Limited
ACN 054 089 520

Emergency Management of Severe Burns


(EMSB)

COURSE MANUAL
17th edition
Feb 2013

ISBN 0-9775182-0-5

Australia and New Zealand Burn Association Ltd 1996


This manual is copyright. No part of the publication may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise without the express written
permission of the Australian and New Zealand Burn Association Limited.

ANZBA, PO Box 550, Albany Creek, Qld 4035.


Ph: 0011 61 7 3325 1030 / Email: info@anzba.org.au

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2
CONTENTS
Prologue and Acknowledgements....................................................................... 5

Course Program - Outline and Timeline .............................................................. 7

Chapter 1: Introduction - Epidemiology and Aetiology ...................................... 8

Chapter 2: Emergency Examination and Treatment ......................................... 15

Chapter 3: Local and General Response to Burn Injury .................................... 24

Chapter 4: Inhalation Injury ............................................................................. 28

Chapter 5: Burn Wound Assessment ................................................................ 36

Chapter 6: Burns Shock and Fluid Resuscitation ............................................... 43

Chapter 7: Management of the Burn Wound ................................................... 48

Chapter 8: Indications and Procedures for Referral .......................................... 54

Chapter 9: Burns in Children ............................................................................ 59

Chapter 10: Electrical Injuries .......................................................................... 67

Chapter 11: Chemical Burns ............................................................................. 75

Chapter 12: Management of the Burn Patient After the First 24 Hours ............ 81

Chapter 13: The Outpatient Management of the Minor Burn........................... 91

References ....................................................................................................... 97

Appendices:

Neurological Assessments .............................................................................. 101

Tetanus Protocol ............................................................................................ 102

Escharotomy Diagrams ................................................................................... 103

Selecting an Appropriate Dressing .................................................................. 104

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Daftar Isi
Bab 1: Introduksi: Epidemiologi dan Etiologi .................................................. 107

Bab 2: Penilaian dan Tatalaksana Emergensi .................................................. 115

Bab 3: Respon Lokal dan Sistemik pada Luka Bakar ....................................... 125

Bab 4: Cedera Inhalasi ................................................................................... 129

Bab 5: Asesmen Luka ..................................................................................... 138

Bab 6: Syok Luka Bakar dan Resusitasi Cairan ................................................ 144

Bab 7: Tatalaksana Luka................................................................................. 150

Bab 8: Indikasi dan Prosedur Rujukan ............................................................ 156

Bab 9: Luka Bakar pada Anak ......................................................................... 161

Bab 10: Luka Bakar Listrik .............................................................................. 171

Bab 11: Luka Bakar Kimia ............................................................................... 180

Bab 12: Manajemen Penderita Luka Bakar setelah 24 Jam Pertama ............... 187

Bab 13: Manajemen Rawat Jalan pada Luka Bakar Ringan.............................. 199

Referensi ........................................................................................................ 197

Lampiran:

Penilaian Neurologik ...................................................................................... 210

Tetanus Protocol ............................................................................................ 211

Rekomendasi untuk Sayatan Eskarotomi ........................................................ 212

Selecting an Appropriate Dressing .................................................................. 213

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PROLOGUE

The Australian and New Zealand Burn


Association Limited
The Association was formed in 1976 by a group of medical and nursing staff who were drawn
together by their common interest in improving the quality of care that their burn patients received.

Since then this group has expanded to now include a truly multidisciplinary group of burn care
professionals who are interested in teaching, care, research, and prevention of burn related
problems.

The multidisciplinary nature of the Association is an extension of every day burn care philosophy, as
practiced in burn units throughout Australia and New Zealand.

The Association has an important role in the promotion of the Minimum Standards of Burn Care in
Australia and New Zealand and it is in this context that this publication and the related EMSB course
have been developed. It is hoped that this initiative will improve standards of burn care for the
severely burnt patient.

Contributors to this Manual


The following, who are members of the Education Committee of the Australian and New Zealand
Burns Association, have generously given of their time and expertise in the initial creation and
development of this course:
Lynne Brodie, New South Wales
Robert K. Brodribb, Tasmania
Diana Dickson, New South Wales
Norman Farey, Victoria
Di Mandeno, New Zealand
Ian Leitch, South Australia
Hugh C.O. Martin, New South Wales
Michael M. Muller, Queensland
Fiona Wood, Western Australia.
Peter Hodgkinson, South Australia.
Mark Magnusson, Queensland.
Mrs Jill Martin, New South Wales
George Skowronski, New South Wales.
Mrs Diedre Stone, South Australia
Peter Widdowson, New Zealand
Jill Clausen, South Australia

A special thanks is owed to Mani M. Mani, M.D., Kansas USA

The Course was reviewed and updated in 2012, and thanks is extended to:

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Lynne Brodie, New South Wales
Peter Campbell, New South Wales
Nicholas Cheng New South Wales
Siobhan Connolly, New South Wales
Anne Darton, New South Wales
Diane Elfleet, New South Wales
John Harvey, New South Wales
Andrew Ives, Victoria
Simon Jensen, Queensland
Chris Johnstone, Queensland
Peter Maitz, New South Wales
Hugh Martin, New South Wales
David Milliss, New South Wales
Alison Mustapha, Northern Territory
Stephen ODonaghue, Queensland
Melinda Pacquola, Victoria
Chris Parker, New South Wales
Kelly Waddell, New South Wales
Alwena Willis, Western Australia
Richard Wong She, New Zealand

The EMSB Course has now been established in the following countries:

Australia, New Zealand, Great Britain, The Netherlands, South Africa and Bangladesh. Each of these
countries has a license to provide the EMSB Providers Courses and the EMSB Instructors Course in
their area under supervision of ANZBA. The course is also taught by a mixture of visiting and local
faculty in Papua New Guinea, The Pacific Islands, Malaysia, Hong Kong, India and Sri Lanka. The
EMSB Manuals and Courses have been adapted to address country specific circumstances, whilst
retaining standardized examination processes and pass marks throughout the world. In addition,
ANZBA has organised several courses in differing countries with a multinational faculty and ANZBA
will endeavour to continue this approach. An EMSB certificate is therefore valid worldwide and is an
expression that the recipient is knowledgeable in the initial treatment of burn injuries.

Since the original course was written and in accordance with this being a consensus course,
repeated updates and refinements have been made by numerous members of the teaching
faculty, and some candidates.

For suggestions please contact :


The Chairman of the Education Committee Prof. Peter Maitz via the Secretariat of the Australian &
New Zealand Burns Association info@anzba.org.au

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Kata Pengantar

Puji syukur kehadirat Allah SWT yang telah memberi kesempatan terselenggaranya kursus
manajemen awal luka bakar kritis (Early Management of Severe Burn, EMSB) yang merupakan
kerjasama Kolegium Ilmu Bedah Indonesia dengan AustralianNew Zealand Burn Association
(ANZBA) setelah diinisiasi lebih sepuluh tahun lamanya.

Kursus ini memuat pengetahuan dasar dan tatalaksana luka bakar kritis pada kesempatan awal yang
perlu diketahui oleh setiap tenaga medik yang dihadapkan pada kasus luka bakar; khususnya luka
bakar kritis.

Di negara maju seperti Amerika Serikat, tatalaksana awal luka bakar diterapkan secara konsisten
mengacu pada petunjuk praktis (practice guidelines) yang ditetapkan oleh American Burn
Association (ABA). Di negara tetangga kita, di Australia dan New Zealand, tidak berbeda halnya. Para
tenaga medis dididik untuk menangani kasus sejak awal melalui kursus dimaksud. Di Amerika
Serikat, kursus ini disebut Advanced Burn Life Support (ABLS) yang serupa dengan Advanced Trauma
Life Support (ATLS), sedang di Australia disebut Early Management of Severe Burn, EMSB.
Penyelenggaraan kursuskursus ini, sebagaimana halnya ATLS tercatat telah membawa dampak
penurunan angka mortalitas luka bakar di dunia internasional.

Kursus ini memberi dampak melalui tertatanya sistem penanganan kasus luka bakar fase akut, bukan
hanya prioritas ABC traumatologi, namun dalam suatu sistem penanganan emergensi (emergency
medical system, EMS) yang baik. EMS yang tertata baik dan dilaksanakan oleh berbagai pihak
membawa kasus luka bakar pada penanganan definitif yang tepat sehingga angka mortalitas dapat
ditekan.

Berbeda halnya dengan situasi di Indonesia. Pengetahuan mengenai luka bakar dirasakan minim,
khususnya pengetahuan mengenai tatalaksana awal. Pengetahuan mengenai hal ini kurang
disosialisasikan sehingga banyak petugas medis tidak mengetahui prioritas dan urgensi merujuk
penderita kritis. Disamping kondisi geografis yang tidak mendukung, kondisi sosial budaya dan
ekonomi masyarakat belum memungkinkan terujudnya suatu tatanan yang baik dalam manajemen
kasus luka bakar sebagaimana diselenggarakan di negaranegara maju.

Penatalaksanaan kasus luka bakar kritis di Indonesia selama ini mengacu pada protokol kaku
berdasarkan pengetahuan yang diperoleh selama masa pendidikan untuk selanjutnya diwarnai
pengetahuan otodidak dan pengalaman klinis individuindividu yang bervariasi dan mengacu pada
kondisi di lapangan.

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Namun, di era kemajuan zaman ini, untuk mendapatkan hasil optimal di tingkat nasional kiranya
masih terlalu banyak hal perlu dibenahi, terutama konsep tatalaksana awal. Karenanya, pada
kesempatan ini perkenankan kami menyelenggarakan kursus Early Management of Severe Burn
yang diharapkan agar setiap insan yang dihadapkan pada penatalaksanaan kasus luka bakar kritis
memiliki kompetensi standar internasional.

Untuk mempermudah pengertian dan menghindari salah persepsi, kami berusaha menerjemahkan
buku pegangan kursus ini ke dalam bahasa Indonesia yang dihadirkan mendampingi bahasa aslinya;
tanpa mengurangi rasa hormat kami pada mereka yang fasih dalam berbahasa Inggris.

Selamat mengikuti kursus.

DR Yefta Moenadjat, dr, SpBP(K)

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COURSE PROGRAM
EMSB Course - Outline and Timeline
Part One Lectures
08:0008:10 Welcome & Introduction (10 min) Faculty
08:1008:20 Local & General Response to Burn Injury (10 min) Faculty
08:2008:45 Emergency Examination & Treatment (25 min) Faculty
08:4508:50 Short Break ( 5 min)
08:5009:05 Airway Management & Inhalation Injury (15 min) Faculty
09:0509:20 Burn Wound Assessment (15 min) Faculty
09:2009:35 Shock & Fluids (15 min) Faculty
09:3509:40 Short Break ( 5 min)
09:4009:55 Burn Wound Management (15 min) Faculty
09:5510:05 Documentation & Transfer / Review (10 min) Faculty

10:0510:20 Morning Tea (15 min)

Part Two Skill Stations(20 min + 2 min turnover) Timekeeper:Faculty


10:2010:40 Burn Area & Fluid Requirements (20 min) Faculty
ROTATE
ROOMS

10:4211:02 Documentation & Transfer (20 min) Faculty


11:0411:24 Escharotomy (20 min) Faculty
11:2611:46 Wound Assessment &Mx (20 min) Faculty
11:4812:08 Airway Management (20 min) Faculty

12:1012:40 Lunch (30 min)

Part Three Interactive Discussion Groups(20 min + 2 min turnover) Timekeeper:Faculty


12:4013:00 Paediatric (20 min) Faculty
ROTATE
ROOMS

13:0213:22 Chemical (20 min) Faculty


13:2413:44 Electrical (20 min) Faculty
13:4614:06 Multiple Injuries (20 min) Faculty

14:1014:45 Demonstration of Simulation + Break (20 + 15 min)

Part Four Multiple Choice Exam & Simulations Timekeeper: Faculty


14:4515:50 Group A MCQ Exam Faculty
Group B Simulations
st
14:4515:00 simulation practice 1 (1 Patient as a Group) (15 min)
nd
15:0215:14 simulation practice 2 (2 Patient as a Group) (12 min) Pt A Faculty / Faculty
rd
15:1615:26 simulation test 1 (3 Patient Individually) (10 min) Pt B Faculty /Faculty
15:2815:38 simulation test 2 (3rd Patient Individually) (10 min) Pt C Faculty / Faculty
rd
15:4015:50 simulation test 3 (3 Patient Individually) (10 min) Pt D Faculty / Faculty
15:5016:00 Break & Turnover (10 min)
16:0017:05 Group B MCQ Exam
Group A Simulations
st
16:0016:15 simulation practice 1 (1 Patient as a Group) (15 min)
nd
16:1716:29 simulation practice 2 (2 Patient as a Group) (12 min)
rd
16:3116:41 simulation test 1 (3 Patient Individually) (10 min)
rd
16:4316:53 simulation test 2 (3 Patient Individually) (10 min)
rd
16:5517:05 simulation test 3 (3 Patient Individually) (10 min)
th
17:05 Re-sits of Simulations if required (with 4 Patient individually as required)
18:00 Summation and Presentations

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CHAPTER 1

Introduction
Epidemiology and Aetiology

Introduction
The patient with burns presents a difficult challenge to most health care personnel. Apart from the
serious nature of the injury and immediate discomfort, there are also potentially permanent changes
to appearance, function and independence, loss of income and compromise of their employment
futureas well as a general uncertainty about the future. All of this is distressing not only for the
patient, but also for their families and for those caring for them. The well known surgical maxim that
the trauma patient who is seen, assessed and treated early by skilled personnel heals more quickly
than the patient whose treatment is delayed, is as true for the burn victim as it is for any other
trauma patient[1]. It is important that the right treatment is instigated quickly not only to save a
persons life, but also their future.

This course is based on the principle that timely emergency assessment, resuscitation and transfer
provide the best chance of recovery[2]. Ultimately, the patient that we will be called upon to
manage with burns, and perhaps with associated severe injuries, willbenefit from this course.

The aim of this course is to provide sufficient factual information regarding the presentation,
diagnosis and initial management of the patient with severe burns, to enable medical and nursing
practitioners to deal competently with this urgent and often life threatening problem.

This course was written by members of the ANZBA Education Committee, with each individual
chapter being written from members personal (and considerable) experience in different areas of
burn care. All the contained material is original material that has not been published in this form
before.

The course follows the trauma management protocols as taught by the Royal Australasian College of
Surgeons in their Emergency Management of Severe Trauma course (EMST), as this course is the
accepted trauma management teaching system for medical practitioners in Australia and New
Zealand.

The Emergency Management of Severe Burns (EMSB) course provides trauma management
guidelines and protocols specific to burns, that are additive in content to EMST. While EMSB is
designed to be a Stand Alone Course, which provides sufficient information to define the
Minimum Standards of Emergency Burn Care (of the Australian and New Zealand Burn Association),
the course can also be taught in conjunction with the EMST, providing extra information specific to
the management of burns.

EMSB covers the principles of the emergency management of severe burns in Australia and New
Zealand. The course is appropriate for medical and nursing practitioners working anywhere in the
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field of burn care, from members of the burn unit, to medical and nursing staff in isolated areas.
Apart from teaching the material contained, the course seeks to emphasise the benefits of all
emergency care givers having knowledge of the same protocols of emergency burn care, as this
facilitates primary care and appropriate referral; the ultimate beneficiary of this approach being our
patient with burns.

The information is taught in six separate and complimentary sections:

1. Course Manual
This manual contains the complete syllabus and is sent to all students before each course. Students
are expected to read the manual, twice if possible, before attending the course. The Structure of the
EMSBimage (page 15) is included to assist in the recognition of the most important aspects of the
course.

2. Formal Lectures
These take place at the beginning of the course. They will outline the course proper, and will
reinforce your reading of the manual. They are not a
substitute for the manual, and will vary to include the individual clinical experience of the lecturers.

3. Skill Stations
These will teach important practical aspects of the course and provide students with the opportunity
to apply the knowledge they have gained from the manual and lectures.

4. Interactive Discussion Groups


This section will teach special areas of burn management in an interactive small group environment
to maximise the opportunities for students to discuss these topics, and to use their own clinical
experience, at their own level, to explore these topics.

5. Simulated Burn Cases


In this section, volunteers who have been moulaged to simulate clinical cases of burns will be used
to give students some practical experience of management of the severe burn. This section will tie
the course together, and make it clinically relevant.

6. Examination and Clinical Test


At the end of the course, students will be asked to take a multiple choice exam paper, as well as a
clinical case test, (using a moulaged simulated burn case), to test students level of knowledge and
the effectiveness of our teaching.

Successful students will receive an official certificate from the Australian and New Zealand Burn
Association.

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The Team Concept of Burn Care
Since the Second World War, significant advances in burn care have resulted in the gradual decrease
in mortality and morbidity from severe burns[2].

Intravenous resuscitation, improved nutrition, the introduction of topical antimicrobials, and the
introduction of protocols for surgery that promote early closure of the burn wound have all
contributed to this remarkable improvement in survival[2].

Burn Units

With these improvements in burn management has come the realisation that specially trained staff
are able to operate more effectively within a purpose built acute facility[2]. These facilities allow
higher quality care to be available even for minor burns than is available outside a burn unit.

The concentration of specialist team members within one facility has the added advantage of being
more cost effective, and the sharing of knowledge in a team environment allows the development of
high levels of expertise by individual team members[2]. This ensures that patients receive the best
care possible. The support that team members give each other during times of stress contributes to
staff morale, and maximises staff retention.

Burn Team

The Burn Team consists of a multidisciplinary group whose individual skills are complementary to
each other. Team members recognise the benefits of interdisciplinary cooperation in providing the
best quality care to the patient with burns[2, 3].

Pre-hospital Clinicians

Ambulance personnel and Retrieval services provide essential pre-hospital care for burn patients by
establishing fluid resuscitation, airway stabilisation and transferring the patient. The early
management provided pre-hospital assists the burn patients chance of survival and optimal
outcome.

Emergency Department

Many burn patients will be assessed and receive their initial treatment in an Emergency Department,
whether in a burn unit hospital, or rural or metropolitan hospital. A high quality working relationship
between the burn unit and Emergency Department is essential to provide top quality care.

Surgeons

Burn Surgery has become a sub-specialty of Plastic Surgery, General Surgery, and Paediatric Surgery.
Burn Surgeons have a particular interest in the management of the seriously injured burn patient, in
wound healing, rehabilitation, and related research[2].

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Nurses

The Burn Nurse is the lynch pin of the team, providing day to day continuity of care. Burn nurses
have specialist expertise in wound care, skin graft care, intensive care of the severely burnt patient,
psychiatric nursing and discharge planning[2].

Anaesthesia

Burn surgery requires specialised anaesthetic techniques to assist the surgeon in treating the
severely ill patient, managing severe blood loss, and maximising the area of burn wound surgery that
can be treated at any one time[2]. This contributes to early burn wound closure.

Intensive Care

Many severely burnt patients will be cared for at some stage of their hospitalisation in Intensive
Care. A high quality working relationship between the Burn and Intensive Care units is essential to
provide top quality care.

Physiotherapist, Occupational Therapist

Therapists play an indispensable role in the care and rehabilitation of the burn patient[2]. This
begins at the time of admission to the burn unit, and continues well into the outpatient treatment
after discharge. Burn therapy is a specialised sub-discipline and is not usually available to patients
outside burn units.

Speech Pathologist
The burn unit Speech Pathologist provides comprehensive clinical assessment and management of
severe burn patients with swallowing, voice and communication disorders as a result of the burn
injury or secondary complications including sepsis, debility, oro-facial contractures or presence of a
tracheostomy

Dietitians
Optimal nutrition is necessary to counteract the extreme catabolic response that occurs with
burns[2]. For this reason burn units have specialised dietetic staff.

Psychosocial

Social Workers, Psychiatrists, Psychologists and Chaplains form part of the burn team, providing
necessary support and treatment for the wide variety of psychosocial problems that burn patients
commonly have. Special expertise is required to manage these difficult problems[2]. The patients
ability to function in society in the long term is as dependent on this psycho-social adjustment as it is
on the quality of the physical result.

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Rehabilitation

Post burn rehabilitation begins at the time of admission[2], and in the minor burn can usually be
managed as part of outpatient care. Severely burnt patients may require much more intensive
rehabilitation to enable the attainment of maximum function, allowing return to daily living activities
and employment. A close relationship with rehabilitation personnel facilitates this.

The burn team provides optimal quality of care utilising shared management protocols which
provide individual support for team members, optimise professional attainment, and provide the
highest quality of care for the patient with burns[2].

The Epidemiology and Aetiology of Burns

A. Epidemiology
Burns are a common form of trauma [2, 4-6]. Some burns occur as genuine accidents, but most are
caused by carelessness or inattention, pre-existing medical conditions (the presentation of which
may be a collapse), or they may follow alcohol or drug abuse. (See Table 1)

Approximately 1% of the population of Australia and New Zealand (220,000) suffer a burn requiring
medical treatment each year. Of those, 10% will require hospitalisation, and 10% of those
hospitalised will be burnt sufficiently severely for their life to be threatened. 50% of all those burnt
will suffer some daily living activity restriction. (Source 2001 Australian National Health Survey)

A 70% TBSA burn may cost $700,000 for acute hospital treatment, to this figure must also be added
the additional costs of rehabilitation, time off work, and loss of earning represent a substantial cost
to the community.

In both adults and children, the commonest place to be burned is the home [1, 7]. In children, over
80% of accidents occur in the home. The most dangerous places in the home are the kitchen and the
bathroom, as most scalds in children and the elderly occur in these two rooms. In addition, the
laundry contains dangerous chemicals, and the garage or of accidents occur in the home. The most
dangerous places in the home are the kitchen and the bathroom, as most scalds in children and the
elderly occur in these two rooms. In addition, the laundry contains dangerous chemicals, and the
garage or garden shed contains chemicals and dangerous flammable liquids.

TABLE 1
Childrens Place of Burning (%)
Home 82%
Outdoors 12%
Roadway 3%
Work 1%
Institutions/School 1%
Other 1%
(ANZBA Bi-NBR Annual Report 2011[8])
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TABLE 2
Adults Place of Burning (%)
Home 56%
Work 17%
Roadway 11%
Outdoors 11%
Institutions 3%
Other 2%
(ANZBA Bi-NBR Annual Report 2011[8])

Injuries caused at work often involve carelessness, and are caused occasionally by unsafe work
practices, particularly the careless handling of flammable liquids. Attention to occupational health
and safety policies has the potential to make these become less frequent.

Military burns

Approximately two thirds of military burns are non battle related casualties[2]. These occur in the
same manner as they do in civilian life.

Burns as battle casualties comprise 10% of total battle related casualties. Military burns with a blast
component have a high risk of producing an inhalation injury as well as a skin injury. Multiple trauma
is likely to coexist.

The contingencies of battle, the evacuation plan and the casualty holding policy at the time, together
with the logistics of re-supply, may impose very different management protocols on burns in
wartime compared with the optimal treatment in peacetime.
70% TBSA

B. Aetiology
Tables3 and 4 lists those factors that caused burns in both children and adult patients admitted to a
burn unit in Australia or New Zealand from 2009 to 2010.

TABLE 3
Causes of Childrens Burns (%)
Scalds 55%
Contact 21%
Flame 13%
Friction 8%
Electrical 1%
Chemical 1%
Other 1%
(ANZBA Bi-NBR Annual Report 2011[8])

TABLE 4
Causes of Adults Burns (%)
Flame 44%
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Scald 28%
Contract 13%
Chemical 5%
Friction 5%
Electrical 2%
Other 3%
(ANZBA Bi-NBR Annual Report 2011[8])

The causes of burns in adults and children differ in that fire is the most common cause in adults, and
scalds are the most common cause in children. As children become older so their patterns of burn
causation become more like the adult.

As adults age, their patterns of injury also change. The elderly are particularly at risk of injury from
scalds at home, or as residents of care institutions.

All age groups are likely to be injured in conditions of social disharmony or disruption. This is
particularly true of children, especially infants and toddlers, who are dependent on surrounding
adults for care and security. Injuries from carelessness, inattention, poor parenting, and
unfortunately from assault (burning is a common method of child abuse) occur frequently, and need
investigation when suspected.

Summary
Burns requiring medical attention affect 1% of the population per year.

Burns are frequently caused by carelessness and inattention, and the influence of intoxicating
drugs is common.

The majority of burn injuries in all age groups occur in the home.

Burning can be a method of assault in adults, and a method of child abuse. The correct diagnosis
of these injuries requires vigilance, and accurate reporting can ensure that appropriate help is
given to patiens and relatives

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CHAPTER 2

Emergency Examination
And Treatment
Introduction
When the survivor of a burn injury is first seen by medical personnel, rapid assessment and
treatment can be life saving [9]. While most patients with minor burns will not have associated
injuries, such injuries are more likely in patients with major burns. Whatever the size of the burn, the
patient will fall into one of two categories; those whose non-burn injuries are obvious, and those
whose other injuries are concealed. Patients who have minor burns with non-burn injuries usually
fall into the first category. However, it is common for life-threatening injuries to be missed when a
significant burn is present because the obvious burn injury catches the attention of the treating
doctor [9].

The history should alert the medical personnel to the possibility of co-existing injuries [9]:

road traffic accident, particularly with ejection or at high speed


blast or explosion
electrical injury, especially high voltage
jump or fall while escaping

Non-communicative patients, whether unconscious, intubated, psychotic, or under the influence of


substances, should be regarded as potentially multiply injured and treated accordingly.

After immediate first aid has been given, the principles of primary and secondary survey and
simultaneous resuscitation should be followed[2].

Staff should don personal protective equipment (PPE) such as gloves, goggles and gowns prior to
attending any patient [2].

First Aid
First aid consists of :
stopping the burning process
cooling the burn wound
It is effective within the first threehours from the time of burn (see Chapter 7).

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Structure of EMSB
A B C D E A.M.P.L.E.
L I R I I X FLUIDS History
O R E R S P
W A C A O
O A T U B S ANALGESIA Head to Toe
Examina on
K Y H L I U
I A L R
N T I E
TESTS Tetanus
G I T
O Y TUBES Documenta on
N
D and Transfer
Haemorrhage
C AVPU Environmental
O spine
O2 control
& Pupils Control Support
I.V.

First Secondary
Primary SurveyEMSB Aid Survey

Primary Survey
Immediately life threatening conditions are identified and emergency management begun [9, 10].
Do not get distracted by the obvious burn injury.

A. Airway maintenance with cervical spine control

B. Breathing and ventilation

C. Circulation with haemorrhage control

D. Disability - neurological status

E. Exposure + environmental control

A. Airway Maintenance with Cervical Spine Control

Check for a patent airway, easiest by speaking to the patient. If the airway is not patent, clear the
airway of foreign material and open the airway with chin lift/jaw thrust. Keep movement of the
cervical spine to a minimum and never hyperflex or hyperextend the head and neck[2, 9].
Control cervical spine (best with rigid collar). Injuries above the clavicle, such as facial injuries or
unconsciousness, are often associated with cervical fractures.

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B. Breathing and Ventilation

Expose the chest and ensure that chest expansion is adequate and equal[2].
Always provide supplemental oxygen 100% high flow(15 l/min) via a non-rebreather mask[2, 9].
If required ventilate via a bag and mask or intubate the patient if necessary.
Carbon monoxide poisoning may give a cherry pink, non-breathing patient.
Beware a respiratory rate <10 or >30 per minute.
Beware circumferential chest burns - is an escharotomy required?

C. Circulation with Haemorrhage Control

Apply pressure to point of haemorrhage


- Pallor occurs with 30% loss of blood volume.
- Mental obtundation occurs with loss of 50% of blood volume.
Check the central pulse is it strong or weak?
Check blood pressure
Capillary refill (centrally and peripherally) normal return is 2 seconds. Longer indicates
hypovolaemia or need for escharotomy on that limb; check another limb.
Insert 2 large bore, IV lines preferably through unburned tissue
Take blood for FBC/U&E/LFT/Coags/-hCG/Cross Match /Carboxyhaemoglobin[2, 9].
If the patient is shocked commence fluid resuscitation with Hartmanns boluses to attain a radial
pulse.

The early appearance of clinical signs of shock is usually due to another cause. Find it and treat it.

D. Disability: Neurological Status

Establish level of consciousness:

A- Alert
V- Response to Vocal stimuli
P- Responds to Painful stimuli
U- Unresponsive

Examine the pupils response to light. They should be brisk and equal.
Be aware that hypoxaemia and shock can cause restlessness and decreased level of
consciousness[9].

E. Exposure with Environmental Control

Remove all clothing and jewellery including piercings and watches[2]


Log roll the patient to visualise posterior surfaces
Keep the patient warm[7, 9]
Area burned is estimated by using the Rule of Nines or palmar (Rule of Ones) methods

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Fluids, Analgesia, Tests and Tubes
The FATT between the primary and secondary survey.

Fluid Resuscitation
(See Chapter 6)

Fluids are given initially as per Modified Parkland formula [7, 11-19]:

34mls x weight (kg) x % burn TBSA


+ maintenance for children.
Crystalloids (e.g. Hartmann's solution) are the recommended fluid
Half of the calculated fluid is given in the first eight hours; the rest is given over the next sixteen
hours [3, 12, 15, 19].
The time of injury marks the start of fluid resuscitation [7].
If haemorrhage or non-burn shock treat as per trauma guidelines.
Monitor adequacy of resuscitation with [3, 7, 11, 14, 18, 20]:
- Urinary catheter with hourly output measured
- ECG, pulse, blood pressure, respiratory rate, pulse oximetry and arterial blood gas
analysis as appropriate
Adjust resuscitation fluids as indicated.

Analgesia[9]
Burns hurt give intravenous morphine 0.050.1mg/kg
Titrate to effect smaller frequent doses are safer.

Tests
X-Ray
- Lateral cervical spine
- Chest
- Pelvis
- Other imaging as clinically indicated

Tubes
Nasogastric tube
Insert nasogastric tube for larger burns (>10% in children; >20% in adults), if associated injuries,
or to decompress stomach for air transfer. Gastroparesis is common.

Secondary Survey
This is a comprehensive, head to toe examination that commences after life threatening conditions
have been excluded or treated[2].

History: A Allergies
M Medications
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P Past illnesses
L Last meal
E Events / Environment related to injury

Mechanism of Injury

As much information regarding the interaction between the person and their environment should be
obtained:

Burn[9]
Duration of exposure
Type of clothing worn
Temperature and nature of fluid if a scald
Adequacy of first aid measures.

Penetrating
Velocity of missile
Proximity
Direction of travel
Length of knife blade, distance inserted, direction

Blunt
Speed of travel and angle of impact
Use of restraints
Amount of damage to passenger compartment
Ejection?
Height of fall
Type of explosion or blast and distance thrown

Examination

Head
Eyes penetrating injuries are often missed
check visual acuity
Scalp lacerations, boggy masses

Face
Stability of mid-face
Check for missing teeth / malocclusion
CSF leak from nose, ears or mouth
Soot, blisters, oedema of the tongue or pharynx

Neck
Inspect, palpate, x-ray. Always suspect cervical fracture
Lacerations deep to platysma operating theatre or angiography

Chest
Examine whole chest front and back

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Ribs, clavicles and sternum
Check breath sounds and heart sounds
Circumferential burns may need escharotomy if restricting ventilation
Cough productive of soot
Altered voice or brassy cough

Abdomen
Requires frequent re-evaluation especially for increasing tenderness and distension
If there is a seat belt bruise, assume intra-abdominal pathology such as ruptured viscus
If assessment of the abdomen is unreliable, equivocal or impractical, for example in the presence of
an extensive abdominal burn, then further investigation with a CT scan, or Focused Assessment with
Sonography for Trauma (FAST) scan is mandatory in multiply injured patients.

Perineum
Bruising, meatal blood

Rectal
Blood, lacerations, sphincter tone, high riding prostate

Vaginal
Foreign bodies, lacerations

Limbs
Contusion, deformity, tenderness, crepitus
Assess extremity pulses regularly. In constricting circumferential extremity burns with developing
oedema, the eschar initially obstructs venous return which in turn embarrasses arterial inflow
producing tissue ischaemia. This may produce the classic signs of decreasing limb perfusion of pain,
paraesthesia (or numbness), pulselessnessand paralysis. When venous return from an extremity is
obstructed by oedema, an escharotomy is indicated to restore adequate circulation. (see Chapter 7)

Pelvis
Rapid access to radiology in most emergency departments/trauma units precludes the need to test
pelvic stability by springing the pelvis with the heel of the hand on the symphysis pubis and the
wings of the ilium anteriorly. If radiology not readily available this should be done once only by a
senior clinician.

Neurological
Glasgow Coma Scale (see appendix)
Motor and sensory assessment of all limbs
Paralysis or paresis indicates a major injury and immobilisation with spinal boards and semi-rigid
collars is indicated.

Note: In burned patients, paresis of a limb may be due to vascular insufficiency caused by rigid
eschar for which escharotomy is necessary.

Decreased level of consciousness could be due to:


- hypovolaemia from undiagnosed bleeding or under resuscitated burn shock
- hypoxaemia

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- intracranial expanding space occupying lesion.

Documentation
Take notes
Seek consent for photography and procedures
Give tetanus prophylaxis if required (see appendix) [21]

Re-evaluate
Re-evaluate Primary Survey particularly
- respiratory compromise
- peripheral circulation insufficiency
- neurological deterioration
- adequate fluid resuscitation
- review imaging
- Note urine colour for haemochromogens
Laboratory investigations:
- Haemoglobin / haematocrit
- Urea / creatinine
- Electrolytes
- Urine microscopy
- Arterial blood gases
- Carboxyhaemoglobin (if available)
- Blood sugar level
- Drug screen (may be required by Police)

Chest x-ray
Electrocardiogram

Emergency Burn Wound Care


(see Chapter 7)

As most burn wounds are sterilised at the time of burning, extensive burn wound care involving
complicated dressings is unnecessary and causes unwarranted delays. The appropriate treatment of
the burn is to cover the wound with plastic cling wrap or a clean sheet and arrange for evacuation
[22]. If the referral of the patient is delayed more than 8 hours, or if the wound has been extensively
contaminated with polluted water or industrial waste, then a topical antimicrobial should be used.
Clean the wound and contact the receiving burn unit regarding advice on which dressing to apply.
They will often recommend an antimicrobial dressing such as a silver or Silver Sulphadiazine cream.

Do not constrict limbs with compromised circulation by using tight dressings. Dressings should be
checked frequently to exclude constriction.

Electrical Injuries
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(see Chapter 10)

Conduction of electrical current through the chest may cause transient cardiac arrhythmias or
cardiac arrest, though this is rare in low voltage injuries (<1000 V). Patients who have been
electrocuted may require 24 hours of ECG monitoring if they have suffered a high voltage injury, loss
of consciousness or have an abnormal ECG on arrival at the hospital [23]. Dysrhythmias are more
likely to occur if the patient has pre-existing myocardial disease which may be aggravated by small
amounts of current damage.

Remember that small entrance or exit wounds may be associated with severe deep tissue damage.

Chemical Burns
(see Chapter 11)

While there is residual chemical on the skin, burning continues. Therefore contaminated clothing
should be removed and the burn washed with copious amounts of water for a long time [24]. Seek
advice for special chemicals from Poisons Information Australia (13 11
26) or New Zealand National Poisons Centre (0800 764 766).

Chemical burns to the eye require continuous flushing with water. Swelling of the eyelids and eyelid
muscle spasm due to pain may make adequate washing difficult. Careful retraction of the eyelids will
facilitate correct irrigation. An early ophthalmological opinion is necessary in these cases.

Support and Reassure Patient, their Relatives and Staff


Burns are associated with significant emotional overlay in the patient and also their relatives and
friends [25].

Feelings of grief and loss are common and are normal accompaniments of burns. In addition feelings
of guilt, self reproach, fear, depression and often anger in the victim and their relatives need to be
addressed.

Burning is a frequent method of successful and attempted suicide. Patients with mortal injuries
require sympathetic handling and counselling during the brief lucid period before death. Large doses
of narcotics or inappropriate endotracheal intubation prevents this important aspect of terminal
management. It also makes the important final rapport with grieving relatives impossible. Every
effort must be made to facilitate this communication.

Patients with non-fatal injuries will require psychiatric assessment and this may be needed urgently
to prevent immediate further suicide attempts.

Some patients with abnormal personalities or under the influence of intoxicating substances may be
violent during their emergency management and staff need to take care to avoid personal injury.
Assistance

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Definitive Care
Definitive burn care is described elsewhere in this manual. Transfer to a burn unit where other
specialised services are available is indicated in accordance with ANZBA referral criteria. (See
Chapter 8.)

Summary
The burn injury may only be part of the problem. Other injuries may also be present and
should be dealt with according to the principles of rapid primary assessment, correcting life-
threatening conditions as required.

Fluid resuscitation, analgesia, tests and tubes represent treating the burn injury once life-
threatening conditions have been dealt with.

Once the patient is stable, an ordered and complete head to toe examination of the patient
beginning with a history should then be undertaken. Definitive care and transfer follow.

In the multiply injured burn patient the following points should be the focus of regular re-
evaluation:
- Adequacy of fluid resuscitation
- Airway or respiratory embarrassment from inhalation injury or constricting eschar
- Peripheral circulatory insufficiency from constricting burn wounds, dressings or oedema
- Neurological deterioration
- Concealed (intra-cavity) bleeding

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CHAPTER 3

Local and General Response


to Burn Injury

A. Local Response
Based on the experimental work undertaken in the 1950s by Jackson in Birmingham, a burn wound
model was created which aided the understanding of the pathophysiology of a burn [26-32].

Jacksons Burn Wound Model

Zone of Coagulation

Zone of Stasis
Zone of Hyperaemia

Figure 3.1

Figure 3.1 depicts this wound model. Nearest the heat source (or other injuring agent) where the
heat cannot be conducted away rapidly enough to prevent immediate coagulation of cellular
proteins, there is rapid cell death. This central zone of tissue death is best called the Zone of
Coagulative Necrosis, but is also referred to as the Zone of Coagulation[25, 26, 29, 32, 33].

Surrounding the Zone of Coagulative Necrosis is an area of tissue where the damage is less severe
than that required to produce immediate cell death, but the circulation in this area of skin and
subcutaneous tissue is compromised due to damage to the microcirculation. Because the circulation
to this area is sluggish, it is called the Zone of Stasis [25, 26, 29, 32]. Untreated, this relatively narrow
zone will undergo necrosis as the inflammatory reaction progresses under the influence of
mediators produced by the tissues response to injury [29]. Clinically this is seen as progression of

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the depth of burning. This produces the phenomenon of areas of burn that appear viable initially but
subsequently (35 days after burning) become necrotic [32].

Surrounding this region of compromised vasculature is a zone where damage to the tissues causes
production of inflammatory mediators which cause widespread dilatation of blood vessels. This zone
is called the Zone of Hyperaemia[25, 26, 29, 32]. Following the resolution of this hyperdynamic
vascular response, the tissues of this area return to normal [27, 34]. In a burn which covers more
than 10% in children or 20% in adults of the total body surface area (TBSA), the Zone of Hyperaemia
may involve virtually the whole of the body.

The contribution of each of these three zones (Necrosis, Stasis and Hyperaemia) to the overall burn
wound depends upon the circumstances of the burn itself. On occasions the Zone of Stasis may
include the mid dermis, but progressive vascular compromise extends the Zone of Necrosis
producing a deep burn. (see Fig 5.4) This is particularly likely to occur in the elderly patient and in
those patients in whom appropriate treatment of post-burn shock and sepsis is not undertaken [14].
Thus timely and effective emergency care of the burned patient can promote wound healing.

B. The General Response


1. Normal Capillary Exchange

(i) Substances pass through the capillary wall in one of three ways: diffusion, filtration, and
large molecular transport.

a) Diffusion is the mechanism of transfer of very small particles such as oxygen, carbon dioxide
or sodium. It implies that these particles cross the capillary wall (membrane) easily and so move in
the direction of concentration (downhill from more concentrated to less).

b) Filtration is the mechanism of transfer of water and some other substances. The amount of
water filtered through the capillary depends on the forces pushing water in and out across the
capillary wall, as well as factors in the capillary wall. The forces causing movement across the
capillary wall are summarised by Starlings Hypothesis[2, 32] (see footnote)1.

c) Large molecule transport is less well understood. Large molecules probably cross the
capillary wall mostly by passing through spaces between the endothelial cells. Most capillaries are
fairly impervious to large molecules which is why they are called semi-permeable (easily
permeable to water and small particles such as Na, Cl, but relatively impermeable to large molecules
such as albumin). Even so, each day 50%100% of the bodys serum albumin crosses the capillaries
and is returned to the blood via the lymphatic system.

1
Starlings Hypothesis states that nett fluid movement is the difference between the forces moving fluid out (hydrostatic pressure in the
capillary pushing fluid out plus the colloid osmotic pressure in the interstitial fluid pulling fluid out) and the forces moving fluid in
(hydrostatic pressure in the interstitial space pushing fluid back in and plasma colloid osmotic pressure pulling fluid in.
1
Hipotesis Starling menyatakan bahwa gerakan fluida nett adalah perbedaan antara kekuatan pindah fluida (tekanan hidrostatik dalam
cairan mendorong kapiler keluar ditambah tekanan osmotik koloid dalam cairan interstitial menarik keluar cairan) dan kekuatan bergerak
cairan ke dalam (tekanan hidrostatik dalam interstitial ruang mendorong cairan kembali dan tekanan osmotik koloid plasma menarik
cairan masuk
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(ii) Normal variations in filtration occur because of factors in the capillary wall (e.g. kidney
capillaries let out much more water than muscle capillaries) as well as the factors mentioned in
Starlings Hypothesis. The capillary hydrostatic pressure depends on the pressure of the blood
flowing in as well as the resistance to blood flowing out (controlled by the pre- and post-capillary
sphincters respectively). Normally most capillaries undergo cycles of active blood flow, interspersed
by long periods of low flow and hence low pressure. The colloid osmotic pressure of the plasma is
almost totally dependent on the serum albumin concentration. The colloid osmotic pressure of the
interstitial fluid is due to the small amount of albumin and the ground substance present between
cells.

2. Abnormal Capillary Exchange

These changes are caused by inflammatory mediators released by damaged endothelial cells, by
platelets, and by leucocytes.

(i) Vasodilatation is one of the major vascular responses to inflammation and causes [32]:

a) Increase in capillary hydrostatic pressure.

b) Opening up of all capillaries instead of only a few.

c) Stretching of the capillary wall which increases the surface area of the capillary
membrane and opens the spaces between endothelial cells.

d) Pooling of blood in small veins.

(ii) There is a marked increase in the permeability of the capillary membrane [7, 18]. This causes
increased transport of substances by all three mechanisms, diffusion, filtration and large molecule
transport. However, large molecule transport is most affected, and there is a dramatic increase in
the movement of albumin across the capillary membrane. This causes mass movement of albumin
out of the circulation and into the interstitial space producing oedema.

(iii) Tissue damage by burning may produce breakdown of intercellular ground substance. This
can contribute to a rapid increase in the colloid osmotic pressure of the interstitial space which has
been observed experimentally. Another effect of burn injury on the intercellular ground substance is
uncoiling of long molecules, which is thought to cause expansion of the space and thereby lower its
hydrostatic pressure.

3. Effects of Burn Injury on the Whole Body

There are changes in virtually every organ system in the body after a burn injury [25]. When the burn
is less than 20% TBSA these effects may not be of great practical significance [20].

The cause of these changes is release of inflammatory mediators and neural stimulation. The result
is that there are major changes in control of body functions as well as direct reactions in some
organs to circulating mediators.

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(i) The most profound and immediate effect is on the circulation. Hypovolaemia is principally
due to loss of protein and fluid into the interstitial space. Loss of albumin alters capillary exchange at
sites remote from the burn. If the burn involves more than 20% TBSA the whole body is affected by
circulating mediators so that capillary permeability is generally increased. Correction of
hypovolaemia is a life saving task in the first hours after major thermal injury [16, 18, 27, 35-40].

(ii) As a result of the injury a hypermetabolic state is caused by the secretion of the stress
hormones cortisol, catecholamines and glucagon. In addition the suppression of (or resistance to)
anabolic hormones (growth hormone, insulin and anabolic steroids) and neural mechanisms cause
profound catabolism resulting in muscle protein breakdown [25]. Clinically these changes are
expressed as tachycardia, hyperthermia and protein wasting.

(iii) Immunosuppression is due to depression of many facets of the immune mechanism, both
cellular and humoral[25]. This is why infection is still the leading cause of mortality in burn patients.

(iv) As part of the reaction to injury and to shock the barrier function of the gut is greatly
impaired leading to an increase in bacterial translocation. This can be minimised by beginning very
early enteral nutrition.

(v) The lungs frequently suffer from the changes of the post-burn systemic inflammatory
response (Acute Respiratory Distress Syndrome [ARDS]) even in the absence of inhalation injury [25,
41].

(vi) Widespread whole body changes in growth also occur and persist for months or years after
healing of the burn wound. There is increased central deposition of fat, decreased muscle growth,
decreased bone mineralisation, and decreased longitudinal growth of the body. Although growth
velocity may return to normal after 13 years it does not exceed normal growth so that catch-up
does not occur.

Summary
The local effect of thermal injury on the skin and subcutaneous tissues causes three zones of
injury. Progression of the intermediate zone to necrosis tends to occur.

Normal capillary exchange is disturbed leading to oedema formation and loss of albumin
from the circulation.

Burn injury also causes widespread general effects on the circulation, the metabolism,
temperature control, immune competence, and function of the gut and lungs as well as long-term
growth changes.

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CHAPTER 4

Inhalation Injury
Inhalation of hot gases and the products of combustion injure various parts of the respiratory tract
in different ways [2, 42]. In addition, the absorption of the products of combustion may lead to
serious local or systemic toxic effects.

Inhalation injury increases mortality in all burns [41-49]. For example, in a middle-aged man with
cutaneous burns, an inhalation injury may increase the mortality rate by 30% and increase the risk of
pneumonia[46]. If pneumonia supervenes, the mortality rate may rise by up to 60%. In children it
has been reported that a 50% TBSA burn with associated inhalation injury carries the same mortality
as a 73% TBSA without an associated inhalation injury[50].

Inhalation injury, previously known as respiratory tract burns, is most likely to be associated with
burns of the head and neck. Forty-five percent of patients with burns to the face have an inhalation
injury.

Classification of Inhalation Injury


An inhalation injury can be broadly classified according to the site of the injury[2].

1. Airway Injury Above the Larynx (obstruction)

2. Airway Injury Below the Larynx (pulmonary damage)

3. Systemic Intoxication (cell hypoxia)

A patient may have one or a combination of these types of injury.

Management of the airway aims at providing a patent and protected airway first and foremost. The
airway may also need to be secured to improve oxygenation and ventilation in the setting of
respiratory failure.

1. Airway Injury above the Larynx (obstruction)

These are actually thermal burns produced by the inhalation of HOT GASES, and so occur in those
patients who have no alternative but to breathe these gases. This is most likely to occur in an
enclosed space, if trapped in a fire, or with the inhalation of steam.

These burns produce the same pathophysiological changes that are produced by thermal injury to
skin with damage proportional to exposure. Inflammatory mediators cause oedema of the tissues
which leads to obstruction initially, and later loss of the protective functions of the mucosa [42].

Respiratory obstruction often develops as a result of soft tissue swelling and may persist beyond the
time of maximal wound oedema (between 12 and 36 hours). A burn to the skin of the neck may
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aggravate this obstruction by producing neck oedema[2]. The latter is much more likely to occur in
children who have relatively narrow airways and short necks with soft tissues that are readily
distorted by oedema.

It should be remembered that burns involving more than 20% TBSA result in a systemic
inflammatory response, even when there is no direct injury to the tissues. The airway mucosa may
become oedematous, especially if large volumes of fluid are required for resuscitation, and this may
further compromise the airway.

The upper respiratory tract has such an efficient ability to conduct heat away that it is only after
extreme heat exposure that direct heat damage to the lower respiratory tract occurs.

2. Airway Injury below the Larynx (pulmonary damage)

These burns are produced by the inhalation of the products of combustion. Fires cause oxidation and
reduction of compounds containing carbon, sulphur, phosphorus and nitrogen. The list of chemical
compounds produced includes carbon monoxide and dioxide, cyanide, esters and complex organic
compounds, ammonia, phosgene, hydrogen chloride, hydrogen fluoride, hydrogen bromide and the
oxides and aldehydes of sulphur, phosphorus, and nitrogen [42]. Polyvinyl chloride (PVC), for
example, produces at least 75 potentially toxic compounds when burnt [51]. Acids and alkalis are
produced when these compounds dissolve in the water contained in respiratory mucous and tissue
fluids. These compounds produce a chemical burn. In addition, the particles of soot less than 1m
are aerosolised. They also contain similar irritant chemicals and can produce damage to the alveolus
[42]. These compounds contact the airway mucosa and lung parenchyma initiating the production of
inflammatory mediators and reactive oxygen species. This results in oedema and potentially
shedding of the trachea-bronchial mucosa. The lower airways too are involved with cast formation
and plugging that may result in distal airway obstruction. The lung parenchyma may be affected with
disruption of the alveolar-capillary membrane, the formation of inflammatory exudates and loss of
surfactant. This results in atelectasis, interstitial and pulmonary oedema causing hypoxaemia and
reduced lung compliance [51, 52].

A number of pathophysiological factors contribute to lung injury, leading to impaired gas exchange
[47]:

Obstruction due to
- bronchoconstriction
- mucus production
- cast formation
Alveolar dysfunction and shunting due to
- emphysematous alveolar destruction
- atelectasis / alveolar collapse
Alveolar fluids
- non-cardiac pulmonary oedema / chemical pneumonitis
- secondary bacterial pneumonia

3. Systemic Intoxication (cell hypoxia)

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The two common intoxications occurring in association with inhalational burns are caused by carbon
monoxide and cyanide[42].

Carbon monoxide (CO)

This is produced by incomplete oxidation of carbon. Carbon monoxide (CO) is a colourless odourless
gas which diffuses rapidly into the blood stream. It combines readily with haemoglobin (Hb), having
a greater affinity for haemoglobin than oxygen (240 times greater) and forms carboxyhaemoglobin
(COHb). This binding to form COHb effectively reduces the oxygen carrying capacity of the blood. CO
causes tissue hypoxia by reducing oxygen delivery and utilisation at a cellular level [42]. It also
dissociates from Hb less readily than does oxygen and so occupies an oxygen-binding site for a long
period of time [42].

In addition to binding preferentially with haemoglobin, CO also binds with great affinity to other
haem- containing compounds, most importantly the intracellular cytochrome system. It may also
have a direct toxic effect. This causes abnormal cellular functioning which is a major component of
CO toxicity. [53]. Post intoxication encephalopathy may be a serious sequel of poisoning; the exact
mechanism of how this develops is not fully understood but may be due to cerebral lipid
peroxidation.

The usual indicators of hypoxia may not be present:

Haemoglobin not carrying O2 causes skin to have a blue colour (cyanosis). COHb gives false
reassurance with a normal pink colour (some say cherry red)
A pulse oximeter (O2 saturation probe) cannot distinguish between COHb and O2-Hb
(oxyhaemoglobin) so even in severe poisoning, the oxygen saturation will read as normal
A standard blood gas machine measures PaO2 as the amount of oxygen dissolved in the
blood. The dissolved oxygen in the plasma remains unaffected so the PaO2may be normal.

Blood gas analysers using co-oximetry are the only reliable way to assess oxyhaemoglobin and
carboxyhaemoglobin levels[54]. Carboxyhaemoglobin dissociates slowly, having a half-life of 250
minutes in room air.

Patients who have CO intoxication are often confused and disorientated, exhibiting symptoms
similar to those of hypoxia, head trauma and acute alcohol intoxication. It is important to consider
CO intoxication in this clinical setting.

Table 4.1
Carbon Monoxide Intoxication[9, 42, 53].

Carboxyhaemog Symptoms
lobin (%)
0 15 None - (Smokers, long distance lorry drivers)

15 20 Headache, Confusion
20 40 Nausea, Fatigue, Disorientation, Irritability
40 60 Hallucination, Ataxia, Syncope, Convulsions, Coma

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> 60 Death

Patients with an altered state of consciousness after burns have CO intoxication unless proven
otherwise.

Cyanide Poisoning (HCN)


This may occur because of the production of hydrogen cyanide from burning plastics[2] or glue used
in furniture. It is absorbed through the lungs, and binds readily to the cytochrome system, inhibiting
its function resulting in anaerobic metabolism. It causes loss of consciousness, neurotoxicity and
convulsions. It is gradually metabolised by the liver enzyme rhodenase. Blood cyanide levels are not
readily available and their usefulness is debated. Smokers will often have levels of 0.1mg/L, while
lethal levels are 1.0 mg/L. In practice, pure HCN poisoning is rare, most patients suffering mixed HCN
and CO poisoning.

Diagnosis of Inhalation Injury


All cases of burns should be examined with a view to excluding the diagnosisof inhalation injury.
As the clinical signs and symptoms may evolve over a period of time, as with all traumas, the patient
must be repeatedly re-evaluated. This is a potentially fatal injury[41, 42, 47, 48].

Patients with severe inhalation injury may present early with severe respiratory distress or
obtundation at the scene of the fire. Early death may occur and emergency resuscitation at the
scene may be required to save life [42]. The respiratory distress seen at the scene of the fire may be
due to anoxia, as oxygen is consumed by the fire itself. CO intoxication is however thought to be
responsible for the majority of
deaths occurring at the scene of the fire, the scenario of being overcome by the fumes.

A common presentation of inhalation injury is one of increasing respiratory obstruction, occurring


over several hours. This requires ongoing vigilance to detect and is due to thermal injury above the
larynx. Increasing abnormalities in oxygenation as shown by increasing restlessness and confusion
suggest injury below the larynx.

History
A history of burns in an enclosed space, such as a house, a motor vehicle, an aeroplane or an
armoured vehicle, or burns with an associated explosion resulting from a petrol or gas fire, from
shells or bombs, should alert medical personnel to the likelihood of an associated inhalation injury
[42].

Examination

The following clinical findings are the signs suggestive of inhalation injury [2, 24, 42, 55]:
Observe for Listen for
Burns to Mouth, Nose and Change of Voice,
Pharynx,
Singed Nasal Hairs Hoarse Brassy Cough
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Sputum containing Soot Croup -like Breathing
Flaring of Nostrils Inspiratory Stridor The symptoms and signs of an inhalation
Respiratory Difficulty Productive Cough injury change or evolve over time
Tracheal Tug according to the particular site and type of
In-drawing of Supraclavicular the injury. An indication of this change is
Fossae given in Table 4.2.
Rib Retraction
After the initial assessment the
subsequent clinical course can be altered by the onset of the known complications of inhalation
injury.

Table 4.2
Change in Clinical Presentation of Inhalational Injury Over Time
Type of Inhalation Timing Signs/Symptoms
1. Above the Larynx 4 to 24 hours Increasing Stridor
Hoarseness or Weak Voice
Brassy Cough
Restlessness
Respiratory Difficulty
Respiratory Obstruction
DEATH
2. Below the Larynx (i) Immediate Restlessness
Life Threatening Anoxia
DEATH
(ii) Gradual Onset Increasing Hypoxia
12 hrs to 5 days Pulmonary Oedema/ARDS
Respiratory Failure
3. Intoxication Death At Scene
Worse Initially Obtundation/Unconsciousness
Stupor
Improves with Time Confusion
Drowsiness
Poor Mentation
Visual Disturbances
Headache

Diagnosis of Inhalation Injury Producing Systemic


Intoxication
Diagnosis of systemic intoxication is made initially by clinical suspicion [48]. Any patient, who is
confused or has an altered state of consciousness after being burned, or inhaling products of
combustion, is deemed to have carbon monoxide intoxication until proven otherwise.

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The diagnosis is confirmed by the presence of COHb in the blood [48]. CO levels estimated on arrival
in hospital may not correlate well with the severity of the CNS symptoms of CO intoxication. They
may appear to be too low. This is due to the washout of CO from the blood between exposure and
arrival in hospital, and although the COHb level may appear to be low, the value of the test is that it
confirms that this type of inhalation injury has occurred.

Treatment of Inhalation Injury


The management of inhalational injury is focussed on the following priorities:
Ensure a patent airway
High flow oxygen
Frequent monitoring for respiratory deterioration
Discuss suspected systemic intoxication (CO, HCN) with a toxicologist by calling Poisons
Information (Australia 13 11 26, New Zealand 0800 764 766)

During initial assessment (The Primary Survey), it is important that all patients with burns be given
high flow oxygen by non re-breathing mask at 15 litres per minute [9]. This will facilitate maximum
tissue oxygenation while emergency assessment and management continues. Remember a patent
airway is required to deliver oxygen to the lungs.

1. Treatment of Inhalation Injury above the Larynx

All patients with suspected inhalation injury should be under close observation. Because early and
rapidly progressive respiratory obstruction is likely (particularly in children who have relatively small
airways), the equipment for emergency intubation should be readily available [55]. Frequent
reassessment of the patients clinical condition is vital. As soon as increasing airway obstruction is
detected the airway must be secured by endotracheal intubation.

Cervical spine protection is mandatory.


The endotracheal intubation should be performed as soon as possible. Delay may allow further
airway oedema to occur and make subsequent intubation impossible. Stridor and respiratory
distress are definite indications for intubation.

The indications for intubation include:

Need to maintain a patent / protect airway


- impending airway obstruction
- impaired level of consciousness
- to facilitate safe transport

Need for ventilation


- deteriorating oxygenation

If in doubt, intubate.

2. Treatment of Inhalation Injury below the Larynx


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Treatment in this category is primarilythat of Respiratory Support:

(i) High Flow Oxygen


All burn patients should receive high flow oxygen at 15 litres per minute via a non-re-breathing
mask. This is made even more necessary in the face of parenchymal lung injury.

(ii) Intubation[9, 55]


Endotracheal intubation may be necessary to perform bronchial toilet to clear secretions, or to allow
higher oxygen concentrations to be given

(iii) Intermittent Positive Pressure Ventilation (IPPV)


This may become necessary if a patients oxygenation is not responding to the administration of
oxygen and simple securing of the airway. This can be achieved by manual ventilation with a bag
attached to the endotracheal tube and the oxygen supply, or by a mechanical ventilator.

3. Treatment of Inhalation Injury Producing Systemic Intoxication

(i) Respiratory Support


As above, it is important to ensure that burnt tissue is perfused with as much oxygen as possible.
High flow oxygen by mask should be administered [9].

(ii) Protection of the Unconscious Patient


As a result of systemic intoxication patients may be unconscious. Emergency treatment consists of
rolling the patient into the left lateral coma position and administration of oxygen. Cervical spine
protection should occur at all times. The airway should be secured, firstly by chin lift,then an
oropharyngeal airway, but in most instances endotracheal intubation will be necessary.

(iii) Natural Washout Effect with Time


Carbon monoxide (CO) is gradually removed from the blood by diffusion in the alveoli. The time
taken for this to occur is slowest breathing room air at atmospheric pressure but can be reduced by
increasing the concentration of the oxygen administered. When available, hyperbaric administration
of high oxygen concentrations will also increase the speed of washout of carbon monoxide[2]
although the evidence is conflicting as to whether their results in improved neurological outcomes.
Logistics may be complicated in a critically ill patient with major burns.

(iv) Oxygen
The standard emergency treatment is breathing 100% oxygen by mask [2, 9]. This should be
continued until COHb levels return to normal. The secondary washout of CO that occurs from the
cytochrome binding may cause a smaller secondary rise of COHb 24 hours later, and oxygen should
be continued.

(v) Oxygen + IPPV


May be necessary in the unconscious patient, or in the patient who has other types of inhalation
injury apart from systemic intoxication.

(vi) Cyanide Intoxication

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Cyanide intoxication is often fatal.Washout of cyanide from the blood by metabolism in the liver is
slow. Whilst formulations containing hydroxycobolamin for injection have been advocated, this
treatment requires large doses and is not readily available in most emergency departments.

(vii) Hydrogen Fluoride Intoxication


HF when absorbed systemically in significant amounts efficiently binds serum calcium.
Hypocalcaemia is likely to develop. Infusion fluids should contain added calcium to counteract this.

Seek advice for inhaled substances such as cyanide, hydrofluoric acid, etc from Poisons
Information Australia (13 11 26) or New Zealand National Poisons Centre (0800 764 766).

Summary
Inhalation Injury and the related Systemic Intoxication are potentially fatal injuries.

Their diagnosis depends upon the clinical suspicion of their occurrence, and the recognition
of their signs from the history and examination.

Emergency treatment consists of providing respiratory support with oxygen and securing of
the airway, undertaking endotracheal intubation if necessary.

Patients with an inhalation injury or suspected inhalation injury should be referred to a burn
unit for ongoing care after initial emergency stabilisation.

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CHAPTER 5

Burn Wound Assessment

Introduction
Whatever the cause of burns, whether they be thermal, chemical or electrical, the amount of tissue
damage and particularly the depth of burning, is related to the temperature or strength of the
injuring agent, and the length of time that the agent has been in contact with the skin[2, 10][21, 56]

Temperature above 50C will produce tissue necrosis, particularly when the skin is thin as in children
and the elderly.

1. Estimation of the Area of the Burn


The two important determinants of the seriousness of the burn injury are the area and depth of the
burn [32]. The likelihood of mortality following burns is a function of the
Age of the Patient
Percentage of the Total Body Surface Area Burnt (% TBSA)

The greater the surface area of the body injured, the greater the mortality rate.

Accurate assessment of the area of the burn requires a method that allows easy estimation of the
size of the burn as a percentage of the body surface area. This is readily accomplished using the
Rule Of Nines (See Figure 5.1)[21, 25].

The Rule of Nines divides the body surface into areas of nine percent or multiples of nine percent,
with the exception that the perineum is estimated at one percent[21, 25, 27, 56-58]. This allows the
extent of the burn to be estimated with reproducible accuracy. In addition to calculating the area
burnt, it is useful to calculate the area not burnt, and to check whether both calculations add up to
100%.

A method of estimating small burns is to use the area of the palmar surface (fingers and palm) of the
patients hand, which approximates to 1% TBSA [7, 21, 56-58]. This method is useful in smaller,
scattered burns that do not lend themselves to a Rule of Nines method. (see Fig 5.2)

The Rule of Nines is relatively accurate in adults, but may be inaccurate in small children [21]. This
is because the child has different body surface area proportions than the adult. Children have
proportionately smaller hips and legs and larger shoulders and heads than adults. Using the Adult
Rule of Nines may seriously under or over estimate the size of the burn wound of a child, and lead
to inaccurate intravenous fluid resuscitation.

For these reasons the Paediatric Rule of Nines should be used. (see Fig 5.3) This can be modified for
different ages to enable accurate surface area calculations. (see Chapter 9) [2, 21].As the child ages
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the percentages are adjusted. For every year of life after 12 months 1% is taken from the head and
0.5% is added to each leg. Once the child reaches 10 years old their body is proportional to an adult

Figure 5.1

Figure 5.2

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Figure 5.3

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2. Estimation of the Depth of the Burn
The Structure and Function of the Skin

The skin consists of two parts, the epidermis and the dermis[2, 57, 59-62]. The epidermis is the
superficial thinner layer that is responsible for limiting the evaporation of water from the body, and
is constantly being reproduced by division of the basal layers of the epidermis [63, 64].
(See Figure 5.3).
Figure 5.3 Cross-section of normal skin

The dermis is the deeper, thicker layer that provides


the strength and durability of the skin [63]. The
dermis contains the blood supply and the sensory
nerves of the skin. The dermis also contains the
epidermal adnexal structures: hair follicles and their
epidermal lining, sebaceous glands, and sweat glands
with their ducts [63][32, 64]. These reservoirs of
epithelial cells under the control of growth factors will
undergo mitosis and can produce an epithelial
covering that will heal a superficial-dermal to mid-
dermal thickness wound [26]. This process is called
epithelialisation.

Underneath the dermis lie the padding layers of subcutaneous fat [63] and fascia that separate the
skin from the deeper muscular and bony structures. These layers provide important cushioning from
trauma and their damage in burns means inevitable tethering of skin to deeper structures.

The anatomy of the skin of the nose and external ears is different from elsewhere in the body, as
here the skin is very closely applied to the underlying cartilage with little subcutaneous fat. The
blood supply for both the skin and cartilage runs between the two. Burns to the nose and pinna may
therefore produce damage to the blood supply of the skin and cartilage. Skin and cartilage loss may
cause significant deformity, particularly if bacterial chondritis supervenes.

Depth of Burn Injury


Depending upon the depth of tissue damage, burns may be grouped in 3 main classifications as
superficial, mid and deep burns. They are then further defined as epidermal, superficial dermal, mid-
dermal, deep dermal or full thickness (see Figure 5.4 and Table 5.1). In practise all burns are a
mixture of areas of different depth [7, 9, 21].
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Depth of Burn
Burn Wound Healing Epidermal
Epidermis
= re-epithelisation
Superficial
Dermis Dermal
- capillaries
- nerves Mid
- collagen
& elastin fibres
Dermal

Sebaceous
gland Deep
Dermal
Hair follicle
Sweat
gland
Full
Subdermal Thickness
fat

Figure 5.4

Table 5.1
Diagnosis Of Burn Depth[10]

Capillary Sensati Heal


Depth Colour Blisters
Refill on ing
Epiderma
Red No Present Present Yes
l
Superficia Pale
Small Present Painful Yes
l Dermal Pink
Mid Dark Usu
Present Sluggish +/-
Dermal Pink ally
Deep Blotchy
+/- Absent Absent No
Dermal Red
Full
White No Absent Absent No
Thickness

A. Superficial Burns

Superficial burns are those that have the ability to heal themselves spontaneously by
epithelialisation. These superficial burns may either be epidermal or superficial dermal in depth.

1. Epidermal Burns

Epidermal burns include only the epidermis. Common causes of this type of burn are the sun
and minor flash injuries from explosions. The stratified layers of the epidermis are burnt
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away and healing occurs by regeneration of the epidermis from the basal layer. Due to the
production of inflammatory mediators, hyperaemia is produced so these burns are red in
colour and may be quite painful (see Table 5.1)[10]. This could be difficult to assess in dark
skin individuals as erythema is often masked by the dark pigment of the skin. They heal
quickly (within seven days), leaving no cosmetic blemish [59]. Hospital admission may be
required for pain relief [21].

Pure erythema (epidermal burn) is not included in estimations of the total body surface area
burnt[10]. Differentiation between pure erythema and superficial dermal burn may be
difficult in the first few hours after injury.

2. Superficial Dermal Burns

Superficial dermal burns include the epidermis and the superficial part of the dermis - the
papillary dermis. The hallmark of this type of burn is the blister[2]. The skin covering the
blister is dead and is separated from the viable base by the outpouring of inflammatory
oedema. This oedema tents up the necrotic roof forming a blister. This blister may burst
exposing the dermis which, following exposure, may desiccate and die. This causes increased
depth of tissue loss. The exposed papillary dermis is pink. Because sensory nerves are
exposed, the burn is usually extremely painful [21]. Under suitable conditions epithelium will
spread outwards from the adnexal structures (hair follicles, sebaceous glands and the ducts
of sweat glands) and join neighbouring islands of epithelium to cover the dermis
(epithelialisation).

Superficial dermal burns should heal spontaneously by epithelialisation within 14 days


leaving only a colour match defect. No scarring should be produced in this type of burn.

If healing is delayed it means that the burn is deeper than originally diagnosed.

B. Mid-dermal Burns
A mid-dermal burn, as its name suggests, is a burn injury that lies between a superficial dermal burn
(described above) which will heal relatively rapidly, and a deep dermal burn (described below) which
will not. At the mid-dermal level, the number of surviving epithelial cells capable of re-
epithelialisation is less due to the deeper burn wound and so rapid spontaneous burn wound healing
does not always occur.

Clinically, the appearance is determined by damage to the dermal vascular plexus of varying
degrees. Capillary refill may be sluggish, and tissue oedema and blistering will be present. The
burned area is usually a darker pink than that of a superficial dermal burns
light pink, but not as dark as a deep dermal burns blotchy red[10]. Sensation to light touch may be
decreased, but pain persists, reflecting the damage to the dermal plexus of cutaneous nerves.

C. Deep Burns
Deep burns are more severe. They will either not heal spontaneously by epithelialisation, or only
heal after a prolonged period with subsequent significant scarring. They may be either deep dermal
or full thickness.

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1. Deep Dermal Burns

Deep dermal burns may have some blistering, but the base of the blister demonstrates the
character of the deeper, reticular dermis often showing an appearance of a blotchy red
colouration[2, 10]. This red blotchy colouration is due to the extravasation of haemoglobin
from destroyed red cells leaking from ruptured blood vessels. The important hallmark of
these burns is the loss of the capillary blush phenomenon. This demonstrates that the burn
has destroyed the dermal vascular plexus. The dermal nerve endings are also situated at this
level and so in these burns sensation to pinprick will be lost.

2. Full Thickness Burns

Full thickness burns destroy both layers of skin (epidermis and dermis), and may penetrate
more deeply into underlying structures[2]. These burns have a dense white, waxy, or even a
charred appearance. The sensory nerves in the dermis are destroyed in a full thickness burn,
and so sensation to pinprick is lost[2, 10]. The coagulated dead skin of a full thickness burn,
which has a leathery appearance, is called eschar.

Summary
The seriousness of a burn is determined by the area of patient burnt, and the depth of the burn.

The mortality from burns is related to the age of the patient and to the extent of the burns.

The Adult and the Paediatric Rule of Nines enable a reproducible assessment of burn extent to
be calculated.

By clinical examination of the burn wound it may be possible to diagnose the depth of the burn.

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CHAPTER 6

Burns Shock and Fluid Resuscitation


Burn injury precipitates a large amount of fluid sequestration into the area of injury and when the
size of greater than 20% TBSA this process becomes generalised [32, 35]. Oedema is formed in great
quantity and when combined with ongoing evaporative loss from the moist burn surface results in
significantly decreased plasma volume. This in turn leads to intravascular hypovolaemia which, if not
corrected, precipitates organ system failure, especially renal failure [16].

This chapter will expand on the pathogenesis of oedema formation and post-burn hypovolaemic
shock, fluid resuscitation and its monitoring.

Thermal injury causes marked changes in the microcirculation both locally at the site of injury and
elsewhere [16]. A burn develops three zones of decreasing injury (see Figure 3.1 Jacksons Burn
Wound Model p23):

1) Central zone of coagulative necrosis.


2) Intermediate zone of injury characterised by stasis of blood flow.
3) An outer, peripheral zone showing vasodilatation, increased blood flow and hyperaemia.

Mediators are produced and released at the burned site that alter vascular membrane integrity and
so increase permeability[2]. These mediators include histamine, serotonin, prostaglandins,
bradykinin and potent vasoconstrictors such as thromboxanes and angiotensin.

In large burns (2030% TBSA), the quantity of these mediators produced at the burn site is so great
that they induce widespread increased vascular permeability which leads to generalised oedema
formation [18]. Hypovolaemic shock soon follows. In addition to this, an anatomical derangement of
the endothelial lining of the microvasculature can be detected on electron microscopy.

Evidence in favour of one resuscitation fluid in comparison with another is conflicting [19, 65]. From
a practical point of view, however, the ready availability of crystalloid solutions such as Hartmanns
Solution (Lactated Ringers) have made them the internationally accepted choice for initiation of
resuscitation [2, 66].

Children have limited physiological reserve and greater surface area to mass ratio compared to
adults. The threshold at which fluid resuscitation is required in children is lower than for adults
(approximately 10%) and they tend to need a higher volume per kilogram [3, 18]. In fact, this
increased need for fluids equates with the volume of normal maintenance requirements over that
calculated by fluid resuscitation formulae. Inhalation injury further increases fluid requirements.
Oedema formation ceases between 1830 hours post-burn. Therefore, the duration of resuscitation
is variable but can be recognised when the volume needed to maintain adequate urine output is
equal to maintenance requirements.

Estimation of Fluid Needs


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The extent of the burn is calculated using the rule of nines or a burn body chart if available. If
possible the patient is weighed or weight obtained during history taking. These data are then used in
a fluid resuscitation formula [3, 12, 13, 15, 17, 18, 35, 67, 68]:

Adults: 34ml crystalloid x kg body weight x percent (%) burn

Children:34ml crystalloid x kg body weight x percent (%) burn plus maintenance with 5% Glucosein
0.45% ( normal) saline2

100 ml/kg up to 10 kg
+
50 ml/kg from 1020 kg
+
20 ml/kg for each kg over 20 kg

NOTE: The calculation of fluid requirements commences at the time of burn, not from the time of
presentation.

Fluid Should Be Administered Via Two Large Cannulae (at least 16g in adults), preferably inserted
through unburned skin. Consider intra-osseous (IO) access if needed.

The calculated volume is that estimated for the first 24 hours [12]. As oedema formation is greatest
soon after injury:

Half the calculated volume is given in the first 8 hours [3] and the remaining half given
over the subsequent 16 hours [12, 15, 19, 67].

Maintenance fluid for children is given at a constant rate over 24 hours.

This step-down does not match the gradual decrease in oedema formation and emphasises that
these formulae are only guidelines that may need to be altered to match individual requirements
[15].

If urine output is not adequate, give extra fluid:

Boluses of 510 ml/kg or increase the next hours fluids to 150% of planned volume.

In the second 24 hours post burn, colloid fluids can be used to help restore circulating volume using
the formula [66, 69]:

0.5ml of 5% albumin x kg body weight x % burn.

2
Some half-normal saline is packaged with 2.5% dextrose: to this add a further 25ml of 50% dextrose to each 500ml bag. If
the solution in the pack is half-normal saline without any glucose, add 50 ml of 50% dextrose to each 500ml bag.Whenever
possible use pre-prepared 5% glucose in 0.45% saline.

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In addition, electrolyte solution should be provided to account for evaporative loss and normal
maintenance requirements. Vomiting is commonplace and such losses should also be replaced. A
commonly used solution is:

Normal Saline + Potassium (+ Dextrose for children)

Monitoring adequacy of fluid resuscitation


The best, easiest and most reliable method of monitoring fluid resuscitation is by following urine
output [3, 7, 11, 14, 18, 20, 35]:

Adults 0.5ml/kg/hr = 3050ml/hour


Children (< 30kg) 1.0ml/kg/hr (range 0.52ml/kg/hr) [66, 68-71]

If urine output is kept near these levels then adequate organ perfusion is being maintained [20].
Large urine output indicates excessive fluid resuscitation with unnecessary oedema formation; low
urine output indicates poor tissue perfusion and likely cellular injury.

Clearly, a urinary catheter is vital for accurate monitoring and should be inserted for burns
>10% TBSA in children
>20% TBSA in adults

Central invasive haemodynamic monitoring is only occasionally indicated and is used for those with
pre-morbid cardiac disease or coexistent injuries causing blood loss such as multiple fractures.

Significant acidaemia (pH 7.35) detected on arterial blood gas analysis commonly indicates
inadequate tissue perfusion and is usually due to lactic acidosis. Increased fluid resuscitation is
indicated. If unsuccessful in restoring pH or if haemochromogens are present in the urine, consider
bicarbonate after discussion with the intensive care unit. Acidosis may also indicate the need for, or
inadequacy of, escharotomy.

Blood pressure readings with a sphygmomanometer are notoriously inaccurate due to oedema
formation and accurate measurements can only be obtained via an arterial line. These are
recommended in large burns.

The heart rate is usually raised in burn patients due to pain and emotion and so is a poor indicator of
adequacy of fluid resuscitation.

Serum electrolytes should be measured initially and at regular intervals. Mild hyponatraemia is
common due to dilution by the infusion depending on the sodium concentrate of the crystalloid
solution used (Hartmanns solution NaCl is only 130 meq/l.). Hyperkalaemia commonly occurs with
tissue injury in electrocution. Bicarbonate and glucose plus insulin may be required to correct this
problem.

Restlessness, mental obtundation, and anxiety are often indicators of hypovolaemia and the first
response should be to look to the adequacy of fluid resuscitation.
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Haemoglobinuria
Tissue injury, particularly muscle tissue, from electrocution, blunt trauma or ischaemia causes
release of myoglobin and haemoglobin. Strongly consider performing a fasciotomy (as opposed to an
escharotomy which doesnt release deep muscle fascia). These haemochromogens colour the urine a
dirty red. Acute renal failure will soon ensue as a result of deposition of these haemochromogens in
the proximal tubules, and prompt treatment is required [23]:

Increase urine output to 2 ml / kg / hr


Consider a single dose of Mannitol 12.5g over 1 hour and observe response

Problems with Resuscitation


Formulae only estimate requirements and the individual patient must be closely monitored.

Oliguria

Low urine output indicates inadequate fluid resuscitation. The appropriate first response is to
increase the rate of infusion. Diuretics are rarely necessary and should not be considered until after
consultation with a burn unit. They are used in patients with haemochromogens in the urine and
occasionally in patients with very large burns.

The following patient groups routinely require extra fluid resuscitation [15]:
Children
Inhalation Injury [19]
Electrical Injury
Delayed Resuscitation
Dehydration - firefighters, intoxicated patients

Infants, elderly and those with cardiac disease should be monitored closely as fluid overload may be
precipitated. Fortunately, pulmonary oedema is uncommon due to disproportionately greater
increase in pulmonary vascular resistance than systemic vascular resistance. It occurs in those with
myocardial hypokinesia and often requires invasive monitoring, inotropic support, ventilation and
difficult alterations in fluid management.

Children

Children are prone to hypoglycaemia, fluid overload and dilutional hyponatraemia due to limited
glycogen stores, higher surface area to weight and intravascular volume ratios. Blood glucose and
electrolyte levels should be measured regularly. Free water should be limited and a source of
carbohydrate instituted early. This could be enteral feeding or addition of dextrose to the electrolyte
solution.

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Abdominal Compartment Syndrome

This rare but serious secondary complication can occur in large burns in adults as well as children
especially when the calculated fluid requirements have been exceeded to achieve adequate urine
output [15, 16, 72]. It is suggested that if the presence or development of Abdominal Compartment
Syndrome is being considered that bladder pressure monitoring can give valuable information.

Summary
Fluid resuscitation is necessary for survival.

Intravenous fluids for: children >10% TBSA


adults >20% TBSA

Two large bore peripheral cannulae

Calculation fluids commences at time of injury:

Child (<30kg) 34 ml x kg x %TBSA burn plus maintenance


Adult 34 ml x kg x %TBSA burn

Half in first 8 hours, rest over next 16 hours.

Use crystalloids (e.g. Hartmann's solution) during first 24 hours.


Children need carbohydrate.
Insert a urinary catheter.
Haemochromogens: increase fluid resuscitation to double urine output.
Measure blood glucose, serum electrolytes, blood pressure, pulse, arterial blood gases, chest x-
ray.

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CHAPTER 7

Management of the Burn Wound


Introduction
In order to manage a burn wound it is essential to understand the mechanism of injury and to be
able to assess the extent of that injury. This establishes a starting point for treatment, the object of
which is the best possible functional and cosmetic outcome.

A wound is a disruption of tissue architecture and cellular processes. In a burn the denaturing of
proteins and disruption of cellular structures is due to thermal insult (either heat or cold), electricity,
chemical action or radiation. The burn wound is significant because it interferes with all seven major
functions of the skin

Aesthetic and psychological interface


Temperature regulation
Sensory interface
Immune response
Protection from bacterial invasion
Control of fluid loss
Metabolic function

The aim of treatment is to minimise the interference with function both locally and systemically.

It is important to understand that the wound is dynamic and often heterogeneous [7, 9, 21]. DO NOT
assume that all areas of the burn are equally deep.

First Aid
The principles of first aid are to
stop the burning process
cool the burn wound [22].

Stopping the burning process reduces tissue damage. Cooling the surface of the burn wound reduces
the production of inflammatory mediators (cytokines) and promotes maintenance of viability in the
zone of stasis. It therefore helps to prevent progression of damage that occurs in an untreated burn
in the first 24 hours after the injury [25].

Stop the Burning Process


In flame burns the flame should be extinguished by the patient rolling on the ground either actively
or passively using the Stop, Drop, Cover (face) & Roll technique [10, 24]. Hot charred clothing should
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then be removed as quickly as possible. It does not help the patient if observers or assistants have
burned hands so it is important that any assistance be rendered in such a way that the helpers are
not themselves injured.

In a scald burn the clothing soaked with fluid acts as a reservoir of heat and so removal of clothing as
rapidly as possible will stop the burning process.

In addition to removing the clothing, all jewellery should be removed[2]. If clothing is firmly stuck to
the surface of the skin cut around the area leaving the adherent cloth in place. However melted
synthetic compounds adhere to the surface of the skin which is non-viable and will come away quite
easily. Because it is non-viable this is no disadvantage to the patient.

Cooling the Burn Surface


The burn surface should be cooled with cold running water [73-78]. The ideal temperature is 15C
and the range that is useful is between 8C and 25C [76, 79]. Cooling the surface reduces the
inflammatory reaction and can therefore stop progression of necrosis in the zone of stasis [73, 80].

The technique of application is by allowing cold water to flow over the burn wound, if this is
possible. Methods such as spraying or sponging water over the wound, wet towels or hydrogels are
not as efficient as running water and should not be used unless there is no water readily available
i.e. in transit to medical care[73, 81]. Wet towels are less efficient as they are not in contact with the
burn wound in all areas, and quickly heat up due to proximity to the body [73]: if used, they must be
changed frequently.

The duration of application should be for twenty minutes unless some other factor prevents this
from happening [73-76, 80].For example, the patient may have multiple injuries and there may not
be personnel available to perform first aid for this length of time. First aid is effective within the first
three hours following the burn injury.

Small children are at significant risk of becoming hypothermic and if this is detected either by taking
the temperature or by clinical assessment of the blue shivering child, application of cold water
should cease. To reduce the risk of hypothermia it is desirable to raise the ambient temperature to
over 30C and to keep the rest of the child well wrapped[4].

Ice or iced water should not be used. The extreme cold causes vasoconstriction and experimentally
has been shown to deepen the tissue injury. There is also a greater risk of hypothermia.

Cooling the surface of the burn is also an extremely effective analgesic [22, 74, 76]. If pain re-
appears within minutes of ceasing cold-water application, and there is no other factor preventing its
continued application, it may be continued for its analgesic effects.

Hypothermia should be prevented at all costs.

Early Management

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Once first aid has been completed the burn wound can be covered with plastic wrap or a clean dry
non-stick dressing while other aspects of the patients care are performed [2, 24]. If the burn wound
has not had cold fluid applied and the lapse of time since the accident is greater than three hours,
application of cold water does not have a beneficial effect. The wound should therefore be washed
and this can be done with saline, soap and water, or chlorhexidine 0.1% solution. Other antiseptics
should not be applied.

In preparation for transport the patient may need a dressing on the burn wound. Depending upon
the time between injury and transport and the expected time taken during the transporting process,
it may be necessary to apply something more than simply wrapping the area in a clean cloth. Plastic
cling film can be used and is particularly useful in children because it limits evaporation and hence
heat loss [22]. Chlorhexidine impregnated Vaseline gauze (e.g. Bactigras) held on with a light
bandage is suitable for patients who are going to take some hours during the transport process. The
use of topical agents on the burn wound is reserved for those patients in whom there is significant
delay or prolonged transport time and should be done in consultation with the receiving burn
centre. For these patients the use of an antimicrobial dressing (e.g. Acticoat, Flamazine or Bactigras)
is suggested.

Elevation
Elevation of an injured limb is useful during initial treatment and transport, as it tends to limit
swelling. In the limbs this may make a difference between the need to perform an escharotomy or
not. There is also a theoretical possibility that tissue nutrition is impaired by oedema increasing the
diffusion distance between the capillaries and the cells.

Special Areas
As mentioned in the section on respiratory burns, thermal burns of the upper airway are often
associated with rapidly accumulating swelling and early intubation is necessary[2].

Burns of the perineum require early urinary catheterisation in order to prevent contamination. Delay
in catheterisation may cause extreme difficulty in insertion of the catheter once swelling has become
established.

Burns of the head and neck should have elevation of the head to limit upper airway swelling.
Children with extensive burns or with burns of the head and neck benefit from the head up position
because they have a greater risk of cerebral oedema with fluid resuscitation.

Escharotomy
When the burn injury affects the whole of the dermis the skin loses its ability to expand as oedema
progresses [82]. It therefore may become necessary to release the burn wound surgically by incising
the burned skin down to the subcutaneous fat [7, 82]. This procedure is called escharotomy.

Trunk
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When the trunk is extensively burned rigidity of the chest wall decreases compliance and this may
reduce ventilation [2, 82]. In adults this problem is seen with circumferential burns of the chest with
or without involvement of the abdomen. In children whose breathing is principally diaphragmatic,
the problem can be seen when the anterior aspect of the chest and abdomen are burned without
the injury extending to the posterior aspect.

The incisions to be made run longitudinally along the anterior axillary lines to the costal margin or to
the upper abdomen if this is burnt [82]. In severe cases it may be beneficial to connect these
incisions by two cross incisions which may be convex upwards across the upper chest below the
clavicles and across the upper part of the abdomen.

Extremities

When a limb is burned circumferentially the increase in pressure due to the accumulation of oedema
under the rigid burned skin may interfere with circulation and cause death of tissue in the distal part
of the extremity [21]. The onset of circulatory embarrassment is slowly progressive and subtle if not
sought. The increase in pressure may be detected by the appearance of one or more of the following
[82, 83]:

Deep pain at rest


Pain on passive movement of distal joints
Loss of distal circulation
Pallor
Loss of capillary return (especially in the nail beds)
Coolness
Decrease in pulse pressure as detected by Doppler ultrasound
Loss of palpable pulses
Numbness
Decreased oxygen saturation as detected by pulse oximetry

The interpretation of these signs may be made difficult by the presence of burned skin (which makes
feeling the pulses difficult), by cold (which gives the appearance of decreased capillary return), and
by hypovolaemia. The most accurate method of assessment is the use of Doppler ultrasound. The
earliest changes will be loss of Doppler signals from the digital vessels. Escharotomies should be
performed before pulses are lost when there is evidence of decreasing circulation.

The incisions should extend by a few millimetres onto normal skin above and below. The incisions
are in the mid-axial lines between flexor and extensor surfaces. Avoid incisions across the flexural
creases of joints. They should be carried down to the fat sufficiently to see obvious separation of the
wound edges. Running a finger along the incision will detect residual restrictive areas. Sometimes
one incision is enough but often incisions on both sides are necessary to restore circulation. The
palpable softness of the limb is a useful guide.

The danger of escharotomy is to structures under the skin. In particular medially at the elbow the
ulnar nerve is vulnerable and laterally at the knee the common peroneal nerve is at risk. Transverse
incisions in the limbs should not be made.

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The distal extent of escharotomy is sometimes difficult to assess. In the upper limb the medial
incision can pass along the medial border of the hand to the base of the little finger. On the lateral
aspect the incision can come down to the proximal phalanx of the thumb. Occasionally further hand
incisions may be necessary but before embarking on this the burn referral unit should be contacted.

Diagrams of appropriate lines of incision are included in the manual as Appendix 3 and can be
rapidly supplied by fax.

Procedure Plan
The first step is to define the lines of incision. If the operator is not familiar with the procedure they
can be drawn with a pen/marker. For this marking the limb needs to be held in its anatomical
position; and then the markings inspected before a final decision is made. When the arm is burnt,
the forearm naturally lies in pronation so needs to be supinated before marking and incising. In the
upper limb the incision should go in front of the medial epicondyle to avoid damage to the ulnar
nerve.

In the lower limb the medial incision passes behind the medial malleolus avoiding the long
saphenous vein and saphenous nerve. If a second incision is required laterally, care should be taken
to avoid the common peroneal nerve where it crosses the neck of the fibula. This incision is in the
mid-lateral line.

The equipment needed is a scalpel or cutting diathermy and some means of haemostasis. Artery
forceps and ties, diathermy or topical haemostatics such as calcium alginate are useful. Blood loss
can at times be extreme.

Anaesthesia is usually not necessary. Local anaesthetic is necessary at the edge of the burn to extend
up into normal tissue adequately. Many of these patients may already be intubated and therefore
sedated under which circumstance a little extra sedation can be given.

Dressings should be available to dress the area once the incision is performed. The area is prepared
as for a surgical procedure and performed in a sterile fashion. Light dressings are applied as firm
dressings may interfere with the effectiveness of the procedure.

If the patient is conscious the procedure should be explained to them prior to commencement.

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Summary
Burns interfere with all functions of the skin.

First aid consists of stopping the burning process and then cooling the burn wound.

Immediate treatment of the wound should be kept simple.


Rigid eschar may interfere with body functions so escharotomy may be needed on the chest
to allow ventilation, or on the limbs to prevent distal circulatory obstruction.

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CHAPTER 8

Indications and Procedures for Referral


Introduction
The patient with electrical, chemical, or thermal injury requires immediate assessment and
stabilisation at the nearest hospital. There is no case for the occasional burn surgeon in Australia
and New Zealand, as expert multidisciplinary care is readily available at central hospitals. All patients
have the right of access to quality burn care. Initial treating personnel should complete a primary
and secondary assessment and evaluate the patient for potential referral and transfer. Burn injuries
may be a manifestation of multiple traumas, and the patient must be evaluated for associated
injuries. All procedures and treatments administered need to be documented to provide the
receiving burn unit with a record that includes a flow sheet of observations, medications and
treatments.

Influence of Geographic Situation


1. Urban Areas
In cases of burns that occur in those cities of Australia and New Zealand that have an established
burn unit, patients requiring hospital admission should be transported to that unit without
unnecessary delay after a primary survey has been conducted, so that resuscitation and definitive
care can begin as soon as possible. The only exception to this rule is in those cases that require
immediate life-saving intervention, such as endotracheal intubation.

When the burn unit is within an hours ambulance ride, unnecessary delays to begin IV fluid
resuscitation may not be in the patients best interests. Nevertheless, significant delays can occur in
short transports, necessitating fluid resuscitation to be

2. Rural and Isolated Areas

In isolated and rural areas, because of distance and sparse facilities and also because of logistic
problems, it may not be possible to transfer the patient immediately. Patients may need to be
transferred by road, aeroplane or helicopter. Twenty-four hours of treatment may be required
before transport is possible. It may occasionally be necessary to treat patients for longer than 24
hours (see Chapter 12). In these circumstances it is the responsibility of the local treating medical
and nursing staff to liaise with the staff at the regional burn unit regarding appropriate emergency
management, so that when the transfer occurs the patient is in optimal condition. Only in the most
exceptional circumstances are the patients best interests served by continuing treatment at a local
or district hospital. Sacrificing good physical care for the perceived advantages of keeping the family
together is detrimental, particularly as the emotional care of the burned patient is as specialised
and as important to their long term outcome as the physical care. All specialised burn units

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recognise this need and have facilities for relatives to stay as well as personnel trained to help both
patient and family achieve an optimal emotional outcome.

Referral Criteria
The Australian and New Zealand Burn Association has identified the following injuries as those
requiring referral to a burn unit - see Table 7.1.

All patients with these injuries should have early consultation with a burn unit. If there are local
resources that are appropriate, some patients may not need transfer, but generally, all patients
listed will need transfer.

Table 7.1
Burns greater than 10% Total Body Surface
Area (TBSA)
Burns greater than 5% TBSA in children
Full Thickness burns greater than 5% TBSA
Burns of Special Areas - Face, Hands, Feet,
Genitalia, Perineum, Major Joints and
circumferential limb or chest burns
Burns with inhalation injury
Electrical burns
Chemical burns
Burns with pre-existing illness
Burns associated with major trauma
Burns at the extremes of age young
children and the elderly
Burn injury in pregnant women
Non-accidental burns

If the patient has a pre-existing disorder that could make management more difficult or the risk of
injury greater, a specialised team is needed to give maximum chance of an optimal result.

Those patients with concurrent trauma should be admitted to a burn unit or a trauma unit
depending upon the severity of the associated trauma and the seriousness of the burn. There needs
to be a balance based on the clinical findings at the time of emergency assessment and following
discussion between the local trauma team and the burn unit personnel. If the associated trauma
poses the greater immediate risk the patient may initially be treated in a trauma unit until stable,
prior to transfer to the burn unit. Burn care must be provided concurrently and transfer arranged
after the patient has recovered from the immediate effects of the multiple trauma. Should the burn
injury present the dominant threat to mortality and the greatest risk of morbidity, then primary
transfer to the burn unit is correct. The priorities are a matter for medical judgement and should be
discussed by the referring doctor, the burns specialist and the trauma or intensive care specialist,
bearing in mind that patients at the extremes of age have a higher mortality and morbidity after a
burn injury. Their pathophysiological responses are less predictable so they need the benefit of a
specialised team.
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The burn team approach, of bringing together doctors, nurses, physiotherapists, occupational
therapists, psychiatrists, psychologists, social workers and dietitians in a management team has a
significant and beneficial effect on the outcome of major burn injuries [2].

Preparation for Transfer


Patients who are physiologically stable are capable of safe transfer over long distances, even after
massive injury. It is therefore essential for the patient to be stabilised prior to starting their journey.
Stabilisation involves all the aspects of resuscitation and management outlined above.

1. Respiratory System

All patients with major injuries should be commenced on high flow oxygen at 15L/min.
Since upper airway obstruction can progress rapidly and its effects peak at a time when the
patient is likely to be in the process of transfer, it is essential to consider and decide about the need
for endotracheal intubation BEFORE the journey is started.
Infraglottic injury is less likely to be a problem during transport.

2. Circulatory System
The principles of treatment of the predictable shifts in fluids and electrolytes given above are valid
for the stabilisation of the patient prior to transport.
If insertion of 2 cannulae (16 gauge in adults, 20 gauge in children) is not possible, other
routes of access should be considered and their feasibility discussed with the referral unit.
The method of vascular access will largely be determined by the experience of the team at
the peripheral site or the experience of the retrieval team.
The routes available are percutaneous central venous line (femoral, subclavian, or internal
jugular), intra-osseous needle or peripheral cutdown (ankle or elbow usually)[3, 7, 9].

The fluid regime is discussed in Chapter 6. In summary, commence resuscitation with


34ml crystalloid (e.g. Hartmanns Solution) x kg x % in 24 hours, 50% of which is given in the
first 8 hours post burn
Add maintenance fluid for children [3, 12, 15, 17].
Adequacy of resuscitation is determined by observation of the patient, particularly the
urinary output (via an indwelling catheter), aiming for 3050 ml/hr in adults, and 1 ml/kg/hr (0.52
ml/kg/hr) in children up to 30 kg [3, 11, 14, 20].
If haemochromogenuria occurs, as is common after electrical injury, the aim is 75100 ml/hr
in adults, or > 2 ml/kg/hr in children.

3. Burn Wound

The burn wound should be washed with aqueous chlorhexidine solution 0.1% or normal saline and
then covered with plastic wrap or a clean dry sheet if evacuation is to occur quickly. Plastic kitchen
wrap is useful as a cover for burn wounds as it reduces evaporation thus preserving heat and
preventing desiccation [22]. Only if transfer is to be delayed should more formal dressing (such as

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slow-release silver dressings, antibacterial cream or chlorhexidine impregnated Vaseline gauze; and
absorbent outer layers) be undertaken. This should only be after liaison with the receiving burn unit.

4. Pain Relief

A burn injury is extremely painful. Even though skin sensation may be lost locally over a deep burn,
the surrounding area is very painful, so all burned patients need adequate pain relief [9]. In all but
the most minor burns, it is essential for narcotic analgesia to be given intravenously. Doses are given
in small increments allowing 35 minutes between each, the final dose being determined by the
patients response. Any pre-existing disease or associated injury should be taken into account when
calculating doses, but a starting dose of morphine is 0.050.1 milligrams per kilogram of body
weight.

5. Gastro-Intestinal System

While early enteric feeding is desirable (either oro-gastric or naso-gastric) the transfer process is
usually safer if the stomach is empty to minimise the risk of vomiting and aspiration. A naso-gastric
tube, regularly aspirated and on free drainage, is needed for adults with burns >20% TBSA, and for
children with burns >10% TBSA.

6. Tetanus

Tetanus prophylaxis should be given at the first point of medical contact. Details are in Appendix 1.

In order to ensure that optimal treatment is continuous between the point of first contact and the
referral centre, documentation must be complete and should include all the above aspects.

Transfer Mechanism
Early telephone contact with a referral unit should be initiated when any patient may need to be
transferred. Once the decision to transfer has been made, the receiving burn unit will be responsible
for arranging a bed and the referral unit will be responsible for arranging transport. Transfer
procedures should be followed in accordance with local protocols.

The responsibility of the referring centre is to stabilise the patient and to document the findings of
the primary and secondary survey, and the care given. Times of events, tests, fluid balance and
treatment, including doses of medications, are important. Transfer the patient and ensure copies of
all documentation accompany them.

The method of retrieval is determined by the referral centre and the retrieval team, who in turn rely
on the advice and assessment of the referring centre.

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Summary
Patients with electrical, chemical, or thermal injuries which meet the ANZBA Criteria for
Burn Unit Referral (Table 7.1) should be assessed and stabilised while referral is initiated.

Retrieval and placement are the responsibility of the referral unit. The retrieval team will
provide help in the stabilisation of the patient.

Documentation is essential for the successful transfer of care from the referring hospital to
the burn unit.

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CHAPTER 9

Burns in Children
Introduction
Many of the basic concepts of emergency burn care in adults also apply in children. Children with
burns should be assessed and treated in the same way using the Primary and Secondary survey. As in
adults, a primary survey should detect and correct immediate life threatening conditions. This
should result in the patient having a secure airway, and adequate circulation that will need to be
monitored by continual re-assessment of fluid input, based on an adequate urinary output.

The significant differences between children and adults are:

the size and body proportions of the child[2]


fluid dynamics
the thickness of the skin
the different social and emotional development of children.

Epidemiology
There is a higher proportion of the paediatric population which suffer burns compared to adults [3],
and causation of paediatric burns differs from adults, as shown in Table 9.1

Table 9.1
Causes of Childrens Burns (%)
Scalds 55%
Contact 21%
Flame 13%
Friction 8%
Electrical 1%
Chemical 1%
Other 1%
(ANZBA Bi-NBR Annual Report 2011[8])

Younger children have a higher proportion of scalds while flame burns are more common in older
children [84, 85].
History
As in all burns an accurate history is essential [21]. This should include a history of the mode of injury
and the time of the accident. Particular notice should be taken of any part of a history in which there
are inconsistencies with the physical findings or a delay in presentation as these may point to non-

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accidental injury. Occult airway problems such as sleep apnoea or asthma should be identified, and
the history is important in forming a basis for the psychological care of the child and family.

It is also useful to find out what first aid was given and in the case of scalds how hot the fluid may
have been at the time of the incident and what clothes the child was wearing. This will help give an
indication of the possible depth and whether any education might be required.

Body Size and Proportions


The child differs from the adult in its overall surface area to body weight ratio, and in the relative
size of different body parts compared with others [7].The higher surface area to body weight ratio
means that for a given body weight there is a [21]:

higher metabolic rate


greater evaporative water loss
greater heat loss

All of these are highly relevant to the care of the burned child as fluid replacement formulae for fluid
resuscitation are based on weight rather than surface area. Use of formulae based on surface area is
complex and therefore too difficult for universal usage, but from a practical standpoint the burned
child is more likely to need variations from the calculated volumes than is an adult.

In a child the head and neck are comparatively larger than in an adult, and the legs are
comparatively smaller (see Figure 5.2) [21]. In a child up to one year of age the head and neck are
18% of the total body surface area whereas each leg is approximately 14%. For every year of life
above the first, the head decreases in relative size by approximately 1% and each leg gains 0.5% in
comparison with total body surface area [3]. Using this rough modification of the rule of nines it can
be seen that for practical purposes the adult proportions are attained at ten years of age. Obviously
there is the chance of seriously miscalculating the size of the burn and hence the fluid resuscitation if
this factor is not borne in mind.

The Depth of Burn


The depth of the burn is proportional to the amount of heat applied and the duration of its
application, and inversely proportional to factors that resist tissue damage. The chief of these factors
is the thickness of the skin. In children the skin is much thinner than in adults. For this reason a given
thermal injury is more likely to result in a deep dermal or full thickness burn in a child than in an
adult.

An example of this is that in infants water of 60C will cause


In infants a full thickness burn in less than a second
Older children can tolerate up to five seconds of immersion at this temperature.
An adult will only receive a deep burn after twenty seconds.

Childrens Avoidance Reactions


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Childrens reactions to painful stimuli are not as rapid or as consistent as adults. A toddler standing
in hot water or on hot embers may not attempt to move away, thus sustaining a deep burn.

Burn Depth Assessment


The assessment of depth of a burn in children is more difficult than in adults. In children scald burns
are more common than flame burns, and the depth of the scald burn is more difficult to assess. The
childs thin skin makes the depth of the burn more difficult to assess [7]. The colour changes in
burned skin in children are not always the same as those in adults. In particular a dark lobster red
with slight mottling in a child is indicative of a deep dermal or full thickness burn, and in a few days
will usually become an opaque even yellow colour of an obviously deep burn.

First Aid and Initial Transport


The principles of first aid remove the heat source and apply cold water - are the same in children
as in adults. However, hypothermia is a much greater risk in children than in adults.

Hypothermia in children is due to a number of factors. The larger body surface area to mass ratio is
of particular importance. Children under one year of age do not have a shivering reflex. Older
children may have a shivering reflex but their muscle bulk is much smaller. Total body mass and
therefore heat content is much smaller.

The risk of hypothermia should be born in mind whilst applying first aid during initial emergency
transport. Good first aid is as important as in an adult but care must be taken to keep cool water
applied only to the burn surface and to keep the rest of the child warmly wrapped. If there is an
extensive burn it may be necessary to reduce the period of application of cold water from the
optimal twenty minutes in order to prevent hypothermia.

Ice should never be used.

During initial stabilisation and transport a space blanket is very useful to reduce heat loss. Parts of
the body exposed at the time should be covered, preferably with a moisture-proof sheet such as
plastic, to reduce heat loss from evaporation and convection.

Airway
Occult upper airway obstruction in children is common. Enlargement of adenoids and tonsils and
laryngomalacia may pre-exist the burn injury [3] and are detected historically by evidence of sleep
apnoea such as snoring or waking at night, somnolence during the day, or noisy breathing. Narcosis
may not only depress respiration but also may relax pharyngeal muscles and thus increase
obstruction. Any swelling on top of occult obstruction may cause problems early.
The lower airway is narrower in absolute diameters in children than in adults [2, 3]. Therefore
swelling of the bronchial mucosa or accumulation of secretions within the bronchi causes a
comparatively larger reduction in cross-sectional area and so interferes with gas flow[2]. For these

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reasons an uncuffed tube has commonly been used up to the age of 10 years, although the use of
specialised paediatric cuffed tubes is increasing.

Bronchial hyper-reactivity (asthma) is extremely common in children and is indicated by a history of


nocturnal cough in winter or for weeks following viral respiratory infection. Smoke inhalation will
frequently lead to bronchospasm in children prone to this reaction.

Endotracheal intubation technique is slightly different in children from in adults. The larynx is more
cephalad compared with adults. Because narrow tubes are used, frequent gentle suction is
necessary to clear secretions. Stabilising tubes is more difficult particularly when the face is burned,
and two woven cotton tapes, one above and one below the ear, which can be lengthened if swelling
increases, are useful in this regard. The position of the tip of the tube should be checked by
auscultation before fixing the tube in position and subsequently followed by chest x-ray to confirm
satisfactory position of the tube tip. Endotracheal intubation should only be attempted by a suitably
trained and experienced practitioner.

If airway obstruction occurs and endotracheal intubation is not possible, a large bore (14 gauge)
needle passed through the cricothyroid membrane should be used instead of cricothyroidotomy.
This is only a temporising solution and urgent tracheostomy may be required.

Fluid Management
1. Differences between Children and Adults

Fluid dynamics and body compartment sizes differ in children and adults. In the child a higher
proportion of body water is extra-cellular. Blood volume in children is 80ml/kg compared with 60
70ml/kg in adults[2]. Renal tubular concentrating capacity in very young children is reduced
compared with adults. For all these reasons the proportion of fluid loss which can occur in a child is
greater and may be more rapid than in an adult[2, 3], and excessive fluid intake is less easily
handled. On the other hand, occult depression of functional cardio-respiratory and renal reserve
does not usually occur in children as it does in adults. Therefore, unless there is a known pre-existing
disease, the physiology of the child can usually be relied upon to cope with a rapid fluid load
although large excesses are less easily dealt with as mentioned above. Cerebral oedema is more
likely in children with fluid overload particularly with hyponatraemia. This risk can be reduced by the
use of the head up position in the first 24 hours.

Due to these differences fluid resuscitation is started in children with 10% burns rather than 20% as
with adults.

2. Assessment of Fluid Status


Good compensatory mechanisms in a child mean that circulation is apparently well maintained in
the face of fluid deficit. Thus little overt warning of circulatory collapse is given until late in the
progression of the pathophysiology of shock. Furthermore, useful signs of shock and hypoxia in the
adult, such as agitation and tachycardia, are less useful in children because they can occur for other
reasons. The observer may therefore not appreciate their significance. For instance tachycardia may

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be due to distress or the hypermetabolic response of an early burn, and visible agitation may be due
to pain or anxiety [7].

Hypotension is a late sign of hypovolaemia and indicates decompensation of homeostasis: by the


time it occurs the patient is rapidly accelerating down the slippery slope that leads to irreversible
shock.

More reliance must be placed therefore on the subtle signs of decreased circulation. The following
indicators of compromise are recommended by the Advanced Paediatric Life Support (APLS) course:

Tachycardia (age appropriate)


Capillary refill >2 seconds (sternum)
Mottled or pale cool peripheries
Organ dysfunction: tachypnoea, altered mental status

3. Urine Output
The most reliable parameter of adequate resuscitation is the urinary output [3, 7, 11, 14, 18, 20, 35].
However this measurement is more difficult in children as mechanical obstruction of fine urinary
catheters occurs more easily, and the collection of a few more millilitres of urine in large bore
drainage tubing can cause errors of assessment. It is important to keep output as close to 1ml / kg /
hr as possible with the acceptable range being 0.52ml / kg / hr [3, 7].

When extra fluid is needed, boluses of 5 to 10ml / kg can safely be given quite rapidly. Additional
fluid can also be given by increasing the next hours fluid to 150% of the calculated volume. Both
methods may be needed if the patients fluid status has become seriously depleted. Frequent re-
assessment at periods of 15 to 30 minutes is needed to decide whether another bolus should be
given.

4. Intravenous Cannulae

As in adults, the first choice of route of administration is percutaneous cannulation of veins through
unburned skin[2]. If the expertise is available, percutaneous insertion of larger catheters into major
veins such as the femoral is useful. In inexperienced hands in children these techniques are
hazardous. Percutaneous cannulation of peripheral veins through burned skin is perfectly acceptable
although more difficult to accomplish[2]. Cut-downs on veins require some expertise, is slow, and
permanently obliterates the vein, so is no longer a recommended technique.

Intra-osseous administration of fluids is relatively safe[2, 3, 7, 9, 72] quick to establish and is now the
preferred technique for emergency venous access.

5. Maintenance Fluids
In children maintenance requirements are significant in relation to the amount of resuscitation fluid
[3]. Maintenance requirements can be calculated:

100ml/kg for the first 10 kg of body weight


+
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50ml/kg for each kg over 10 kg & less than 20 kg body weight
+
20ml/kg for each kg over 20 kg of body weight

5% Glucose in 0.45% (normal) saline [3].

This maintenance fluid should contain glucose which should be added to the volume of resuscitation
fluid of all children whose total body weight is up to 30kg. The addition of glucose is necessary
because of the decreased glycogen stores in children and the speed with which hypoglycaemia can
occur, particularly in association with hypothermia. Regular blood glucose estimations are necessary
during initial stabilisation and transport.

Escharotomies
Limb escharotomies are needed in children as they are in adults[2]. Trunk escharotomies, however,
are necessary more often in children than in adults. The reason is that breathing by diaphragmatic
movement is more important in children and this means that abdominal wall rigidity is more likely to
restrict tidal volume. For this reason interference with gas movement may occur with trunk burns
that are not circumferential. Therefore, if a burn involves the anterior and lateral aspects of the
chest and the upper half of the abdomen, trunk escharotomies should be considered. In this
situation in addition to the procedures outlined in Chapter 7 under Escharotomy, an incision should
also be made across the upper abdomen and parallel with the costal

Gut
Children are more prone to gastric dilatation than adults and tend to swallow air when crying. A
nasogastric tube on free drainage is therefore necessary in the initial assessment phase and during
transport particularly if aerial evacuation is needed. However, childrens high metabolic rate and
their nutritional needs for growth mean that they have less tolerance of nutritional deprivation. Very
early enteral feeding should be established as soon as they arrive at the definitive treatment centre,
as it prevents loss of gut function and maintains nutrition.

Progressive Assessment of Burn Wound


Assessment of the depth of the burn wound can remain difficult in children up to seven to ten days
after the injury. However, a burn wound that is unhealed in a child at day 10 should be considered as
needing skin grafting.

Emotional Aspects
Pre-existing psychosocial pathology is common in paediatric burns as well as in adults, but the type
of pathology is different. The cycle of deprivation, lack of societal and parental skills causing
impoverishment and further deprivation is common because the parents of such families lack
satisfactory parenting techniques to protect their child, often themselves indulging in risk-taking
behaviour. They are frequently pre-occupied by their own emotional and social problems. Teenage

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children of such families are frequently involved in risk-taking behaviour and are frequently without
any parental influence.

The emotional and social needs of children are very different from adults. Play is an essential part
of a childs normal daily activities and the frivolous connotation that adults give to the word is not
appropriate in children. Socialisation in their peer group and minimisation of separation are
important aspects of a childs emotional life. Person-to-person interaction is different and language
used should be appropriate for the age of the child. The importance children place on trust in their
relationships demands that adults be truthful with their paediatric patients at all times but stark or
brittle phraseology should be avoided as it can frighten a child unnecessarily.

After a child is burned the whole family suffers from major emotional disturbance of which guilt and
blame are prominent features. Siblings are often severely affected. The wider peer group (e.g. the
childs school class) is also often affected. All these aspects of a paediatric burn need to be
addressed eventually, and appreciated from the outset.

The long-term emotional outcome after a paediatric burn is more dependent on the whole familys
emotional care than in adult burns where the concentration is on the patient. Therefore early and
adequate care of the family is essential, and this starts from the moment of burn injury.

Non-Accidental Injury
The emotional factors which often contribute to the causation of a childs burn form a spectrum
which varies from momentary lack of supervision through more overt, long-term psychopathology to
the other extreme of deliberate abuse [7]. The point on the spectrum at which Non-accidental
Injury begins is often difficult to define. The decision as to which children may be at risk in future
is often easier. While medical attendants have legal obligations (which vary from state to state) to
report suspicious or deliberate injury, the report can be made by the referral unit [7].

Suspicion of child abuse requires transferring the child to a specialist burn unit, and during this
transfer process such suspicions should be passed on and clearly documented. Each hospital should
have its own protocol to follow with the key emphasis being placed on good inter-agency
communication to protect the child in need.

Suspicion of non-accidental injury may be raised by [1, 10]:


delay in presentation
vague or inconsistent history from different observers
history not compatible with pattern of injury
presence of other signs of trauma
certain patterns of injury (e.g. cigarette marks or bilateral shoes and socks scalds

Remember that false accusation of non-accidental injury is extremely damaging to the family.
Unusual and bizarre distribution of burns can be caused by accidental injury and should not
automatically be assumed to be deliberate trauma. These children should be transferred to a
paediatric burn unit so that experts in child protection and burns can assess the situation and act
appropriately.

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In practice the distinction between accidental and non-accidental is less important medically than
socially because all of these families will need considerable help over a prolonged period so that the
patients long-term functional result is as good as possible.

Transfer Criteria
In children the need to transfer occurs at a lower threshold than in adults. A child with more than 5%
deep burns should be considered for transfer. Some children may need to be transferred simply for
pain relief if techniques such as continuous narcotic infusion are not available locally. Finally, the
possibility of non-accidental injury should prompt early consultation with the Burn Unit regarding
the need for transfer. Other criteria applicable to adults, such as burns of special areas (hands, face,
feet, perineum), and known or suspected respiratory burn, burns with associated major trauma, or
burns in patients with significant pre-existing disease, are also valid criteria for transfer in children.

Summary
The principles of burn care are as valid in children as in adults.

Factors that modify the care of children are:


- different body proportions
- different fluid dynamics
- thinner skin
- different psychosocial needs

Major physical differences in care are:


- tendency to hypothermia
- increased depth of burning for a given insult
- increased fluid needs

The psychosocial background and emotional needs of the burned child and its family are
very different to those of adult burn patients.

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CHAPTER 10

Electrical Injuries
Introduction
Electrical injuries are divided into three groups; low voltage, high voltage and lightning strike. Each
group has its own particular features which are worthy of separate consideration. The common
feature of each is heat generation resulting in a thermal burn.

Table 10.1
Overview of Electrical Injuries
Voltage Skin Deep tissue Cardiac
arrhythmias
Low Local Unlikely Immediate
voltage entrance cardiac arrest
(<1000V) and exit possible,
wounds otherwise nil
High Flashover Muscle damage Transthoracic
voltage burn, full- with current may
(>1000V) thickness rhabdomyolysis cause
entrance and myocardial
and exit compartment damage and
wounds syndrome, delayed
arrhythmias
Lightning Superficial Respiratory
or dermal Eardrum arrest
flashover perforation and needs
burns. Exit corneal prolonged
burns on damage CPR
feet

Low Voltage is considered to be anything below 1000 volts. This includes standard single-phase
household electrical supply in Australia and New Zealand which is 240 volts alternating current (AC)
at 50 cycles per second. Industrial power supplies are often three phase and commonly 415 volts.

Other low voltage electrical accidents can occur with direct current (DC) which is used in the
electroplating industry, electrolyte purification and some transport systems.

The common car battery is capable of producing a current of sufficient amperage at only 12 volts to
cause a significant thermal burn when a short circuit occurs through such articles as metallic watch
bands, wedding rings and jewellery. Surgical diathermy is a commonly encountered direct current in
operating theatres.

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High Voltage includes anything above 1000 volts [10]but is often 11000 or 33000 volts which are the
currents most commonly encountered in high tension transmission cables. Even higher voltages
occur in power stations and substations.

Lightning is an extremely high voltage, high amperage, DC electrical discharge of ultra-short duration
which produces its own peculiar injury pattern.

Pathophysiology
Tissue damage from electrical injury results from the generation of heat which is a function of
the resistance of the tissue
the duration of the contact
the square of the current [86].

Different tissues exhibit characteristic electrical resistance according to their electrolyte content. In
order of decreasing resistance, the various tissues may be listed:

bone
skin
fat
nerve
muscle
blood and body fluids.

Skin resistance varies according to whether it is thick and callused like the sole of the foot, or thin
skin. It also depends on whether the skin is wet or dry, dry skin having a higher resistance than moist
or sweaty skin.

The rise in temperature produced by a conductor depends on the heat produced and the rate at
which heat can escape from the conductor by conduction, convection and radiation.

Electricity conducted through bone therefore may cause a substantial rise in temperature. The
increase in bone temperature continues even after the current flow has ceased causing secondary
thermal damage. This phenomenon is known as the Joule effect. Due to the depth of the bone, heat
escape is slow and considerable periosteal, muscle and nerve damage close to the heated bone may
occur.

The high concentration of current at the contact points and the high resistance of the skin causes
intense heat and charring occurs. Once the skin has been breached increased current is permitted to
flow. In high voltage injuries arcing may occur across such joints as the wrist and elbow causing
charring and penetration wounds. Similar charring and exit wounds occur on the feet and hands
because of the thick skin and resistance to flow resulting in intense heat and blowout type injuries.

Types of Burn Injury


Low voltage current will cause significant local contact, entrance and exit, wounds [10, 87] and may
cause cardiac arrest but no deep tissue damage. The 50 cycles per second alternating household
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current can cause muscle spasm or tetany and prevent the victim from releasing the source of
discharge[2][23].

High voltage current causes injury in two ways; flash burns and current transmission. A cutaneous
burn without deep tissue damage results when there is a high-tension discharge or flash over, the
current not passing through the victim. The arc ignites clothing and causes deep dermal burns
without the formation of contact sites or entrance and exit wounds[10].

High voltage current transmission generally results in both cutaneous and deep tissue damage and
the entrance, exit and contact areas are always full thickness defects [23]. Less commonly there may
be internal organ damage, though this is more likely to occur as a result of an associated injury such
as a fall from a pole or tower.

Deep muscle damage which occurs under apparently normal skin and subcutaneous tissue may be
very extensive and involve whole compartments of the limbs [88].

Swelling within the limbs as a result of the muscle damage may produce a situation similar to the
crush syndrome where fasciotomy may be required. The limb becomes very swollen and tense to
palpation. The symptoms are severe deep pain and tenderness. It eventually causes decrease in
peripheral circulation and loss of pulses. If fasciotomy is required it should be done as an open
procedure and will probably require a general anaesthetic.

The muscle injury and necrosis results in release of myoglobin from the muscle cells into the
circulation. This pigment along with haemoglobin from haemolysis of red cells may lead to renal
impairment. As both these haemochromogens precipitate in the renal tubules, they can cause rapid
onset of acute renal failure[10].

Lightning injuries result from an ultra high tension, high amperage short duration electrical
discharge of direct current. This form of injury is not particularly common in Australia or New
Zealand. 5 to 10 Australians, 90 in the US, and 10,000 people worldwide die from lightning strikes
each year.

The pattern of injury is variable[2]. A direct strike is where the discharge occurs directly through the
victim and this, as expected, has a very high mortality.

More commonly a side flash or splash occurs, when lightning strikes an object of high resistance
such as a tree and the current is then deflected through a victim on its way to the ground. Stride
potential may occur as the discharge flowing through the ground may pass up one leg and down the
other. Typically the current flows over the surface of the victim causing superficial or dermal
thickness burns. However, there may be significant exit burns on the feet.

The short duration of lightning strike is not commonly associated with significant internal tissue
damage but respiratory arrest is common and this is followed by cardiac arrest[2]. The initial
respiratory arrest occurs as a result of the discharge affecting the medullary respiratory centre. This
is usually reversible so prolonged efforts at resuscitation are justified.
Another organ which can be damaged is the ear. The tympanic membrane may be perforated due to
the blast and should be checked at the time of the strike[2].

Corneal damage has also been recorded and this may be acute, or a long-term sequel of the injury.
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Lightning may also be responsible for unusual skin damage which has an arborescent or splashed on
appearance. These are known as Lichtenberg flowers. These lesions are pathognomonic of lightning
strike[2].

Management
Initial rescue of the victim of an electrical accident may place the rescuer at risk of succumbing to
the same fate [24].
First switch off the power source or remove the live wire from the victim [24]. If this is not possible,
remove the victim from the power source with a non-conductor.

Remember that high voltage electricity will discharge through air; 1,000 volts will only jump a few
millimetres, 5,000 volts will bridge one centimetre, and 40,000 volts, 13 centimetres.

Once clear of the power source the primary survey begins as with any burn injury.

The airway must be cleared and the cervical spine protected. Breathing may be arrested as a result
of the discharge affecting the medulla and cardiac arrest may also have occurred due to the effect of
the current on the myocardium. C.P.R. is therefore vital to the resuscitation of victims of electrical
injury. Endotracheal intubation may be indicated to maintain airway patency.

Protection of the cervical spine is of importance because trauma may be associated with the
electrical injury [24]. Violent muscular spasms may occur with alternating household current, which
can produce fractures. Electrical workers may suffer from falls from poles, towers or elevated
equipment.

Cervical spine fracture should be excluded using appropriate methods of examination or imaging
before abandoning immobilisation with hard collar, sand bag or simply holding the head
immobilised. A spine board or sandbags should be used to protect the thoracic and lumbar spines
until fractures of these areas have been excluded.

History of the Event


Having completed the primary survey, a full history of the circumstances of the electrical injury
should be obtained either from the patient, bystanders, or paramedics.

How did the accident occur?


How long ago did the accident occur?
Was there loss of consciousness and for how long?
Is there amnesia for the event?
Was there any associated trauma?
Did cardiac arrest occur or was any dysrhythmia recorded?

Secondary Survey

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First remove all clothing and in particular any watches and jewellery.
Examine for sites of entry or contact wounds with particular attention to scalp, hands and
feet.
Estimate the total area of burn wound and the burn depth.
Undertake neurological examination with particular reference to the peripheral and spinal
nerves.
Thoroughly document all clinical findings.

Resuscitation
If, on completion of the secondary survey, the extent of the injury is sufficient to require fluid
resuscitation, use two large bore intravenous cannulae as for other major burns.
Fluid requirements in electrical injuries are likely to be greater in volume than would be anticipated
in a pure cutaneous burn. Concealed muscle damage in the limbs will be responsible for fluid loss
which is not accounted for by the standard formula.

In those patients with deep tissue damage, haemochromogenuria is to be anticipated [2, 23]. A
urinary catheter should be inserted both to detect the earliest sign of urine discolouration, and to
monitor urine output. If pigments appear in the urine, the infusion rate of fluids must be increased
to maintain a urine output of 75100 ml/hr for adults, 2ml/kg/hr for children.

In circumstances where urine output cannot be maintained by appropriate IV infusion, 12.5g of


mannitol should be added to each litre of replacement fluid to produce an osmotic diuresis.

Alkalisation of the urine [23] by the addition of sodium bicarbonate has traditionally been used to
increase the solubility of haemochromogens in the urine, but its efficacy has been brought into
doubt by more recent work. If more than simple fluid replacement is required to clear the urine
pigment it is suggested that the advice of the receiving burn unit be obtained.

On clearing the haemochromogens from the urine the rate of fluid replacement should be reduced
to a level which will maintain the urine output of 3050 ml/hr, or in children < 30kg, an output of 1
ml/kg/hr.

Dysrhythmias
Conduction of electrical current through the chest may cause transient cardiac arrhythmias or
cardiac arrest, though this is rare in low voltage injuries (<1000V). Patients who have been
electrocuted may require 24 hours of ECG monitoring if they have suffered a high voltage injury, loss
of consciousness, or have an abnormal ECG on arrival.[23]. Dysrhythmias are more likely to occur if
the patient has pre-existing myocardial disease which may be aggravated by small amounts of
current damage.

Assessment of Peripheral Circulation


Hourly assessment of the peripheral circulation must be made:
Skin colour
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Oedema
Capillary refill
Peripheral pulses
Skin sensation

Where there is evidence of an entrance or exit wound on an extremity, the possibility of sub-fascial
oedema must be anticipated. This oedema may cause an increase in muscle compartment pressure
sufficient to obstruct the circulation[2]. This increase in muscle compartment pressure causes severe
deep-seated pain. The limb becomes stony-hard to palpation and there is progressive loss of
peripheral sensation and loss of pulses. Under these circumstances fasciotomy is required.

Fasciotomy
Unlike escharotomy which is used to release constrictive dermal eschar, a fasciotomy is used to
relieve deep compartment pressure and restore muscle perfusion. Fasciotomy is best done under a
general anaesthetic and in a sterile environment. Blood loss may be considerable and facilities for
diathermy and ligature haemostasis should be available. Again, delayed haemorrhage may be
considerable after resuscitation. The fasciotomy incisions should be dressed with Vaseline gauze and
a lightly applied gauze dressing.

It is important to have the patient well resuscitated prior to fasciotomy so that haemochromogens
released from the newly perfused muscle are flushed rapidly through the kidneys. The burn unit
should be contacted regarding prophylactic mannitol prior to fasciotomy.

1. Upper Limb
The forearm muscles are very susceptible to ischaemia and the development of a compartment
syndrome. This is relieved by performing a longitudinal incision along the mid-medial and mid-lateral
lines of the forearm, extending from just above the elbow down to the wrist. The incision is made
through skin and subcutaneous fat to expose the deep fascia which is then incised. Particular care
must be taken to protect the ulnar nerve at the elbow. Bleeding may be brisk and require control
with diathermy or ligature.

If the patient is hypotensive at the time of the procedure then delayed haemorrhage may occur.
Carpal tunnel release may be necessary for burns to the hands. Before proceeding with this
measure, consultation with the receiving burn unit is advised.

2. Lower Limb
There are four compartments of the lower limb which may be affected by sub-fascial oedema
resulting in a compartment syndrome[2]. Each of these compartments requires incision. The four
incisions can be made through two cutaneous incisions. The lateral incision is made over the fibula,
extending from the head down three quarters of its length, care being taken not to damage the
peroneal nerve which passes around the neck of the fibula. The intermuscular septum separating the
anterior and lateral compartments is incised over the full length of the skin incision.

The medial incision begins proximally, commencing one fingerbreadth below the subcutaneous
border of the tibia, and extends down to the medial malleolus. The incision is made through the skin,
subcutaneous fat and the investing fascia with care being taken not to injure the saphenous nerve

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and vein. Carefully retracting this incision the deep posterior compartment can be identified and
decompressed over the full length of the incision.
As in the forearm, fasciotomy of the leg is best done under a general anaesthetic and in a sterile
environment. Blood loss may be considerable and facilities for diathermy and ligature haemostasis
should be available. Again, delayed haemorrhage may be considerable after resuscitation. The
fasciotomy incisions should be dressed with Vaseline gauze and a lightly applied gauze dressing.

Wound Care
The general principles of burn wound care apply to electrical burns and are described elsewhere.

The presence of large amounts of dead muscle make meticulous wound management and infection
prevention mandatory by use of a topical antimicrobial.

Paediatric Electrical Injury


The majority of electrical burn injuries in children are low voltage accidents which occur at home
[65, 86]. Discharge from faulty insulation of electrical appliances and cords, or placing metal objects
in power points are responsible for most paediatric injuries [65]. The very young who are prone to
picking up and sucking electrical cords sustain deep burns around the mouth when the saliva soaks
into the faulty or frayed insulation resulting in a discharge [86, 89]. Finger and hand injuries are seen
in older children, handymen, and electricians while playing with or working on radio or TV sets or
household appliances which are still turned on. Many of these accidents could be avoided by the use
of earth leakage circuit breakers.

Most of these low voltage discharges will result in small full thickness defects which require excision
and closure, skin grafting or even small flap repairs and should be referred to a burn unit for
definitive care. Low voltage household accidents do not usually result in deep muscle damage in the
limbs, however 24 hours of ECG monitoring may be required if they have suffered a high voltage
injury, unconsciousness, or have an abnormal ECG on arrival, as previously stated [23].

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Summary
Avoid injury to those rendering assistance.

Treat cardiac and respiratory arrest.

Assess and manage associated trauma.

24 hours of ECG monitoring may be required for high voltage injury, loss of consciousness, or
abnormal ECG on arrival

Patterns of injury are specific to high voltage, low voltage and lightning strike.

Standard burns resuscitation formula may be inadequate.

Haemochromogenuria is common in high voltage injury and requires maintenance of a urine


output 75100ml/hr in adults, 2ml/kg/hr in children, until urine clears.

High voltage injury involving limbs may require fasciotomy.

According to ANZBA referral criteria, all electrical burns should be admitted to a burn unit for
definitive treatment.

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CHAPTER 11

Chemical Burns
Introduction
More than 25,000 products capable of producing chemical burns are now marketed for use in
industry, agriculture, military science and the home. In the USA more than 3,000 deaths directly
related to cutaneous or gastrointestinal chemical injury are documented each year with an
estimated 60,000 patients requiring medical care for chemical burns.

As an exposed part of the body and the part handling these noxious materials, the hands and upper
limbs are the most frequently injured sites and, indeed, suffer chemical burns as often as all other
sites combined.

Protection
It is vital that all carers and first aid workers are aware of the need to protect themselves from the
contaminant e.g. wearing gloves, aprons and protective face mask and overalls. All clothes should be
removed as soon as possible if contaminated and stored in a protective container for disposal later.

Aetiology and Classification


Laboratory accidents, civilian assaults, industrial mishap and inexpert application of agents used for
medical purposes account for most of the chemical burns in the civilian population.

Commonly used chemicals capable of producing burns are:

1. Industry

Alkalis - sodium, potassium, ammonium, lithium, barium and calcium hydroxide (washing
powders, drain cleaners, paint removers).
Acids - picric, sulfasalicylic, tannic, trichloroacetic, cresylic, acetic, formic, hydrochloric and
hydrofluoric (etching glass and electronics).

2. Household

Alkalis (lyes) - drain cleaners, paint removers, urine sugar reagent test tablets.
Phenols - deodorants, sanitizers, disinfectants.
Sodium hypochlorite - disinfectants, bleaches, deodorants.
Sulphuric acid - toilet bowl cleaners
Phosphorous - fireworks, insecticides, fertilizers.
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3. Military

Phosphorous red or white


Vesicants

Pathophysiology
Tissue damage as a direct result of exposure to any chemical is dependent upon:

strength or concentration of agent


quantity of agent
manner and duration of skin/mucosa contact
extent of penetration into tissue
mechanism of action

The principal difference between thermal and chemical burns is the length of time during which
tissue destruction continues since the chemical agent causes progressive damage until it is
inactivated by a neutralizing agent or by dilution with water.

The estimation of burn depth by clinical examination following chemical injury may be difficult
during the first few days after injury.

The above agents all cause cell injury but by means of different types of chemical reactions.

Generally speaking:

Acids produce a coagulative necrosis[10].


Alkalis produce a liquefactive necrosis.
Vesicants cause ischaemic and anoxic necrosis (liberate tissue amines and cause blistering).
All produce coagulation of protein by oxidising, corrosive or salt forming effects on protein.

An important feature of some chemicals is their systemic toxicity.

Hypocalcaemia - oxalic, hydrofluoric acid and phosphorous burns.


Liver and/or kidney damage - tannic, formic and picric acid, phosphorous injury and
petroleum
Inhalation injuries - strong acids or ammonia.
Methaemoglobinaemia and massive haemolysis - cresol
Perforation nasal septum - chromic acid

First Aid

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Remove contaminated clothing and dry chemicals [24]. Constant water flow is the most important
treatment of most chemical burns[2] (except elemental sodium, potassium or lithium). For best
effect it should be started within 10 minutes of contact.

Specific Agents
Some[VAC1] non-specific chemical treatments such as Diphoterine are now available and are useful
for most chemical injuries

1. Acid Burns

Very painful
Appearance varies from erythema (superficial) to black eschar (deep)
Irrigate with water
Surgical treatment as for thermal burn

Hydrofluoric Acid

Very corrosive, inorganic acid of elemental fluorine: 2% body surface area can prove fatal
Mechanisms of injury
a) Hydrogen ions cause typical acid skin injury which is minimised by irrigation with water.
b) Soluble free fluoride ions penetrate damaged skin and bind calcium ions. This causes
necrosis of soft tissue and hypocalcaemia that is so severe that mobilisation of calcium ions from the
bones is inadequate to overcome it. Extent of injury depends on concentration of acids and extent
and duration of contact [90].
Arrhythmias may occur secondary to hypocalcaemia and hypomagnesaemia.

Treatment[90]

Prompt water irrigation[10]


Trim fingernails
Inactivate toxic free fluoride ions and change to insoluble salt with:
a) topical calcium gluconate burn gel [10, 90] (10% with Dimethyl sulfoxide [DMSO]).
b) local injection with 10% calcium gluconate (multiple injections 0.10.2 ml through 30G
needle into burn wound). Number and frequency of injections monitored by pain response.
c) intra-arterial infusion of calcium gluconate.
d) intravenous ischaemic retrograde infusion (Biers block) of calcium gluconate.
e) early excision sometimes required.

2. Alkali Burns

most common around house


less immediate damage than acid but more long-term tissue destruction as they liquefy
tissue and so penetrate more deeply[10].
irrigate for longer than acid (at least 1 hour)

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surgical treatment required for deep burns

Cement Burns

wet cement caustic with a pH up to 12.9


pain and burning occur late (after several hours)
prolonged irrigation is important

Phosphorous Burns

more common in military personnel


white phosphorus ignites spontaneously when exposed to air
oxidises to phosphorous pentoxide
is extinguished by water
particles of phosphorous embedded in the skin continue to burn
treatment
a) copious water irrigation
b) debride visible particles
c) apply copper sulphate (forms black cupric phosphide and facilitates removal of phosphorous
particles)
mortality is related to the systemic effects of hypotension and acute tubular necrosis

Petrol (Gasoline)

complex mixture of alkanes, cycloalkanes and hydrocarbons.


hydrocarbon component is incriminated in endothelial cell damage which is the common
pathway of injury to the lungs, liver, spleen and kidneys in immersion or extensive skin contact.
petrol dissolves lipid compounds readily, causing increased membrane permeability and fluid
loss.
the two types of petrol burn:
a) Ignition - fluid requirements frequently higher than other thermal burns. Burns tend to be
larger, require more surgery and have longer hospital stays.
b) Immersion or extensive skin contact without ignition results in dermal thickness skin injury,
sometimes with systemic and inhalation lung damage.

Bitumen
a product of petroleum refining.
miscible with other petroleum products (kerosene, medicinal paraffin, paraffin wax) and
vegetable oil.
transported and used at temperatures up to 190C (150C is the norm).
liquid at 150C, but forms semisolid at atmospheric temperatures.
burns are due to the hot liquid, not the toxic effects of bitumen.
treat by cooling bitumen with copious amounts of water.
remove loose clothing but do not attempt to physically remove bitumen.
remove bitumen with paraffin oil (can add 1/3 kerosene).
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Tar
by-product of coal gas industry.
not common in Australasia.
contains complex chemicals including phenols, hydrocarbons etc, thus some toxicity.
burns by heat and phenol toxicity.
soluble only in highly aromatic liquids (e.g. benzene, toluene, xylene) NOT petrol / vegetable
oils.
treat by cooling and remove with toluene.

Special Anatomic Complications


Gastrointestinal
accidental ingestion of corrosive agents utilized in household are more common in children.
1/3 of all patients with intra-oral burns eventually prove to have associated oesophageal
injury.
symptoms are unreliable and definitive diagnosis requires endoscopic evaluation.
panendoscopy past the initial site of injury desirable to ascertain the extent of the injury.
x-ray chest and abdomen; CT scan of chest/abdomen may show extra-luminal damage.
surgical exploration and debridement of necrotic tissue may be necessary.
steroids are of no proven benefit.
stricture formation of the oesophagus is common.
endoscopic and surgical treatment of stricture may be necessary.

Eye

chemical burns of eyes are associated with a high incidence of residual ocular impairment.
physical signs include blepharospasm, tearing, conjunctivitis and uncontrolled forceful
rubbing of the eye.
rapid swelling of corneal epithelium, clouding of the anterior layers of stroma and cells
floating within the anterior chamber occur.
treat with copious irrigation of water. Diphoterine very useful.
prolonged period of time (48 hours) in hospital.
topical antibiotics prevent secondary infection.
corneal ulceration and perforation, cataract formation, secondary glaucoma, iridocyclytis
and symblepharon are possible late complications.

Tracheobronchial Tract

direct injury to trachea and bronchi rare, but occurs occasionally after ingestion of caustic
agents or exposure to chemical gases (e.g. ammonia).
respiratory distress or hypoxia call for prompt investigation by fibre-optic bronchoscopy.
Bronchodilators and steroids minimise bronchospasm and inflammation.
temporary mechanical ventilatory support may be necessary.
bronchiectasis as a late complication may occur.
follow up pulmonary function studies and chest x-ray are necessary.
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Summary
Agents capable of causing chemical burns are common in the environment.

All chemical burns require copious irrigation with water.

Hydrofluoric acid burns require neutralisation with calcium gluconate.

Systemic toxicity is common after exposure to hydrofluoric acid, petrol, or cresol.

Bitumen and alkali burns require irrigation with water for an even longer period than other
chemical burns.

Chemical injuries to the eye also require copious irrigation, and then referral.

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CHAPTER 12

Management ofthe Burn Patient afterthe


First 24 Hours

Introduction
In Australia and New Zealand there are times when a burn patient cannot be transferred
immediately to a burn unit due to difficulties of transport and access. This chapter is designed to
help doctors and nurses who are placed in the situation of having to continue the care of a patient
who fits the ANZBA criteria for transfer, but for whom it is impossible to arrange evacuation within
24 hours. It may be necessary to continue care of the patient for longer than 24 hours, but it should
be emphasised that failure to transfer a patient to a burn unit early will adversely affect the
outcome.

It is important to heal the patients burn wound as quickly as possible following the injury. In the
deep dermal and full thickness burn this is accomplished by early excision and skin grafting. The
optimal time to undertake this is between days three and five post burn. Delays in undertaking this
surgery may allow infection to supervene and morbidity and mortality rate can rise.

Even though it may not be possible to evacuate a patient to a burn unit within 24 hours after injury it
is emphasised that every effort must be made to transfer the patient as soon as possible after that
time. The principles described in this chapter are not seen as a means of justifying the treatment of
severely burned patients in outlying centres. These guidelines are designed to assist you in keeping
the severely burned patient in an optimal condition, so that when the transfer is possible, definitive
management of the patient can proceed as part of the normal course of events. These guidelines are
designed to supplement telephone, email and fax contact with the burn unit.

Many of the principles in this chapter are guidelines and are designed to complement the assistance
and further advice that may be available to remote centres either locally or from a distance.
Personnel with intensive care, anaesthesia or trauma management backgrounds may be more
directly available than staff of the regional burn unit and their expertise can be drawn upon in an
emergency.

A. Respiratory Support
It may be beneficial for severely burnt patients to continue to breathe high flow oxygen at 15 litres
per minuteuntil their COHb levels are normal and then titrated to maintain a PaO2 sufficient to
maximise oxygenation of burned tissues.

Repeated reassessment of the patient should be undertaken, particularly when there are burns to
the head and neck or a history or suspicion of inhalation injury because, as is highlighted in Chapter
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2, endotracheal intubation may be required at this stage. Clinicians may also be in the position of
having to continue care of the patient who has been intubated and whose transfer for logistic
reasons was not possible. Access to investigations, including blood gas estimation and chest X-rays is
useful to help monitor treatment.

During this time it may also be necessary for efforts at non-invasive respiratory support to be
undertaken. This includes frequent suctioning and positioning of the patients head and neck. If it is
not possible to secure the airway by these means then endotracheal intubation will be required and
this must be undertaken as soon as it appears to be necessary, before increased swelling of the
pharynx makes intubation impossible.

1. Endotracheal Intubation
A correctly placed endotracheal tube guarantees a patent and protected airway, allows high
concentrations of oxygen to be delivered reliably, provides airway access for secretion clearance,
may allow large doses of analgesia and sedation to be given safely and enables mechanical
ventilation to be carried out. In the presence of an upper airway burn or smoke inhalation,
intubation may become progressively more difficult as airway swelling or hypoxia worsens and
therefore should be considered early.

On the other hand, endotracheal intubation may be technically difficult, especially in an upper
airway burn with severe swelling already present or facial injuries. The most important complication
is technical failure and this is often lethal for the patient. Other short-term problems include endo-
bronchial tube misplacement, upper airway trauma and tube obstruction by secretions or
mechanical kinking.

Any burn patient requiring intubation needs definitive care by a specialist intensivist in a major
hospital, preferably one which also has a specialised burn unit.

2. Indications and Techniques


Intubation and ventilation should be considered in patients with clinically apparent respiratory
distress, severe or worsening hypoxia or hypercarbia, an obtunded neurological state with impaired
airway reflexes or respiratory drive, severe chest injuries, or upper airway obstruction from swelling
due to an airway burn. Occasionally mechanical ventilation may be indicated for logistical reasons,
such as safe transport or to facilitate some therapeutic or diagnostic procedure.

The oro-tracheal route is usually the simplest, but naso-tracheal intubation may occasionally be
successful where oral intubation is impossible. If neither can be performed quickly in a patient with
complete or near complete airway obstruction, surgical cricothyroidotomy is the only alternative. It
is usually straightforward and should be performed without hesitation.

Anaesthetic induction agents or muscle relaxants may make intubation easier, but should only be
used by those with confidence and training. All these agents have significant side effects of their
own and there is the potential to convert a patient with impaired but acceptable airway, and
adequate ventilation, to one who is apnoeic and unable to be intubated or ventilated.

Following intubation the tube position should be checked both clinically and radiologically.
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3. Physiology
Oxygen transport from inspired gas to alveolar capillary blood occurs predominantly by diffusion and
continuous removal of oxygenated blood from the lungs depends on pulmonary blood flow (i.e.
cardiac output). By contrast CO2 diffusing into the alveoli from capillary blood is removed from the
airways by ventilation, which is necessary to provide a downhill gradient for CO2. Thus oxygenation
depends mainly on inspired oxygen concentration, diffusing capacity of the lungs and the cardiac
output, whereas the main determinant of arterial pCO2 is alveolar ventilation.

The alveolar ventilation can be delivered in a variety of patterns. A small tidal volume with a rapid
rate would minimise the adverse effects of a high intrathoracic pressure (see below), but a
substantial proportion of each breath would be wasted, ventilating dead space (which is increased
by endotracheal tube and ventilator circuitry as well as by a number of patient factors), and there
would be a greater tendency to atelectasis. Conversely large volumes at a slow rate minimise
atelectasis and waste the least possible ventilation on dead space, but problems due to high
pressure and volume are maximised. Clinical practice is always a compromise between these
extremes.

4. Benefits and Disadvantages of Mechanical Ventilation


In addition to replacing or supplementing inadequate spontaneous breathing, mechanical ventilation
allows control of arterial pO2 and pCO2. It also eliminates the work of breathing and hence saves the
oxygen used in this process. However, positive pressure breathing reduces venous return and may
result in hypotension, especially in a hypovolaemic patient. Matching ventilation and perfusion is
generally less efficient than with spontaneous breathing.

Over distension may occur if pathology (including respiratory burns and smoke inhalation) makes the
lungs stiff (non-compliant), excessive tidal volumes are used, or the presence of lower airway
obstruction (asthma or chronic obstructive lung disease) causes hyperinflation. This can produce life-
threatening complications such as tension pneumothorax.

Finally, mechanical ventilation almost always requires sedation and possibly muscle relaxation
introducing still further potential for complications and side effects.

5. Specific Respiratory Problems in Burns


(i) Carbon Monoxide (CO) Poisoning
Where hyperbaric facilities are immediately available, most authorities would recommend their use.
However, the elimination of CO when the patient breathes 100% oxygen is rapid and the early use of
oxygen is mandatory when there is reasonable suspicion of CO poisoning. A decision regarding
hyperbaric oxygen can be made electively in consultation with the burn unit.

(ii) Respiratory Burns and Smoke Inhalation


These injuries affect both the gas exchange function of the lung and its mechanical stiffness
(compliance). Presentation is usually with otherwise unexplained worsening respiratory distress and
hypoxaemia. A cough productive of soot particles may be present and the chest X-ray may show a
diffuse interstitial/alveolar opacity consistent with other forms of acute respiratory distress
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syndrome (ARDS). This situation mandates definitive management by a specialist intensivist in a
major hospital with sophisticated facilities.

(iii) Chest Injuries


Pulmonary contusion may result in significant hypoxia or haemoptysis and a large flail segment will
render spontaneous breathing inefficient. The presence of these injuries in a burn patient increases
the likelihood that mechanical ventilation will be required.

Chest injuries increase the likelihood of lung injury during mechanical ventilation. The possibility of
tension pneumothorax, in particular, should be carefully considered. If a severe injury with multiple
fractured ribs is present and mechanical ventilation is required prophylactic intercostal drainage may
be appropriate.

Such cases should be discussed with a specialist intensivist.

(iv) Chest Wall Burns


The presence of a circumferential deep chest wall burn may markedly affect chest wall compliance.
This situation should be distinguished from that of poor lung compliance and the use of higher
inspiratory pressures to achieve the required tidal volumes is probably less dangerous. Chest
escharotomies may, however, be needed.

6. Optimal Ventilatory Patterns/Settings


A tidal volume of 57ml/kg body weight with a rate of 10 breaths/min and an inspired oxygen
concentration of 50% is commonly used initially in adults. This is reasonably safe provided adequate
oxygen saturation can be maintained, inspiratory pressures do not rise above 35cmH2O, and there is
cardiovascular stability. Rates of 1520 may be more appropriate in children.

Arterial blood gases should be checked as soon as practicable after ventilation is initiated and
appropriate adjustments made. These should be repeated frequently until the patient is stable.

If lung compliance is poor or cardiovascular instability occurs, the tidal volume should be reduced,
even if normocarbia cannot be attained. This will not be harmful in the short term unless severe
head injury is present. If there is suspicion of CO poisoning or continuing cardiovascular instability
100% oxygen should be used. Progressive deterioration in lung compliance suggests the
development of a tension pneumothorax or some other mechanical problem and a chest X-ray
should be obtained as soon as possible.

Modern intensive care ventilators allow a wide variety of settings, allowing the patient to breathe
spontaneously but with variable degree of assistance from the machine. These modes of ventilation
offer substantial benefits for difficult problems, long-term management and ventilator weaning, but
they require more expertise and sophisticated equipment. For the occasional practitioner using
simple equipment, full control of ventilation assisted by heavy sedation and where necessary,
muscle relaxation may be the simplest short-term option. However, extremely close monitoring and
one to one nursing is essential to ensure safety under these circumstances.

7. Sedation/Muscle Relaxation During Ventilation

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Sedation during mechanical ventilation is usually provided by a combination of opioids and
benzodiazepines. Morphine and midazolam are most commonly given as a single continuous
infusion, titrated to achieve the desired effect (010mg/hr of each in adults), with occasional
supplementary boluses as required.

If adequate control of ventilation cannot be achieved by this means a non-depolarising muscle


relaxant may be added. Pancuronium and vecuronium are most commonly used and are usually
given by intermittent IV boluses (6-8mg adult dose, followed by 2-4mg prn). It must be stressed that
heavy sedation or paralysis renders the patient completely helpless in the event of ventilator
malfunction or disconnection and constant vigilance is required.

8. Simple Monitoring of Ventilation


Pulse oximetry, heart rate, blood pressure, end tidal CO2 and pressure-disconnect alarms should be
regarded as an absolute minimum requirement for any such mechanically ventilated patient.
Pressure disconnect alarms are built into all but the simplest portable ventilators but are also
available as stand-alone units. Some monitoring of tidal/minute volume is also highly desirable and
may also be built-in but is most simply provided by a Wrights respirator. The ability to perform
blood gases and serial X-rays is desirable if ventilation is undertaken.

The use of monitors is no substitute for the continuous presence of a trained and attentive nurse at
the bedside performing frequent clinical observations. This is mandatory for any ventilated patient.

9. Ventilation during Transport


Transport of a ventilated patient involves a level of risk substantially greater than in a hospital
environment. In addition to the increased potential for accidental extubation, dislodgment of lines
and equipment malfunction, movement and vibration may contribute to further cardio-respiratory
deterioration. Those attending to the patient must often work in cramped, dimly lit, unstable
environment and may themselves be affected by problems such as motion sickness. The transport
team must be fully self-contained with respect to portable equipment, power, oxygen, supplies and
consumables and must be capable of dealing with unforseen problems arising en route.

Altitude results in reduced inspired oxygen tension, especially if non pressurised aircraft are used an
increase in the volume of any gas collections (such as a pneumothorax, the air in an endotracheal
tube cuff or the dead space in an IV flask) and may alter the performance of some ventilators.

All these issues must be carefully considered when planning to transport any seriously ill patient.
Before such a patient is moved there should be discussion between the transferring and receiving
institutions.

Reliable vascular access and monitoring should be secured and every effort should be made to
stabilise the patients condition as far as practicable. If experienced critical care transport teams are
available it is almost always preferable to use them even if this further delays definitive care. No
ventilated patient should be transported without medical and nursing escorts of appropriate
seniority and skill.

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B. Circulatory Support
Patients with major burns continue to remain haemodynamically unstable in the second 24 hours.
Fluid requirements often do not follow standard rules and continuing reassessment using the
general criteria of clinical appearance, pulse, urine output and blood pressure is necessary to ensure
that the correct amount of fluid is given.

The following laboratory investigations will help guide the fluid treatment:-

Haemoglobin and Haematocrit


Urea and Electrolytes
Arterial blood gases (as appropriate)
Blood glucose (in children)

1. Composition of Fluid
As capillary permeability gradually returns to normal during the end of the first post-burn day,
colloid containing fluids can be used to keep the intravascular space expanded. The amount of
overall volume is adjusted to keep urine output of 3050ml/hour in the adult and children (less than
30 kg) 1.0 ml/kg/hour.

The fluids given during the second 24 hours should include 0.30.5 ml of colloid per kg body weight
per percentage body surface area burn. The colloid should be 5% normal serum albumin (50g per
litre).

In the adult 4% dextrose in 0.18% normal saline is added to maintain an adequate urinary output. In
children half normal saline with glucose added as necessary is used to maintain an adequate urine
output.

2. Ora/Nasogastric/Nasojejunal Fluids
Patients who are able to tolerate oral fluids can take small amounts in addition to the intravenous
regime, or oral fluids can be substituted for the dextrose/saline component. Patients with severe
burns should receive high protein fluid supplements either freely by mouth if tolerated or by naso-
gastric/nasojejunal tube if there is no evidence of ileus. This will be further discussed in the section
on nutrition but care must be taken not to overload the patient.

3. Fluid Balance
During the second 24 hours the fluid requirements are less than in the first 24 hours and it is
important not to overload the patients with fluid, particularly those with pre-existing pulmonary and
cardiac abnormalities. A fluid regime that produces an excessive urinary output is not appropriate
and it is possible to produce pulmonary oedema during this time by giving the patient too much fluid
[16].

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Abdominal Compartment Syndrome can develop as serious secondary complication if excessive fluid
volumes have been given to maintain or achieve adequate urine output and hemodynamic stability.
Bladder pressure monitoring can give valuable information about intra-abdominal pressures.

During the second 24 hours a natural diuresis should begin and urinary output may increase above
the levels expected from the amount of fluid infused. In addition any haemochromogenuria will
begin to settle from 24 to 48 hours post burn.

Estimation of the haemoglobin and haematocrit at this stage may demonstrate a falling
haemoglobin due to haemolysis and whole blood may need to be introduced at this stage.
Consequently the haematocrit becomes an increasingly unreliable guide to fluid requirement.

C. Wound Care
The wound should be reassessed to obtain a more accurate diagnosis of the extent and depth of
burning. Areas of the burn which during the first 24 hours were thought to have been erythema only
may progress in depth and in the second 24 hours be diagnosed as a significant dermal thickness
burn. Formal reassessment of the area of the burn will enable a recalculation of fluid replacement
for the second 24 hours.

Burns which were judged to be superficial to mid dermal thickness may well have been treated with
a biologically compatible dressing (Biobrane, Opsite, Duoderm or similar) and if these dressings are
in a satisfactory condition during the second 24 hours then they do not need to be changed.

Any areas of burn judged to be deep dermal or full thickness should be treated with the topical
antimicrobial, in all patients for whom evacuation has been abnormally delayed. Contact the
appropriate burn unit for advice on the most appropriate dressing.

Continuing care of the burn dressed with antimicrobial dressing is best achieved by washing, either
in a bowl, bath, or shower. Old dressings and sloughing skin should be removed and loose pieces of
skin debrided with sterile forceps and scissors.

After drying the patient digital images should be taken for monitoring of the wound. A clean dressing
should then be applied to the wound and the patient left comfortable.

Care should be taken to ensure that dressings are not too tight and that on completion of the
dressing the underlying limbs have appropriate sensation and circulation distally. In the initial 24-48
hours dressings on limb burns should be applied to leave the tips of the fingers and toes exposed so
that the colour and circulation can be frequently checked.

Upper and lower limbs should be elevated on pillows or foam wedges to encourage resolution of
dependant oedema. If available a Doppler may be used to assist in the monitoring of circulation of
swollen limbs.

Escharotomy and Haemorrhage

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Regular capillary refill and limb observations should indicate the possible need for an escharotomy.
Post burn swelling may continue during the second 24 hours post burn, so an escharotomy may be
necessary to ensure adequate circulation.

As peripheral circulation returns to normal during this stage there will be a gradual opening up of
peripheral vessels and so bleeding may occur from previously performed escharotomy sites. Bipolar
diathermy or simple application of an artery forcep with ligature may be necessary to control this
bleeding. It is not appropriate to attempt to control bleeding by application of firm bandages as this
may restore the peripheral constriction released by the escharotomy.

D. Pain Relief
During the second 24 hours the simplest, safest, way of providing adequate analgesia is with small
incremental doses of intravenous narcotics. The dose should be titrated against the patients
response including the respiratory rate, and no sophisticated facilities are required for
administration or monitoring [9].

However, if facilities for morphine infusions are available a 20-30 microgram per kg per hour dose
(after the loading dose) may be the most flexible form of pain relief. Higher doses may be needed
and it may be necessary to top up this intravenous infusion with small incremental intravenous
doses as it takes many hours for the infusion alone to provide a blood level that will give satisfactory
analgesia. There are no concerns regarding addiction to narcotics at this stage. When pain is
genuinely present appropriate analgesia should be given.

Pain will be most severe during dressing changes, episodes of mobilisation, and physiotherapy.
Adequate levels of intravenous narcotics should be provided to cover the patient during these
painful episodes.

Patient controlled analgesia (PCA) is extremely effective in burns and if PCA is available it is the
method of choice. PCA can be used in quite small children with care. An acute pain expert or
anaesthetist may be necessary to assist with the regime.

Nitrous oxide or methoxyfluorane administered by a device which prevents inadequate oxygen


delivery is a useful supplement, particularly when procedures are being undertaken but it should be
supervised by an anaesthetist or other experienced staff member.

E. Nutrition
It is important to establish normal gastric feeding as soon as possible after burn injury. The presence
of food passing through the intestine protects the small bowel mucosa from damage that occurs
following trauma and starvation. This damage to the mucosal cells allows bacteria from the bowel to
move into the blood stream and it is this translocation of intestinal bacteria that is responsible for
the severe secondary gram-negative sepsis that is often fatal in severe burns. Early introduction of
food helps prevent this.

Patients with severe burns (>10% in children, >20% in adults) frequently have intestinal ileus,
particularly if their intravenous fluid resuscitation is delayed and they suffer significant shock. A
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naso-gastric tube must be passed to empty the stomach to avoid vomiting and aspiration but as
soon as bowel sounds are present or if present at the time of admission then feeding should begin.

Approximately twice the usual amount of energy is required per day in severely burned patient and
this can be given using a number of propriety dietary supplements. If these are not available milk
based foods are most useful.

Patients may be able to eat a normal diet. This should be rich in eggs and dairy products so that
sufficient protein and calories are provided. The addition of skimmed milk powder to ordinary milk
(200 gm per litre) significantly increases the protein level. In addition, high protein high calorie
milkshakes can be made by adding ice-cream, eggs and glucose based flavouring agents to milk.
These are often well tolerated.

Patients with large burns are often unable to consume adequate amounts of nutrients. In these
patients a naso-gastric feeding tube or naso-jejunal tubeshould be inserted for supplemental
feeding. The head of the bed should be elevated 30 whilst the feed is being given. Gradual increase
in rate often overcomes the problem of troublesome diarrhoea.

The patient should be weighed daily, bowel movements should be recorded to document any
change and if the patients are eating spontaneously extra time should be allowed for them to
complete their meals. Extra food can be provided as small snacks between meals if patients are not
able to eat a full meal at regular times. Patients with hand burns may need assistance with their
eating.

Because the risk of acute gastric ulceration following severe burn injuries is so high, protection in the
form of proton-pump inhibitors, H2 antagonist, and most importantly, enteral feeding should be
instigated.

F. Physiotherapy/Occupational Therapy
Because deep burn wounds contract, it is important to maintain all joints in an appropriate position.

Prevention of contractures starts early (first few days). Patients should not be allowed to adopt
positions that are those of contracture. The position of comfort is the position of contracture. The
precise position depends on the aspect of the joint involved. Usually the correct positions are:

neck - extension
axilla - abduction
elbows - extension
wrists - neutral or extension
metacarpophalangeal joints - flexion
interphalangeal joints of fingers - extension
knees - extension
ankles - 90o dorsiflexion

A splinting regime may be required and at least once a day all joints should be put through a range
of movement as far as pain will allow. Those patients with respiratory burns who are conscious, or

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who have chest wall burns should have supervised breathing or coughing exercises to ensure
adequate pulmonary expansion.

As part of the splinting regime it is particularly important to avoid tight bandages and splints that
press on nerves surrounding joints. Particularly at risk is the ulnar nerve at the elbow which may be
easily damaged from splints or from resting on the edge of a bed or operating table. Also, the
common peroneal nerve around the head of the fibula is frequently damaged in elderly people by
bandages or incorrectly applied splints and often results in permanent foot drop.

During ICU admission the severely burned patient is usually immobile so meticulous care of pressure
areas is essential. In the elderly, sacral, occipital and calcaneal pressure sores are very common.
Other pressure sores may also occur at less usual sites. Patients should be turned every two hours
around the clock utilising pillows for comfort. Pressure relieving beds and mattress should be used
but care should be taken to prevent the patient getting into the position of contracture.

G. Infection Control
All equipment should be cleaned effectively between use of each patient. Hand washing
between patients is the most effective means of preventing cross infection.
A three-minute scrub should be performed prior to the beginning of each shift.
When undertaking direct patient care a different isolation gown should be worn for each
patient.
The patients mattress and beside area should be wiped down daily with an antiseptic.

Summary
Patients should be transferred to a burn unit within 24 hours of burning to maximise
survival. If this is not possible intensive care management is required to keep the patient in the best
state for transfer.

Attention to respiratoryand circulatory support, careful wound care, pain relief, nutrition,
physiotherapy, and infection control will present the patient to the burn unit in the optimal
condition.

Frequent telephone contact with the burn referral unit or receiving ICU is essential.

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CHAPTER 13

The Outpatient Management of the Minor


Burn

Introduction
Approximately 1% of all Australians seek treatment after sustaining a burn injury every year.Of these
220,000 peopleburnt each year approximately 10% (22,000) are hospitalised and close to 100 die as
a result of their burns (Source: 2001 Australian National Health Survey)

Many patients sustaining acute burns will attend the emergency department of a rural or urban
hospital. Many patients receive primary care from their General Practitioner.

A. Burn Assessment
1. History

The history of the incident is essential [21]. A history of what the causative agent was, and any first
aid received, will give clues as to whether the burn is likely to be superficial, mid, deepdermal or full
thickness.

Scald burns, receiving recommended first aid, are less likely to be deep than flame burns, but in a
child, as in the elderly, scald burns are frequently deeper than first assessed. An idea of how hot the
scalding liquid was should be obtained. Flame burns are usually deep, particularly where flammable
solvents were involved, or the clothing has caught fire.

Suspicion of non-accidental injury in a child or assault in an adult can often be guided by an


inconsistency noted between the appearance of the visible injury and the history of occurrence. Any
suspicion of non-accidental injury or assault should prompt referral to a burn unit for further
investigation.

2. Examination
The burnshould be carefully examined and the appearance recorded[2].
Note:
i. the colour of the burn
ii. the presence or absence of blistering
iii. the presence or absence of capillary return following digital pressure
iv. the level of pain caused by the burn (superficial burns are more painful than deep burns)
v. the nature of any exudate on the burn wound (which can indicate possible wound
infection in a burn presenting after a delayed period)
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vi. the presence or absence of surrounding inflammation suggesting invasive sepsis

It is usually possible to diagnose the depth of burning with reference to the above findings. This is
set out in more detail in Chapter 7 Wound Management. The small burn can be referred to a
surgeon with an expertise in excision and skin grafting if it is not appropriate for these patients to be
referred to a burn unit (refer to criteria in Chapter 10). If there is any doubt about the depth or
treatment required for a burn, contact the burn unit for advice.

3. Assessment of the Area of Burn


Use of the Wallace Rule of Nines as discussed in Chapter 5, should enable accurate assessment of
the area of burning [21, 25, 27, 56-58]. Alternatively, the palmar surface of the hand (from fingertips
to wrist) is approximately 1% of body surface area and this can be used as a guide to assess the
extent of small or patchy burns [21, 56-58].

Superficial to mid-dermal thickness burns less than 10% TBSA for adults, 5% TBSA for children, are
ideally suited to outpatient management, and with the advent of the newer biologically compatible
dressings it is possible to treat these burns with dressings that protect the wound and facilitate
normal healing. However, larger superficial burns approaching 10% consume considerable dressing
resources and may be outside the scope of frequent redressing in the General Practitioner or
regional hospital setting. For this reason they may be better off treated at an outpatient department
and all burn units have associated outpatient clinics where these burns can be readily managed in
conjunction with care provided by the General Practitioner.

B. Pain Relief
Small burns, when appropriately dressed, are well suited to oral administration of paracetamol with
codeine in various concentrations.Oral, intranasal or inhaled analgesia may be used in the outpatient
setting with appropriate protocols butf this is not sufficient or available to provide appropriate
analgesia admission of the patient for interim treatment should be considered, until the pain of the
burn wound has decreased. Subsequently, it may be appropriate for outpatient management to
recommence.

Dressing of burns may be difficult and produce considerable pain, particularly in children. Oral
sedatives and analgesics can be given 3045 mins before dressings are undertaken to enable these
burns to be treated as outpatients. Intranasal opioids have a quicker onset and duration of action
which are suited to the outpatient environment. Again, if it is not possible to provide adequate
analgesia in the outpatient or primary care setting, then hospital admission should be sought.

C. Wound Management
Following first aid (Chapter 2), management of the burn should be based on the same principles that
apply to treatment of any wound. Aseptic technique should be used to minimise the risk of
contamination, and care should be taken to prevent further tissue damage.

In the acute stage the burn wound should be washed using a dilute antibacterial agent. Dilute
aqueous chlorhexidine 0.1 or 0.2% is often used, but if this is not available it is appropriate to wash
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the area with saline or soap and water[10]. During cleansingit is important to have a clean wound
bed thus the clinician should remove any loose skin with sterile scissors. Small blisters can be left
intact. In cases where there are large areas of blisters which have ruptured and the skin has rolled
up, the loose skin should be removed[10].

Once the area has been cleansed and debrided, further examination will help assess the depth of the
burn.

Epidermal burns
Burns that are bright pink to red, very tender without blistering are likely to be epidermal only[2].
The typical examples are sunburn or a minor flash from a gas explosion. These burns do not need
specific treatment, but may be very painful and require pain relief. Moisturising cream may be all
that is needed, dressings are not required.

Dermal burns

Burns that have blistered are usually dermal burns. The base below the blister skin should have
capillary return and sensation if the burn is only superficial dermal, and should heal
spontaneously[2]. After the blistered superficial dermis and epidermis have been removed, the
papillary dermis will be exposed. If this is allowed to dry out or become infected, the contained
epidermal elements that should heal the burn by epithelialisation will die and the burn wound will
become deeper. As a consequence it may not heal spontaneously and may require skin grafting.

The appropriate treatment for these wounds is a biologically compatible dressing such as one of the
silicone dressings a hydro-colloid a silver dressing or a film. For some dressing selection suggestions
see table in Appendix 4.

Dressings such as Biobrane, pig skin or preserved human cadaver skin are also ideal. However, these
are very expensive and generally only applied in a burn unit.

The superficial dermal burn will continue to exude serum secondary to the inflammatory reaction.
Some dressings may becomesaturated with blister fluid and require more frequent dressing
changes.Hydrocolloid dressings will need to be changed approximately every 35 days, or more
frequently if there is excess exudate or a foul odour. Dressings that adhere to the wound such as
Biobrane or various forms of preserved human skin should gradually peel off at the edges as
epithelialisation proceeds.

In most burn wounds a repeat wound inspection after approximately 3 days is advised to make sure
that the initial assessment of burn depth was correct and that complications of the burn (particularly
infection) have not occurred. A change in management may be required if repeat assessment
suggests that the burn is deep dermal or full thickness or that the burn is infected.

Infected burns
Burn wound sepsis may occur in those burns contaminated at the time of injury, or where the
wound has been treated with a dressing lacking antibacterial properties.

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Those burns which appear infected at the time of initial presentation, or are judged likely to have
been contaminated at the time of injury, should be treated initially with a topical anti-microbial
agent. The most appropriate product in Australia and New Zealand is a slow-release silver dressing.
After applying the primary dressing it is important to secure the dressing with a bandage or adhesive
dressing.

Flammazine may be used however this preparation often converts the burn wound into a moist
wound witha khaki coloured exudates which makes inspection of the base of the burn difficult.

Any evidence of surrounding inflammation or systemic signs of infection is suggestive of invasive


burn wound sepsis. At this stage it is appropriate for a referral to occur because invasive burn wound
sepsis in a dermal thickness burn usually produces a deep dermal or full thickness injury.

Because exposure allows desiccation which produces deepening of the wound, exposure treatment
of the minor burn, except for epidermal burns is not appropriate.

If at re-examination of the burn, the initial diagnosis of superficial burn appears incorrect, then
referral for surgery should occur.

D. Follow Up
Depending on the primary dressing applied, follow up is usually at 2 to 3 days following initial
dressing, then at 3 to 7 day intervals.

On these occasions, it is important to determine whether the patients home circumstances are
satisfactory for continuing outpatient management. In situations where the patient may not be able
to cope, hospital admission may be needed, e.g. the elderly, the patient who lives alone, or the child
with working parents whose ongoing outpatient care may be compromised by lack of family support.
Patients co-morbidities can also affect possible outpatient management. Those patients with
incontinence or mental impairment may require more frequent dressing changes and wound
management.

Home nursing services may be useful in extending the role of the primary care outpatient service
and can assist in provision of repeated dressings of the minor burn, particularly when it is difficult for
the patient to come to the outpatient clinic or surgery.

1. Physiotherapy/Occupational Therapy

Minor burns to the hands, limbs and around joints that do not fit the criteria for admission to a burn
unit may need therapy. In burns that take longer than 2 weeks to heal, or those requiring surgery,
hypertrophic scarring may occur. Physiotherapists and occupational therapists might be required for
scar management using elasticised garments, contact media or adhesive tape[2]. The General
Practitioner can co-ordinate the management, and burn units are able to give advice as to the
availability of physiotherapists and occupational therapists to provide this care.

2. Education Post Healing


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It is important to protect the recently healed burn and to provide appropriate protection from
sunburn by use of 30+ sunscreens and appropriate clothing. Recently healed burns may not stand up
to the rigours required during work, and some time off may be needed to allow normal thickening of
the healed area. Frequent application of moisturising creams to overcome the problem of lack of
natural skin moisture due to the damage of sebaceous glands might also be needed for some time
after the burn has healed.

Itching may be a problem in the recently healed minor burn and is helped by moisturising creams
and massage. Pressure also helps. Prescription of antihistamines and application of cold compresses
may help relieve itch. Bathing in lukewarm water with solutions such as Pinetarsal, an oatmeal
treatment or aloe vera solution can also be helpful, particularly in hot weather.

3. Post Burn Functional Impairment


Some small burns that take longer than 14 days to heal and produce hypertrophic scar tissue may
leave a primary skin shortage or contracture. If this occurs around joints there might be secondary
loss of function. Burns with loss of function that do not respond to scar management and
physiotherapy may require referral to a burn unit for secondary reconstruction to overcome this
functional problem. Many minor degrees of skin shortage and contracture are well treated by
therapists and the majority of these patients with good therapy do not need secondary surgical
treatment.

4. Post Burn Cosmetic Disability


Small burns may produce considerable cosmetic disability either due to colour match defects
following spontaneous healing of the dermal thickness burn or as a result of post burn hypertrophic
scarring. Some patients will not be concerned, but occasionally a patient will be abnormally
distressed by the appearance of what is otherwise a minor burn.

The secondary body image disturbance that may occur following a minor burn is sometimes quite
out of proportion to the size of the burn itself. Counselling at the primary care facility or by a
psychologist or psychiatrist skilled in body image problems may assist in the management at this
stage. There may be unreasonable requests for cosmetic correction of these minor defects. Revision
surgery by excision of scar and skin grafting might leave a blemish that is no better than the original
appearance. In these cases, supportive psycho-therapy with repeated counselling sessions is the
appropriate management.

In addition to the cosmetic defect, many patients and relatives may have unresolved anger or guilt
relating to the circumstances of burning and this may need to be dealt with as part of treatment.
Make-up preparations can mask many skin colour mismatches.

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Summary
Many minor burns can be satisfactorily treated at the primary care level. As the great
majority of burns in Australia and New Zealand fall into this category, it is appropriate for local
practitioners to develop expertise in the management of these minor burns and for burn units to
remain available to provide advice or treatment as necessary.

Management of the burn patient includes meticulous attention to the burn wound to
facilitate normal healing and prevent complications. Many products are not mentioned in this
chapter which are just as effective. The list of products mentioned is not all inclusive.

Secondary referral of the healed minor burn may be required for reconstructive surgery, scar
management, physiotherapy, occupational therapy or psychotherapy.

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APPENDIX 1

Neurological Assessments
Glasgow Coma Scoring
RESPONSE SCORE
Eye Opening Spontaneous 4
To name 3
To pain 2
None 1
Best Verbal Response Oriented 5
Confused 4
Inappropriate 3
Incomprehensible 2
None 1
Best Motor Response Obeying 6
Localizing 5
Withdrawal 4
Abnormal Flexion 3
Extension 2
None 1
15
Figure 2.1

Severity of Head Injury


Severe GCS < 9
Moderate GCS 9 - 12
Minor GCS 13 - 15
Figure 2.2

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APPENDIX 2

Tetanus Protocol

Table 3.21.1: Guide to tetanus prophylaxis in wound management

History of Time Type of DTPa, DTPa- Tetanus


tetanus since last wound combinations, dT, immunoglobulin*
vaccination dose dTpa, as (TIG)
appropriate.
3 doses <5 years All wounds NO NO
3 doses 510 Clean minor NO NO
years wounds
3 doses 510 All other YES NO
years wounds
3 doses >10 years All wounds YES NO
<3 doses or Clean minor YES NO
uncertain wounds
<3 doses or All other YES YES
uncertain wounds

The recommended dose for TIG is 250 IU, given by IM injection using a 21 gauge needle, as soon as
practicable after the injury. If more than 24 hours has elapsed, 500 IU should be given.
Individuals who have no documented history of a primary vaccination course (3 doses) with a
tetanus toxoid-containing vaccine should receive all missing doses. See Section 1.3.5, Catch-up.

(Source: The Australian Immunisation Handbook (Ninth edition) Page 288)

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APPENDIX 3

Recommended Escharotomy Incision Lines

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APPENDIX 4
Selecting an Appropriate Dressing
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Silicone/foam Non- Superficial Apply to clean wound Do not use if
Hydrophilic adherent burns bed any infection
polyurethane foam + Conformable Cover with
soft silicone layer + fixation/retention dressing
waterproof outer layer
Also available with
silver
Hydrocolloid Aids Superficial to Allow 2-5cm margin Do not use if
Hydrocolloid wafer autolysis of mid dermal burns around wound. any infection
devitalised tissue Low to Can remain intact 2-3
Provides moderately days
moist wound exudating wounds Wafers up to 5 days if
environment no signs infection.
Absorbs
exudate
Vaseline Gauze Antiseptic Dermal Apply directly to Soak off if
Vaseline petroleum dressing thickness burns wound adhered to wound
coated gauze Conformable Grafts & donor 2-3 layers for acute bed
sites wounds
Cover with secondary
dressing
Change every 1-3 days
Silver Broad Mid to deep Apply to moist wound Exudate level
Sodium spectrum dermal thickness bed indicates frequency
carboxymethycellulose antimicrobial burns Allow 2-5 cm overlap of dressing change
(CMC) & 1.2% ionic Ag in Facilitates Moderately Cover with secondary
fibrous material debridement exuding wound dressing
Also Contreet H Absorbs Review 7-10 days
exudate Leave intact until
healed
Silver Broad Dermal to full Wet with H20; drain Temporary
Nanocrystalline Ag spectrum thickness burns and apply blue/silver side skin staining
coated mesh with inner antimicrobial Grafts & donor down Avoid if allergy
rayon layer. protection sites Moistened secondary to Silver
Decreases Infected dressing Avoid
exudate wounds Replace 3-4 days hypothermia
formation (Acticoat) or 7 days
(Acticoat 7)
Silver Reduces Infected Apply generous Not recommended
Silver infection wounds amount to sterile for most burns due
Sulphadiazine 1% Dermal to full handtowel to ease to changes to
thickness burns if application wound appearance
only available Apply to wound and frequency of
option Cover with secondary required dressing
dressing changes

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Bab 1
Introduksi:
Epidemiologi dan Etiologi
Pendahuluan
Luka bakar merupakan suatu tantangan bagi para tenaga kesehatan. Selain perjalanan
penyakit suatu bentuk trauma dan ketidaknyamanan yang nyata, gangguan permanen pada
penampilan dan fungsi diikuti oleh ketergantungan, kehilangan pekerjaan dan ketidakpastian
masa depan. Masalah ini tidak hanya dihadapi oleh pasien, namun juga keluarga mereka dan
orang di sekitar. Pepatah menyatakan, pasien trauma yang nyata, ditolong dan dirawat lebih
awal oleh personil yang terampil akan sembuh lebih cepat dibandingkan pasien yang
perawatannya tertunda. Demikian pula halnya dengan pasien luka bakar maupun trauma
lainnya [1]. KArenanya, sangatlah penting untuk melakukan perawatan yang tepat dilakukan
secara cepat. Hal ini tidak saja menyelamatkan nyawa seseorang, tapi lebih jauh, demi masa
depan mereka.

Kursus ini didasari prinsip bahwa penilaian emergensi yang tepat waktu, resusitasi dan rujukan
merupakan kunci keberhasilan tatalaksana yang akan diikuti penyembuhan. Dengan mengikuti
kursus ini, pasien luka bakar berat akan memperoleh pelayanan yang sesuai dengan prinsip di
atas.

Kursus in bertujuan menghadirkan informasi akurat mengenai diagnosis dan penanganan awal
pada pasien dengan luka bakar berat, yang memungkinkan para praktisi medis dan
keperawatan memiliki kompetensi menangani masalah mendesak dan mengancam nyawa.

Kursus ini disusun oleh para anggota dari Komite Pendidikan ANZBA dimana tiap bab ditulis
berdasarkan pengalaman pribadi para anggota berbagai disiplin ilmu dalam penanganan luka
bakar. Kursus ini memuat materi orisinil yang belum pernah dipublikasikan sebelumnya.

Kursus ini mengikuti protokol penanganan trauma seperti yang diajarkan oleh Royal
Australasian College of Surgeons pada Emergency Management of Severe Trauma course
(EMST) dan diterima sebagai suatu sistem pendidikan trauma bagi para praktisi medis di
Australia dan Selandia Baru.

Kursus Emergency Management of Severe Burns (EMSB) memuat pedoman dan prokol
penanganan trauma yang spesifik untuk luka bakar; merupakan tambahan EMST. EMSB
dirancang sebagai suatu kursus yang berdiri sendiri, menghadirkan informasi dalam

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menentukan standar minimal perawatan luka bakar akut (dari ANZBA) dan dapat pada EMST
dengan menghadirkan informasi yang lebih spesifik pada penanganan dari luka bakar.

EMSB mencakup prinsipprinsip dari penanganan emergensi luka bakar berat di Australia dan
Selandia Baru. Kursus ini sesuai bagi praktisi medis dan keperawatan dimanapun yang
melakukan pelayanan luka bakar; baik bagi mereka yang bekerja di unit luka bakar maupun
staf medis dan keperawatan yang bekerja di daerah terpencil. Selain menyampaikan materi,
kursus ini menekankan keuntungan memiliki pengetahuan yang sama mengenai protokol
penanganan luka bakar darurat pada semua petugas pelayanan, karena memfasilitasi
penanganan utama serta rujukan yang sesuai; yang merupakan keutamaan pendekatan ini.

Informasi mengenai kursus dibagi dalam enam bagian terpisah di tambah bagian
komplementer:

1. Pegangan Kursus
Buku pegangan berisi silabus lengkap kursus yang dikirim ke semua peserta kursus
sebelum kursus. Peserta diharapkan membaca buku ini beberapa kali bila memungkinkan,
sebelum menghadiri kursus dimaksud. Gambar 'Struktur EMSB' (halaman 15) disertakan
sebagai upaya membantu pengenalan aspek penting dalam kursus.

2. Kuliah Formal
Kuliah diselenggarakan di awal kursus. Dijelaskan garis besar kursus dan akan
memperjelas halhal yang sudah dibaca pada buku pegangan. Kuliah tidak menggantikan
buku pegangan, disampaikan secara bervariasi berdasarkan pengalaman klinis para
pemberi kuliah.

3. Stasi Keterampilan
Di stasi ini diajarkan aspek praktis dari kursus dan memberikan kesempatan pada peserta
kursus untuk menerapkan pengetahuan yang telah mereka peroleh dari buku pegangan
maupun kuliah.

4. Kelompok Diskusi (Interaktif)


Pada bagian ini diajarkan lingkup manajemen luka bakar dalam kelompokkelompok kecil
secara interaktif untuk memberikan kesempatan sebesar mungkin bagi peserta melkukan
diskusi topik dan menerapkan pengalaman klinis mereka masingmasing sesuai tingkat
kompetensi masingmasing, dalam mengeksplorasi topik.

5. Simulasi Kasus Luka Bakar


Pada bagian ini, dilakukan simulasi menggunakan model pasien luka bakar oleh relawan,
yang memberikan kesempatan bagi peserta untuk melaksanakan praktik dalam

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penanganan luka bakar berat. Bagian ini akan menggabungkan kursus dan membuatnya
relevan secara klinis.

6. Ujian
Di akhir kursus, peserta menjawab pertanyaan dalam bentuk soal pilihan ganda, kasus
klinis, (menggunakan model pasien luka bakar simulasi), dalam menguji tingkat
pengetahuan peserta dan efektivitas kursus.

Peserta yang berhasil akan menerima sertifikat resmi dari Australian and New Zealand Burn
Association (ANZBA).

Konsep Kerja Tim dalam Pentalaksanaan Luka Bakar


Sejak Perang Dunia kedua, dicapai kemajuan bermakna dalam penatalaksanaan luka bakar
yang diikuti penurunan mortalitas dan morbiditas luka bakar berat secara bertahap [2].

Resusitasi cairan intravena, perbaikan gizi, penggunaan antimikroba topikal, dan penerapan
protokol bedah yang menerapkan konsep penutupan luka lebih awal, kesemuanya memberi
kontribusi untuk kemajuan yang luar biasa dalam hal ketahanan hidup (survival) [2].

Unit Luka Bakar

Dengan adanya perbaikan dalam penanganan luka bakar ini, terealisasi bagi seorang staf
terlatih untuk melakukan bekerja secara lebih efektif di suatu fasilitas akut [2]. Pada fasilitas
ini, penatalaksanaan berkualitas baik dimungkinkan terselenggara; bahkan untuk luka bakar
ringan sekalipun, dibandingkan pelayanan yang tersedia di luar suatu unit luka bakar.

Konsentrasi tim spesialis di satu fasilitas memiliki nilai tambah yang efektif dengan biaya yang
relatif hemat, berbagi pengetahuan di antara anggota tim yang akan mengembangkan tingkat
keahlian tinggi pada masingmasing anggota tim [2]. Hal ini memastikan bahwa pasien
mendapatkan pelayanan terbaik. Dukungan yang diberikan anggota tim satu sama lain
mengahdapi stres akan memberi kontribusi bagi moral para staf dan memaksimalkan
keterpaduan.

Tim Luka Bakar

Tim Luka Bakar terdiri dari kelompok multidisiplin di mana keterampilan masingmasing
individu saling melengkapi satu sama lain. Anggota tim menyadari keuntungan kerjasama tim
interdisipliner dalam penyelenggaraan pelayanan luka bakar berkualitas [2, 3].

Tenaga Prarumah sakit

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Petugas ambulans dan layanan rujukan menyediakan pelayananan prarumah sakit yang
penting bagi pasien luka bakar dengan pengadaan fasiliats resusitasi cairan, stabilisasi jalan
napas dan transportasi pasien. Penanganan awal prarumah sakit memberi kesempatan
pasien luka bakar untuk bertahan hidup dan memperoleh hasil optimal.

Unit Gawat Darurat

Pasien luka bakar dinilai dan memperoleh tatalaksana awal di unit gawat darurat; baik di
rumah sakit yang memiliki unit luka bakar, atau di rumah sakit tanpa unit luka bakar.
Keterkaitan yang baik antara unit luka bakar dan unit gawat darurat sangat penting dalam
pelayanan bekualitas.

Ahli Bedah

Bedah luka bakar telah berkembang menjadi suatu subspesialisasi dari bedah plastik, bedah
umum, dan bedah anak. Ahli bedah luka bakar memiliki peminatan khusus dalam pengelolaan
pasien luka bakar kritis, dalam penyembuhan luka, rehabilitasi, dan penelitian terkait [2].

Perawat

Perawat luka bakar merupakan anggota tim yang sangat penting dalam perawatan
berkesinambungan. Perawat luka bakar memiliki keahlian khusus dalam perawatan intensif
luka bakar, perawatan luka, perawatan skin graft, perawatan psikiatrik dan perencanaan rawat
jalan [2].

Anestesi

Bedah luka bakar membutuhkan teknik anestesi khusus yang membantu para ahli bedah
dalam menangani pasien kritis, mengelola perdarahan, dan memaksimalkan area operasi luka
yang dapat ditangani dalam satu kesempatan [2]. Hal ini memberikan kontribusi dalam
penutupan luka bakar dini.

Perawatan Intensif

Banyak pasien luka bakar berat memerlukan perawatan intensif. Hubungan kerja berkualitas
antara unit perawatan intensif dan unit luka bakar merupakan hal yang sangat penting dalam
pelayanan berkualitas.

Fisioterapi, Terapi Okupasi

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Terapis sangat berperan dalam perawatan dan rehabilitasi pasien luka bakar [2]. Tindakan ini
dimulai sejak masuk ke unit luka bakar dan berlanjut hingga rawat jalan. Terapi rehabilitatif
pada luka bakar merupakan suatu subdisiplin tersendiri yang umumnya tidak tersedia pada
fasilitas pelayanan rawat jalan lainnya.

Terapi wicara

Para ahli terapi wicara memberikan pelayanan komprehensif dalam manajemen pasien luka
bakar berat yang disertai gangguan menelan, gangguan bicara dan gangguan komunikasi
akibat luka bakar atau komplikasi sekunder termasuk sepsis, kondisi debil, kontraktur wajah
serta pasienpasien dengan trakeostomi.

Ahli Gizi

Nutrisi optimal diperlukan untuk mengatasi respon katabolik yang terjadi pada luka bakar [2].
Untuk tujuan itu, para ahli gizi ada di unit luka bakar.

Psikososial

Pekerja Sosial, Psikiater, Psikolog dan rohaniawan merupakan bagian dari tim luka bakar;
memberikan dukungan yang diperlukan dan penatalaksanaan berbagai masalah psikososial
yang dihadapi pasien luka bakar. Masalahmasalah sulit yang dihadapi tersebut memerlukan
penanganan oleh pakar yang memiliki keahlian khusus [2]. Kapasitas pasien menjalankan
fungsi di masyarakat jangka panjang sangat bergantung pada penyesuaian psikososial akibat
kendala fisik yang dialaminya.

Rehabilitasi

Rehabilitasi pasien luka bakar dimulai sejak pasien dirawat [2]; pada luka bakar ringan biasanya
dapat dilaksanakan rawat jalan. Pasien luka bakar berat kerap memerlukan rehabilitasi jauh
lebih intensif untuk tercapainya fungsi maksimal, sehingga dapat kembali ke aktivitas sehari
hari terutama bekerja. Hubungan yang dekat dengan petugas rehabilitasi dapat memfasilitasi.

Tim luka bakar membuat protokol manajemen optimal yang dapat diterapkan dalam
perawatan dan memberikan dukungan pada setiap anggota tim, optimalisasi pelayanan yang
bersifat profesional, dan memberikan kualitas terbaik perawatan pasien luka bakar [2].

Epidemiologi and Etiologi dari Luka Bakar

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A. Epidemiologi
Luka bakar adalah bentuk umum dari trauma [2, 46]. Sebagian luka bakar terjadi akibat
kecelakaan murni, tetapi sebagian besar disebabkan oleh kelalaian atau kurangnya perhatian,
kondisi medis yang sudah ada (kondisi yang menyebabkan pasien kolaps), atau penderita
penyalahgunaan alkohol dan narkoba. (Lihat Tabel 1)

Sekitar 1% dari penduduk Australia dan Selandia Baru (220. 000) menderita luka bakar dan
membutuhkan perawatan medis setiap tahunnya. Dari mereka, 10% memerlukan rawat inap,
dan 10% dari tergolong luka bakar berat yang mengancam jiwa. 50% pasien mengalami
keterbatasan dalam kegiatan kehidupan seharihari. (Sumber 2001 Survei Kesehatan Nasional
Australia)

Luka bakar 70% mungkin menghabiskan biaya 700. 000 dolar untuk perawatan fase akut,
belum termasuk biaya rehabilitasi, cuti kerja, dan hilangnya kesempatan mendapatkan
penghasilan.

Baik pada dewasa maupun anakanak, umumnya kecelakaan terjadi di rumah [1, 7]. Pada
anakanak, lebih dari 80% terjadi di rumah. Lokasi paling berbahaya adalah dapur dan kamar
mandi. Selain itu, larutan pencuci yang mengandung bahan kimia berbahaya, dan garasi atau
gudang berisi bahan kimia dan cairan berbahaya yang mudah terbakar.

Tabel 1
Lokasi Anak Terbakar (%)
Rumah 82%
Luar Rumah 12%
Jalan 3%
Tempat Kerja 1%
Lembaga / Sekolah 1%
Lainnya 1%
(ANZBA Laporan Tahunan BiNBR 2011 [8])

Tabel 2
Lokasi Dewasa Terbakar (%)
Rumah 56%
Tempat Kerja 17%
Jalan 11%
Luar Rumah 11%
Lembaga 3%
Lainnya 2%
(ANZBA Laporan Tahunan BiNBR 2011 [8])

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Cedera yang terjadi di tempat kerja kerap terjadi akibat kecerobohan dan tidak
memperhatikan faktor keamanan, terutama dalam penggunaan cairan yang mudah terbakar.
Perhatian terhadap regulasi kesehatan dan keselamatan kerja sangat penting untuk mencegah
terajdinya hal ini.

Luka bakar Militer

Lebih kurang dua per tiga luka bakar pada militer tidak berhubungan dengan pertempuran [2].
Kejadiannya sama dengan kecelakaan pada kehidupan sipil.

Luka bakar akibat pertempuran mencapai hanya 10%. Luka bakar akibat ledakan memiliki
risiko tinggi mengyebabkan cedera inhalasi dan kerusakan kulit. Selain itu, trauma multipel
kerap dijumpai.
Segala upaya harus dilakukan agar tentara yang cedera memperoleh pelayanan emergensi
maupun definitif yang sama dengan masyarakat sipil.
Persiapan dan pencegahan saat bertempur, rencana evakuasi dan pemegang kebijakan
penanganan korban, bersamaan dengan logistik dan pemasokan, memerlukan penerapan
protokol manajemen yang sangat berbeda dibandingkan dengan perawatan yang optimal di
masa damai.

B. Etiologi
Pada tabel 3 dan 4 tercantum penyebab luka bakar pada anakanak dan dewasa yang dirawat
di unit luka bakar di Australia atau Selandia Baru 20092010.

Tabel 3
Penyebab Luka Bakar Anak (%)
Air panas 55%
Kontak 21%
Api 13%
Gesekan 8%
Listrik 1%
Kimia 1%
Lainnya 1%
(ANZBA Laporan Tahunan BiNBR 2011 [8])

Tabel 4
Penyebab Luka Bakar pada Dewasa (%)
Api 44%
Air panas 28%
Kontak 13%

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Kimia 5%
Gesekan 5%
Listrik 2%
Lainnya 3%
(ANZBA Laporan Tahunan BiNBR 2011 [8])

Penyebab luka bakar pada dewasa dan anakanak berbeda. Penyebab umum pada dewasa
adalah api sedangkan pada anakanak umumnya air panas. Penyebab pada anakanak yang
berusia lebih besar, umumnya sama dengan pola dewasa.
Semakin tua, pola cedera mereka juga berubah. Orang tua berisiko mengalami luka bakar
karena air panas di rumah atau di rumah jompo (panti wreda).

Pada semua kelompok usia kemungkinan cedera terjadi pada kondisi disharmoni sosial atau
keretakan. Khususnya pada anakanak, terutama bayi dan balita, yang tergantung pada
dewasa di sekitarnya dalam hal perawatan dan keamanan. Kecelakaan karena kurang
perhatian atau kelalaian, asuhan yang buruk dan sangat penyiksaan anak kerap terjadi; dan
bila dicurigai, perlu penyidikan.

Ringkasan
- Luka bakar yang membutuhkan perhatian medik, melibatkan 1% dari penduduk per tahun.
- Luka bakar umumnya disebabkan oleh kecerobohan dan kurangnya perhatian, serta
pengaruh keracunan obat.
- Sebagian besar luka bakar untuk semua kelompok usia terjadi di rumah.
- Luka bakar dapat merupakan akibat kejahatan pada dewasa dan penyiksaan anak.
Diagnosis yang tepat mengenai cedera ini memerlukan kewaspadaan, dan pelaporan yang
akurat dapat memastikan bahwa bantuan sesuai diberikan pada pasien maupun keluarga.

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Bab 2

Penilaian dan Tatalaksana


Emergensi
Pendahuluan
Pada kesempatan pertama berjumpa korban, tenaga medis melakukan penilaian cepat dan
penanganan untuk menyelamatkan jiwa [9]. Sementara pasien luka bakar ringan tidak disertai
cedera penyerta, pasien luka bakar berat umumnya disertai cedera lainnya. Berapapun luas
luka bakar yang dialami, ada dua kemungkinan yang dihadapi, cedera nonluka bakar yang
jelas terlihat maupun tersembunyi. Pasien dengan luka bakar ringan disertai cedera nonluka
bakar biasanya dihadapkan pada kemungkinan pertama. Bagaimanapun, umumnya cedera
mengancam jiwa sering terliwatkan dari perhatian dokter yang menangani karena terfokus
luka yang menarik perhatian [9].

Pada anamnesis, petugas medik harus mendapatkan informasi mengenai kemungkinan adanya
cedera lain pada beberapa kondisi di bawah ini [9]:
- Kecelakaan lalu lintas, terutama terlontar pada kecepatan tinggi
- Letusan atau ledakan
- Luka bakar listrik, terutama tegangan tinggi
- Lompat dan jatuh saat terjadi kepanikan

Pasien yang nonkomunikatif, baik dalam keadaan tidak sadar, diintubasi, psikotik, atau
berada di bawah pengaruh obat, harus dianggap berpotensi mengalami cedera multipel dan
diperlakukan dengan sesuai dengan kondisi pada cedera multipel.

Setelah pertolongan pertama diberikan, prinsipprinsip survei primer dan sekunder dan
resusitasi simultan harus diterapkan [2].

Petugas harus mengenakan alat pelindung diri (APD) i seperti sarung tangan, kacamata goggle
dan gaun khusus sebelum menangani pasien [2].

Pertolongan Pertama
Pertolongan pertama terdiri dari:
- Hentikan proses pembakaran
- Turunkan suhu luka

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Hal ini efektif dalam 3 jam pertama sejak terbakar (Lihat Bab 7).

Survei Primer
Segera identifikasi kondisikondisi mengancam jiwa dan lakukan manajemen emergensi [9,
10]. Jangan terpengaruh oleh luka bakarnya.

A. Penatalaksanan jalan napas dan manajemen tulang servikal


B. Pernapasan dan ventilasi
C. Sirkulasi dengan kontrol perdarahan
D. Disabilitas Status neurologik
E. Paparan + pengendalian lingkungan

A. Penatalaksanaan jalan napas dan manajemen tulang servikal

- Nilai patensi jalan napas, cara termudah adalah berbicara dengan pasien. Jika tidak paten,
bersihkan jalan napas dari benda asing dan membuka jalan napas dengan manuver chin
lift/jaw thrust. Jaga gerakan tulang servikal seminim mungkin dan jangan melakukan fleksi
dan ekstensi kepala dan leher [2, 9].
- Manajemen tulang belakang servikal (terbaik dengan rigid collar). Adanya cedera di atas
klavikula seperti trauma muka atau tidak sadarkan diri kerap disertai patah tulang
belakang servikal.

B. Pernapasan dan Ventilasi

- Paparkan dada dan pastikan bahwa ekspansi rongga toraks adekuat dan simetri [2].
- Berikan oksigen 100% (15 L/menit) menggunakan nonrebreather mask [2, 9].
- Bila diperlukan, ventilasi menggunakan bag dan sungkup atau, intubasi bila perlu.

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- Keracunan karbon monoksida dapat menyebabkan pasien bewarna merahbuah cherry,
dan pasien tidak bernapas.
- Hatihati bila frekuensi pernapasan <10 atau> 30 kali per menit.
- Waspada pada luka bakar melingkar dada dan apakah memerlukan eskarotomi

C. Sirkulasi dan Kontrol Perdarahan

- Lakukan penekanan pada pusat perdarahan


- Pucat menunjukkan kehilangan 30% volume darah.
- Perubahan mental terjadi pada kehilangan 50% volume darah.
- Periksa pulsasi sentral apakah kuat atau lemah?
- Periksa tekanan darah
- Periksa capillary refill (sentral dan perifer) normal bila 2 detik. Bila >2 detik
menunjukkan hipovolemia atau kebutuhan untuk eskarotomi pada tungkai bersangkutan,
periksa tungkai lainnya.
- Masukkan 2 buah kateter IV berdiameter besar, sebaiknya daerah yang tidak terbakar
(normal)
- Ambil darah untuk pemeriksaan darah lengkap / ureum kreatinin / fungsi hari / koagulasi /
hCG / Cross Match / carboxyhaemoglobin [2, 9].
- Bila pasien syok lakukan resusitasi cairan bolus dengan metode Hartmann untuk
memperbaiki pulsasi radialis.
Pertanda klinisawal syok biasanya ditimbulkan penyebab lain. Carilah dan atasi.

D. Disabilitas: Status Neurologis

- Tetapkan derajat kesadaran:

A dari Alert (Sadar, waspada)


V dari Vocal (Respon terhadap rangsang suara)
P dari Pain (Respon terhadap rangsang nyeri)
U dari Unresponsive (Tidak memberi respon)

- Lakukan pemriksaan respon pupil terhadap cahaya. Harus cepat dan sama.
- Tanggap terhadap hipoksemia dan syok yang menyebabkan kegelisahan dan penurunan
derajat kesadaran [9].

E. Paparan dan Pengendalian Lingkungan

- Lepaskan semua pakaian dan perhiasan termasuk anting dan jam tangan [2]
- Miringkan pasien untuk visualisasi sisi posterior

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- Jaga agar pasien tetap hangat [7, 9]
- Area luka bakar dihitung menggunakan metode Rule of Nines atau palmaris (Rule
of One).

Cairan, Analgesia, Penilaian dan Pipa


Hubungan 'Fatt' antara survei primer dan sekunder.

Resusitasi Cairan
(Lihat Bab 6)

- Cairan inisial diberikan menggunakan rumus Parkland yang dimodifikasi [7, 1119]:
34 mL / kg berat badan / % luas luka bakar + tetes maintenance pada anakanak
- Kristaloid (misal: larutan Hartmann atau Plasmalyte) adalah cairan yang direkomendasikan.
- Separuh cairan berdasarkan perhitungan diberikan dalam delapan jam pertama, sisanya
diberikan selama enam belas jam berikutnya [3, 12, 15, 19].
- Saat terjadinya trauma ditetapkan sebagai awal resusitasi cairan [7].
- Bila dijumpai perdarahan atau syok nonbakar, perlakukan sesuai pedoman trauma.
- Pantau adekuasi resusitasi [3, 7, 11, 14, 18, 20]:
- Produksi urin melalui kateter per jam
- EKG, denyut nadi, tekanan darah, frekuensi pernapasan, analisis gas darah arterial dan
pulse oxymetri
- Sesuaikan cairan resusitasi sesuai indikasi.

Analgesia [9]

- Nyeri: berikan morfin iv 0. 050.1 mg/kg


- Titrasi untuk memperoleh efek (pemberian dosis lebih kecil secara frekuen akan lebih
aman).

Pemeriksaan

Radiologi
- Tulang belakang servikal
- Toraks
- Panggul
- Pencitraan lain sesuai indikasi klinis

Pipa
Pemasangan NGT

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Insersi NGT pada luka bakar luas (> 10% pada anakanak,> 20% pada dewasa) bila dijumpai
cedera penyerta, atau untuk melakukan dekompresi saluran cerna. Gastroparesis
merupakan hal yang umum terjadi.

Survei Sekunder
Merupakan pemeriksaan menyeluruh mulai dari kepala sampai kaki. Pemeriksaan dilaksanakan
setelah kondisi mengancam nyawa diyakini tidak ada atau telah diatasi [2].

Riwayat Penyakit:
A Alergy
M Medicine (obatobatan yang baru dikonsumsi)
P Past illness (penyakit sebelum terjadi trauma)
L Last meal (makan terakhir)
E Event (peristiwa yang terjadi saat trauma)

Mekanisme trauma

Informasi yang harus didapatkan mengenai interaksi antara pasien dengan lingkungan:

Luka bakar [9]


- Durasi paparan
- Jenis pakaian yang dikenakan
- Suhu dan kondisi air, jika penyebab luka bakar adalah air panas
- Kecukupan tindakan pertolongan pertama.

Trauma tajam
- Kecepatan proyektil
- Jarak
- Arah gerakan pasien saat terjadi trauma
- Panjang pisau, jarak dimasukkan, arah

Trauma tumpul
- Kecepatan dan arah benturan
- Penggunaan sabuk pengaman
- Jumlah kerusakan kompartemen penumpang
- Ejeksi (terlontar)?
- Jatuh dari ketinggian
- Jenis letupan atau ledakan dan jarak terhempas

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Pemeriksaan

Kepala
- Mata . . . luka tembus kerap terlewatkan Cek ketajaman penglihatan
- Kulit kepala . . . luka tidak beraturan, benda asing

Wajah
- Stabilitas tulang tulang wajah 1/3 tengah
- Periksa adanya gigi yang hilang /maloklusi
- Kebocoran cairan serebrospinal melalui hidung, telinga atau mulut
- Jelaga, lepuh, edema lidah atau faring

Leher
- Inspeksi, palpasi, pemeriksaan radiologi. Selalu curigai adanya fraktur servikal
- Luka menembusmuskulus platisma ruang operasi atau pemeriksaan angiografi

Dada
- Periksa seluruh dadadepan dan belakang
- Tulang iga, klavikula dan tulang dada
- Periksa bising napas dan suara jantung
- Luka bakar melingkar mungkin perlu eskarotomibila menyebabkan restriksi ventilasi
- Batuk yang produktif
- Perubahan suara, parau

Abdomen
- Memperlukan evaluasi berulang untuk menilai nyeri dan distensi abdomen
- Bila dijumpai memar terutama jejas sabuk pengaman, curiga adanya kelainan intra
abdomen seperti ruptur viskus
- Bila penilaian abdomen tidak dapat jelas, samar atau tidak praktis, misalnya pada luka
bakar di daerah abdomen yang luas, maka investigasi lebih lanjut menggunakann CT scan,
atau Focused Assessment with Sonography for Trauma (FAST) merupakan pemeriksaan
mandatorik.

Perineum
- Jejas, hematoma, darah keluar melalui meatus uretra eksterna

Rektum
- Darah, laserasi, tonus sfingter, prostat mengambang

Vagina
- Benda asing, laserasi

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Tungkai
- Kontusio, deformitas, nyeri, krepitus
- Lakukan penilaian pulsasi ekstremitas secara reguler. Pada luka bakar melingkar diikuti
perkembangan edema, awalnya eskar mengnyebabkan terhambatnya aliran balik vena
diikuti terhambatnya aliran arteri yang mengakibatkan iskemia jaringan. Hal ini
mengakibatkan penurunan perfusi ekstremitas diikuti nyeri, parestesia, tidak ada denyut
dan paralisis. Eskarotomi merupakan indikasi saat aliran balik vena ekstremitas terhambat
oleh edema; untuk mengembalikan kecukupan sirkulasi (Lihat Bab 7)
Pelvis
- Diperlukan akses cepat pemeriksaan radiologi di unit gawat darurat untuk menilai
stabilitas tulang pelvis. Bila pemeriksaan raadiologi tidak dimungkinkan, pemeriksaan
stabilitas dengan menekan simfisis dan ilium anterior harus dilakukan. Manuver ini hanya
dapat dilakukan satu kali saja oleh seorang senior.

Pemeriksaan Neurologik
- Pemeriksaan Glasgow Coma Scale (lihat lampiran)
- Penilaian sensorik dan motorik semua tungkai
- Paralisis atau paresis menunjukkan adanya cedera berat, segera lakukan imobilisasi
menggunakan papan spinal dan semirigid collars.
Catatan:
1) Pada pasien luka bakar, paresis tungkai mungkin disebabkan oleh insufisiensi vaskular
akibat eskar yang kaku. Pada kondisi ini, eskarotomi merupakan indikasi.

2) Penurunan tingkat kesadaran bisa disebabkan:


- Hipovolemia akibat pendarahan tak terdiagnosis atau resusitasi yang inadekuat.
- Hipoksemia
- Lesi yang menyebabkan pendesakan ruang intrakranial.

Dokumentasi
- Buatcatatan
- Mintakan persetujuan untuk dokumentasi fotografi dan persetujuan prosedur
- Berikan profilaksis tetanus jika diperlukan (lihat lampiran) [21]

Reevaluasi
Reevaluasi Survei Primer khususnya untuk:
- Gangguan pernapasan
- Insufisiensi sirkulasi perifer
- Gangguan neurologis
- Kecukupan resusitasi cairan
- Penilaian radiologi: foto radiologi toraks

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- Warna urine untuk deteksi haemochromogens
- Pemeriksaan laboratorium:
- Hemoglobin / hematokrit
- Urea / kreatinin
- Elektrolit
- Urine mikroskopik
- Analisis gas darah
- Karboksihaemoglobin (jika tersedia)
- Kadar gula darah
- Skrining obat (mungkin diperlukan oleh Polisi)
- Elektrokardiogram

Perawatan Emergensi Luka


(Lihat Bab 7)

Umumnya, luka bakar steril saat luka bakar terjadi. Perawatan luka bakar berlebihan
menggunakan balutan modern tidak diperlukan bahkan hal ini menyebabkan penanganan yang
memerlukan prioritas tertunda. Tindakan yang tepat untuk penatalaksanaan luka adalah
menutupinya dengan penutup plastik atau kain bersih dan mengatur prosedur evakuasi [22].
Bila rujukan pasien tertunda lebih dari 8 jam, atau pada luka telah terkontaminasi air tercemar
atau limbah industri, maka antimikroba topikal harus digunakan. Bersihkan luka dan konsultasi
ke unit luka bakar rujukan untuk balutan yang dianjurkan. Umumnya direkomendasikan
pembalut antimikroba antimikroba yang mengandung silver atau krim silver sulfadiazin.

Jangan menggunakan balut tekan yang memperberat gangguan sirkulasi pada tungkai yang
sebelumnya memang sudah terganggu. Balutan harus sesering mungkin dibuka untuk
menghilangkan konstriksi.

Luka Bakar Listrik


(Lihat Bab 10)

Konduksi arus listrik melalui dada menyebabkan aritmia jantung sepintas atau henti jantung;
meski hal ini jarang terjadi pada tegangan rendah (<1000 V). Pasien sengatan listrik tegangan
tinggi, penurunan kesadaran atau memiliki EKG abnormal saat masuk rumah sakit mungkin
memerlukan pemantauan EKG 24 jam [23]. Gangguan ritmik jantung lebih mungkin terjadi
pada pasien yang memiliki gangguan jantung sebelumnya.

Selalu ingat bahwa luka masuk atau luka keluar yang lebih kecil dapat disertai kerusakan
jaringan yang berat.

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Luka Bakar Kimia
(Lihat Bab 11)

Bila dijumpai residu bahan kimia di kulit, proses pembakaran akan terus berlanjut. Karenanya,
pakaian yang terkontaminasi harus dibuka dan luka dicuci menggunakan sejumlah besar air
dalam waktu cukup lama [24]. Informasi khusus untuk keracunan zat kimia dapat
menghubungi Poisons Information Australia (13 11 26) danNew Zealand National Poisons
Centre (0800 764 766).

Luka bakar kimia pada mata memerlukan pembilasan secara kontinu menggunakan air. Adanya
pembengkakan kelopak mata dan spasme otot disertai nyeri akan menghalangi pencucian
adekuat. Untuk irigasi kadang diperlukan prosedur retraksi kelopak mata yang baik, konsultasi
dengan oftalmologi pada kasus ini sangat diperlukan.

Dukungan pada pasien, dan keluarga


Luka bakar kerap diikuti gangguan emosional baik pada pasien maupun keluarga dan
kerabatnya [25].
Kesedihan dan kehilangan merupakan hal yang lazim, kadang disertai rasa bersalah atau
menyalahkan diri, ketakutan, depresi atau amarah. Kesemuanya ini perlu diatasi.

Bakar diri merupakan suatu cara tersering yang diambil dalam upaya bunuh diri. Pasien ini
dalam masa kritisnya memerlukan penanganan yang simpatik dan konseling.
Penggunaan narkotik dosis tinggi dan intubasi yang tidak tepat akan menghalangi aspek
terpenting pada manajemen di fase terminal. Hal ini juga menjadikan hubungan harmonik di
akhir hayat dengan keluarga tidak dimungkinkan. Untuk itu, komunikasi yang baik perlu
diupayakan. Sedangkan untuk kasuskasus yang bersifat nonfatal diperlukan bantuan
psikiatrik dalam mencegah upaya bunuh diri terulang kembali.

Beberapa kasus dengan kelainan kepribadian atau di bawah pengaruh zat toksik sering
menunjukkan sikap kasar saat manajemen emergensi, hal ini memerlukan perhatian khusus
untuk tidak mencelakai diri sendiri maupun orang lain. Bantuan tenaga dari disiplin ilmu
lainnya (dalam hal ini konsultasi psikiatri) mungkin diperlukan untuk dapat menagani pasien
pasien ini dengan aman.
Lain halnya pada kasus anak, uraian mengenai mekanisme trauma sulit diperoleh dan
kemungkinan penyebabk nonaksidental harus dipikirkan. Dokumentasi akurat merupakan hal
yang sangat penting dan melaporkan pada yang berwajib merupakan proses yang harus
dijalankan untuk penyidikan lebih lanjut [7].

Perawatan definitif

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Perawatan definitif luka bakar dijelaskan lebih lanjut pada buku pegangan ini. Rujukan ke unit
luka bakar dengan perawatan spesialistik multidisipliner mengacu pada kriteria rujukan dari
ANZBA (Lihat Bab 8)

Ringkasan
Luka bakar sendiri mungkin hanya sebagian dari masalah yang dihadapi; trauma lain sangat
mungkin dijumpai dan ditatalaksanai sesuai survei primer dan sekunder ABC traumatologi.
Demikian pula mengenai perawatan definitif dan kriteria rujukan.

Pada luka bakar terutama dengan trauma penyerta lainnya, beberapa hal di bawah ini perlu
dilakukan evaluasi secara teratur:
- Gangguan jalan napas dan proses pengembangan rongga dada dalam mekanisme
bernapas, terutama karena adanya eskar
- Kecukupan resusitasi cairan
- Insufisiensi sirkulasi perifer karena adanya luka bakar melingkar, edema dan balutan
- Gangguan neurologik
- Perdarahan di dalam rongga

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Bab 3

Respon Lokal dan Sistemik


pada Luka Bakar
A. Respon Lokal
Jackson di Birmingham pada tahun 1950 melakukan studi eksperimental dengan menciptakan
model luka bakar yang selanjutnya memperkaya pemahaman mengenai patofisiologi luka
bakar[2632].

Gambar 3. 1 Luka Bakar model Jackson

Gambar 3. 1 Menunjukkan model luka bakar. Pada daerah yang paling dekat dekat sumber
termal (atau penyebab lainnya), panas tidak dapat dikonduksi secara cepat dan baik, sehingga
terjadi koagulasi protein sel; selanjutnya terjadi kematian sel yang berlangsung sangat cepat.
Daerah ini disebut zona koagulasi atau zona nekrosis (atau zona nekrosis koagulatif) [25, 26,
29, 32, 33].

Di sekitar zona koagulasi adalah daerah dengan kerusakan tidak seberat zona pertama, namun
sirkulasi di daerah tersebut mengalami kerusakan diikuti gangguan mikrosirkulasi. Dengan
terhambatnya mikrosirkulasi, daerah ini disebut zona statis [25, 26, 29, 32]. Bila tidak
ditatalaksanai dengan baik, maka daerah yang cukup luas ini akan mengalami nekrosis saat
dilepaskannya mediatormediator inflamasi sebagai respon terhadap jaringan yang rusak [29].
Secara klinis, hal ini disebut sebagai degradasi luka (bertambah dalamnya luka bakar). Dalam
35 hari pasca luka bakar, luka yang awalnya terlihat vital akan tampak nekrotik. [32].

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Di sekitar zona stasis adalah suatu daerah dimana jaringan melepaskan mediatormediator
inflamasi yang menyebabkan dilatasi pembuluh darah. Daerah ini terlihat kemerahan dan
disebut zona hiperemia [25, 26, 29, 32]. Dengan kembalinya respon vaskular yang bersifat
hiperdinamik, daerah ini akan kembalii normal [27, 34].
Pada luka bakar yang mencakup luas melebihi 10% pada anak atau 20% pada dewasa, zona
hiperemia sangat mungkin terjadi di seluruh tubuh.

Kondisi ketiga zona ini berbeda pada setiap luka itu bakar. Kadang zona statis mencapai
kedalaman dermis namun disertai gangguan vaskular yang progresif pada zona nekrosis
sehingga hal ini menyebabkan luka bakar dalam. (lihatgambar 5. 4) Hal ini umumnya dijumpai
pada orang tua dan pasienpasien luka bakar (maupun sudah mengalami sepsis) dengan
perawatan luka yang tidak tepat. [14]. Dengan demikian, waktu dan penatalaksanaan tindakan
emergensi yang efektif sangat berperan pada proses penyembuhan luka.

B. Responsistemik

1. Permeabilitas kapiler dalam keadaan normal

1) Suatu zat dapat melintas dinding pembuluh kapiler melalui tiga cara: difusi, filtrasi dan
transport molekul.
a) Difusi. Partikel berukuran sangat kecil misalnya oksigen, karbondioksida dan natrium
akan melintasi dinding pembuluh kapiler (membran) dengan mudah dan berhubungan
dengan konsentrasi zat bersangkutan (dari arah konsentrasi tinggi ke konsentrasi
rendah).
b) Filtrasi adalah suatu mekanisme perpindahan air dan zat lainnya. Sejumlah air
terfiltrasi melalui kapiler tergantung pada daya dorong menembus dinding kapiler.
Daya yang menyebabkan pergerakan air tersebut dijelaskan pada hukum Starling [2,
32] (lihat footnote)1.
c) Transpor molekul besar sangat minim dimengerti. Transpor mungkin berlangsung
melalui ruang yang terbentuk di antara selsel endotel. Umumnya pembuluh kapiler
memiliki karakteristik ini (mudah ditembus oleh suatu molekul) sehingga disebut
semipermeabel (permeabelterhadap air dan partikel kecil seperti Na dan Cl, namun
relatif impermeabel terhadap molekul besar misalnya albumin). Namun, faktanya
50%100% serum albumin melintas kapiler dan kembali ke sirkulasi melalui sistem
limfatik dalam sehari.

1
Hukum Starlingmenyatakan bahwa pergerakan cairan netoadalah perbedaan antara gaya yang mendorong cairan
keluar (tekanan hidrostatik dalam kapiler mendorong cairan keluar intravaskular disertai tekanan osmotik cairan
interstisium yang menarik cairan keluar ruang intravaskular) dengan gaya yang mendorong cairan masuk ke ruang
intravaskular (tekanan hidrostatikdi ruang interstisium mendorong cairan masuk kembali ke ruang intravaskular
disertai tekanan osmotik cairan plasma menarik cairan interstisium masuk ke ruang intravaskular).

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2) Variasi normal filtrasi dimungkinkan terjadi karena peran beberapa faktor dinding kapiler
(misalnya, pembuluh kapiler di ginjal lebih banyak dapat dilintasi air, dibandingkan
pembuluh kapiler pada otot) sebagai faktor yang dijelaskan pada hukum Starling. Tekanan
hidrostatik pada pembuluh kapiler tergantung pada tekanan darah yang mengalir dan
tekanan yang menahan (resistance) darah untuk keluar (masingmasing dikendalikan oleh
sfingter pre dan postkapiler). Pada keadaan normal, pembuluh kapiler dilalui oleh
sirkulasi darah secara aktif, dengan interval periode panjang aliran yang rendah diikuti
tekanan yang rendah. Tekanan osmotik koloid plasma yang terutama dipengaruhi
konsentrasi albumin sedangkan tekanan osmotik koloid cairan interstisium dipengaruhi
albumin dan substansi dasar yang terdapat di antara selsel.

2. Peningkatan permeabilitas kapiler

Perubahan ini terjadi karena dilepaskannya mediatormediator inflamasi oleh selsel endotel
yang rusak, trombosit dan leukosit.

1) Vasodilatasi merupakan suatu respon vaskular utama pada proses inflamasi dan
menyebabkan[32]:
a) Peningkatan tekanan hidrostatik di kapiler
b) Terbukanya semua pembuluh kapiler; tidak hanya sebagian.
c) Meregangnya dinding kapiler yang meningkatkan area permukaan membran kapiler
dan terbentuknya celah di antara selsel endotel.
d) Berkumpulnya darah di pembuluh vena kecil.

2) Terjadi peningkatan permeabilitas membran kapiler yang nyata [7, 18]. Hal ini
menyebabkan peningkatan transpor zat melalui ketiga mekanisme, yaitu difusi, filtrasti
dan transpor molekul. Namun, mekanisme ketiga yang tampaknya paling dipengaruhi,
kemudian diikuti oleh meningkatnya perpindahan albumin melintas membran kapiler
(kebocoran). Perpindahan cairan disertai albumin ke ruang interstisium mengalami
akumulasi menyebabkan edema.

3) Kerusakan jaringan akibat paparan terhadap sumber termal menyebabkan terurainya


substansi dasar intersel. Hal ini mempercepat peningkatan tekanan osmotik koloid di
ruang interstisium; yang dapat diamati secara eksperimental. Efek lainnya dari luka bakar
substansi dasar intersel adalah terurainya molekul yang diduga berperan menyebabkan
ekspansi ruang diikuti penurunan tekanan hidrostatik.

3. Efek Sistemik

Pada luka bakar dijumpai perubahan pada semua organ sistem yang nyata [25].
Bagaimanapun, pada luka bakar dengan luas <20% efek dimaksud tidak terlalu bermakna [20].

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Perubahan ini terjadi karena dilepaskannya mediator inflamasi dan rangsang neural, yang
menyebabkan perubahan dalam pengendalian fungsi tubuh akibat reaksi langsung terhadap
mediator di sirkulasi.
1) Efek langsung yang nyata pada sirkulasi. Hipovolemia terjadi karena kebocoran cairan dan
protein ke jaringan interstisium. Albumin menngalami kebocoran akibat peningkatan
permeabilitas kapiler di daerah luka bakar. Pada luka bakar dengn luas >20%, seluruh
sirkulasi sistemik dipengaruhi dengan akibat peningkatan permeabilitas kapiler sistemik.
Koreksi hipovolemia merupakan tindakan life saving pada jam pertama pada luka bakar
berat [16, 18, 27, 3540].
2) Pada luka bakar berlangsung kondisi hipermetabolik yang disebabkan sekresi hormon
stres seperti kortisol, katekolamin danglukagon disertai supresi (atau resistensi) hormon
anabolik (growth hormone, insulin dansteroid) dan mekanisme sarafi yang menyebabkan
katabolisme dan mengakibatkan penguraian protein otot [25]. Perubahanperubahan, ini
dapat diamati secara klinis dengan adanya takikardia, hipertermia dan balans protein
negatif.
3) Imunosupresi akibat depresi berbagai mekanisme imun, baik seluler maupun humoral
[25]. Hal ini menjelaskan, mengapa infeksi merupakan faktor penyebab tingginya
mortalitas pada luka bakar
4) Sebagai bagian dari respon terhdap trauma dan syok, fungsi barier usus terganggu
demikian nyata, diikuti translokasi bakteri. Kejadian ini dapat dihindari dan dicegah
dengan penerapan pemberian nutrisi enteral dini.
5) Paru kerap mengalami perubahan inflamatorik yaitu Acute Respiratory Distress Syndrome
(ARDS) meski tanpa cedera inhalasi [25, 41].
6) Perubahan sistemik yang melibatkan gangguan pertumbuhan terjadi dan dapat dijumpai
selama beberapa bulan hingga beberapa tahun pasca luka bakar setelah penyembuhan
luka. Respons yang dijumpai berupa deposisi lemak, gangguan pertumbuhan massa otot,
berkurangnya mineralisasi tulang dan terhambatnya pertumbuhan longitudinal tubuh.
Meski kecepatan pertumbuhan kembali normal dalam waktu 13 tahun, namun
pertumbuhan normal secara keseluruhan tidak pernah tercapai.

Ringkasan
- Efek lokal terhadap cedera termal pada kulit dan jaringan subkutan terlihat sebagai tiga
zona kerusakan. Progresivitas zona nekrosis merupakan hal yang lazim dan berkaitan
dengan tatalaksana awal.
- Peningkatan permeabilitas kapiler diikuti edema dan penurunan kadar albumin dari darah
sirkulasi.
- Luka bakar menyebabkan gangguan sirkulasi sistemik, gangguan metabolisme,
pengendalian suhu, status imun, fungsi usus, gangguan paru dan gangguan pertumbuhan
jangka panjang.

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Bab 4

Cedera Inhalasi
Terhirupnya uap panas dan atau produk pembakaran menyebabkan kerusakan traktus
respiratorius dalam berbagai cara [2, 42]. Lebih lanjut, absorpsi produk pembakaran
menimbulkan efek toksik yang serius, baik lokal maupun sistemik.

Cedera inhalasi diikuti tingginya mortalitas pada luka bakar [4149]. Dengan adanya cedera
inhalasi, angka mortalitas luka bakar meningkat 30% diikuti risiko timbulnya pneumonia [46].
Bila dijumpai pneumonia, angka mortalitas meningkat hingga 60%. Pada anakanak, luka bakar
dengan luas 50% disertai cedera inhalasi memiliki mortalitas yang sama dengan luas 73% tanpa
cedera inhalasi [50].

Cedera inhalasi yang sebelumnya disebut luka bakar traktus respiratorius, kerap menyertai
luka bakar di daerah kepala dan leher. Lebih kurang 45% luka bakar pada muka, disertai cedera
inhalasi.

Klasifikasi cedera inhalasi


Cedera inhalasi dibagi menurut lokasi cedera [2].

1. Kerusakan jalan napas di atas laring (obstruksi)


2. Kerusakan jalan napas di bawah laring (kerusakan pulmoner)
3. Intoksikasi sistemik (hipoksia sel)
Seorang pasien dapat menderita satu atau kombinasi ketiga jenis kelainan yang disebutkan di
atas.

Manajemen jalan napas bertujuan untuk mempertahankan patensi dan melindungi jalan
napas. Pada gagal napas, jalan napas harus diamankan untuk memperbaiki oksigenasi dan
ventilasi.

1. Cedera jalan napas di atas laring (obstruksi)

Cedera jalan napas di daerah ini umumnya disebabkan oleh terhirupnya uap panas, terutama
pada mereka yang terpaksa menghirupnya tanpa ada pilihan lain. Hal ini dimungkinkan terjadi
saat seorang terperangkap di ruang tertutup pada ruang yang terpenuhi oleh api maupun uap
panas.

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Perubahan patologik yang terjadi adalah sama dengan yang terjadi di kulit; dengan kerusakan
sesuai proporsinya. Dilepaskannya mediator inflamasi pasca paparan ini menyebabkan edema
yang awalnya mengakibatkan obstruksi, selanjutnya menyebabkan hilangnya fungsi proteksi
mukosa. [42].

Obstruksi jalan napas akibat edema ini dapat menetap, melampaui batas waktu edema pada
luka (umumnya antara 1236 jam). Edema di kulit leher kerap memperberat obstruksi [2]. Hal
ini lebih sering dijumpai pada anakanak yang memiliki jalan napas lebih sempit disamping
leher yang pendek, sehingga edema sangat cepat menimbulkan abnormalitas.

Harus selalu diingat, bahwa luka bakar yang mencakup luas lebih dari 20% permukaan tubuh,
kerap dijumpai respon inflamasi sistemik. Meski tidak ada cedera langsung pada jalan napas,
mukosa mengalami edema, terutama kasuskasus yang memerlukan cairan dalam jumlah
besar untuk tujuan resusitasi; hal ini akan memperburuk kondisi jalan napas.

Jalan napas bagian atas memiliki kemampuan lebih efektif untuk menyalurkan panas pada
paparan termal dibandingkan saluran napas bagian bawah.

2. Cedera jalan napas di bawah laring (kerusakan pulmonar)

Perubahan patologik terjadi akibat terhirupnya produk pembakaran. Api menyebabkan


oksidasi dan reduksi dari komponen yang mengandung karbon, sulfur, fosfor dan nitrogen.
Komponen kimiawi yang terbentuk antara lain adalah karbon monooksida,karbon dioksida,
sianida, ester dan komponen organik kompleks seperti amonia, fosgen, hidrogen klorida [42].
Polyvinyl chloride (PVC), misalnya, saat terbakar menghasilkan sekurangnya 75 macam zat
toksik potensial yang berbahaya untuk jalan napas [51]. Asam dan basa dihasilkan saat
komponen ini terlarut di dalam cairan yang ada di saluran napas (mukus, dsb). Zatzat ini
selanjutnya menyebabkan luka bakar kimia.
Disamping itu, partikel berukuran kurang dari 1m yang terhirup mengandung zat kimia yang
bersifat iritan dan menyebabkan kerusakan alveolus [42]. Zatzat kimia ini, saat kontak dengan
mukosa dan parenkim paru menginisiasi produksi mediator inflamasi dan reactive oxygen
species. Kondisi ini memicu edema dan memiliki potensi melapisimukosa trakeabronkus.
Jalan napas bagian bawah juga terpapar pada kemungkinan terbentuknya cast dan sumbatan
yang mengakibatkan obstruksi. Selanjutnya, parenkim paru mengalami kerusakan. Terjadi
disrupsi membran alveolarkapilar, terbentuknya eksudat inflamasidan hilangnya surfaktan.
Kondisi ini menyebabkan atelektasis, edema interstisium dan edema paru yang mengakibatkan
hipoksemia dan menurunnya compliance paru [51, 52].

Faktorfaktor berepran pada kerusakan paru yang mengakibatkan gangguan pertukaran gas
antara lain[47]:

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3. Intoksikasi sistemik

Terdapat dua penyebab intoksikasi pada cedera inhalasi, yaitu karbon monooksida dan
sianida [42]. Keduanya menyebabkan oksidasi karbon inkomplit.

Carbon monoxide (CO)


Merupakan gas tidak bewarna dan tidak berbau yang sangat cepat masuk ke aliran darah dan
mengalami difusi dengan hemoglobin (Hb), karena memiliki afinitas terhadap hemoglobin 240
kali lebih besar dibandingkan dengan oksigen; selanjutnya membentuk carboxyhaemoglobin
(COHb). Ikatan ini menurunkan efektivitas kemampuan darah mengikat oksigen karena
menempati oxygenbinding site untuk duatu kurun waktu yang panjang. CO menyebabkan
hipoksia jaringan dengan cara mengurangi oxygen delivery dan utilisasi di tingkat sel [42].

Selain mengikat hemoglobin, CO juga memiliki afinitas kuat untuk berikatan dengan komponen
selain haem, diantaranya yang sangat penting adalah sistem cytochrome intrasel. Ikatan ini
memiliki dampak toksik langsung diikuti abnormalitas fungsi sel sebagai komponen utama
toksisitas CO. [53]. Pada intoksikasi CO ini, ensefalopati merupakan gejala sisa (sequelae) yang
serius; meski mekanismenya belum diketahui secara pasti, namun diduga kuat terjadi akibat
proses peroksidasi lipid serebral.

Kadar oksigen terlarut dalam plasma tidak terpengaruhi, sehingga kerap dijumpai nilai
PaO2dalam batas normal. Indikator hipoksia umumnya tidak menghadirkan informasi adanya
hipoksia.

Hemoglobin yang tidak berikatan dengan O2 menyebabkan perubahan warna kulit menjadi
kebiruan (sianosis). COHb menunjukkan perubahan warna merah muda (cherry red)

Pemeriksaan oksimetri standar tidak dapat membedakan oxyhaemoglobin dengan


carboxyhaemoglobin sehingga jarang digunakan pada metode asesmen pada keracunan CO.
Analisis gas darah dengan cooximetry merupakan satusatunya metode yang dapat
diandalkan untuk menilai kadar oxyhaemoglobin dan carboxyhaemoglobin [54].
Carboxyhaemoglobin mengalami disosiasi lambat, dengan waktu paruh 250 menit pada suhu
kamar.
Penderita dengan intoksikasi CO kerap mengalami confusion dan disorientasi, menunjukkan
gejala serupa dengan hipoksia, cedera kepala dan keracunan alkohol.

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Tabel 4. 1 Intoksikasi karbon monoksida[9, 42, 53]

Carboxyhaemoglobin (%) Gejala


0 15 Tidak ada (Perokok, pekerja tambang)
15 20 Nyeri kepala, Confusion
20 40 Nausea, Fatigue, Disorientasi, Iritabel
40 60 Halusinasi, Ataksia, Sinkop, konvulsi, koma
> 60 Meninggal

Pasien luka bakar dengan perubahan status kesadaran harus dianggap mengalami intoksikasi
CO hinggaterbukti tidak.

Keracunan sianida (HCN)


Terjadi karena produksi hidrogen sianida akibat terbakarnya plastik [2] atau lem yang
digunakan untuk furnitur. Zat ini diabsorbsi melalui paru dan berikatan dengan sistem
cytochrome. Fungsi cytochrome terhambat mengakibatkan berlangsungnya metabolisme
anaerob. Secara bertahap dimetabolisme oleh enzim hati (rhodenase). Kadar sianida dalam
darah hampir tidak dapat dideteksi dan maknanya masih diperdebatkan. Pada perokok
kadarnya mencapai 0. 1mg/L, dan diketahui bahwa kadar letal mencapai 1. 0 mg/L. Gejala yang
ditimbulkannya antara lain hilangnya kesadaran, neurotoksitas dan konvulsi. Pada praktek
seharihari, keracunan sianida termasuk jarang terjadi, kerap dijumpai bersama intoksikasi CO.

Diagnosis cedera inhalasi


Semua kasus luka bakar harus menjalani pemeriksaan untuk menyingkirkan adanya cedera
inhalasi. Karena gejala dan tanda mungkin baru dijumpai setelah suatu kurun waktu tertentu,
sebagaimana pada semua trauma, harus dilakukan evaluasi ulang setiap saat karena memiliki
potensi berakhir fatal [41, 42, 47, 48].
Pasien dengan cedera inhalasi mungkin mengalami distres pernapasan berat pada fase awal di
tempat kejadian. Kematian awal dapat terjadi dan dalam kondisi seperti ini resusitasi jalan
napas sangat diperlukan sebagai prosedur penyelamatan jiwa [42]. Distres pernapasan di
tempat kejadian dapat terjadi karena anoksia, hal ini disebabkan karena oksigen terpakai pada
proses pembakaran. Intoksikasi harus dicurigai kaerna merupakan penyebab utama kematian
di tempat kejadian; dengan skenario terselubung oleh sisa pembakaran (toxic fumes).

Gambaran umum pada cedera inhalasi adalah obstruksi jalan napas yang semakin hebat dan
terjadi dalam beberapa jam. Untuk itu, dibutuhkan kewaspadaan penuh dalam deteksi. Hal ini
umumnya dijumpai pada obstruksi di atas laring. Sedangkan kecurigaan adanya obstruksi di
bawah laring timbul bila dijumpai pasien gelisah dan confusion.

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Anamnesis

Riwayat terbakar di ruang tertutup atau adanya ledakan bahan bakar (bensin, gas), ledakan
bom harus dicurigai adanya cedera inhalasi. [42].

Pemeriksaan fisik

Pemeriksaan berikut menunjukkan adanya kecurigaan cedera inhalasi[2, 24, 42, 55]:
Hal yang diobservasi Yang didengar
Luka bakar di rongga mulut, hidung dan Perubahan suara
faring,
Bulu hidung terbakar Suara parau dengan batuk
berdahak
Sputum mengandung sisa karbon Napas pendek
Nostril datar Stridor Inspirasi
Kesulitan bernapas Batuk produktif
Tracheal Tug
Fosa supraklavikula mendatar
Retraksi iga

Gejala dan tanda dapat berubah dengan berjalannya waktu tergantung letak cedera. Indikasi
adanya perubahan dimaksud terlihat pada tabel 4. 2 berikut.

Tabel 4. 2 Perubahan gambaran klinik cedera inhalasi sesuai perubahan waktu

Jenis inhalasi Periode waktu Gejala dan tanda


1. Di atas laring 4 24 jam Bertambahnya stridor
Suara parau atau melemah
Batuk basah
Gelisah
Kesulitan bernapas
Obstruksi jalan napas
Kematian
2. Di bawah i. Segera Gelisah
laring
Anoksia yang mengancam jiwa
Kematian
ii. Timbul bertahap Bertambahnya hipoksia
12 jam 5 hari Edema paru /ARDS
Gagal pernapasan

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3. Intoksikasi Meninggal di tempat
Perburukan awal Penurunan kesadaran
Stupor
Perbaikan dengan berjalannya Confusion
waktu Drowsiness
Poor Mentation
Gangguan visual
Nyeri kepala

Cedera inhalasi dan intoksikasi sistemik


Intoksikasi sistemik dicurigai secara klinis sejak awal [48]. Setiap penderita dengan
confusionatau penurunan kesadaran pasca trauma termal atau inhalasi produk pembakaran
dianggap mengalami intoksikasi CO sampai terbukti tidak.

Diagnosis dikonfirmasi oleh adanya COHb di dalam darah [48]. Kadar CO yang diestimasi saat
datang mungkin tidak memiliki korelasi dengan gejala pada susunan saraf pusat akibat
intoksikasi CO. Mungkin dijumpai kadarnya demikian rendah karena terjadi pembersihan CO
dari darah saat masuk rumah sakit. Meski demikian pemeriksaan dapat menunjukkan bahwa
intoksikasitelah terjadi.

Tatalaksana
Tatalaksana cedera inhalasi terfokus pada prioritas sebagai berikut:
- Patensi jalan napas
- Oksigen tinggi
- Pemantauan gangguan respirasi secara frekuen
- Diskusikan kecurigaan adanya intoksikasi sistemik (CO, HCN) dengan ahli toksikologidi
Poisons Information (Australia 13 11 26, New Zealand 0800 764 766)

Pada asesmen awal (survei primer), berikan oksigen dosis tinggi (15L/menit) menggunakan non
rebreathing mask [9]. Hal ini akan memfasilitasi oksigenasi jaringan selama asesmen dan
tatalaksana berikutnya. Patensi jalan napas mutlak diperlukan untuk sampainya oksigen ke
paru.

1. Tatalaksana cedera inhalasi di atas laring

Proteksi tulang belakang servikal bersifat mandatorik. Semua penderita dengan kecurigaan
cedera inhalasi harus diobservasi secara ketat. Karena obstruksi yang berlangsung progresif

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dan cepat sangat mungkin terjadi (terutama pada anakanak dimana jalan napas relatif
pendek dan kecil), maka peralatan emergensi untuk prosedur intubasi harus disiapkan [55].
Asesmen mengenai kondidi klinik penderita secara frekuen menjadi sangat penting karenanya.
Bila dijumpai obstruksi, segera amankan jalan napas dengan intubasi endotrakea.
Intubasi harus dikerjakan segera. Keterlambatan akan diikuti edema jalan napas semakin berat
yang menyebabkan kesulitan dalam prosedur intubasi. Stridor dan distres pernapasan
merupakan indikasi intubasi.

Indikasi intubasi:
- Kebutuhan mempertahankan patensi jalan napas / proteksi jalan napas
- Obstruksi mengancam
- Penurunan tingkat kesadaran
- Fasilitasi transpor penderita
- Kebutuhan untuk penggunaan ventilator
- Oksigenasi terganggu
Bila dijumpai keraguan, intubasi.

2. Tatalaksana cedera inhalasi di bawah laring

Tatalaksana ditujukan sebagai penopang respirasi:


a. Oksgen dosis tinggi
Pada semua penderita luka bakar harus diberikan oksigen dosis tinggi (15 L/menit)
menggunakannonrebreathing mask. Hal ini terutama diperlukan pada kecurigaan
mengenai parenkim paru.
b. Intubasi[9, 55]
Intubasi endotrakea diperlukan untuk memfasilitasi pencucian brokus (bronchialtoilet)
untuk mengatasi hipersekresi, sehingga pemberian oksigen efektif
c. Intermittent Positive Pressure Ventilation (IPPV)
Hal ini menjadi penting bila oksigenasi pada penderita tidak menunjukkan respon pada
pemberian oksigen melalui prosedur sederhana sebagaimana diuraikan sebelumnya.
Karena itu diperlukan ventilasi manual menggunakan bag yang terpasang pada pipa
endotrakea dan pasokan oksigen, atau menggunakan ventilator mekanik.

3. Tatalaksana pada cedera inhalasi dengan intoksikasi sistemik

a. Topangan respirasi
Penting untuk meyakinkan bahwa jaringan mendapatkan perfusi oksigen sebayak
mungkin. Untuk itu dilakukan pemberian oksigen dosis tinggi (15 L/menit) menggunakan
nonrebreathing mask. [9].
b. Proteksi pada penderita tidak sadar

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Penurunan kesadaran terjadi akibat respon intoksikasi sistemik. Tatalaksana emergensi
termasuk mengupayakan posisi penderita miring ke sisi kiri diikuti pemberian oksigen.
Proteksi tulang belakang servikal jangan pernah dilupakan. Jalan napas diamankan,
mulanya dengan prosedur chin lift, dilanjutkan dengan pemasangan oropharyngeal
airway, namun yang terpenting adalah pemasangan intubasi endotrakea.
c. Efek pencucianalamidengan berjalannya waktu
CO dieliminasi bertahap dari darah melalui difusi di alveoli. Waktu yang diperlukan adalah
saat bernapas lambat pada suhu ruangan dengan tekanan atmosfir, namun akan
berkurang dengan meningkatkan konsentrasi oksigen. Bila tersedia, berikan oksigen
dengan tekanan hiperbarik untuk tujuan pencucian CO [2] meski masih dijumpai keraguan
evidencedalam perbaikan neurologik.
d. Oksigen
Tatalaksana emergensi standar adalah menghembuskan oksigen 100% menggunakan
sungkup (mask) [2, 9]. Proedur ini dilanjutkan hingga kadar COHb kembali normal.
Prosedur pencucian COsekunderpada ikatannya dengancytochrome hanya akan
menyebabkan peningkatan kecil kadar COHb dalam 24 jam berikutnya, dan pemberian
oksigen dalam hal ini harus dilanjutkan
e. Oksigen + IPPV
Modalitas ini diperlukan pada penderita tidak sadar, atau cedera inhalasi dengan respon
intoksikasi sistemik.
f. Intoksikasi sianida
Intoksikasi sianida kerap bersifat fatal. Prosedur eliminasi sianida di hepar berlangsung
sangat lambat. Meski pemberian hydroxycobolamindosis tinggi dalam bentuk injeksi
dianjurkan, namun pada umumnya tidak tersedia di instalasi gawat darurat.
g. Intoksikasi Hidrogen Fluorida (HF)
Bila HF diabsorbsi sistemik, akan memengaruhi efisiensi kalsium serum. Hal ini akan
mengakibatkan hipokalsaemia. Pemberian cairan yang ditambahkan kalsium akan
melawan efek negatif HF.

HubungiPoisons Information Australia (13 11 26) atau New Zealand National Poisons Centre
(0800 764 766) untuk informasi mengenai intoksikasi sianida, hydrofluoric acid, dan lainnya.

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Ringkasan
- Cedera inhalasi dan respon intoksikasi sistemik merupakan suatu keadaan berpotensi fatal.
- Diagnosis tergantung adanya kecurigaan klinik yang diperoleh dari anamnesis dan deteksi
gejala serta tanda pada pemeriksaan.
- Tatalaksana emergensi terdiri dari upaya menopang respirasi dengan pemberian oksigen
dan pengamanan jalan napas, disertai insersi pipa endotrakea bila diperlukan.
- Penderita dengan cedera inhalasi atai dengan kecurigaan cedera inhalasi harus dirujuk ke
unit luka bakar untuk memperoleh tindakan sesuai setelah stabilisasi.

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Bab 5

Asesmen Luka
Introduksi
Apapun penyebabnya (termal, kimiawi atau listrik), kerusakan jaringan khususnya kedalaman
luka berhubungan dengan suhu dan kekuatan agen penyebab dan lamanya kontak [2, 10][21,
56] Suhu di atas 50C menyebabkan nekrosis jaringan, terutama pada anakanak dan usia
lanjut.

1. Estimasi luas luka bakar


Terdapat dua faktor yang menentukan beratnya luka bakar, luas dan kedalaman luka [32].
Mortalitas dihubungkan dengan kedua faktor tersebut, yaitu:
Usia penderita
Luas luka bakar

Semakin luas luka bakar, semakin tinggi angka mortalitas

Asesmen yang tepat dalam estimasi luas luka bakar diperoleh dengan melakukan perhitungan
berdsarkan Rule Of Nines (gambar 5. 1) [21, 25].

Rule of Ninesmembagi permukaan tubuh ke area seluas 9 atau kelipatan 9%, dengan
pengecualian perineum yang diestimasikan seluas 1% [21, 25, 27, 5658]. Dengan
menerapkan perhitungan berdasrkan metode ini, diperoleh estimasi luas dengan akurasi yang
dapat dipertanggungjawabkan. Namun, selain melakukan perhitungan luas luka bakar, perlu
pula diperhitungkan area yang tidak mengalami luka bakar; kemudian menggabungkan
keduanya hingga mencapai 100% [7, 21, 5658]. Cara ini bermanfaat pada luka bakar yang
tidak luas, luka tersebar, atau mereka yang tidak berkenan menggunakan metode estimasi
menurut Rule of Nines (gambar 5. 2)

Perhitungan menggunakan Rule of Nines relatif akurat pada dewasa, namun tidak demikian
halnya pada anakanak [21]. Hal ini disebabkan karena perbedaan proporsi luas permukaan
tubuh dibandingkan dewasa. Anakanak secara proporsional memiliki panggul dan tungkai
lebih kecil, namun memiliki kepala dan bahu lebih besar dibandingkan dewasa. Penerapan Rule
of Nines dewasa pada anakanak akan menyebabkan kekurangan atau kelebihan estimasi
ukuran, dan diikuti konsekuensi ketidaktepatan dalam perhitungan kebutuhan cairan
resusitasi.

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Atas dasar hal ini, digunakan Rule of Nines pediatrik (gambar 5. 3) Pada metode ini,
perhitungan dimodifiaksi pada berbagai kelompok usia untuk memperoleh akurasi perhitungan
(lihat bab 9) [2, 21].

Struktur dan fungsi kulit

Kulit terdiri dari dua lapis, yaitu epidermis dan dermis[2, 57, 5962]. Epidermis merupakan
lapisan tipissuperfisial yang ebrperan mengendalikan evaporasi cairan tubuh, dan secara
teratur diproduksi oleh proses divisi lamina basalis epidermis [63, 64]. (gambar 5. 3).

Dibawah epidermis, terdapat lapis dermis yang membatasi kulit dengan lapis lemak subkutis
[63] dan fasia yang memisahkan kulit dari lapisan muskular dan struktur tulang. Lapis ini
memberi bantalan dan pelindung terhadap trauma. Pada luka bakar, kerusakan lapis ini
menyebabkan kerusakan jaringan yang lebih dalam.

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Anatomi kulit hidung dan telinga memiliki perbedaan dengan kulit di bagian tubuh lainnya,
karena kulit melekat dengan kartilago dan hanya dibatasi oleh lapisan lemak subkutis yang
tipis. Suplai darah pada kulit maupun kartilago berjalan di antara kedua lapisan tersebut. Luka
bakar yang mengenai hidung dan telinga menyebabkan kerusakan pembuluh darah sehingga
menimbulkan deformitas yang nyata; terutama saat terdapat infeksi bakterial.

Kedalaman luka bakar


Tergantung kedalamannya, dibedakan luka bakar superfisial, sedang dan dalam. Ketiganya
masingmasing disebut luka bakar epidermal, middermal dan deep dermal atau seluruh
ketebalan kulit (gambar 5. 4 dantabel 5. 1). Pada praktek dilapangan, umumnya dijumpai
dalam bentuk gabungan [7, 9, 21].

A. Luka bakar superfisial

Disebut juga luka bakar dangkal. Merupakan bentuk luka bakar yang memiliki potensi
mengalami proses epitelialisasi spontan. Termasuk ke dalam kategori ini adalah luka bakar
epidermal dan dermal bagian superfisial.

1. Luka bakar epidermal


Luka bakar ini hanya melibatkan lapis epidermis. Penyebab tersering adalah paparan sinar
matahari atau flash injury minor (percikan api). Lapis permukaan mengalami kerusakan
dan proses penyembuhan berlangsung melalui regenerasi epidermis yang berasal dari
lamina basalis. Dengan adanya produksi mediator inflamasi, didapatkan hiperemia yang
menyebabkan luka yang kemerahan dan nyeri (tabel 5. 1)[10]. Adanya eritema, kerap
sulitan dinilai pada seorang yang bewarna kulit gelap. Luka bakar jenis ini mengalami

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epitelialisai dalam waktu singkat (dalam 7 hari) tanpa parut maupun perubahan warna.
[59]. Kadang diperlukan perawatan di rumah askit untuk manajemen nyeri [21].

Eritema (luka bakar epidermal) tidak diperhitungkan pada kalkulasi luas luka bakar [10].
Memang untuk membedakan eritema (luka bakar epidermal) dengan luka bakar superfisial
(dermal) adalah sulit dalam beberapa jam pertama pasca luka bakar.

Tabel 5. 1
Diagnosis kedalaman luka bakar [10]

Pengisian Penyembu
Kedalaman Warna Bula Sensasi
Kapiler han
Epidermal Merah Tidak Cepat Nyeri Ya
Merah
Dermalsuperfisial
muda Kecil Cepat Nyeri Ya
(dangkal)
Pucat
Merah
Middermal Awal Lambat +/ Biasanya
mudagelap
Merah
Dermal dalam +/ Tidak ada Tidak ada Tidak
Bernoda
Seluruh ketebalan Putih Tidak Tidak ada Tidak ada Tidak

2. Luka bakar dermalsuperfisial


Luka bakar dermalsuperfisial mengenai epidermis dan lapis dermis bagian superfisial,
yaitu dermal papilae. Ciri khas luka bakar jenis ini yaitu lepuh (blister, bula) [2]. Lapis kulit
di atas bula (nonvital) terlepas dari lapis dermis (vital) karena edema. Edema
menyebabkan terlepasnya epidermis dari lapisan dermis dan proses eksudasi
menyebabkan akumulasi cairan dan mendorong epidermis; lapis epidermis mengalami
kematian. Cairan tersebut selnjutnya menyebabkan kerusakan dermis berlanjut sehingga
luka bertambah dalam. Terpaparnya dermal pailae memberikan warna merah muda dan
karena ujungujung saraf sensorik terpapar, maka hal ini diikuti nyeri yang ekstrim[21].

Dengan suasana kondusif, epitel akan menyebar dari struktur adneksa kulit (folikel rambut,
kelenjar sebasea dan kelenjar keringat) dan menutupi dermis (proses epitelialisasi). Proses
tersebut berlangsung dalam waktu maksimal 14 hari dengan bekas luka yang menunjukkan
perbedaan warna. Tidak ada skar yang dibentuk pada luka bakar dermalsuperfisial ini.

Bila proses epitelialisasi mengalami keterlambatan, hal ini menunjukkan bahwa kedalaman
luka lebih dalam dibandingkan saat diagnosis ditegakkan.

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B. Luka bakar middermal

Luka bakar middermal sebagaimana namanya, melibatkan kedalaman di antara luka bakar
superfisial dan luka bakar dalam. Lebih cepat mengalami epitelialisasi dibandingkan luka bakar
dalam.

Secara klinis, terlihat adanya variasi derajat kerusakan pleksus dermal. Trombosis kapiler dan
keterlambatan pengisian kapiler disertai edema dan pembentukan bula dapat diamati.
Jaringan bewarna merah muda lebih gelap dibandingkan luka bakar superfisial.

C. Luka bakar dalam

Luka bakar dalam lebih berat dibandingkan dua jenis luka bakar yang dijelaskan sebelumnya.
Proses epitelialisasi spontan tidak terjadi, atau terjadi dalam waktu relatif panjang dengan skar
yang nyata. Luka bakar ini terdiri dari dermaldalam dan seluruh ketebalan kulit.

1. Luka bakardermaldalam

Pada luka bakar dermaldalam mungkin dapat dijumpai bula, namun di dasar bula
ditunjukkan karakteristik luka bakar dalam, retikulum dermis menunjukkan warna merah
berbercak [2, 10]. Hal ini disebabkan karena ekstrapasasi hemoglobin dari selsel darah
merah yang rusak dan keluar dari pembuluh darah. Pertanda khas pada luka bakar ini
adalah suatu tampilan yang disebut fenomena hilangnya capillary blush. Ini
menunjukkan kerusakan pleksus dermal. Ujungujung saraf di lapis dermis juga
mengalami nasib yang sama, karenanya akan diikuti hilang sensasi terutama saat
dilakukan uji pinprick.

2. Seluruh ketebalan kulit (Full Thickness Burns)

Full thickness burns menyebabkan kerusakan lapis epidermis dan dermis dan dapat
menyebabkan kerusakan struktur jaringan yang lebih dalam [2]. Pada penampilan klinik
dijumpai kulit bewarna putih (dense white, waxy, dancharredappearance). Ujung saraf
sensorik di dermis rusak sehingga hilang sensasi. [2, 10]. Kulit yang mengalami koagulasi
menunjukkan konsistensi seperti kulit ini disebut eskar.

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Ringkasan
Masalah pada luka bakar dikaitkan pada beratnya luka bakar.
Mortalitas pada luka bakar berhubungan dengan usia dan beratnya luka bakar.
Rule of Ninespada dewasa dan anakanak dapat diterapkan untuk memperhitungkan luas
luka bakar.
Pemeriksaan klinik luka sangat penting dalam menentukan kedalaman luka.

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Bab 6

Syok Luka Bakar


dan Resusitasi Cairan

Pada luka bakar, terjadi sekuestrasi cairan ke daerah cedera dan saat mencapai atau melebihi
2030%, akan bersifat masif (sistemik) [32, 35]. Edema dalam jumlah besar ditambah adanya
evaporative loss pada luka akan menyebabkan defisit volume plasma. Hal ini akan
menyebabkan hipovolemia yang manakala tidak dikoreksi, akan memicu terjadinya gagal organ
yang bersifat sistemik, khususnya acute kidney injury [16].

Dalam bab ini akan dijelaskan patogenesis edema dan syok hipovolemia pasca luka bakar,
resusitasi dan pemantauannya.

Cedera termal menyebabkan perubahan nyata pada mikrosirkulasi baik di daerah luka bakar
maupun di daerah nonluka bakar (sistemik). Tiga zona terbentuk pada suatu cedera termal
(gambar 3. 1 Model Jackson):

1) Zone sentral,nekrosis koagulatif.


2) Zona intermediate atau zonastasis, tidak ada aliran darah.
3) Zona perifer, menunjukkan vasodilatasi, peningkatan aliran darah dan hiperemia.

Mediator inflamasi yang dilepaskan dari daerah cedera menyebabkan perubahan integritas
dinding vaskular diikuti peningkatan permeabilitas [2]. Mediatormediator ini diantaranya
adalah histamin, serotonin, prostaglandin, bradikinin dan vasokonstriktor poten seperti
tromboksan dan angiotensin.
Pada luka bakar luas (>2030% luas permukaan tubuh), jumlah mediator yang diproduksi
demikian banyak diikuti peningkatan permeabilitas yang berlangsung luas hingga dijumpai
pembentukan edema yang masif dan sistemik [18]. Hal ini menyebabkan terjadinya syok
hipovolemia dalam waktu singkat. Hal ini ditunjang adanya kerusakan anatomik endothelial
lining sistem mikrovaskulatur yang terdeteksi pada pemeriksaan mikroskop elektron.

Dijumpai berbagai metode resusitasi cairan yang masingmasing menunjukkan hasil berbeda.
[19, 65]. Secara praktis, bagaimanapun, larutan kristaloid misalnya larutan Hartmann (Lactated
Ringers) atau Plasmalyte diakui secara luas untuk digunakan sebagai inisiasi prosedur resusitasi
[2, 66].

Pada kasus anak, dijumpai keterbatasan sistem cadangan fisiologik dan besarnya rasio luas
permukaan tubuh terhadap massa tubuh dibandingkan dengan dewasa. Dengan demikian,
ambang cairan resusitasi yang perlu diberikan pada anak lebih rendah dibandingkan dewasa

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(kurang lebih 10%) dan cenderung memerlukan volume yang lebih tinggi untuk tiap kilogram
[3, 18]. Karenanya, diperlukan cairan lebih banyak untuk menyeimbangkan kebutuhan cairan
yang diperoleh melalui perhitungan formula resusitasi. Pada cedera inhalasi dibutuhkan lebih
banyak cairan. Pembentukan edema semakin berkurang dalam 1830 jam pasca luka bakar.
Dengan demikian, durasi resusitasi merupakan suatu variabel dan jumlah cairan yang
dibutuhkan untuk maintenance dapat diketahui dari mengetahui jumlah cairan yang
diperlukan untuk mempertahankan jumlah produksi urin adekuat.

Estimasi kebutuhan cairan


Luas luka bakar dihitung menggunakan rule of nines atau burn body chart bila tersedia.
Timbang berat badan pasien bila mungkin, atau peroleh informasi data tersebut pada
anamnesis. Data ini diperlukan dalam memperhitungkan formula resusitasi [3, 12, 13, 15, 17,
18, 35, 67, 68]:

Dewasa : 34 mL kristaloid (larutan Hartman atau Plasmalyte) / berat badan /


luas luka bakar (%)
Anakanak : 34 mL kristaloid (larutan Hartman atau Plasmalyte) / berat badan /
luas luka bakar (%) di tambah maintenance glukosa 5% + 20 mmol Kcl
dalam larutan salin 0. 45%
Untuk 10 kg pertama 100 mL/kg
1020 kg 50 mL/kg

Catatan: Kalkulasi kebutuhan cairan dimulai sejak saat terjadi cedera, bukan terhitung sejak
masuk rumah sakit.

Cairan diberikan melalui dua buah kanul berdiameter besar (pada dewasa 16G) sedapat
mungkin di daerah nonluka bakar. Pertimbangkan akses intraosseous (IO) bila diperlukan.
Larutan salin normal umumnya dikemas bersama dekstrosa 2.5%: untuk kemasan ini,
tambahkan 25mL dekstrosa 50% ke dalam kantong berisi 500 mL cairan. Bila larutan tersedia
merupakan larutan salin hipotonik tanpa glukosa, tambahkan 50 mL dekstrosa 50% ke dalam
kantong berisi 500mL cairan)

Kalkulasi volume yang diestimasi dalam 24 jam pertama [12] saat edema terbentuk beberapa
saat pasca luka bakar:
Separuh kebutuhan berdasarkan kalkulasi volume diberikan dalam 8 hours [3] dan separuh
sisanya diberikan dalam16 jam berikutnya [12, 15, 19, 67].
Cairan maintenance bagi anakanak dibagi dalam 24 jam secara merata.

Pengurangan cairan tidak sebanding dengan berkurangnya pembentukan edema; formula ini
hanya merupakan petunjuk (panduan, guidelines) yang harus disesuaikan sesuai kebutuhan
individu [15].

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Bila produksi urine tidak mencukupi, berikan cairan ekstra:
Bolus cairan 510 mL/kg dan / atau tingkatkan jumlah cairan berikutnya sejumlah 150%
volume sebelumnya.

Dalam 24 jam kedua pasca luka bakar, larutan koloid dapat diberikan untuk restorasi volume
sirkulasi menggunakan formula [66, 69]:
0. 5mL albumin 5% x kg berat badan x % luas luka bakar.

Disamping itu, larutan elektrolit harus diberikan untuk kebutuhan evaporative lossdan
kebutuhan maintenance normal. Untuk tujuan ini, larutan yang umum digunakan adalah
larutan salin normal Kcl (+ dekstrosa untuk anakanak)

Pemantauan kecukupan resusitasi cairan


Metode terbaik dan termudah adalah melakukan pemantauan jumlah produksi urine [3, 7, 11,
14, 18, 20, 35]:
Dewasa : 0. 5mL/kg/jam = 3050mL/jam
Anak (< 30kg): 1. 0mL/kg/jam (rentang 0. 52mL/kg/jam) [66, 6871]

Bila jumlah produksi urine berkisar pada nilai ini, maka kecukupan perfusi ke organ akan
terpelihara [20]. Produksi urine yang berlebih menunjukkan pemberian cairan berlebihan dan
akan menyebabkan terbentuknya edema masif; produksi urine yang rendah menunjukkan
perfusi ke jaringan yang buruk yang diikuti kerusakan sel

Terlihat bahwa pemasangan kateter urine menjadi sangat penting pada pemantauan dan
menjadi suatu keharusan dilakukan pada:
Luka bakar >10% pada anakanak dan
Luka bakar >20% pada dewasa.

Pemantauan hemodinamik invasif sentral diperlukan pada luka bakar dengan kondisi pre
morbid seperti adanya penyakit jantung atau cedera penyerta yang disertai kehilangan darah
seperti adanya fraktur multipel.

Asidosis yang nyata (pH<7. 35) pada analisis gas darahu menunjukkan perfusi jaringan yang
tidak tercukupi dan menyebabkan asidosis laktat. Pada konsisi demikian, penambahan cairan
resusitasi merupakan indikasi. Bila tindakan koreksi mengalami kegagalan dan dijumpai adanya
hemochromogen di urine, pertimbangkan pemberian bikarbonat setelah melakukan diskusi
dengan intensivis. Asidosis juga menunjukkan kebutuhan, atau ketidakcukupan (inadekuasi)
prosedur eskarotomi.

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Pada luka bakar luas, tekanan darah yang diukur menggunakan sphygmomanometer kerap
tidak akurat karena edema; pengukuran akurat hanya didapatkan pada pemeriksaan melalui
jalur arterial. Laju jantung kerap mengalami peningkatan karena nyeri dan faktor emosional;
merupakan indikator yang buruk untuk digunakan pada pemantauan kecukupan resusitasi
cairan.

Elektrolit serum harus diukur pada kesempatan awal dan selanjutnya secara regular dalam
interval waktu tertentu. Adanya hiponatremia ringan merupakan hal yang umum akibat dilusi
karena pemberian cairan infus dan sangat tergantung pada konsentrasi natrium pada larutan
kristaloid yang diberikan (larutan NaCl Hartmann hanya mengandung natrium 130 mEq/L).
Hiperkalemia merupakan hal umum dijumpai; terjadi karena kerusakan jaringan pada luka
bakar. Bikarbonat dan glukosa ditambah insulin mungkin diperlukan untuk melakukan koreksi.

Gelisah, perubahan mental dan ansietas sering dijumpai dan merupakan indikator
hipovolemia; dan harus diamati sebagai respon pertama dalam menilai kecukupan resusitasi
cairan.

Hemoglobinuria

Kerusakan jaringan khususnya jaringan otot akibat cedera termal, trauma tumpul atau iskemia
(eskarotomi!) menyebabkan dilepaskannya mioglobin dan hemoglobin. Pertimbangan kuat
untuk melakukan fasiotomi (eskarotomi tidak membebaskan fasia otot). Urine yang
mengandung hemochromogen ini menunjukkan warna merah gelap. Gagal gnjal akut (GGA,
Acute kidney injury, AKI) merupakan suatu kondisi yang sangat mungkin dijumpai karena
penimbunan deposit haemochromogen di tubulus proksimal dan memerlukan terapi yang
sesuai [23]:

- Pemberian cairan hingga produksi urine mencapai 2 mL / kg / jam


Pertimbangkan pemberian Mannitol 12.5g dosis tunggal selama 1 jam / L dalam pola
resusitasi cairan dan
- Observasi respon yang terjadi

Masalah yang dijumpai pada resusitasi cairan


Formula yang ada hanya merupakan estimasi kebutuhan, sementara kebutuhan tiap individu
harus dipantau secara ketat.

Oliguria
Rendahnya jumlah produksi urinmenunjukkan ketidakcukupan cairan resusitasi. Dalam hal ini,
tindakan pertama yang dilakukan adalah meningkatkan jumlah tetesan cairan. Diuretikum

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sangat jarang diperlukan dan jangan pernah dipertimbangkan untuk diberikan sebelum
penderita sampai di unit luka bakar. Diuretikum diberikan hanya pada penderita dengan
haemochromogen di urine dan kadang pada penderita luka bakar luas.

Penderitapenderita di bawah ini termasuk kelompok yang kerap memerlukan ekstra cairan
resusitasi [15]:
- Anakanak
- Penderita dengan cedera inhalasi [19]
- Luka bakar listrik
- Keterlambatan
- Dehidrasi petugas pemadam kebakaran, penderita intoksikasi

Neonatus dan usia lanjut dengan kelainan jantung harus dipantau ketat karena kelebihan
cairan sangat mudah terjadi. Untungnya, edema paru merupakan hal yang jarang dijumpai
karena peningkatan resistensi vakcular di pulmoner jauh lebih tinggi secara disproporsional
dibandingkan resistensi sistemik. Hal ini terjadi karena terjadinya hipokinesia miokardial dan
kerap memerlukan pemantauan invasif, topangan inotropik, ventilasi dan manajemen cairan
secara khusus.

Anakanak
Anakanak sangat rentan terhadap hipoglikemia, kelebihan cairan dan hiponatremia karena
keterbatasan simpanan glikogen, rasio luas permukaan tubuh yang lebih besar dibandingkan
berat badan dan volume cairan intravaskular. Kadar glukosa darah dan elektrolit harus
dipantau secara reguler. Pemberian air harus dibatasi dan pemberian glukosa dilakukan sejak
awal. Hal ini dapat dilakukan melalui pemberian enteral maupun penambahan dekstrosa ke
dalam larutan elektrolit.

Sindroma kompertemen abdominal (Abdominal Compartment Syndrome, ACS)


Keadaan ini jarang dijumpai namun merupakan suatu kondisi serius; merupakan komplikasi
yang timbul pada luka bakar luas baik pada kasus dewasa maupun anakanak, terutama bila
kebutuhan cairan demikian besar untuk mencapai produksi urine yang cukup [15, 16, 72].
Adanya ACS dapat diketahui dengan melakukan pengukuran tekanan intra vesika (urinaria).

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Ringkasan
- Resusitasi cairan diperlukan agar penderita luka bakar dapat bertahan hidup
- Cairan intravena untuk anakanak dengan luas luka bakar>10% dan dewasa dengan luka
bakar >20%
- Dua buah kanula perifer berdiameter besar
- Kalkulasi cairan dihitung berdasarkan saat terjadinya trauma:
- Anakanak (<30kg) : 34 mL /kg /% luas luka bakar ditambah maintenance
- Dewasa : 34 ml /kg /% luas luka bakar
- Separuh jumlah dari perhitungan tersebut diberikan dalam 8 jam, sisanya diberikan
dalam 16 jam berikutnya
- Berikan kristaloid (misal, larutan Hartmann atau Plasmalyte) dalam 24 jam pertama.
- Anakanak memerlukankarbohidrat.
- Pasang kateter urine
- Haemochromogens: tambahkan cairan untuk meningkatkan produksi urine.
- Lakukan pemeriksaankadar glukosa darah, elektrolit serum, tekanan darah, frekuensi nadi,
analisis gas darah dan foto toraks.

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Bab 7

Tatalaksana Luka
Introduksi
Dalam penatalaksanaan luka, hal penting yang perlu dipahami yaitu mekanisme trauma dan
penilaian luasberatnya trauma. Hal ini merupakan titik awal tatalaksana, yang akan
menentukan hasil yaitu fungsi dan penampilan.
Luka adalah disrupsi arsitektur jaringan dan prosesproses seluler. Pada luka bakar, denaturasi
protein dan disrupsi struktur sel terjadi akibat kontak dengan sumber termal (baik suhu tinggi
maupun suhu rendah), listrik, kimiawi atau radiasi. Luka bakar demikian merusak karena
menyebabkan terganggunya ketujuh fungsi utama kulit.
- Regulasi suhu
- Pengaturan sensorik
- Respon imun
- Proteksi dari invasi bakteri
- Pengendalian kehilangan (penguapan) cairan
- Fungsi metabolik
- Fungsi estetik dan psikologi

Tujuan tatalaksana adalah untuk memperkecil terganggunya fungsi baik di tingkat lokal
maupun sistemik. Pemahaman luka sebagai suatu hal yang bersifat dinamik dan heterogen
adalah sangat penting. Jangan sampai diduga bahwa luka di berbagai area adalah sama.

Pertolongan pertama

Prinsip penanganan pertama adalah


- Menghentikan proses pembakaran
- Menurunkan suhu luka [22].

Menghentikan proses pembakaran akan mengurangi kerusakan jaringan. Menurunkan suhu


permukaan akan mengurangi produksi mediator inflamasi (cytokines) dan promosi
maintenance viabilitas di zona stasis. Oleh karenanya, hal ini sangat membantu pencegahan
progres kerusakan yang terjadi pada luka bakar dalam 24 jam pertama[25].

Hentikan proses pembakaran


Pada luka bakar api, penderita berguling di tanah secara aktif maupun pasif menerapkan Stop,
Drop, Cover (face) & Roll technique [10, 24]. Pakaian yang terbakar harus segera dilepaskan

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secepat mungkin. Perhatikan jangan sampai penolong mengalami cedera akibat pertolongan
ini.
Pada luka bakar karena air panas, pakaian yang dibasahi air panas berperan sebagai reservoir,
karenanya segera lepaskan sesegera mungkin.
Selain melepaskan pakaian, setiap jenis perhiasan juga harus dilepaskan[2]. Bila pakaian
melekat pada permukaan kulit, potong dan biarkan melekat di tempatnya. Namun, pakaian
terbuat dari bahan sintetik yang meleleh melekat pada kulit yang tidak vital akan mudah
dilepaskan.

Menurunkan suhu luka


Permukaan luka harus diturunkan suhunya menggunakan air mengalir[7378]. Suhu ideal
adalah 15C atau berkisar antara 8C sampai 25C [76, 79]. Dengan menurunkan suhu
permukaan luka, reaksi inflamasi diredam dan menghentikan progress pengrusakan zona stasis
[73, 80].
Berbagai cara dapat diterapkan untuk tujuan ini. Menyemprotkan air atau melekatkan busa
basah di atas luka, handuk basah atau hidrogel dapat dilakukan, namun tidak seefektif air
mengalir dan hanya dianjurkan saat air mengalir tidak ada (misalnya saat meminta
pertolongan ke pusat pelayanan medik) [73, 81]. Handuk basah tidak efektif karena tidak
seluruhnya melekat dengan permukaan luka dan cepat menjadi panas akibat proksimitas
terhadap tubuh[73]: karenanya, bila digunakan, harus sering diganti.
Lamanya aplikasi minimal adalah dua puluh menit, kecuali tidak dimungkinkan [7376, 80].
Misalnya pada penderita multi trauma dan tidak ada petugas yang memberi pertolongan
pertama untuk menerapkan metode tersebut. Lebih lanjut, diperoleh data bahwa pertolongan
pertama efektif bila dilakukan dalam tiga jam pertama pasca luka bakar.
Anakanak terpapar pada risiko hipotermia dan hal ini terdeteksi pada pengukuran suhu saat
asesmen klinik dimana dijumpai anak kebiruan dan mengigil. Aplikasi penurunan suhu luka
harus dihentikan. Pada keadaan seperti ini, dianjurkan mengupayakan suhu si atas 30C dan
membungkus anak bersangkutan [4].

Es atau air es jangan pernah digunakan untuk menurunkan suhu. Suhu yang ekstrim
dingin ini akan menyebabkan vasokonstriksi dan secara eksperimen menunjukkan luka yang
semakin dalam; disamping risiko hipotermia.

Penurunan suhu permukaan sekaligus merupakan analgetik yang efektif [22, 74, 76]. Saat nyeri
timbul kembali dalam beberapa menit setelah aplikasi penurunan suhu dihentikan, dan bila
tidak ada kontra indikasi, maka lanjutkan penurunan suhu hingga dicapai efek analgetik.

Hipotermia harus dicegah

Manajemen awal

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Setelah pertolongan pertama, luka ditutup menggunakan bungkus plastik atau bahan
keringyang tidak melekat selama prioritas manajemen lainnya dilakukan [2, 24]. Bila luka
sebelumnya tidak diturunkan suhunya, lanjutkan metode penurunan suhu sebagaimana
dianjurkan dalam waktu tersisa hingga mencapai tiga jam. Setelah tiga jam, tidak ada efek
benefit. Karenanya, luka kemudian dicuci menggunakan air atau salin, dengan sabun atau
larutan klorheksidin 0. 1% Antiseptik lain jangan digunakan.

Pada penyiapan prosedur transpor, luka dibalut. Tergantung waktu terjadinya trauma, saat
transportasi dan waktu tempuh, diperlukan lebih dari sekedar pembalutan luka menggunakan
kain kering. Lembar plastik dapat dipakai terutama pada anakanak untuk membatasi
penguapan dan kehilangan panas tubuh [22]. Klorheksidin pada tulle (misal: Bactigras) dibalut
dengan kasa akan sangat bermanfaat pada penderita yang memerlukan perjalanan beberapa
jam ke pusat rujukan. Aplikasi krim topikal seyogyanya dihindari karena akan memperpanjang
waktu dan menyebabkan keterlambatan transportasi ke pusat rujukan.

Elevasi
Elevasi ekstremitas yang mengalami cedera sangat bermanfaat selama tatalaksana awal dan
selama prosedur transpor karena akan mengurangi edema. Pada tungkai, dijumpai perbedaan
bermakna dengan kasuskasus yang tidak dilakukan elevasi dalam hal perlunya dilakukan
eskarotomi.

Area khusus
Pada luka bakar dengan cedera inhalasi kerap diikuti berkembangnya edema jalan napas
sehingga diperlukan intubasi [2].
Luka bakar perineum memerlukan pemasangan kateter lebih awal untuk mencegah
kontaminasi. Bila pemasangan kateter terlambat, prosedur insersi pada saat edema akan
mengalami kesulitan.
Luka bakar pada kepala dan leher. Kepala harus dilakukan elevasi untuk menghambat edema
jalan napas bagian atas. Pada anakanak dengan luka bakar luas, prosedur elevasi kepala ini
sangat bermanfaat karena risiko besar terjadinya edema serebral pada resusitasi cairan.

Eskarotomi
Bila luka bakar melibatkan seluruh ketebalan dermis dan kulit mengalami kehilangan elastisitas
saat edema berkembang,[82] maka diperlukan tindakan melakukan sayatan pada kulit hingga
kedalaman subkutis [7, 82]. Prosedur ini disebut eskarotomi.

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Trunkus

Bila trunkus mengalami luka bakar ekstensif, elastisitas dinding dada menurun diikuti
penurunan compliance yang menyebabkan berkurangnya ventilasi [2, 82]. Pada dewasa, kerap
terlihat luka bakar melingkar (sirkumferensial) di dada dengan atau tanpa melibatkan
abdomen. Pada anakanak yang bernapas terutama dengan diafragma, terlihat eskar di
dinding anterior dan abdomen tanpa luka bakar di sisi posterior.
Insisi dilakukan longitudinal sepanjang linea aksilaris anterior ketepi kosta atau ke abdomen
bagian atas [82]. Pada kasus berat, mungkin diperlukan insisi yang menghubungkan kedua
insisi sebelumnya (kanan dan kiri) berbentuk konvekspada sisi atas (kranial) dinding dada, di
bawahklavikuladan melintang di abdomen.

Ekstremitas

Bila pada ekstremitas dijumpai luka bakar melingkar (sirkumferensial), dengan adanya edema
di bawah kulit yang tidak elastik tersebut maka aliran sirkulasi akan terganggu dan
menyebabkan gangguan perfusi diikuti kematian jaringan bagian distal [21]. Gangguan ini
bersifat progresif lambat dan tidak terduga. Adanya peningkatan tekanan kompartemen dapat
diamati dengan adanya gejala dan tanda sebagaimana diuraikan berikut [82, 83]:

- Pain (nyeri) : Nyeri saat istirahat


Nyeri saat menggerakkan sendisendi distal
- Pallor (pucat) : Sirkulasi ke distal terganggu
Pengisian kapiler terhambat (terutama di kuku)
Saturasi oksigen tidak terdeteksi pada pemeriksaan
pulse oximetry
Dingin
- Pulseless (nadi tak : Tidak teraba denyut nadi
teraba)
Tidak ada denyut, terutama pada pemeriksaan USG
Doppler
- Parestesia : Kesemutan hingga hilang rasa (numbness)

Interpretasitandatanda ini mungkin sulit karena terbakarnya kulit (yang menyebabkan palpasi
denyut nadi sulit teraba), suhu dingin (gambaran aliran darah terganggu), dan adanya
hipovolemia. Pemeriksaan akurat didapatkan dengan melakukan USG Doppler. Perubahan
paling awal ditandai hilangnya sinyal Doppler pada pembuluh di jarijari. Eskarotomi harus
segera dilakukan sebelum pulsasinadi hilang dan saat menurunnya sirkulasi.

Sayatan dilakukan hingga kulit sehat beberapa milimeter di proksimal dan distal; di garis mid
aksial antara permukaan fleksor dan ekstensor. Hindari melakukan sayatan melintas lengkung

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fleksura pada sendisendi. Sayatan harus dilakukan hingga ke lemak subkutis dan kulit terpisah
secara nyata. Perabaan menggunakan jari akan dapat meraba adanya sisa tahanan. Kadang
satu insisi cukup namun kadang diperlukan sayatan di kedua sisi untuk restorasi sirkulasi.
Perabaan mengenai ketegangan ekstremitas bersangkutan merupakan petunjuk yang sangat
berharga.

Penyulit eskarotomi adalah tercederainya struktur di bawah kulit. Disisi medial siku, saraf
ulnaris berjalan dan di sisi lateral lutut berjalan saraf peroneal komunis. Jangan melakukan
sayatan transversal di ekstremitas.

Batas distal dari suatu eskarotomikadang sulit ditentukan. Di ekstremitas atas, sayatan lateral
dapat dilakukan sepanjang batas lateral tangan hingga pangkal jari kelima. Di sisi medial,
sayatan dapat dilakukan hingga proksimal ibu jari. Kadangkadang beberapa sayatan
tambahan di tangan diperlukan, dan sebelum memberangkatkan penderita, hubungi unit luka
bakar yang menjadi rujukan.
Diagram lokasi sayatan terdapat di lampiran 3 dalam buku pegangan.

Prosedur
Pertama, tentukan lokasi sayatan. Bila operator belum terbiasa, maka tandai dengan tinta
sementara ekstremitas bersangkutan berada pada posisi anatomik. Perhatikan kembali garis
sayatan.
Lengan dalam posisi supinasi sebelum member tanda dan sayatan berjalan di depan
epikondilus medialis untuk menghindari cedera saraf ulnaris. Pada tungkai, insisi medial
berjalan di belakang maleolus medialis untuk menghindari cedera pembuluh darah dan saraf
safena. Bila diperlukan sayatan lateral, hindari tercederainya saraf peroneus komunis yang
melintas leher fibula; karenanya lokasi sayatan terletak pada garis midlateral.
Instrumen yang diperlukan yaitu pisau atau elektrokauter dan sarana haemostasis seperti klem
arteridan benang, diatermi atau hemostatiktopikal misalnyacalcium alginate. Perdarahan akan
terjadi dalam jumlah ekstrim.
Anestesia umumnya tidak diperlukan. Anestesi lokal diperlukan hanya diperlukan di tepi luka
ke daerah normal. Selain itu, penderita umumnya sudah terintubasi, sehingga sedasi ringan
dapat diberikan.
Prosedur ini dikerjakan dalam kondisi steril. Kasa disiapkan untuk membalut luka sayatan dan
balutan ini seyogyanya tidak menekan agar efektivitas prosedur tercapai.
Pada penderita yang sadar, penjelasan mengenai prosedur harus diberikan sebelum
melakukan tindakan (informed consent)

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Ringkasan
- Luka bakar merusak seluruh fungsi kulit
- Pertolongan pertama adalah hentikan prose pembakaran dan menurunkan suhu luka.
- Tatalaksana luka dilakukan sesederhana mungkin.
- Eskar yang kaku memengaruhi fungsi dan memerlukan eskarotomi; di dada untuk
memperbaiki ventilasi, di ekstremitas untuk memperbaiki sirkulasi ke distal.

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Bab 8

Indikasi dan Prosedur Rujukan


Introduksi
Penderita luka bakar listrik, kimia, atau cedera termal memerlukan asesmen dan stabilisasi di
rumah sakit terdekat. Tidak ada istilah ahli bedah musiman Australia dan New Zealand, karena
tatalaksana multidisiplin tersedia di rumah sakit pusat. Semua penderita memiliki hal untuk
memperoleh pelayanan luka bakar yang berkualitas.
Petugas kesehatan yang mengawali pertolongan harus melakukan asesmen (survei) primer dan
sekunder dan melakukan evaluasi untuk menilai penderita yang harus dirujuk. Luka bakar
kerap dijumpai sebagai suatu trauma multipel, dan setiap penderita harus dilakukan evaluasi
untuk trauma lain atau penyerta. Semua prosedur dan terapi yang diberikan dicatat dan di
informasikan ke unit luka bakar rujukan, termasuklembar pemantauan, obatobatan dan
tindakan yang dilakukan.

Peran faktor geografik

1. Daerah perkotaan

Luka bakar yang terjadi di daerah perkotaan di Australia dan New Zealand yang telah memiliki
unit luka bakar, penderita yang memerlukan perawatan langsung dirujuk setelah survei primer
dikerjakan. Resusitasi dan tatalaksana definitif dengan demikian dapat dilaksanakan sesegera
mungkin tanpa keterlambatan, dengan pengecualian mereka yang memerlukan tindakan
intervensi sebagai tatalaksana penyelamatan hidup seperti prosedur intubasi.
Bila diperkirakan perjalanan ambulans memakan waktu 1 jam atau lebih, maka prosedur
resusitasi cairan dimulai baik di ambulans menuju ke rumah sakit, menghindari syok luka
bakar. Hal ini akan sangat bermakna pada anakanak dan usia lanjut, karena keterlambatan
akan mempengaruhi hasil akhir.

2. Daerah perifer dan terisolasi

Di daerah perifer dan terisolasi, karena keterbatasan fasilitas dan masalah logistik, prosedur
rujukan segera tidak dimungkinkan; penderita memerlukan sarana transportasi darat, udara
atau laut. Dalam keadaan seperti ini, tatalaksana dalam 24 jam pertama dilakukan sebelum
penderita dirujuk; kadang diperlukan tatalaksana lebih dari 24 jam (lihat bab 12). Konsultasi
dengan personel di unit luka bakar regional untuk tatalaksana yang tepat, sehingga penderita
berada pada kondisi optimal saat dirujuk.

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Hanya ada beberapa kondisi penderita yang mengharuskannya tetap dirawat di rumah sakit
lokal atau distrik. Mengorbankan pelayanan yang baik dengan mempertahankan konsep
perawatan agar dekat dengan keluarga merupakan suatu konsep yang kurang baik, terutama
menyangkut penanganan masalah gangguan emosi yang penting dalam tatalaksana.

Kriteria rujukan
Australian and New Zealand Burn Association menetapkan kasuskasus berikut memerlukan
rujukan ke unit luka bakar (lihat tabel 7. 1).

Tabel 7. 1
- Luka bakar > 10% luas permukaan tubuh pada dewasa dan >5% pada anakanak
- Luka bakar seluruh ketebalan kulit (luka bakar dalam, full thickness burns)> 5%
- Luka bakar mengenai area khusus, termasuk wajah, tangan, kaki, genitalia dan perineum,
persendian serta luka bakar melingkar pada dada dan tungkai
- Luka bakar dengan cedera inhalasi
- Luka bakar listrik
- Luka bakar kimia
- Luka bakar dengan penyakit premorbid
- Luka bakar dengan trauma berat lainnya
- Luka bakar pada usia tertentu: anakanak dan usia lanjut
- Luka bakar pada wanita hamil
- Luka bakar bukan karena kecelakaan

Bila penderita memiliki kelainan yang menyebabkan tatalaksana menjadi sulit dengan risiko
yang semakin besar, diperlukan penatalaksanaan oleh tenaga dalam tim spesialis yang akan
memberi kesempatan sebesar mungkin untuk mendapatkan hasil optimal.

Penderitapenderita dengan trauma penyerta harus dibawa ke unit trauma atau unit luka
bakar sesuai dengan beratnya trauma. Harus ada pertimbangan antara temuan klinik saat
asesmen emergensi dan diskusikan dengan pengelola petugas di unit luka bakar rujukan. Pada
trauma berat yang memiliki risiko besar, maka perlu prioritas penaganan dan stabilisasi
sebelum dirujuk. Perawatan luka bakar dilaksanakan dan prosedur rujukan direncanakan
segera setelah penderita berhasil menjalani prosedur emergensi yang diperlukan. Bila luka
bakar merupakan kondisi yang dominan dalam hal mortalitas dan morbiditas, maka prosedur
rujukan ke unit luka bakar merupakan tindakan yang tepat. Prioritas merupakan suatu
pertimbangan klinik yang didiskusikan oleh dokter yang merujuk, ahli luka bakar dan tim
trauma serta ahli intensivis; dengan mempertimbangkan usiapenderita yang memiliki
mortalitas tinggi. Hal ini disebabkan respon pada kelompok usia tertentu yang tidak dapat
diprediksi sehingga mereka memerlukan penanganan spesialistik oleh tim multidisipliner.

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Pendekatan tim menunjukkan banyak kelebihan dalam penatalaksanaan luka bakar [2].

Persiapan rujukan
Dalam keadaan stabil secara fisiologik, penderita luka bakar masif dapat dan aman ditransfer
meski dalam waktu yang relatif lama. Namun untuk dapat ditransfer, penderita harus stabil.
Stabilisasi mencakup semua aspek yang diuraikan sebelumnya.

1. Sistem respirasi

- Semua penderita cedera berat diberi oksigen 15L/menit.


- Karena obstruksi jalan napas bagian atas dapat mengalami progres dengan cepat dan
mencapai puncaknya saat penderita ditransfer, maka pentiing untuk
mempertimbangkan intubasi endotrakea sebelum penderita di rujuk.
- Cedera inhalasi dengan kerusakan infraglotik kerap menimbulkan masalah saat
transportasi berlangsung.

2. Sistem sirkulasi

Prinsip tatalaksana gangguan sirkulasi akibat perpindahan cairan dan elektrolit


sebagaimana diuraikan sebelumnya diberikan untuk stabilisasi penderita sebelum proses
transfer.
- Bila insersi 2 kanul (16G pada dewasa, 20G pada anakanak) tidak dimungkinkan,
ambil rute lain untuk pemberian cairan, dan diskusikan sebelumnya dengan unit luka
bakar rujukan.
- Metode akses vaskular umumnya tergantung pengalaman tim baik di perifer maupun
di unit luka bakar rujukan.
- Rute yang dapat digunakan antaralain adalah jalur vena sentral perkutan (femoral,
subklavia, atau jugularinterna), intraosseous atauvena seksi (ankleatausiku) [3, 7, 9].
- Regimen pemberian cairan dibahas pada diskusi di bab 6. Ringkasnya, mulai resusitasi
cairan
- 34mLkrstaloid (misal, larutan Hartmann atau Plasmalyte) /kg / % luas luka bakar
dalam 24 jam, 50% diberikan dalam 8 jam pertama
- Tambahkan cairan maintenancepada anakanak [3, 12, 15, 17].
- Kecukupan resusitasi ditentukan berdasarkan observasi penderita, dalam hal ini
terutama jumlah produksi urine (yang dipantau melalui kateter) bertujuan mencapai
3050 mL/jampada dewasa, dan 1 mL/kg/jam (0. 52 mL/kg/jam) pada anak
sampaidengan 30 kg [3, 11, 14, 20].

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- Bila dijumpai haemochromogenuria sebagaimana kerap dijumpai pada luka bakar
listrik, kebutuhan cairan ditujukan untuk menghasilkan urine 75100 mL/jam pada
dewasa, dan> 2 mL/kg/jam pada anakanak.

3. Luka

Luka dicuci dengan air mengandung larutan klorheksidin 0. 1% atausalin normal dan dibungkus
dengan plastik atau kain kering bila prosedur transfer harus disegerakan. Plasticwrapyang
kerap digunakan untuk membungkus makanan sangat bermanfaat digunakan untuk mencegah
evaporasi, mempertahankan panas dan mencegah desikasi (luka mengering) [22]. Hanya bila
prosedur transfer tertunda, gunakan balutan atau pembalut formal (misalnya, slowrelease
silver dressings, krim antibakteri atau chlorhexidine impregnated vaseline gauze; dan bahan
penutup absorben). Hal ini dikerjakan setelah melakukan konsultasi dengan unit luka bakar.

4. Manajemen nyeri

Luka bakar diikuti nyeri yang ekstrim. Meski sensasi kulit hilang pada luka bakar dalam, area
sekitar luka dirasakan sangat nyeri; karenanya pemberian analgetika sangat diperlukan [9].
Pada semua kasus, kecuali luka bakar ringan, pemberisan analgetika diberikan secara intra
vena. Dosis awal diberikan relatif kecil selang waktu tiap 35 menit, dan dosis akhir sangat
tergantung respon penderita. Trauma penyerta maupun kelainan yang ada sebelumnya harus
diperhitungkan dalam menetapkan dosis, umumnya diberikan morfin dengan dosis awal 0. 05
0. 1 miligram per kilogram berat badan.

5. Sistem gastrointestinal

Bila dimungkinkan, segera memulai pemberian nutrisi enteral dini melalui akses pipa oro atau
nasogastrik. Selama proses transfer, umumnya lebih aman lambung dalam keadaan kosong
untuk memperkecil risiko aspirasi saat terjadi muntah. Untuk tujuan ini, pipa oro atau naso
gastrik secara reguler diaspirasi dan dilakukan drenase terbuka. Hal ini diterapkan pada kasus
dewasa dengan luka bakar>20% atau anakanak dengan luka bakar >10%.

6. Tetanus

Profilaksis tetanus diberikan pada kesempatan pertama. Detilnya dapat dilihat dalam lampiran
1. Untuk mendapatkan hasil optimal, lakukan kontak secara berkesinambungan dengan unit
luka bakar rujukan, lengkapi semua dokumentasi termasuk halhal yang diuraikan di atas.

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Mekanisme Transfer
Hubungan telefon dengan unit luka bakar rujukan saat penderita memerlukan prosedur
rujukan. Bila keputusan untuk rujukan telah ditetapkan, unit luka bakar rujukan berkewajiban
menyiapkan tempat dan unit luka bakar rujukan bertanggungjawab mengatur prosedur
transportasi. Prosedur transpor mengikuti protokol yang ada.

Pusat pelayanan yang melakukan rujukan bertanggungjawab pada stabilisasi penderita dan
membuat dokumentasi asesmen awal (survei primer dan sekunder) serta tatalaksana yang
sudah dilakukan; termasuk saat melakukan pemeriksaan, balans cairan, terapi termasuk dosis
obat yang diberikan. Pada saat transfer, sertakan dokumentasi ini.

Metode pengiriman ditentukan oleh pusat pelayanan yang melakukan rujukan beserta tim dan
petugas yang selanjutnya mengambil alih tugas dalam asesmen dan tindakan selama
pengiriman.

Ringkasan
- Penderita luka bakar listrik, kimia, cedera termal yang memenuhi kriteria rujukan yang
ditetapkan dalam ANZBA Criteria for Burn Unit Referral (Tabel 7. 1) harus memperoleh
asesmen dan dilakukan stabilisasi saat dirujuk ke unit luka bakar rujukan.
- Prosedur pengiriman merupakan tanggungjawab unit rujukan. Tim yang ikut dalam proses
rujukan bertugas melakukan stabilisasi penderita selama proses transfer.
- Dokumentasi merupakan hal yang sangat penting untuk suatu mekanisme transfer
pelayanan dari unit pelayanan pertama ke unit luka bakar.

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Bab 9

Luka Bakar pada Anak

Introduksi
Demikian banyak konsep emergensi penatalaksanaan luka bakar pada dewasa berlaku pula
pada anakanak. Kasus anak dengan luka bakar harus dinilai dengan pola yang sama
sebagaimana asesmen pada kasus dewasa. Pada survei primer, harus terdeteksi adanya kondisi
mengancam jiwa. Prosedur tersebut dilanjutkan dengan melakukan pengamanan jalan napas
dan kecukupan sirkulasi yang perlu dipantau secara berkesinambungan berdasarkan produksi
urine.

Perbedaan bermakna antara anakanak dengan dewasa adalah sebagaimana diuraikan


berikut:
- Ukuran dan proporsi tubuh pada anak [2]
- Dinamika cairan
- Ketebalan kulit
- Perbedaan sosial dan perkembangan emosional.

Epidemiologi
Insiden luka bakar pada populasi anak jauh lebih tinggi dibandingkan dewasa [3], dengan
penyebab yang berbeda sebagaimana terlihat pada tabel 9. 1

Tabel 9. 1
Penyebab luka bakar pada anak (%)

Air panas 55%


Kontak 21%
Api 13%
Friksi 8%
Listrik l 1%
Kimia 1%
Lainnya 1%
(ANZBA Bi-NBR Annual Report 2011[8])

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PAda anak yang usianya lebih kecil, insiden luka bakar karena air panas menempati urutan
pertama, sementara luka bakar akrena api lebih umum dijumpai pada anak yang usianya lebih
besar [84, 85].

Riwayat
Sebagai pada luka bakar pada umumnya, anamnesis merupakan hal yang sangat penting [21].
Pada anamnesis harus diperoleh informasi mengenai modus dan waktu terjadinya cedera.
Catatan khusus harus diperoleh dari anamnesis tersebut adalah adanya inkonsistensi dari
riwayat dengan dengan temuan pada pemeriksaan fisik atau keterlambatan karena ada
kemungkinan berhubungan dengan luka bakar yang bukan terjadi karena kecelakaan. Masalah
jalan napas yang tidak nyata tampak seperti sleep apnoea atau asma harus teridentifikasi,
demikian pula halnya dengan hubungan psikologik anak dengan keluarganya.
Informasi penting lainnya yang perlu diperoleh adalah pertolongan yang sudah diberikan. Pada
kasus air panas, berapa suhu air, termasuk jenis pakaian yang dikenakan saat terjadi cedera.
Hal ini akan membantu memperkirakan kedalaman luka bakar dan perlunya diberikan edukasi
lebih lanjut.

Ukuran dan proporsi tubuh


Anak berbeda dengan dewasa dalam hal rasio luas permukaan tubuh terhadap berat badan
dan dalam hal ukuran relatif bagian tubuh tertentu dengan bagian tubuh lainya [7]. Dengan
besarnya rasio luas permukaan tubuh terhadap berat badan maka [21]:
- Rasio metabolisme besar
- Proses evaporasi tinggi
- Proses kehilangan panas lebih besar

Kesemuanya memiliki relevansi dengan penatalaksanaan luka bakar pada anak, karena
pemebrian cairan resusitasi didasarkan pada berat badan ketimbang luas permukaan.
Penerapan formula karenanya menjadi kompleks, sehingga sulit untuk diterapkan secara
universal. Namun, pada prakteknya, kasus luka bakar pada anak memerlukan lebih banyak
variasi kalkulasi volume cairan dibandingkan pada dewasa.
Pada anak, kepala dan leher merupakan bagian yang secara komparatif lebih besar
dibandingkan dewasa; demikian pula ukuran tungkai yang secara komparatif lebih kecil
dibandingkan dewasa (gambar 5. 2) [21]. Bayi berusia sampai satu tahun, luas permukaan
kepala dan leher berkisar 18% luas permukaan tubuh dan tungkai berkisar 14%. Dalam masa
pertumbuhannya, setiap tahun di atas usia satu tahun, maka ukuran kepala berkurang sekitar
1% dan ukuran tungkai bertambah 0. 5% dibandingkan luas permukaan tubuh [3]. Dengan
modifikasi kasar dari rule of nines terlihat untuk kepentingan klinik bahwa proporsi dewasa
tercapai saat seorang anak mencapai usia sepuluh tahun. Karenanya, dapat terjadi kesalahan
kalkulasi perhitungan laus luka bakar dan perhitungan kebutuhan cairanresusitasi.

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Kedalaman Luka Bakar
Kedalaman luka bakar sebanding dengan suhu, durasi penggunaan dan berbanding terbalik
dengan faktorfaktor yang merusak jaringan. Salah satu faktor adalah ketebalan kulit. Pada
anakanak, kulit lebih tipis dibanding dewasa. Atas dasar ini, cedera termal menyebabkan
kerusakan deepdermal atau bahkan seluruh ketebalan kulit; dibandingkan suhu dan durasi
yang sama pada dewasa.

Pada bayi, air dengan 60C akan menyebabkan


- Luka bakar seluruh ketebalan kulit dalam waktu kurang dari satu detik
- Anak yang sudah besar mampu bertahan sampai lima detik pada suhu ini.
- Dewasa hanya mendapat luka bakar yang dalam setelah 20 detik.

Refleks menghindar pada anakanak


Adanya rangsang menyakitkan tidak menimbulkan respon dalam waktu cepat dan konsisten
sebagaimana pada dewasa. Seorang balita yang berdiri di air panas atau api tidak akan
berusaha menjauh, hal ini menyebabkan luka bakar dalam.

Asesmen kedalaman luka bakar


Pemeriksaan kedalaman luka bakar pada anakanak lebih sulit dibanding pada dewasa. Pada
anakanak, luka bakar superfisial (dengan lepuh) lebih umum dibandingkan luka bakar api dan
kedalamannya sangat sulit dinilai. Kulit tipis pada anakanak menyebabkan kesulitan dalam
asesmen kedalaman luka bakar[7]. Perubahan warna kulit yang terbakar pada anak tidak selalu
sama dengan dewasa. Warna merah tua dengan sedikit bintik pada anak merupakan indikasi
dari deepdermal atau seluruh ketebalan kulitdan beberapa hari berikutnya akan berubah
suram bahkan kekuningan yang menunjukkan kerusakan seluruh ketebalan kulit.

Pertolongan pertama dan transpor


Prinsip dari pertolongan pertama hentikan kontak dengan sumber panas, hentikan proses
pembakaran dan gunakan air dingin adalah sama sebagaimana pada dewasa. Namun, harus
diingat bahwa risiko hipotermia lebih besar pada anak dibandingkan dengan dewasa.

Hipotermia pada anak dikarenakan beberapa faktor. Besar rasio luas permukaan tubuh
terhadap massa tubuh merupakan hal yang sangat penting. Anak di bawah usia 1 tahun tidak
memiliki refleks mengigil. Anak yang lebih besar mungkin memiliki refleks mengigil, namun

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massa otot mereka jauh lebih kecil; dengan demikian, rasio total massa tubuh dan konten suhu
jauh lebih kecil.

Risiko hipotermia harus diperhatikan saat melakukan pertolongan pertama dan selama
transportasi. Pertolongan pertama yang baik dan beanr harus diterapkan sebagaimana pada
dewasa namun harus benarbenar diaplikasikan pada daerah luka dan menjaga agar tubuh
anak tetap hangat. Pada luka bakar ekstensif, waktu penggunaan air dingin optimal dibatasi
hanya selama 20 menit guna menghindari hipotermia.

Jangan menggunakan es

Selama stabilisasi dan selama transportasi, selimut sangat sangat berguna mencegah
kehilangan panas tubuhmelalui evaporasi dan konveksi.Bagian tubuh yang terpapar harus
ditutup, sebaiknya gunakan lembaran yang menjaga kelembabansemacam plastik.

Jalan napas
Obstruksi jalannapas atas pada anakanak merupakan hal umum. Pembesaran kelenjar
gondok, amandel dan laryngomalacia mungkin ada sebelum cedera termal (3) dan menurut
anamnesis terdeteksi adanya sleep apnoea seperti mendengkur atau melindur, mengantuk di
siang hari atau pernapasan bising. Narkosis mungkin tidak hanya akan menyebabkan depresi
respirasi namun juga menyebabkan relaksasi otototot faring dan meningkatkan kemungkinan
obstruksi. Adanya pembengkakan pada obstruksi dapat menimbulkan masalah.
Diameter saluran napas bagian bawah memiliki ukuran absolut lebih kecil pada anak
dibandingkan dewasa (2,3). Karenanya, adanya pembengkakan di mukosa bronkus atau
akumulasi sekret di bronkus menyebabkan jauh berkurangnya penampang dearah permukaan
mukosa sehingga menganggu aliran udara (2). Atas dasar ini, pipa tanpa cuff digunakan pada
anak dengan usia di bawah 10 tahun.

Reaksi hiperaktivitas bronkus (asma) merupakan kondisi umum dijumpai pada anakanak yang
ditandai adanya riwayat batuk malam hari terutama dimusim dingin atau setelah suatu infeksi
pada sistem respirasi. Inhalasi asap sering menyebabkan bronkopasme pada anakanak yang
rentan terhadap reaksi ini.

Teknik intubasi endotrakea sedikit berbeda pada anak dibandingkan dewasa. Laring lebih tinggi
ke arah sefalad dibanding dengan dewasa. Dengan pipayang berdiameter lebih kecil, maka
frekuensi suction harus ditingkatkan untuk pembersihan sekret. Stabilisasi pipa lebih sulit
khususnya bila wajah terbakar; pengunaan 2 buah pengikat, satu di atas telinga dan satu
dibawahnya (dandapat dipanjangkan saat edema bertambah) akan sangat berguna. Posisi
ujung pipa harus diperiksa melalui auskultasi sebelum memperbaiki posisi pipa diikuti
pemeriksaan foto toraksuntuk konfirmasi posisi pipa. Intubasi endotrakea pada anak hanya
dilakukan oleh praktisi yang terlatih dan berpengalaman.

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Jika terjadi obstruksi jalan napas dan intubasi endotrakea tidak dimungkinkan, lakukan
krikotiroidotomi. Jarum berdiameter besar (14G) melalui membran krikotiroid ditembuskan
dan berperan sebagai cricothyroidotomy. Ini merupakan solusi sementara dan mungkin
diperlukan trakeostomi emergensi.

Manajemen Cairan

1. Perbedaan antara anak dan dewasa

Dinamika cairan dan ukuran tubuh berbeda antara anak dan dewasa. Pada anak, proporsi
terbesar cairan tubuh adalah pada ekstra sel. Pada anak volume darah 80mL/kg, sedangkan
pada dewasa 6070mL/kg [2]. Kapasitas konsentrasi tubulus renalis pada anak lebih kecil
dibanding dewasa. Berdasarkan hal ini, kehilangan cairan pada anak lebih besar dan mungkin
lebih cepat dibandingkan dewasa [2, 3] dan asupan cairan berlebihan sulit ditangani. Disisi lain,
depresi fungsi kardiorespirasi dan cadangan renal yang dijumpai pada dewasa tidak terjadi
pada anakanak. Oleh karenanya, kecuali ada penyakit premorbid, fisiologi anak dapat
diandalkan untuk mengatasi beban cairan dengan cepat, meskipun ekses cairan dalam jumlah
besar kurang mudah ditangani seperti yang disebutkan di atas. Edema serebri lebih mungkin
dijumpai pada anak dengan kelebihan cairan terutama disertai hiponatremia. Risiko ini dapat
dikurangi dengan meninggikan posisi kepala dalam 24 jam pertama.

Atas dasar perbedaan ini, resusitasi cairan dimulai pada anak dengan luka bakar 10% bukan
20% seperti dewasa.

2. Asesmen status cairan

Mekanisme kompensasi yang baik pada anak menunjukkan sirkulasi yang terpelihara baik pada
kondisi dijumpai kekurangan cairan. Dengan demikian, sangat minim informasi yang dapat
menunjukkan gagal sirkulasi hingga dijumpainya tanda syok yang nyata. Pertanda syok dan
hipoksia yang umum dijumpai pada dewasa seperti agitasi dan takikardia kurang bermakna
karena kondisi ini dipengaruhi faktor lain. Misalnya, takikardia dapat disebabkan stres atau
respon hipermetabolik pada luka bakar dan agitasi akibat nyeri atau ansietas [7].

Hipotensi merupakan tanda lanjut dari suatu hipovolemia dan menunjukkan adanya
dekompensasi homeostasis: dan bila hal ini terjadi, penderita dengan sangat cepat jatuh ke
syok ireversibel.

Pertanda yang memberikan informasi ketidakcukupan sirkulasi merupakan indikator yang


direkomendasikan pada kursus Advanced Paediatric Life Support (APLS):

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- Takikardia(sesuai usia)
- Waktu pengisian ulangkapiler >2 detik
- Suhu perifer (akral)dingin, pucat atau berbintik
- Disfungsi organ,takipnu, perubahan status mental

3. Produksi urin

Parameter yang dapat diandalkan untuk mengukur kecukupan resusitasi adalah produksi
urin[3, 7, 11, 14, 18, 20, 35]. Namun, pengukuran ini sangat sulit pada anak karena obstruksi
mekanik pada kateter urin yang berdiameter kecil sangat mudah terjadi; dan terkumpulnya
beberapa mililiter urin dalam pipa berdiameter besar dapat menyebabkan kekeliruan dalam
penilaian. Upayakan produksi urin 1mL / kg / jam sedapat mungkin dalam rentang 0. 52mL /
kg / jam [3, 7].

Saat penambahan cairan diperlukan, berikan 5 sampai 10 mL/kg dengan cepat. Penambahan
cairan juga dapat dilakukan dengan meningkatkan kebutuhan cairan berikutnya hingga 150%
dari volume kalkulasi. Kedua metode ini mungkin diperlukan saat status cairan mengalami
deplesi. Penilaian berulang tiap 1530 menit diperlukan untuk menentukan apakah perlu
diberikan bolus cairan kembali.

4. Kanula intravena

Sebagaimana pada dewasa, pilihan utama pada pemberian cairan adalah kanulasi vena
perkutan; di daerah yang tidak terbakar [2]. Di tangan yang ahli, insersi perkutan dengan
kateter berdiameter besar pada vena utama seeprti femoralis akan sangat bermanfaat. Bagi
yang belum berpengalaman, teknik ini sangat berbahaya dilakukan pada anakanak. Kanulasi
vena perifer perkutan pada daerah terbakar dapat dibenarkan meski lebih sulit [2]. Prosedur
vena sksi memerlukan keahlian, lebih lamban dan memisahkan vena secara permanen hingga
tidak direkomendasikan lagi.

Pemberian cairan intraosseousrelatif lebih aman [2, 3, 7, 9, 72]dan cepat; kini merupakan
teknik pilihan untuk akses vena darurat.

5. Maintenance cairan

Pada anakanak, kebutuhan cairan maintenance berhubungan dengan jumlah cairan resusitasi
[3]. Perhitungan kebutuhan cairan maintenance:
- 100mL/kg untuk 10kg pertama
- 50mL/kg untuk berat badan 10 kg20kg
- 20mL/kg untuk berat badan di atas 20kg

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- 5% glukosa dalam0. 45% salin (normal) [3].

Cairan harus mengandung glukosa yang dapat ditambahkan ke dalam volume cairan resusitasi
pada anakanak dengan berat badannya sampai dengan 30 kg. Tambahan glukosa ini sangat
diperlukan karena terjadi penurunan glikogen pada anak dan hipoglikemia terjadi dengan
cepat dan khususnya berkaitan dengan hipotermia. Estimasi kadar glukosa darah secara
reguler sangat diperlukan selama stabilisasi dan transportasi.

Eskarotomi
Eskarotomi ekstremitas pada anak sangat diperlukan sebagaimana pada dewasa [2].
Eskarotomi pada trunkus lebih sering diperlukan pada anak dibandingkan dewasa, karena anak
bernapas secara diafragmatik; adanya kekakuan dinding abdomen lebih mungkin
menyebabkan keterbatasan volume tidal. Untuk alasan ini, gangguan gerakan gas dapat terjadi
pada trunkus yang terbakar tanpa harus melingkar. Karenanya, pada luka bakar di sekitar dada
anterior, lateral dan bagian atas abdomen, eskarotomi harus dipertimbangkan. Pada situasi ini,
prosedur tambahan disamping prosedur yang dijelaskan pada bab 7 eskarotomi; diperlukan
sayatan melintas bagian atas abdomen sejajar tepi iga untuk memungkinkan gerakan dinding
abdomen terpisah dari gerakan dinding dada.

Saluran cerna
Anakanak lebih rentan terhadap dilatasi lambung dibandingkan dewasa dan cenderung
menelan udara saat menangis. Diperlukan insersi pipa nasogastrik pada fase awal pemeriksaan
dan selama transportasi khususnya jika diperlukan evakuasi udara. Namun, tingkat
metabolisme anakanak yang tinggi dan kebutuhan gizi mereka untuk pertumbuhan berarti
bahwa mereka memiliki toleransi yang sedikit atas kekurangan gizi. Makanan utama yang dini
harus diberikan secepat mungkin saat mereka tiba di rumah sakit karena ini dapat mengurangi
hilangnya fungsi usus dan menjaga nutrisi mereka.

Penilaian Progresivitas Luka


Penilaiankedalaman luka pada anak sulit dalam 710 hari pertama. Bagaimanapun, luka bakar
pada anak yang tidak mengalami epitelialisasi dalam 10 hari harus dilakukan skin grafting.

Aspek Emosional
Patologi psikososial sebelum traumamerupakan hal umum dijumpai pada luka bakar anak
sebagaimana dijumpai padadewasa, namun dengan patologi berbeda. Kekurangan dalam
berbagai hal, kurangnya bimbingan sosial dan asuhan menyebabkan kekurangan berlanjut

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dalam hal perlindungan anak. Orang tua kerap bermuatan dan terlibat dalam kesibukan
masingmasing (masalah sosial dan emosional mereka) dan tak jarang membuat keputusan
yang berisiko bagi anaknya. Anakanak remaja dari keluarga dengan orang tua seperti ini
sering melakukan pengambilan keputusan berisiko tanpa peran orang tua.

Perubahan emosional dan sosial pada anak sangat berbeda dengan dewasa. Bermain
merupakan bagian terpenting pada aktivas normal anak seharihari. Sosialisasi dalam
kelompok sebaya dan pemisahan merupakan aspek yang sangat penting dalam kehidupan
emosional seorang anak. Interaksi antar individu berbeda dan bahasa yang digunakan harus
sesuai dengan usia anak bersangkutan. Pentingnya menempatkan kepercayaan dalam
hubungan anak, menuntut seorang dewasa jujur terhadap anak mereka setiap saat.
Pernyataan tegas dan menakutkan harus dihindari.

Bila seorang anak mengalami luka bakar, maka seluruh keluarga mengalami gangguan
emosional; merasa bersalah dan saling menyalahkan adalah suatu keadaan yang paling
menonjol. Saudara sering sangat terpengaruh. Teman bermain, kelompok sebaya (misalnya
sekolah) juga terlibat. Semua aspek pada anak ini harus ditangani dan mendapat perhatian
sejak awal.

Perubahan emosional jangka panjang seorang anak pasca luka bakar tergantung peran /
bantuan emosional seluruh anggota keluarga;berbeda dengan dewasa yang terkonsentrasi
pada pasien itu sendiri. Oleh karena itu, dukungan keluarga sangat penting dan dimulai sejak
awal.

Cedera bukan kecelakaan


Faktor emosional yang sering memberi kontribusi pada penyebab luka bakar pada anak terdiri
darisuatu spektrum yang bervariasi dari kurangpengawasan sesaat, hingga suatu kondisi
psikopatologik jangka panjang berupa tindak kekerasan pda anak [7]. Untuk menetapkan
cedera bukan kecelakaan ini berada di titik mana pada spektrum adalah sulit. Namun,
menentukan bahwa seorang anak memiliki risiko di masa depan akan lebih mudah. Di sisi
lain, petugas medik memiliki kewajiban hukum (yang bervariasi antar di setiap negara) untuk
melaporkan cedera yang dicurigai disengaja. Laporan mengenai hal ini dilakukan oleh unit
rujukan[7].

Bila terdapat kecurigaan adanya tindak kekerasan anak, maka rujukan ke unit luka bakar
diperlukan. Selama proses transfer ini, halhal yang menimbulkan kecurigaan
didokumentasikan dengan jelas dan dilaporkan. Tiap rumah sakit harus memiliki protokol
dalam penanganan hal ini dengan penekanan komunikasi antarlembaga untuk memberikan
perlindungan anak.

Dugaan cedera bukan kecelakaan dapat dikemukakan bila [1, 10]:

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- Penderita tidak segera dibawa ke rumah sakit
- Informasi pada anamnesis tidak konsisten dengan pemeriksaan fisik
- Informasi pada anamnesistidak sesuai dengan pola cedera
- Adanya tandatanda trauma lainnya
- Pola cedera tertentu (misalnya tanda rokok atau luka bakar melepuh pada sepatu dan
kaos kaki

Harus diingat bahwa tuduhan yang tidak benar atas cedera bukan kecelakaan sangat merusak
reputasi keluarga.Tampilan luka bakar yang tidak lazim dapat saja disebabkan oleh kecelakaan
dan jangan secara otomatis diasumsikan sebagai sesuatu yang disengaja. Anakanak ini harus
ditransfer ke unit luka bakar anakdan mendapatkan penilaian dengan teknik sebagaimana
mestinya.

Dalam prakteknya, perbedaan antara kecelakaan dan bukan karena kecelakaan kurang
penting secara medis dibanding sosial. Semua anggota keluarga memerlukan bantuan selama
jangka waktu panjang dan yang terpenting adalah hasil akhir jangka panjang yang terbaik
secara fungsional.

Kriteria transfer
Pada anakanak, batas kebutuhan untuk prosedur transfer lebih kecil dibandingkan dewasa.
Anak dengan luka bakar > 5%, prosedur transfer harus dipertimbangkan. Pada beberapa kasus,
alasan prosedur transfer mungkin demikian sederhana, misanya untuk manajemen nyeri,
karena pemberian opioid perkontinum tidak tersedia. Pada beberapa kasus lain, prosedur
transfer timbul pada kasus bukan kecelakaan yang memerlukan konsultasi dini dengan unit
luka bakar dan transfer secepat mungkin. Kriteria lainnya yang berlaku pada dewasa, seperti
luka bakar di area khusus (tangan, wajah, kaki dan perineum), dan diketahui atau diduga
cedera inhalasi, luka bakar disertai trauma berat lain, luka bakar pada pasien dengan kondisi
premorbid, juga berlaku pada kasus anak.

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Ringkasan
Semua prinsip pelayanan luka bakar yang berlaku pada dewasajuga berlaku pada kasus anak.

Faktorfaktor yang membedakan fokus pelayanan pada anak adalah:


- Perbedaan proporsi tubuh
- Perbedaan dinamika cairan
- Kulit yang tipis
- Perbedaan keperluan psikososial
Perbedaan fisikpada anak:
- Tendensi hipotermia
- Kedalaman luka bakar
- Tingginya kebutuhan cairan

Latar belakang psikososial dan kebutuhan emosional pada anak yang menderita luka bakar
beserta keluarganya berbeda dengan pasien dewasa.

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Bab 10

Luka Bakar Listrik


Introduksi
Luka bakar listrik terdiri dari tiga bagian, yaitu listrik tegangan rendah, tegangan tinggi dan
sengatan petir. Setiap kelompok memiliki gambaran tersendiri yang patut dipertimbangkan.
Gamabaran umum dari masingmasing adalah panas yang dihasilkan dapat berakibat pada
luka bakar.

Tabel 10. 1
Luka bakar listrik
Tegangan Kulit Kedalaman jaringan Gangguan irama jantung
Tegangan Luka masuk dan luka Jarang mencapai Henti jantung dini atau
Rendah keluar kedalaman tidak ada sama sekali
(<1000V)
Tegangan Luka bakar percikan Kerusakan otot dan Aliran melalui toraks
Tinggi (>1000V) apidengan luka rabdomiolisisdan dapat menyebabkan
masuk dan keluar sindroma kerusakanmiokardial dan
mencapai seluruh kompartemen, gangguan ritmik yang
ketebalan kulit (full timbul lambat
thickness)
Sambaran Petir Luka bakar percikan Henti napasdan
Perforasi gendang resusitasiberkepanjangan
apisuperfisial atau
telinga dan kerusakan
sedalam dermal.
kornea
Luka bakar keluar di
kaki

Tegangan listrik masuk ke dalam kategori rendah bila berada di bawah 1000 volt. Termasuk
suplai listrik satufase sebesar 240 volt alternating current (AC) dengan 50 siklus (50Hz) per
detik yang digunakan untuk perumahan di Australia dan Selandia Baru. Pasokan listrik pada
industri umumnya tiga fase dengan tegangan 415 volt.
Kecelakaan listrik tegangan rendah dapat terjadi pula pada arus satu arah (direct current, DC)
yang digunakan pada industri pelapisan logam, purifikasi elektrolit dan beberapa sistem
transportasi. Aki mobil umumnya menghasilkan arus dengan tegangan 12 volt yang
menyebabkan luka bakar ketika terjadi sirkuit / hubungan pendek dengan logam (misal, cincin

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dan perhiasan). Prosedur hemostasis menggunakan diatermi merupakan penerapan efek
kauter direct current (DC).

Tegangan listrik masuk ke dalam kategori tinggi bila berada di atas 1000 volt.[10] Arus sebesar
11000 atau 33000 volt dalam kabel transmisi tegangan tinggi merupakan arus yang paling
umum digunakan. Tegangan lebih tinggi dijumpai pada pembangkit tenaga listrik maupun
gardu listrik.

Sambaran petir merupakan tegangan tinggi yang ekstrim, amplitude (amper) yang tinggi, aliran
listrik DC yang menghasilkan durasi sangat pendek dan dapat menyebabkan pola cedera yang
tidak lazim.

Patofisiologi
Kerusakan jaringan pada luka bakar listrik terjadi karena dihasilkannya panas akibat adanya:
- Resistensi jaringan
- Durasi kontak
- Besar arus listrik [86].

Setiap jaringan menunjukkan perbedaan karakteristik resistensi listrik sesuai dengan isi
elektrolitnya. Dalam rangka penurunan resistensi, berbagai jaringan terdaftar dibawah ini

- Tulang
- Kulit
- Lemak
- Saraf
- Otot
- Darah dan cairan tubuh.

Resistensi kulit bervariasi berdasarkan ketebalan, serta basah atau keringnya kulit. Kulit tebal
dan kering memiliki resistensi yang tinggi dibandingkan kulit yang tipis dan lembab (misal
berkeringat). Tingginya suhu yang dihasilkan konduktor tergantung pada panas yang
melampaui konduktor melalui proses konduksi, konveksi dan radiasi.
Listrik melampaui tulang sebagai suatu konduktor buruk menyebabkan kenaikan suhu
bermakna karena panas diserap. Kenaikan suhu tulang berkelanjutan bahkan setelah arus
listrik berhenti, menyebabkan kerusakan sekunder. Fenomena ini dikenal sebagai the joule
effect. Karena kedalaman tulang, panas dilepas perlahan dan menyebabkan kerusakan pada
periosteum, otot dan saraf di sekitarnya.
Tingginya arus pada titik kontak dan resistensi kulit yang tinggi menyebabkan panas tinggi yang
menyebabkan kulit hangus. Pada cedera tegangan tinggi, terjadi proses arcing (locatan arus
listrik, red.) pada sendi seperti pergelangan tangan dan siku, menyebabkan gosongnya kulit

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dan luka dalam. Kulit hangus dengan luka serupa merupakan luka keluar yang terdapat di kaki
atau telapak tangan karena resistensi tinggi dan ketebalan kulit yang menghasilkan panas
tinggi.

Jenis luka
Pada listrik dengan arus tegangan rendah, terjadi kerusakan lokal yang signifikan di tempat
kontak, luka masuk dan luka keluar [10, 87] mungkin dijumpai kelainan jantung tetapi tidak
terjadi kerusakan jaringan dalam. Pada arus listrik di perumahan (50 Hz) terjadi kejang otot
atau tetani dan menyebabkan penderita tidak dapat lepas dari kontak dengan benda beraliran
listrik [2][23].

Pada arus tegangan tinggi ada dua kemungkinan mekanisme cedera. Pertama, luka akibat
letupan listrik yang menimbulkan bunga api. Pada luka jenis ini, dijumpai luka bakar di kulit
tanpa kerusakan jaringan dalam karena arus tidak melalui tubuh penderita. Adanya letupan
menyebabkan pakaian terbakar dan mengakibatkan luka bakar kulit tanpa luka kontak, luka
masuk dan luka keluar[10].

Transmisi arus tegangan tinggi umumnya menghasilkan kerusakan jaringan di titik kontak
berupa kerusakan seluruh ketebalan kulit (full thickness) dan kerusakan jaringan dalam [23].
Kerusakan organ tubuh adalah hal yang tidak umum, lebih mungkin disenbabkan karena jatuh
dari ketunggian (tiang atau menara listrik).
Kerusakan otot terjadi dibawah kulit yang kadang terlihat normal mungkin terjadi sangat hebat
melibatkan keseluruhan kompartemen di ekstremitas [88].

Pembengkakan ekstremitas akibat kerusakan otot menyebabkan kondisi menyerupai crushed


syndrome. Ekstremitas tegang pada perabaan, disertai gejalanyeri hebat, dan kondisi ini
menyebabkan penurunan sirkulasi ke distal, hilangnya pulsasi. Kondisi ini memerlukan
fasiotomi dan mungkin diperlukan anestesi umum.

Kerusakan dan nekrosis otot diikuti pelepasan mioglobin dari sel otot ke sirkulasi. Pigmen ini
bersama hemoglobin yang berasal dari hemolisis sel darah merah menyebabkan gangguan
ginjal karena kedua jenis haemochromogens tersebut mengendap di tubulus ginjal diikuti gagal
ginjal akut [10].

Sambaran petir diakibatkan tegangan yang sangat tinggi, dengan amplitudo (ampere) tinggi
dan sirkuit / hubungan pendek arus satu arah (direct current, DC). Bentuk cedera ini kurang
populer di Australia dan Selandia Baru. Tiap tahun 5 sampai 10 orang Australia, 90 di Amerika
Serikat, 10,000 orang di dunia mengalami kematian yang disebabkan oleh sambaran petir.

Pola cederanya sangat bervariasi [2]. Sengatan / sambaran langsung mengenai korban memiliki
risiko kematian tinggi. Yang umum terjadi adalah sambaran dalam bentuk kilatan atau

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percikan, ketika petir menyambar sebuah obyek dengan resistensi tinggi seperti pohon.
Sengatan listrik selanjutnya mengenai tungkai penderita setelah sampai di tanah. Kekhasannya
adalah arus mengalir di permukaan tubuh penderita menyebabkan luka bakar superfisial
hingga ketebalan dermis. Juga dijumpai luka bakar keluar di tungkai atau kaki.

Durasi singkat sambaran petir umumnya tidak diikuti kerusakan jaringan dalam yang
nyatanamun kerap terjadi hentinapas henti jantung [2]. Gangguan napas terjadi awal akibat
dari dampak arus pada pada pusat napas di medula. Kondisi ini biasanya bersifat reversibel dan
memerlukan tindakan resusitasi yang panjang.

Organ lain yang dapat mengalami kerusakan adalah telinga. Perforasi membran timpani
mungkin dijumpai akibat ledakan dan harus diperiksa [2]. Kerusakan kornea juga dapat terjadi
dan ini mungkin dalam bentuk akut atau sekuel jangka panjang.

Sambaran petir juga dapat mengakibatkan kerusakan kulit yang tidak biasa, penampilan
arborescent atausplashedyang disebut Lichtenberg flowers dan patognomonik suatu sambaran
petir [2].

Manajemen
Prosedur penyelamatan korban kecelakaan listrik menghadapkan penyelamat pada risiko nasib
yang sama[24]. Hal yang harus diperhatikan adalah, pertama putuskan hubungan dengan
sumber arus listrik atau singkirkan kabel beraliran dari korban [24]. Jika hal ini tidak
dimungkinkan, pindahkan korban dari sumber arus listrik menggunakan sebuah non
konduktor.
Harus diingat bahwa listrik bahwa tegangan tinggi akan dialirkan melalui udara; tegangan listrik
1.000 volt hanya akan menimbulkan loncatan beberapa milimeter saja, 5.000 volt akan
menyeberang sampai satu sentimeter, dan 40.000 volt hingga 13 sentimeter.

Setelah terbebas dari arus listrik, survei primer dapat dilakukan pada tiap cedera luka bakar.
Jalan napas harus bebas dan tulang belakang servikal terlindungi. Henti napas dapat terjadi
dampak arus listrik pada medula, dan henti jantung akibat efek arus listrik pada miokardium.
Sehingga resusitasi jantungparu sangat penting pada tatalaksana korban luka bakar listrik.
Intubasi endotrakea mungkin diindikasikan untuk mempertahankan patensi jalan napas.
Proteksi tulang belakang servikal sangat penting karena trauma daerah ini sangat mungkin
terjadi bersamaan dengan luka bakar listrik [24]. Kejang otot hebat dapat terjadi pada arus
listrik di rumah tangga dan menyebabkan fraktur tulang. Petugas listrik mungkin jatuh dari
ketinggian seperti tiang, menara atau peralatan tinggi lainnya).

Kemungkinan fraktur pada tulang belakang servikal harus disingkirkan melalui pemeriksaan
pencitraan dengan metode khusus (penggunaan meja khusus untuk foto tulang belakang).
Sebelum menanggalkan imobilisan (hard collar) saat pemeriksaan radiologik, gunakan kantong

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pasir atau fiksasi kepala dengan cara memegangnya. Gunakan papan tulang belakang atau
kantong pasir untuk melindungi tulang belakang torasik dan lumbal sampai kemungkinan
fraktur di daerah ini tersingkirkan.

Riwayat trauma
Selesai melakukansurvei primer, dapatkan riwayat trauma baik dengan melakukan anamnesis
pada pasien, saksi atau paramedis.
- Bagaimana terjadinya kecelakaan?
- Kapan terjadinya?
- Apakah pasien pinsan, bila ya, berapa lama?
- Apakah terjadi amnesia pada saat itu?
- Apakah terdapat trauma yang terkait?
- Apakah terjadi serangan jantung atau apakah terdapat gangguan aritmia?

Survei Sekunder
- Pertama, lepaskan semua pakaian dan barangbarang seperti jam tangan dan perhiasan.
- Lakukan pemeriksaan luka masuk atau kontak luka dengan perhatian khusus pada kulit
kepala, tangan dan kaki.
- Memperkirakan total area luka bakar dan kedalaman luka bakar tersebut.
- Lakukan pemeriksaan neurologik dengan fokus khusus pada susunan saraf pusat dan
perifer.
- Dokumentasikan semua temuan klinis.

Resusitasi
Jika pada saat penyelesaian survei sekunder, cedera yang ada memerlukan resusitasi cairan,
gunakan dua jalur intravena kanula besar seperti pada luka bakar luas lainnya.

Kebutuhan cairan pada luka bakar listrik cenderung volumenya lebih besar dibandingkan
jumlah yang diantisipasi pada luka bakar kulit saja. Kerusakan otot yang tidak tampak pada
ekstremitas mengakibatkan kehilangan cairan yang tidak diperhitungkan menggunakan rumus
standar.

Pada pasien dengan kerusakan jaringan yang dalam, haemochromogenuria harus diantisipasi
[2, 23]. Kateter urin harus dimasukkan untuk deteksi gejala dini perubahan warna urin dan
untuk memantau produksi urin. Jika terlihat pigmen pada urin, laju infus cairan harus
ditingkatkan guna mempertahankan produksi urin 75100 mL/jam bagi dewasa dan 2
mL/kg/jam pada anakanak.

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Bila produksi urin tidak tercapai dengan pemberian cairan yang sesuai, tambahkan 12.5 g
mannitol ke setiap liter cairan untuk tujuan dieresis osmotik.

Alkalisasi urin [23] dengan penambahan natrium bikarbonat secara tradisional telah digunakan
untuk meningkatkan larutan haemochromogens pada urin. Namun rasionalnya kini
dipertanyakan. Jika diperlukan penggantian cairan yang lebih dari sederhana untuk
membersihkan pigmen urin, diusulkan untuk meminta saran ke unit luka bakar.

Bila haemochromogens tidak dijumpai lagi di urine, jumlah cairan harus dikurangi hingga
produksi urine dapat dipertahankan 3050 mL/jam pada dewasa, atau pada anakanak < 30kg
1 mL/kg/jam.

Gangguan aritimia
Konduksi arus listrik melalui dada dapat menyebabkan gangguan ritmik jantung mulai dari
aritmia yang bersifat temporer hingga henti jantung; meskipun hal ini jarang terjadi pada
cedera tegangan listrik rendah (<1000V). Penderita dengan sengatan listrik mungkin
memerlukan pemantauan EKG selama 24 jam; jika mereka terpapar pada tegangan tinggi,
pingsan atau menunjukkan EKG abnormal saat datang di instalasi gawat darurat (23). Aritmia
mungkin terjadi jika pasien memiliki gangguan miokardium yang sudah ada sebelumnya dan
diperburuk oleh adanya aliran listrik.

Penilaian Sirkulasi Perifer


Penilaian sirkulasi perifer harus dilakukan setiap jam:
- Warna kulit
- Edema
- Pengisian ulang kapiler
- Pulsasi perifer
- Sensasi kulit

Jika terdapat luka masuk atau keluar yang ekstrim, kemungkinan edema di bawah fasia harus
diantisipasi. Edema ini sangat mungkin menyebabkan peningkatan tekanan kompartemen
pada yang menyebabkan gangguan sirkulasi [2]. Peningkatan tekanan kompartemen pada otot
menyebabkan nyeri hebat. Ekstremitas tegang pada palpasi dan hilangnya pulsasi perifer.
Dalam keadaan ini, diperlukan tindakan fasiotomi.

Fasiotomi

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Berbeda dengan eskarotomi yang dilakukan untuk melepaskan jeratan eskar, fasiotomi
dilakukan untuk melepas tekanan di suatu kompartemen untuk memperbaiki perfusi ke otot.
Cara terbaik dalam melakukan fasiotomi adalah dalam anestesia umum dan dilakukan di ruang
steril. Kehilangan darah mungkin dapat diperkirakan, dan fasilitas hemostasis seperti diatermi
dan ligasi harus tersedia. Pendarahan yang timbulnya perlahan dan lambat dapat terajdi
setelah penderita teresusitasi. Sayatan fasiotomi harus dibalut dengan perban atau kasa
pembalut yangn tidak menekan.

Sangat penting untuk memberikan resusitasi yang baik kepada pasien sebelum fasiotomi
dilaksanakan sehingga haemochromogens terlepas dari otot i yang baru mengalami perbaikan
perfus dengan cepat terbilas dan dibuang melalui ginjal. Perlu melakukan konsultasi dengan
unit luka bakar untuk pemberian mannitol sebelum fasiotomi sebagai prosedur profilaksis.

1. Ekstremitas atas

Otototot lengan bawah sangat rentan terhadap iskemia dan sindroma kompartemen.
Tekanan ini dibebaskan dengan melakukan sayatan panjang melintang garis midmedial dan
midlateral pada lengan, melintas di atas siku dan pergelangan tangan. Sayatan dibuat pada
kulit dan lemak subkutis selanjutnya membuka fasia dalam; lakukan sayatan pada fasia.
Perhatian khusus untuk melindungi saraf ulnaris di daerah siku. Pendarahan mungkin terjadi
dengan cepat dan memerlukan pengendalian hemostasis menggunakan diatermi atau ligasi.

Jika pasien mengalami hipotensi saat prosedur dilakukan, maka pendarahan biasanya
tertunda. Pembebasan carpal tunnel mungkin diperlukan pada luka bakar di tangan. Sebelum
melanjutkan prosedur ini, lakukan konsultasi dengan unit luka bakar.

2. Ekstremitas bawah

Ada empat kompartemen ekstremitas bawah yang dipengaruhi adanya edema subfasia yang
menyebabkan sindroma kompartemen [2]. Masingmasing kompartemen ini memerlukan
sayatan tersendiri. Empat buah sayatan dapat dilakukan melalui dua sayatan di kulit. Sayatan
lateral dilakukan di atas fibula, memanjang dari kaput hingga tiga perempat panjangn fibula.
Hatihati jangan sampai mencederai saraf peroneal yang meliwati kolum fibula. Septum
intermuskular memisahkan kompartemen anterior dan lateral disayat sepanjang sayatan kulit.

Sayatan medial dimulai dari proksimal, berjarak satu jari di bawah margo subkutan tibia dan
dilanjutkan hingga maleolus medialis. Sayatan pada kulit, lemak subkutis dan fasia dengan
hatihati agar tidak mencederai vena dan saraf safena. Fasia diretraksi, selanjutnya
kompartemen posterior dapat diidentifikasi dan lakukan sayatan dekompresi sepanjang
sayatan kulit.

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Sebagaimana halnya dengan lengan, fasiotomi ekstremitas bawah terbaik dilakukan dalam
anestesia umum dan dilakukan di ruang steril. Pendarahan mungkin terjadi dengan cepat dan
memerlukan pengendalian hemostasis menggunakan diatermi atau ligasi. Sekali lagi,
Pendarahan yang timbulnya perlahan dan lambat dapat terajdi setelah penderita teresusitasi.
Sayatan fasiotomi harus dibalut dengan perban atau kasa pembalut yangn tidak menekan.

Manajemen luka
Prinsipprinsip umum luka bakar berlaku untuk luka bakar listrik dan telah dijelaskan
sebelumnya.

Banyaknya otot non vital mengharuskan manajemen luka bakar yang baik dan pemberian
antibiotika topikal menjadi keharusan untuk pencegahan infeksi.

Luka bakar listrik pada anak


Mayoritas luka bakar listrik pada anak disebabkan tegangan rendah yang terjadi di rumah
tangga [65, 86]. Isolasi peralatan listrik dan kabel yang rusak atau menempatkan benda logan
di titik sumber listrik merupakan penyebab utama luka bakar listrik pada anakanak [65]. Anak
kecil cenderung mengambil dan mengisap kabel listrik dan menyebabkan luka bakar dalam di
sekitar mulut; difasilitasi air liur yang membasahi kabel listrik [86, 89]. Luka bakar pada jari dan
tangan umumnya terjadi pada anak yang sudah lebih besar, teknisi yang bekerja memperbaiki
peralatan rumah tangga dalam keadaan menyala. Pada kebanyakan kejadian, hal ini dapat
dicegah menggunakan pemutus sirkuit pengaman.

Sebagian besar listrik tegangan rendah menyebabkan luka seluruh ketebalan berukuran kecil
yang memerlukan eksisi dan penutupan, skin grafting atau perbaikan lain dan harus dirujuk ke
unit pelayanan luka bakar untuk mendapat pelayanan yang memadai. Kejadian pada tegangan
rendah rumah tangga biasanya tidak menyebabkan kerusakan jaringan otot yang besar pada
ekstremitas. Bagaimanapun, pengawasan EKG selama 24 jam mungkin diperlukan jika mereka
menderita luka bakar yang disebabkan oleh listrik tegangan tinggi, pingsan atau menunjukkan
EKG abnormal saat masuk rumah sakit sebagaimana dijelaskan sebelumnya (23).

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Ringkasan
- Hindari cedera bagi mereka yang akan memberikan bantuan
- Atasi serangan jantung dan pernapassan
- Periksa dan kelola trauma yang terkait.
- Pola cedera terbagi dalam tiga bagian: tegangan tinggi, tegangan rendah dan sambaran
petir atau halilintar.
- Rumus standar resusitasi luka bakar mungkin tidak sama.
- Haemochromogenuria merupakan hal yang umum pada cedera tegangan tinggi dan
memerlukan tindakan khusus untuk mengupayakan produksi urine 75100 mL/jam bagi
dewasa, 2 mL/kg/jam pada anakanak, setelah urine dijernihkan.
- Cedera tegangan tinggi pada ekstremitas mungkin memerlukan fasiotomi.
- Berdasarkan kriteria rujukan dari ANZBA, semua luka bakar listrik harus dibawa ke rumah
sakit untuk mendapat pelayanan kesehatan yang memadai.

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Bab11

Luka Bakar Kimia

Introduksi
Lebih dari 25,000 produk yang dapat menyebabkan luka bakar kimia saat ini dipasarkan untuk
digunakan dalam bidang industri, agrikultur, kepentingan militer dan rumah tangga. Di
Amerika Serikat, lebih dari 3,000 kematian terkait langsung dengan cedera kulit kimia atau
saluran cerna tercatat setiap tahunnya dengan estimasi penderita 60,000 memerlukan
pelayanan medis untuk luka bakar kimia.

Sebagai bagian tubuh yang rentan cedera dan bagian tubuh yang berhubungan langsung
dengan bahanbahan berbahaya, tangan dan bagian atas tubuh merupakanarea yang paling
sering mengalami cedera.

Proteksi
Sangat penting bahwa semua petugas yang memberi pertolongan pertama menyadari
kepentingan menjaga diri dari kontaminasi, misalnya menggunakan sarung tangan, masker
pelindung wajah. Semua pakaian terkontaminasi harus dilepas secepat mungkin dan
ditempatkan dalam wadah pelindung untuk pembuangan selanjutnya.

Etiologi dan Klasifikasi


Kecelakaan di laboratorium, penggunaan zat kimiawi dalam industri, penggunaan untuk tujuan
medis dan tindak kekerasan menyebabkan sebagian besar luka bakar kimia pada populasi sipil.

Bahan kimia yang biasa digunakan dan menyebabkan luka bakar antara lain:

1. Keperluan industri

Alkali: Natrium, kalium, amonium, lithium, barium dan kalsium hidroksida (sabun deterjen,
pembersih dren, dan penghilang cat).
Asam: pikrat, sulfasalisilat, tannic, trichloroacetic, cresylic, asetat, format, klorida dan flourida
(kaca dan elektronik).

2. Keperluan Rumah Tangga

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Alkali: pembersih dren, penghilang cat, reagen tablet tes glukosa urin.
Fenol: deodoran, pembersih, disinfektan.
Natrium hipoklorat: disinfektan, pemutih, deodoran.
Asam sulfat: pembersih toilet
Fosfor: kembang api, insektida, pupuk

3. Keperluan Militer

Fosfor merah atau putih


Vesicants

Patofisiologi
Kerusakan jaringan merupakan dampak langsung paparan bahan kimia apapun tergantung
pada:
- Kekuatan atau konsentrasi agen
- Kuantitas agen
- Cara dan lamanya kontak dengan kulit /kontak mukosa
- Daya penetrasi ke dalam jaringan
- Mekanisme kerja

Perbedaan utama antara luka bakar kimia dan termal adalah lamanya waktu dimana kerusakan
jaringan berlanjut sejak agen kimia menyebabkan kerusakan yang progresif hingga
dinonaktifkan menggunakan bahan penetral atau pengeceran menggunakan air.

Estimasi kedalaman luka bakar dengan penilaian klinis setelah luka bakar mungkin sulit dalam
beberapa hari pertama pasca cedera.

Semua agen di atas menyebabkan cedera sel melalui berbagai jenis reaksi kimia.

Secara umum dapat dikatakan sebagai berikut:


- Asam menghasilkan nekrosis koagulasi.
- Alkali menghasilkan nekrosis likuifaktif.
- Vesicants menyebabkan nekrosis iskemia dan anoksia (dilepaskannya amin dari jaringan
yang menyebabkan terbentuknya bula).
- Kesemuanya menyebabkan koagulasi protein melalui proses oksidasi, korosif atau
penggaraman protein.

Gambaran penting akibat toksisitas sistemik beberapa zat kimia.


- Hipokalsemia: oksalat, asam flourida dan fosfor yang terbakar.

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- Gangguan / kerusakan sel hati dan ginjal: tannic, formic dan asam pikrat, fosfor dan minyak
bumi
- Cedera Inhalasi: asam kuat atau amonia.
- Methemoglobinemia dan hemolisis masif: kresol
- Perforasi septum nasi: asam kromat

Pertolongan Pertama
Tanggalkan semua pakaian yang terkontaminasi bahan kimia yang kering [24]. Alirkan air
dengan konstan adalah pertolongan utama pada luka bakar kimia [2] (kecuali unsur natrium,
kalium dan lithium). Untuk mendapatkan efek terbaik, tindakan ini dimulai dalam waktu 10
menit setelah terjadinya kontak.

Agen yang Aspesifik


Beberapa zat kimia nonespesifik semacam diphoterine saat ini tersedia dan bermanfaat pada
kebanyakan luka bakar kimia

1. Luka Bakar karena asam

- Nyeri hebat
- Penampilannya bervariasi mulai dari eritema (dangkal) hingga eskar hitam (dalam)
- Irigasi menggunakan air
- Diatasi dengan tindakan pembedahan seperti pada luka bakar termal

Asam Flourida
- Sangat korosif, asam nonorganik dari unsur fluorine: luas permukaan tubuh 2% dapat
berakibat fatal

Mekanisme kerusakan
a) Ion hidrogen menyebabkan luka bakar asam pada kulit yang khas, yang dapat
diminimalisasi dengan air.
b) Ion flourida yang bebas masuk melalui kulit rusak akan mengikat ion kalsium. Hal ini
menyebabkan nekrosis jaringan yang lunak dan hipokalsemia berat sehingga mobilisasi
ion kalsium dari tulang tidak memadai untuk mengatasinya. Derajat kerusakan
tergantung pada konsentrasi asam, tingkat dan durasi kontak [90].
c) Aritmia mungkin terjadi akibat hipokalsemia dan hipomagnesemia.

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Tatalaksana [90]
- Aliran air [10]
- Potong kuku
- Inaktivasi ion fluoride bebas racun dan mengubah garam tidak larut dengan:
a) Jel untuk luka bakar mengandung kalsium glukonat [10, 90] (dengan dimetil
sulfoksid 10% [DMSO]).
b) Injeksi kalsium glukonat 10% topical (injeksi multipel 0.10.2 mL menggunakan
jarum 30G di jaringan luka bakar). Jumlah dan frekuensi injeksi dipantau dengan
menilai respon nyeri.
c) Infus kalsium glukonat intraarterial.
d) Infus kalsium glukonat intravena ischaemic retrograde (Biers block).
e) Kadang diperlukan eksisi dini.

2. Luka Bakar Alkali


- Paling umum terjadi di rumah
- Kerusakan jaringan tidak secepat zat asam, namun kerusakan jaringan terjadi dalam kurun
waktu panjang karena terjadi likuifaksi (pencairan) yang menyebabkan kerusakan lebih
dalam [10].
- Irigasi lebih lama dibanding dengan asam (kurang lebih 1 jam)
- Untuk luka bakar dalam diperlukan operasi

Luka Bakar Semen


- Semen basah mengandung zat kaustik dengan pH 12. 9
- Nyeri dan luka bakar timbul lambat (dalam beberapa jam)
- Irigasi dalam waktu lama diperlukan

Luka Bakar Fosfor


- Umumnya terjadi pada tentara
- Fosfor putih terbakar spontan saat terpapar pada udara
- Teroksidasi menjadi fosfor pentoksida
- Diredam dengan air
- Partikel fosfor yang tertanam di kulit akan terus membakar
- Pengobatan
a) Pemberian air dalam jumlah yang banyak
b) Singkirkan partikel yang tampak
c) Berikan tembaga sulfat (akan terbentuk tembaga fosfid hitam yang memfasilitasi
terlepasnya partikel fosfor)
d) Kematian berhubungan dengan efek sistemik dari hipotensi dan tubular nekrosis akut

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Bensin
- Campuran alkana, sikloalkana dan hidrokarbon yang kompleks.
- Komponen hidrokarbon merusak sel endotel yang menyebabkan kerusakan paruparu,
hati, limpa dan ginjal setelah kontak dengan kulit mencakup area luas.
- Bensin melarutkan senyawa lipid dengan cepat dan menyebabkan peningkatan
permeabilitas membran diikuti kehilangan cairan.
- Ada dua macam luka bakar bensin:
a) Terbakar. Kebutuhan cairan sering lebih tinggi dari luka bakar lainnya. Luka bakar
cenderung menjadi lebih luas, memerlukan operasi dan perawatan di rumah sakit
lebih lama.
b) Terendam atau kontak kulit yang luas berdampak pada luka bakar dengan seluruh
ketebalan kulit, kadang disertai kerusakan sistemik termasuk paruparu.

Aspal
- Produk penyulingan minyak bumi.
- Dilarutkan dengan produk minyak lainnya (minyak tanah, parafin medis, parafin lilin) dan
minyak sayuran.
- Untuk tujuan transportasi dan penggunaan, suhu mencapai 190C (normal 150C).
- Cair pada suhu 150C, dan semisolid pada suhu atmosfir.
- Luka bakar disebabkan bentuk cair yang panas, bukan efek racun dari aspal.
- Diobati dengan mendinginkan aspal menggunakan air dalam jumlah besar.
- Lepaskan pakaian namun jangan mencoba untuk melepaskan aspal melekat.
- Lepaskan aspal menggunakan minyak parafin (dapat ditambahkan minyak tanah 1/3 nya).

Ter

- Produk sisa industri gas batubara.


- Tidak umum di Australasia.
- Mengandung bahan kimia kompleks termasuk fenol, hidrokarbon dll menyebabkan
toksisitas berganda.
- Luka bakar disebabkan panas dan toksisitas fenol.
- Hanya larut dalam cairan aromatik (misalnya benzene, toluene, xylene) bukan bensin atau
minyak sayuran.
- Diatasi dengan pendingin dan lepaskan menggunakan toluene.

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Komplikasi Anatomik Khusus

Gastrointestinal
- Kecelakaan menelan zat korosif yang digunakan untuk keperluan rumah tangga biasanya
terjadi pada anakanak.
- 1/3 dari penderita dengan luka bakar intraoral terbukti diikuti kerusakans esofagus.
- Gejala yang tidak khas dan untuk diagnosis pasti memerlukan pemeriksaan endoskopik.
- Panendoskopi yang melalui area cedera diperlukan untuk memastikan luas kerusakan.
- Foto toraks dan abdomen; CT scan toraksabdomen menunjukkan kerusakan ekstra
lumen.
- Eksplorasi bedah dan debriment jaringan nekrotik mungkin diperlukan.
- Steroid tidak terbukti manfaatnya.
- Terjadinya striktur esofagus merupakan hal yang umum.
Diperlukan tindakan endoskopik dan operasi untuk mengatasi striktur.

Mata
- Luka bakar kimia pada mata diikuti tingginya insiden kerusakan mata residual.
- Tandatanda fisik termasuk blefarospasme, keluarnya air mata berlebihan dan
konjungtivitis
- Pembengkakan cepat epitel kornea, kekeruhan lapis anterior stroma dan terlepasnya sel di
kambra anterior.
- Atasi dengan pemberian air dalam jumlah besar. Diphoterine sangat berguna.
- Perawatan di rumah sakit lama (48jam).
- Antibiotika topikal untuk pencegahan infeksi sekunder.
- Perforasi dan ulserasi kornea, terbentuknya katarak, glaukoma sekunder, iridosiklitis dan
simblefaron adalah beberapa komplikasi lanjut.

Saluran Trakeobronkus
- Luka bakar langsung pada trakea dan bronkus jarang, terjadi setelah menghirup agen
kaustik atau terpapar gas kimia (misalnya amonia).
- Gangguan pernapassan atau hipoksia membutuhkan pemeriksaan bronkoskopi fibreoptic
- Bronkodilator dan steroid mengurangi bronkopasme serta peradangan.
- Mungkin diperlukan dukungan ventilator mekanik temporer.
- Dapat terjadi bronkiektasis sebagai komplikasi akhir.
- Diperlukan pemeriksaan lanjutan untuk fungsi paruparu dan foto toraks.

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Ringkasan
- Zat penyebab menyebabkan luka bakar kimia umum di jumpai di lingkungan.
- Semua luka bakar kimia memerlukan pemberian air dalam jumlah besar.
- Luka bakar asam hidrofluorat memerlukan netralisasi menggunakan kalsium glukonat.
- Toksisitas sistemik emrupakan hal umum pasca paparan terhadap asam hidroflourat,
bensin atau cresol.
- Luka bakar aspal dan alkali memerlukan pemberian air dengan waktu yang lama dibanding
luka bakar kimia lainnya.

- Luka bakar kimia pada mata juga memerlukan pemberian air dan selanjutnya rujukan ke
pusat pelayanan luka bakar.

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Bab 12

Manajemen Penderita Luka Bakar


setelah 24 Jam Pertama
Introduksi
Di Australia dan Selandia Baru, ada kalanya seorang penderita luka bakar tidak dapat segera
dirujuk ke unit luka bakar karena kesulitan transportasi dan akses. Bab ini dirancang untuk
membantu dokter dan perawat yang ditempatkan dalam situasi yang mengharuskan
perawatan berkelanjutan bagi penderita yang memenuhi kriteria ANZBA untuk transfer,
namun tidak mungkin dievakuasi dalam waktu 24 jam. Perawatan penderita lebih dari 24 jam
diperlukan, namun harus disadari bahwa kegagalan melakukan transfer penderita ke unit luka
bakar sedini mungkin akan berdampak buruk pada hasil akhir.

Adalah penting menyembuhkan luka bakar penderita secepat mungkin pasca cedera. Pada luka
bakar yang tebal dan dalam, perlu dilakukan eksisi dini dan pencangkokan kulit. Waktu yang
optimal untuk prosedur ini adalah antara tiga dan lima hari pasca cedera. Keterlambatan
dalam melakukan operasi ini memungkinkan timbulnya infeksi yang diikuti tingginya
morbiditas dan mortalitas.

Meski tidak dimungkinkan untuk melakukan evakuasi penderita ke unit luka bakar dalam
waktu 24 jam pasca cedera, perlu ditekankan bahwa setiap upaya harus tetap dilakukan untuk
mentransfer penderita sesegera mungkin. Prinsipprinsip yang diuraikan dalam bab ini tidak
dilihat sebagai sebuah pembenaran penanganan penderita luka bakar kritis di pusat pelayanan
terpencil. Pedoman ini dirancang untuk membantu untuk menjaga penderita luka bakar kritis
berada pada kondisi optimal, sehingga bila transfer dimungkinkan, maka tatalaksana definitif
dapat dilanjutkan sebagai bagian dari kasus biasa. Pedoman ini dirancang sebagai suplemen
dari kontak telepon, email dan fax dengan unit luka bakar.

Prinsipprinsip berikut adalah petunjuk yang dirancang untuk melengkapi bantuan dan saran
lebih lanjut yang mungkin dapat dilakukan di pusat pelayanan terpencil. Personil dengan
perawatan intensif dengan latar belakang anestesi atau trauma mungkin ada ketimbang staf
unit luka bakar, dan keahlian mereka dapat dimanfaatkan dalam keadaan darurat.

a. Topangan respirasi

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Bermanfaat bagi penderita luka bakar kritis untuk terus bernapas dengan aliran oksigen 15
liter per menit sampai kadar COHb normal, kemudian titrasi untuk mempertahankan PaO2
yang cukup untuk oksigenasi jaringan yang terbakar.

Penilaian berulang harus dilakukan, terutama pada luka bakar di kepala dan leher, riwayat atau
adanya kecurigaan cedera inhalasi, seperti yang diuraikan pada Bab 2, intubasi endotrakea
mungkin diperlukan pada fase ini. Tenaga medis berperan melanjutkan perawatan penderita
yang terintubasi yang tidak mungkin ditransfer karena alasan logistik. Beberapa pemeriksaan,
termasuk analisis gas darah dan foto toraks bermanfaat dalam membantu proses pemantauan.
Selama fasse ini, mungkin diperlukan topangan respirasi noninvasif, termasuk penghisapan
sekret berkala dan pengaturan posisi kepala dan leher penderita. Perasat chin lift dan
pengamanan jalan napas menggunakan oro-pharyngeal airway atau naso-pharyngeal airway
direkomendasikan. Bila dengan metode ini pengamanan jalan napas tidak berhasil, mungkin
diperlukan intubasi endotrakea dan harus dilakukan secepatnya, sebelum pembengkakan
faring semakin berat yang akan menyulitkan prosedur intubasi.

1. Intubasi endotrakea

Pemasangan pipa endotrakea yang benar menjamin patensi dan terlindunginya jalan napas,
memungkinkan pemberian oksigen efektif, mempermudah pembersihan sekret,
memungkinkan pemberian analgesia dosis besar, pemberian sedasi yang aman dan
memungkinkan diterapkannya ventilasi mekanis. Pada kasus luka bakar dengan cedera
inhalasi, prosedur intubasi semakin sulit karena pembengkakan mukosa jalan napas
membengkak dan hipoksia semakin berat. Karenanya prosedur intubasi dipertimbangkan lebih
awal.

Prosedur intubasi endotrakea secara teknis sulit pada luka bakar jalan napas bagian atas
disertai edema dan cedera di daerah wajah. Komplikasi ter penting adalah kegagalan teknis
yang dalam hal ini sering berakhir fatal. Masalah jangka pendek lainnya termasuk penempatan
pipa endobronkea yang salah, trauma pada jalan napas bagian atas dan obstruksi pipa oleh
sekret serta tertekuknya pipa.

Setiap penderita luka bakar yang memerlukan intubasi membutuhkan perawatan definitif oleh
spesialis di rumah sakit besar, sebaiknya sebuah rumah sakit yang memiliki unit luka bakar
khusus.

2. Indikasi dan Teknik

Intubasi dan ventilasi harus dipertimbangkan pada penderita dengan distres pernapasan yang
jelas secara klinis, hipoksia berat atau hiperkarbia, defek neurologik disertai gangguan refleks
pernapasan atau upaya bernapas, luka dada yang parah, atau obstruksi jalan napas bagian atas
akibat pembengkakan karenakan cedera inhalasi. Kadang indikasi ventilasi mekanik didasari

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suatu alasan logis, seperti keamanan transportasi atau memfasilitasi beberapa prosedur
terapeutik maupun diagnostik.

Rute orotrakea merupakan yang paling sederhana, namun intubasi nasotrakeal terkadang
berhasil pada situasi dimana intubasi oral tidak dimungkinkan. Bila tidak dapat dilakukan
dengan cepat atau dijumpai obstruksi jalan napas, prosedur kricotiroidotomi merupakan satu
satunya alternatif. Hal ini relatif mudah dan harus dilakukan tanpa keraguan.

Zat induksi anestesi atau relaksan otot akan mempermudah prosedur intubasi, namun hanya
dapat digunakan oleh mereka yang memiliki kepercayaan diri tinggi dan terlatih. Semua zat ini
memiliki efek samping yang signifikandan memiliki potensi terjadinya penurunan status,
penderita yang mulanya dihadapkan pada gangguan respirasi namun jalan napas baik dengan
ventilasi mencukupi, menjadi penderita yang tidak dapat diintubasi atau diventilasi.
Setelah prosedur intubasi, dilakukan penilaian posisi pipa dilakukan secara klinis dan
radiologis.

3. Fisiologi

Transportasi oksigen dari udara ke darah kapiler alveoli berlangsung terutama melalui difusi
dan aliran darah di arteri pulmoner (yaitu cardiac output). Sebaliknya, CO2 mengalami difusi
dari pembuluh kapiler ke alveoli dan dihembuskan pada proses ventilasi, yang yang akan
menurunkan kadar CO2. Dengan demikian, oksigenasi tergantung pada konsentrasi oksigen
inspirasi, kapasitas difusi paru dan cardiac output, sedangkan kadar pCO2 arteri ditentukan
oleh ventilasi alveolar.

Ventilasi alveolar mengalami delivery dalam berbagai pola. Volume tidal yang kecil dengan
frekuensi cepat memperkecil efek samping tekanan intratorakal yang tinggi (lihat di bawah),
dan sebagian besar udara yang dihirup pada pernapasan terbuang siasia, ventilasi ruang mati
(yang meningkat pada penggunaan pipa endotrakea, sirkuit ventilator dan faktor penderita
lainnya), dan meningkatkan kecenderungan terjadinya atelektasis. Sebaliknya volume besar
dengan frekuensi lambat memperkecil kemungkinan atelektasis dan memperkecil terbuangnya
ventilasi di ruang mati, namun masalah yang ditimbulkan tekanan tinggi dan volume
diperbesar. Pada praktek klinik, halhal seperti ini harus dijadikan orientasi dalam tatalaksana.

4. Kelebihan (keuntungan) dan kekurangan (kerugian) Ventilasi


Mekanik

Sebagai upaya memperbaiki pernapasan spontan yang tidak tercukupi, ventilasi mekanik
memungkinkan pengendalian pO2 dan pCO2 arteri. Ventilasi mekanik juga meniadakan kerja
pernapasan hingga menghemat oksigen yang digunakan dalam proses. Namun, tekanan positif
akan mengurangi aliran vena ke jantung (venous return) yang menyebabkan hipotensi,

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terutama pada penderita hipovolemik. Kesesuaian ventilasiperfusi (ventilationperfusion
match) biasanya tidak seefektif pernapasan spontan.

Distensi berlebihan dapat terjadi saat dijumpai kondisi patologik (termasuk luka bakar jalan
napas dan cedera inhalasi) menyebabkan paruparu kaku (noncompliant), menggunakan
volume tidal berlebihan, atau adanya obstruksi jalan napas letak rendah (asma atau penyakit
paru obstruktif kronis) menyebabkan hiperinflasi. Kondisi ini mennimbulkan komplikasi
mengancam jiwa seperti tension pneumothorax.

Karenanya, ventilasi mekanik hampir selalu membutuhkan sedasi dan pemberian relaksan otot
masih tetap dihadapkan pada potensi timbulnya komplikasi dan efek samping.

5. Masalah Respirasi khusus pada Luka Bakar

1. Intoksikasi Karbon Monoksida (CO)

Bila fasilitas hiperbarik tersedia dan mudah diperoleh, banyak pihak merekomendasikan
penggunaannya. Namun, eliminasi CO berlangsung cepat bila penderita segera menghirup
oksigen 100% secara cepat. Atas dasar itu, pemberian awal oksigen bersifat mandatorik bila
ada kecurigaan keracunan CO. Penggunaan oksigen hiperbarik dapat dilakukan secara elektif
setelah konsultasi dengan unit luka bakar.

2. Cedera inhalasi dan Luka Bakar pada dinding dada

Kedua bentuk cedera ini mempengaruhi pertukaran udara di paru (gas exchange) dan
kekakuan mekanik (complaince). Gejala yang ditimbulkannya adalah distres pernapasan dan
hipoksemia. Mungkin dijumpai batuk produktif dan partikel jelaga di jalan napas, dan pada
foto toraks dijumpai peningkatan densitas jaringan interstisium alveolar difus yang konsisten
dengan bentuk sindroma distress pernapasan akut lainnya. Kondisi ini memerlukan
penatalaksanaan definitif yang melibatkan spesialis yang intensif di rumah sakit yang besar
dengan fasilitas canggih.

3. Trauma toraks

Kontusio paru dapat menyebabkan hipoksia yang nyata atau hemoptisis dan flail chest yang
menimbulkan inefisiensi pernapasan spontan. Dikumpainya cedera ini pada penderita luka
bakar meningkatkan kebutuhan penggunaan ventilasi mekanis.

Trauma toraks meningkatkan kemungkinan kerusakan paru selama ventilasi mekanik.


Kemungkinan timbulnya tension pneumothorax harus dipertimbangkan. Bila terdapat fraktur
tulang iga dan ventilasi mekanik diperlukan, maka drenase interkostal (pipa intratorakal)
sebagai profilaksis, mungkin merupakan tindakan yang tepat.

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Kasuskasus seperti ini harus didiskusikan dengan spesialis intensif.

4. Luka bakar pada dinding dada

Adanya eskar melingkar dinding dada memengaruhi compliance dinding dada. Kondisi ini harus
dibedakan dengan penurunan compliance paru pada penggunaan tekanan inspiratorik tinggi
yang digunakan untuk mencapai volume tidal yang dibutuhkan yang mungkin tidak terlalu
membahayakan. Bagaimanapun, pada kondisi ini diperlukan eskarotomi dinding dada.

6. Pola / setting Ventilator optimal

Pada umumnya, untuk dewasa dimulai dengan volume tidal 57 mL/kg berat badan dengan
frekuensi napas 10 kali/menit dan 50% oksigen. Hal ini cukup aman untuk mempertahankan
saturasi oksigen adekuat. Tekanan inspiratorik pada dewasa tidak lebih dari 35 cmH2O (pada
anak, 1520 cmH2O), dan sistem kardiovaskular stabil.
Analisis gas darah arteri harus diperiksa segera setelah dimulainya ventilasi, dan selanjutnya
dilakukan penyesuaiannya. Pemeriksaan diulang secara frekuen hingga penderita dalam
kondisi stabil.

Bila compliance paru buruk dan atau dijumpai instabilitas sistem kardiovaskular, volume tidal
harus diturunkan, juga bila normokarbia tidak tercapai. Dalam jangka pendek, hal ini tidak akan
membahayakan kecuali dijumpai cedera kepala berat. Bila ada kecurigaan intoksikasi CO atau
instabilitas kardiovaskular berkelanjutan, maka harus diberikan oksigen 100%. Gangguan
compliance paru progresif menunjukkan adanya tension pneumothorax maupun beberapa
masalah mekanik lainnya, dalam hal ini, pemeriksaan foto toraks harus diperoleh sesegera
mungkin.

Ventilator perawatan intensif modern memiliki berbagai setting, yang memungkinkan


penderita bernapas spontan dengan sejumlah variabel bantuan mesin ventilator yang
bervariasi. Tipe ventilator ini bermanfaat pada kasuskasus sulit dan tatalaksana jangka
panjang dan penyapihan (weaning) ventilator, namun memerlukan keahlian dan peralatan
canggih. Bagi praktisi umum, penggunaan ventilator sederhana, kontrolpenuh bantuan
ventilasi dengan sedasi dalam dan penggunaan relaksan otot merupakan pilihan jangka pendek
yang relatif mudah. Namun, pengawasan dan perawatan one to one sangat penting untuk
menjamin keamanan penderita pada situasi seperti ini.

7. Sedasi / Relaksan otot selama ventilasi

Sedasi selama ventilasi mekanik biasanya menggunakan kombinasi opioid dan benzodiazepin.
Morfin dan midazolam paling sering diberikan perinfus secara kontinu, titrasi untuk

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mendapatkan efek yang diinginkan (masingmasing 010 mg/jam pada dewasa), sesekali
dengan bolus tambahan bila diperlukan.

Bila pengendalian ventilasi adekuat tidak tercapai, dengan cara ini, maka relaksan non
depolarisasi otot dapat ditambahkan. Pankuronium dan vekuronium paling sering digunakan
dan biasanya diberikan bergantian bolus iv (68 mg dosis dewasa, diikuti oleh 24mg prn).
Harus ditekankan bahwa sedasi dalam dan atau kelumpuhan otot menjadikan penderita
benarbenar tak berdaya saat terjadi kerusakan ventilator atau terjadi gangguan koneksi;
maka dalam hal ini mutlak diperlukan pengawasan yang konstan.

8. Pementauan sederhana pada penggunaan ventilator

Pulse oxymetry, denyut jantung, tekanan darah, end tidal CO2 dan alarm pemutustekanan
merupakan syarat minimal yang mutlak pada semua penderita dengan ventilasi mekanik.
Alarm pemutustekanan bukan hanya merupakan satu kesatuan dalam unit ventilator, namun
juga tersedia dalam bentuk portable tetapi juga tersedia sebagai suatu unit tersendiri; terlepas
dari ventilator. Beberapa alat pemantauan volume tidal/menit juga sangat diperlukan,
beberapa ventilator memiliki sarana ini dalam kesatuan (built in) namun bentuk yang
sederhana tersedia pada ventilator Wright. Pada penggunaan ventilator, sangat dibutuhkan
pemantauan analisis gas darah dan foto toraks.

Hal yang perlu menjadi perhatian adalah, penggunaan alat pemantau (monitor) bukan sebagai
penganti perawat terlatih dalam pemantauan klinis. Pemantauan merupakan suatu yang
bersifat mandatorik pada penderita dengan ventilator.

9. Ventilasi selama prosedur transportasi

Transportasi penderita terventilasi memiliki risiko jauh lebih tinggi dibandingkan


penggunaannya di rumah sakit. Selain dihadapkan potensi terjadinya ekstubasi yang tidak
disengaja, perubahan posisi pipa, kerusakan peralatan, pergerakan dan getaran berkontribusi
pada gangguan kardiorespirasi. Petugas yang mendampingi harus bekerja di tempat sempit,
pencahayaan kurang, lingkungan tidak stabil dan sangat mungkin dihadapkan pada masalah
transportasi seperti mabuk perjalanan. Tim petugas yang terlibat dalam transportasi harus
dilengkapi peralatan portabel, sumber listrik, oksigen, obatobatan, dan harus mampu
menangani masalahmasalah tak terduga yang muncul di perjalanan.

Di ketinggian terjadi penurunan tekanan oksigen inspirasi, terutama pada pesawat tanpa
sarana pengatur tekanan, peningkatan volume udara (seperti pada pneumothorax, udara pada
balon pipa endotrakea atau ruang mati di iv flask) dapat mengubah kinerja ventilator.

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Halhal yang diuraikan di atas harus dijadikan pertimbangan saat merencanakan untuk
merujuk penderita kritis. Sebelum dipindahkan, harus ada diskusi antara pihak yang merujuk
dan pihak yang menerima.

Akses vaskular yang handal dan pemantauan harus terjamin, dan setiap upaya harus dilakukan
untuk stabilisasi kondisi penderita sejauh mungkin. Bila ada tim transportasi perawatan kritis
yang berpengalaman, akan lebih baik memanfaatkan tenaga mereka bahkan bila penundaan
terjadi. Tidak ada satupun penderita terventilasi yang harus dirujuk tidak dikawal oleh petugas
medis senior yang terampil.

B. Topangan sirkulasi
Kondisi hemodinamik penderita luka bakar berat tetap berada pada kondisi tidak stabil dalam
24 jam kedua. Kebutuhan cairan seringkali tidak mengikuti aturan standar dan penilaian
berulang berkelanjutan menggunakan kriteria klinis umum, nadi, urine dan tekanan darah
diperlukan untuk memastikan bahwa jumlah cairan yang diberikan adalah tepat.

Pemeriksaan laboratorium berikut ini akan membantu memandu pengobatan dengan cairan:

- Hemoglobin dan hematokrit


- Urea dan Elektrolit
- Analisis gas darah arteri (yang sesuai)
- Kadar glukosa darah (pada anak)

1. Komposisi Cairan

Seiring dengan kembali permeabilitas kapiler secara bertahap di akhir hari pertama pasca luka
bakar, cairan koloid dapat diberikan untuk menjaga ruang intravaskular terekspansi. Jumlah
keseluruhan volume disesuaikan untuk untuk mempertahankan produksi urin 3050 mL/jam
pada dewasa dan pada anakanak (kurang dari 30 kg) 1,0 mL / kg /jam.

Cairan yang diberikan selama 24 jam kedua harus mencakup 0.30.5 mL koloid per kg berat
badan per persentase luas luka bakar. Cairan koloid yang diberikan adalah albumin serum
normal 5% (50g per liter).

Pada dewasa, dekstrosa 4% dengan larutan salin normal 0,18% ditambahkan untuk
mempertahankan produksi urin cukup. Pada anakanak, perlu ditambahkan glukosa dengan
larutan salin normaluntuk tujuan yang sama.

2. Cairan per oral / nasogastrik / nasojejunal

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Penderita yang tolerir terhadap cairan per oral dapat menerima porsi kecil cairan disamping
cairan intravena, atau cairan per oral dapat menggantikan komponen dekstrosa / salin.
Penderita luka bakar berat tanpa ileus harus menerima suplementasi cairan tinggi protein baik
secara bebas melalui oral bila ditoleransi atau melalui pipa nasogastric / nasojejunal. Hal ini
memerlukan diskusi dengan ahli gizi namun harus diperhatikan jangan sampai menyebabkan
kelebihan cairan.

3. Keseimbangan Cairan

Selama 24 jam kedua kebutuhan cairan lebih kecil dibandingkan dengan 24 jam pertama, hal
terpenting adalah jangan sampai terjadi kelebihan cairan, terutama pada mereka yang disertai
kelainan jantung dan paru. Pola cairan yang menghasilkan urin berlebihan tidak tepat dan
diikuti kemungkinan terjadinya edema paru karena pemberian cairan terlalu banyak [16].

Sindroma kompartemen abdominal dapat terjadi sebagai komplikasi sekunder serius bila
volume cairan berlebihan diberikan untuk mempertahankan produksi urin yang cukup dan
mempertahankan stabilitas hemodinamik. Pemantauan tekanan kandung kemih sangat
bermanfaat untuk memperoleh informasi penting mengenai tekanan intraabdomen.

Selama 24 jam kedua, diuresis alami harus sudah mulai dan produksi urin mungkin mengalami
peningkatan, melebihi jumlah cairan yang diberikan. Sedangkan pada kondisi dimana dijumpai
haemochromogenuria, dieresis alami akan dimulai 2448 jam pasca luka bakar.

Pemantauan hemoglobin dan hematokrit pada tahap ini mungkin menunjukkan penurunan
hemoglobin yang terjadi akibat hemolisis, sehingga pemberian whole blood mungkin
diperlukan pada tahap ini. Dengan demikian, hematokrit tidak dapat digunakan sebagai
panduan.

C. Perawatan Luka
Luka harus diperiksa ulang untuk memperoleh informasi akurat mengenai luas dan kedalaman
luka bakar. Luka bakar yang dalam 24 jam pertama hanya berujud eritema mungkin
kedalamannya berkembang menjadi luka bakar seluruh ketebalan kulit (full thickness) dalam
24 jam kedua. Penilaian ulang formal luka bakar mengharuskan dilakukannya kalkulasi ulang
kebutuhan cairan untuk 24 jam kedua.

Luka bakar dangkal hingga mid dermal dirawat dengan pembalut biologik yang sesuai
(Biobrane, Opsite, Duoderm atau sejenisnya) dan bila pembalut ini pada 24 jam kedua masih
dalam kondisi baik, maka tidak perlu ditukar.

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Setiap luka bakar dalam atau tebal harus diberi antimikroba topikal, demikian pula pada semua
penderita yang evakuasinya tertunda. Hubungi unit luka bakar untuk mendapat saran tentang
pembalut yang tepat.

Sebagai kelanjutan perawatan luka bakar menggunakan pembalut antimikroba, yang terbaik
adalah melakukan pencucian luka, baik dalam bath tube, di kamar mandi, atau menggunakan
shower. Pembalut lama dan kulit yang terkelupas harus dibuang.

Setelah pengeringan, ambil foto klinik untuk tujuan pemantauan luka. Aplikasi balutan bersih
pada luka agar penderita merasa nyaman.

Perhatian ditujukan untuk memastikan balutan tidak terlalu ketat, sensasi dan sirkulasi distal
baik. Dalam 2448 jam pertama, dalam melakukan pembalutan, ujung jari tangan dan kaki
harus dubiiarkan terbuka sehingga adanya perubahan warna dan penilaian sirkulasi dapat
dilakukan secara reguler.

Ekstremitas atas dan bawah harus ditinggikan denegan bantal atau bantalan busa untuk
memfasilitasi resolusi edema. Bila tersedia, USG Doppler dapat digunakan untuk membantu
pemantauan sirkulasi pada ekstremitas yang mengalami edema.

Eskarotomi dan Pendarahan

Pengisian ulang kapiler secara reguler dan observasi ekstrremitas harus memberi informasi
kemungkinan dilakukannya eskarotomi. Edema pada luka bakar dapat berlanjut selama 24 jam
kedua pasca luka bakar, sehingga mungkin diperlukan eskarotomi untuk memastikan sirkulasi
darah yang baik ke distal.

Dengan kembali normalnya sirkulasi perifer pada tahap ini, terbukanya pembuluh perifer yang
bertahap dari memungkinkan terjadi pendarahan pasca eskarotomi yang dilakukan
sebelumnya. Mungkin diperlukan diatermi bipolar atau klem arteri dan ligasi untuk
mengendalikan pendarahan. Penerapan balut tekan untuk mengatasi pendarahan adalah tidak
tepat karena menghalagi sirkulasi perifer yang telah diperbaiki melalui eskarotomi.

D. Manajemen nyeri
Pada 24 jam kedua, cara sederhana dan aman dalam manajemen nyeri adalah pemberian
analgesia cukup dengan narkotika intravena dosis rendah. Dosis tersebut harus dititrasi
terhadap respon penderita termasuk frekuensit pernapasan. Tidak ada fasilitas canggih
diperlukan untuk pemberian dan pemantauannya [9].

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Namun, bila fasilitas (pompa infus) tersedia, dosis 2030 mikrogram per kg per jam (setelah
pemberian dosis awal) merupakan bentuk yang paling fleksibel dalam manajemen nyeri. Dosis
yang lebih tinggi kadang diperlukan, dan untuk tujuan tersebut dilakukan penambahan
kecepatan pemberian infus intravena ini; dibutuhkan waktu cukup panjang agar dicapai
kadarnya di dalam darah untuk memberi efek analgesia yang baik. Tidak akan ada efek adiksi
narkotika pada tahap ini. Saat nyeri dirasakan, pemberian analgetik yang tepat harus
diberikan.
Nyeri akan terasa lebih selama penggantian balutan, episode mobilisasi, dan fisioterapi.
Analgetik narkotik intravena harus diberikan untuk mengatasi nyeri selama episode nyeri ini.

Pemberian analgesia yang dikendalikan penderita (patient controlled analgesia, PCA) sangat
efektif pada luka bakar dan bila peralatan ini tersedia, maka menjadi metode pilihan. Peralatan
ini dapat digunakan pada anak kecil dengan hatihati. Diperlukan keahlian bidang anestesi
untuk prosedur ini.

Oksida nitrit atau methoxyfluorane yang diberikan mencegah distribusi oksigen tidak tercukupi
merupakan suplemen bermanfaat, terutama saat melakukan prosedur, namun pemberiannya
harus dilakukan oleh seorang ahli anestesi atau staf yang berpengalaman.

E. Nutrisi
Pemberian nutrisi melalui rute gastrik seawal mungkin pasca luka bakar adalah penting.
Kehadiran nutrien melalui usus akan melindungi mukosa usus halus dari kerusakan yang terjadi
pada trauma dan starvasi. Kerusakan sel mukosa memungkinkan terjadinya translokasi bakteri
usus ke aliran darah menyebabkan sepsis berat oleh gram negatif yang kerap berakibat fatal
pada luka bakar kritis. Pemberian nutrisi dini membantu mencegah hal ini.

Pada penderita dengan luka bakar berat (>10% pada anakanak,>20% pada dewasa) kerap
dijumpai ileus, terutama pada keterlambatan resusitasi cairan dan syok yang nyata. Pipa naso
gastrik harus dimasukkan untuk mengosongkan lambung, menghindari aspirasi bila muntah.
Nutrisi segera diberikan bila terdengar bising usus atau memang bising usus terdengar sejak
penderita masuk rumah sakit.

Kurang lebih dua kali jumlah energi yang dibutuhkan per hari pada keadaan normal (biasa).
Pada penderita luka bakar kritis, nutrisi diberikan dalam bentuk suplemen diet yang tersedia.
Bila ini tidak, produk susu akan sangat bermanfaat.

Penderita dapat mengonsumsi diet normal. Komposisi diet harus kaya akan protein dan kalori
yang mencukupi. Penambahan susu bubuk skim ke dalam susu biasa (200 gram per liter)
secara signifikan meningkatkan kadar protein. Pemberian protein tinggi dengan penambahan
telur sering kali dapat ditolerir.

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Penderita luka bakar berat sering tidak dapat mengonsumsi cukup nutrisi. Pada kondisi ini,
pipa nasogastrik atau nasojejunal dimasukkan untuk pemberian nutrisi. Kepala ditinggikan
30 saat pemberian. Pemberian dimulai dengan jumlah kecil dan ditingkatkan secara bertahap.
Dengan cara ini masalah diare dapat dicegah.
Penderita harus ditimbang setiap hari, peristaltik usus didokumentasikan, demikian pula setiap
perubahan dan bila penderita makan secara spontan, berikan waktu ekstra untuk
menghabiskan makanan. Makanan ekstra dapat diberikan berupa makanan kecil diantara
waktu makan biasa bila penderita tidak mampu menghabiskan makanannya. Penderita luka
bakar pada tangan mungkin memerlukan bantuan.

Karena risiko ulserasi lambung akut pasca luka bakar kritis demikian tinggi, perlindungan
dengan pemberian inhibitor pompa proton, H2 antagonis, dan yang paling penting, pemberian
nutrisi enteral.

F. Fisioterapi dan Terapi Okupasional


Karena luka bakar dalam cenderung diikuti kontraktur, maka sangat penting menjaga semua
sendi berada pada posisi yang tepat.

Pencegahan kontraktur dimulai sejak awal (pada harihari pertama). Penderita tidak
diperbolehkan mengikuti posisi kontraktur karena posisi yang nyaman adalah posisi
kontraktur. Posisi yang tepat tergantung pada aspek sendi yang terlibat. Biasanya posisi yang
benar adalah:
- leher ekstensi
- ketiak abduksi
- siku ekstensi
- pergelangan tangan netral atau ekstensi
- sendi metakarpofalangeal fleksi
- sendi jari interfalangeal ekstensi
- lutut ekstensi
- pergelangan kaki 90o dorsofleksi

Bidai diperlukan dan setidaknya sekali dalam sehari semua sendi harus digerakkan dalam
rentang gerak (range of movement, ROM) sejauh nyeri dapat ditolerir. Penderita dengan
cedera inhalasi dan dalam keadaan sadar atau yang eskar dinding dada harus menjalani latihan
bernapas dan batuk untuk memastikan ekspansi paru.

Pada penggunaan bidai, hindari balutan yang ketat dan menekan saraf di sekitar sendi. Saraf
ulnaris di siku dihadapkan risiko mengalami cedera pada penggunaan bidai atau tekanan tepi
tempat tidur dan meja operasi. Demikian pula saraf peroneal komunis di sekitar kaput fibula
dihadapkan pada risiko drop foot.

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Selama perawatan di ICU, imobilisasi penderita luka bakar berat dihadapkan risiko ulkus
dekubitus sehingga perawatan area tekanan sangat penting, terutama di daerah sakrum,
oksipital dan kalkaneus. Penekanan di daerah lain juga mungkin terjadi. Posisi penderita harus
diatur setiap dua jam. Penggunaan kasur anti dekubitus menjadi suatu kebutuhan.

G. Pengendalian Infeksi

Semua peralatan harus dibersihkan secara efektif, terutama alat yang digunakan untuk
beberapa penderita. Pencucian tangan sebelum dan sesudah menangani penderita adalah
cara yang paling efektif untuk mencegah penularan infeksi.
Pembersihan selama tiga menit harus dilakukan sebelum mengawali setiap prosedur.
Ketika melakukan perawatan penderita secara langsung, gaun isolasi berbeda harus
dipakai untuk setiap penderita.
Kasur penderita dan daerah disampingnya harus dibersihkan tiap hari menggunakan
antiseptik.

Ringkasan
- Penderita harus dirujuk ke unit luka bakar dalam waktu 24 jam untuk memaksimalkan
pertolongan penderita. Bila hal ini tidak mungkin, manajemen perawatan intensif
diperlukan untuk menjaga penderita dalam keadaan terbaik untuk dirujuk.
- Perhatian untuk alat penopang respirasi dan sirkulasi, perawatan luka, manajemen nyeri,
nutrisi, fisioterapi, dan pengendalian infeksi.
- Hubungi unit luka bakar atau ICU diperlukan.

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Bab 13

Manajemen Rawat Jalan pada


Luka Bakar Ringan
Introduksi
Sekitar 1% warga Australia memerlukan pengobatan setelah mengalami luka bakar setiap
tahun. Dari 220.000 penderita setiap tahun, sekitar 10% (22.000) memerlukan perawatan
rumah sakit dan 100 orang meninggal akibat luka bakar (Sumber: Survei Kesehatan Nasional
Australia 2001 2001)

Cukup banyak penderita luka bakar akut pergi ke unit gawat darurat rumah sakit di perifer atau
perkotaan dan cukup banyak penderita mendapat perawatan pertama dari dokter umum.

A. Penilaian

1. Riwayat penyakit dan anamnesis

Riwayat/ terjadinya kecelakaan sangat penting [21]. Penyebab dan pertolongan yang sudah
dilakukan memberi petunjuk dalam menentukan kedalaman luka.

Luka bakar akibat air panas yang mendapat pertolongan sesuai dengan rekomendasi
cenderung tidak terlalu dalam seperti luka bakar api. Namun pada anak dan orang tua, luka
bakar akibat air panas seringkali dijumpai lebih dalam dibandingkan pemeriksaan awal.
Informasi mengenai seberapa panas air yang menyebabkan cedera harus diperoleh. Luka bakar
api biasanya dalam, terutama bila menggunakan bahan bakar, atau bahan pakaian yang
terbakar.

Kecurigaan mengenai cedera bukan karena kecelakaan pada anak maupun dewasa seringkali
terpandu oleh adanya inkonsistensi antara pemeriksaan fisik dengan anamnesis yang
diperoleh. Adanya kecurigaan ini menimbulkan keharusan segera merujuk ke unit luka bakar
untuk penyelidikan lebih lanjut.

2. Pemeriksaan fisik

Lakukan pemeriksaan dan lakukan pencatatan dengan teliti [2] halhal sebagai berikut.
1) Warna
2) Adanya bula

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3) Waktu pengisian kapiler
4) Neyri (luka bakar dangkal lebih nyeri dibandingkan luka bakar dalam)
5) Kondisi eksudat (yang dapat mengindikasikan risiko infeksi bila terjadi penundaan)
6) Adanya inflamasi sekitar yang menunjukkan sepsis.

Umumnya kedalaman luka dapat ditentukan berdasarkan temuan butirbutir di atas; lihat
lebih rinci pada Bab 7 Manajemen Luka. Untuk luka bakar tidak luas, dan bila dijumpai kendala
rujukan (lihat kriteria di Bab 10), maka kasus ini dapat dikelola oleh ahli bedah untuk prosedur
eksisi dan prosedur skin graft. Bila ada keraguan mengenai kedalaman atau tatalaksana,
hubungi unit luka bakar.

3. Penilaian luas Luka Bakar

Terapkan rule of nines dari Wallace sebagaimana dibahas pada Bab 5 dan dapatkan informasi
akurat luas luka bakar [21, 25, 27, 5658]. Sebagai alternatif, gunakan permukaan telapak
tangan (1% dari luas permukaan tubuh) sebagai panduan menilai luas luka bakar [21, 5658].

Pada penderita dengan luka bakar superfisial dan middengan luas kurang dari 10% pada
dewasa atau kurang dari 5% pada anak dapat menjalani rawat jalan. Dengan tersedianya
balutan biologis modern yang sesuai, diungkinkan untuk melindungi, mengobati dan
memfasilitasi proses penyembuhan alami. Namun, pada luka mendekati 10% dan perawatan
yang memerlukan pergantian balutan secara frekuen dengan metode di luar kompetensi
dokter umum atau rumah sakit daerah, pertimbangkan untuk merujuk ke rumah sakit yang
telah menjalin kerjasama dengan unit luka bakar untuk pelaksanaan rawat jalan.

B. Manajemen Nyeri
Pada luka bakar tidak luas, dengan pembalutan yang baik dapat diberikan parasetamol
digabung dengan kodein peroral, intranasal atau inhalasi untuk penderita rawat jalan.
Pada prosedur pembalutan, kerap dijumpai kesulitan dan nyeri, terutama pada anakanak.
Untuk tujuan ini, pemebrian sedatif dan analgesik oral dapat diberikan 3045 menit sebelum
pembalutan. Opioid intranasal memiliki onset yang lebih cepat dan masa kerja yang cocok
untuk lingkungan rawat jalan. Sekali lagi, bila tidak mungkin untuk memberikan analgesia yang
memadai dalam kondisi rawat jalan atau perawatan primer, maka perlu untuk dilakukannya
rawat inap.

C. Manajemen Luka
Setelah pertolongan pertama (Bab 2), manajemen luka harus mengacu pada prinsip yang
berlaku untuk penanganan luka apapun. Teknik aseptik harus diterapkan dalam memperkecil

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risiko kontaminasi, dan setiap upaya perawatan harus ditujukan mencegah kerusakan jaringan
lebih lanjut.
Pada tahap akut, luka dicuci menggunakan antibakteri. Cairan mengandung klorheksidin 0,1
atau 0,2% umum digunakan, tetapi bila ini tidak tersedia, gunakan sabun dan air [10]. Selama
prosedur pembersihan, harus diperoleh dasar luka yang bersih, sehingga kulit yang terkelupas
harus dibuang menggunakan gunting steril. Bula kecil dapat dibiarkan, sedangkan bula
berukuran besar maupun pecah dan kulit melipat, maka kulit terkelupas harus dibuang [10].

Setelah luka bersih, pemeriksaan lebih lanjut diperlukan untuk menilai kedalaman luka bakar.

Luka bakar Epidermal

Luka bakar bewarna merah muda cerah ke merahan, sangat nyeri tanpa bula menunjukkan
kedalaman hanya mencapai epidermis [2]. Contoh yang khas adalah sengatan matahari atau
percikan api. Luka kedalaman initidak memerlukan pengobatan spesifik, tapi mungkin sangat
nyeri dan membutuhkan analgetik. Krim pelembab mungkin diperlukan tanpa balutan.

Luka bakar Dermal

Luka bakar dengan bula biasanya mencapai kedalaman dermis. Dasar luka dengan
pengembalian kapiler dengan sensasi menunjukkan luka bakar dangkal dan akan mengalami
penyembuhan spontan [2]. Setelah dibersihkan, luka dengan kedalaman dermis dan epidermis
superfisial dihadapkan terpaparnya papilae dermis. Bila dibiarkan mengering atau terinfeksi,
unsurunsur epidermis yang berepran untuk proses epitelialisasi akan mati dan luka akan
bertambah dalam. Akibatnya penyembuhan spontan tidak dimungkinkan dan memerlukan skin
graft.

Pengobatan yang tepat untuk luka jenis ini adalah pembalut biologis atau balutan silikon
hidrokoloid balutan perak atau film. Beberapa balutan dapat di lihat dalam tabel pada
Lampiran 4.

Pembalut seperti Biobrane, kulit babi atau kulit kadaver yang diawetkan juga ideal. Namun,
sangat mahal dan umumnya hanya dipakai di unit luka bakar.

Luka bakar dangkal terus mengeluarkan eksudat sebagai reaksi inflamasi. Balutan mengalami
kejenuhan akibat produksi cairan dan harus lebih sering diganti. Balutan hidrokoloid
memerlukan penggantian setiap 35 hari, atau lebih sering bila eksudat berlebihan atau bau
yang menusuk. Balutan yang melekat pada luka seperti Biobrane atau kulit manusia yang
diawetkan harus dikelupas secara bertahap (mulai di tepi) setelah epitelialisasi berlangsung.

Pada luka bakar, inspeksi luka berulang direkomendasikan setiap 3 hari untuk memastikan
bahwa penilaian awal kedalaman luka bakar benar dan komplikasi dari luka (terutama infeksi)

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tidak terjadi. Perubahan manajemen mungkin diperlukan bila pada penilaian ulang
menunjukkan luka bakar dalam atau terinfeksi.

Luka terinfeksi

Sepsis luka mungkin terjadi pada luka yang terkontaminasi saat cedera, atau luka yang dirawat
dengan balutan yang tidak mengandung antibakteri.

Luka yang terinfeksi di saat awal, atau diduga terkontaminasi saat cedera, harus ditatalaksanai
lebih dini menggunakan antimikroba topikal. Produk yang paling tepat di Australia dan
Selandia Baru adalah balutan silver slowrelease. Setelah menerapkan balutan utama, penting
untuk mengamankan balutan dengan perban atau perekat.

Silver sulfadiazin dapat digunakan, namun preparat ini sering menyebabkan perubahan luka
menjadi luka lembab bewarna kuning kecoklatan yang menyebabkan penilaian dasar luka lebih
sulit.

Tanda peradangan di sekitar atau tandatanda infeksi sistemik menunjukkan sepsis. Bila hal ini
dijumpai, maka prosedur rujukan disegerakan karena luka bakar dermal sejenis ini berubah
menjadi luka lebih dalam.

Dengan perawatan terbuka, luka mengering dan berubah menjadi luka bakar dalam,
karenanya perawatan terbuka kecuali untuk luka bakar epidermal sangat tidak tepat.

Bila pada penilaian ulang, atau diagnosis awal tidak benar, maka rujukan untuk prosedur
operasi harus dilaksanakan.

D. Tindak Lanjut / Follow Up


Tergantung pembalut yang digunakan, umumnya penilaian dilakukan dalam 23 hari setelah
balutan pertama untuk kemudian dilakukan dalam interval 37 hari.

Pada setiap kesempatan, penting diperoleh informasi apakah lingkungan rumah penderita
memenuhi syarat dalam penerapaan manajemen rawat jalan. Dalam situasi dimana penderita
tidak mampu mengatasi, maka rawat inap diperlukan. Misalnya orang tua, penderita yang
tinggal sendiri, atau anak dengan orang tua yang bekerja, yang kelanjutan rawat jalannya sulit
dilanjutkan karena kurang dukungan dari keluarga. Komorbiditas penderita juga memengaruhi
manajemen rawat jalan. Penderita dengan inkontinensia atau gangguan mental mungkin
memerlukan pergantian balutan lebih sering dan manajemen luka.

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Pelayanan keperawatan rawat jalan di rumah bermanfaat dalam esktensi pelayanan rawat
jalan primer dan membantu dalam pelaksanaan penggantian balutan luka, terutama pada
penderita yang sulit datang ke klinik rawat jalan atau operasi.

1. Fisioterapi / Terapi Okupasi

Luka bakar ringan pada tangan, ekstremitas dan di sekitar sendi yang tidak sesuai kriteria
rawat unit luka bakar membutuhkan terapi. Pada luka bakar yang memerlukan waktu
penyembuhan lebih lama dari 2 minggu atau mereka yang membutuhkan operasi, kerap
terjadi parut hipertrofik. Fisioterapi dan terapi okupasi mungkin diperlukan dalam manajemen
parut menggunakan garmen elastis, media kontak atau plester [2]. Dokter umum dapat
melakukan koordinasi manajemen, dan unit luka bakar dapat memberikan saran fisioterapi
dan terapi okupasi untuk perawatan ini.

2. Edukasi pada proses penyembuhan

Luka yang baru mengalami penyembuhan (epitelialisasi) memerlukan perlindungan dari


sengatan matahari menggunakan pelindung sinar matahari 30+ dan pakaian yang sesuai. Luka
yang baru mengalami penyembuhan jangan terlalu banyak dibebani untuk bekerja, dan
diperlukan istirahat untuk memungkinkan penebalan normal. Pemakaian krim pelembab yang
berkelanjutan untuk mengatasi kurangnya kelembaban alami kulit akibat kerusakan kelenjar
sebasea selama beberapa waktu pasca luka bakar.

Gatal merupakan masalah pada luka bakar yang baru mengalami penyembuhan. Aplikasi krim
pelembab, pijatan dan tekanan sangat membantu mengatasi hal ini. Antihistamin dan kompres
dingin dapat meringankan. Mandi air hangat mengandung solusi seperti Pinetarsal, gandum
atau aloe vera dapat membantu, terutama pada luka bakar akibat air panas.

3. Penurunan fungsi pasca Luka Bakar

Beberapa luka bakar yang memerlukan waktu penyembuhanlebih lama dari 14 hari akan
diikuti terbentuknya jaringan parut hipertrofik dan kontraktur. Bila terjadi di sekitar sendi
maka akan diikuti gangguan fungsi sekunder. Kehilangan fungsi dan tidak respon terhadap
manajemen parut disertai fisioterapi memerlukan rujukan ke unit luka bakar untuk
rekonstruksi dalam mengatasi masalah fungsi ini. Pada luka bakar minor dengan kontraktur
ringan dapat dirawat oleh terapis dan umumnya dengan terapi yang baik tidak memerlukan
operasi.

4. Masalah estetik pasca Luka Bakar

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Luka bakar menyebabkan kecacadan yang nyata, baik masalah warna defek pada
penyembuhan spontan maupun masalah parut hipertrofik. Beberapa penderita tidak
mempedulikan, namun sebagian lainnya mengalami depresi menghadapi hal ini.

Ganguan body image pasca luka bakar kadang melebihi proporsi ukuran luka bakar itu sendiri.
Konseling pada awal perawatan yang difasilitasi oleh psikolog atau psikiater dapat membantu
manajemen. Mungkin ada permintaan tidak masuk akal untuk perbaikan estetik pada cacat ini.
Operasi revisi dengan eksisi parut dan skin graft selalu meninggalkan bekas yang tidak lebih
baik dibandingkan bentuk awal. Dalam kasus ini, dukungan psikoterapi dengan konseling
berulang merupakan manajemen yang tepat.

Selain masalah estetik, banyak penderita dan keluarga mungkin dihadapkan pada amarah yang
tak kunjung reda atau rasa bersalah terkait dan mungkin memerlukan penanganan yang
merupakan bagian dari pengobatan.

Ringkasan

- Banyak luka bakar ringan dapat ditangani secara memuaskan di tingkat perawatan primer.
Karena sebagian besar luka bakar di Australia dan Selandia Baru masuk ke dalam kategori
ini, tepat bagi praktisi lokal untuk mengembangkan keahlian dalam manajemen luka bakar
ringan dan unit luka bakar tersedia untuk memberi nasihat atau pengobatan yang
diperlukan.
- Pengelolaan penderita luka bakar meliputi perhatian yang cermat pada luka bakar untuk
memfasilitasi penyembuhan normal dan mencegah komplikasi. Banyak produk yang tidak
disebutkan dalam bab ini yang sama efektifnya. Daftar produk yang dicantumkan pada
tabel tidak semuanya termasuk.
- Rujukan sekunder dari luka bakar ringan yang telah sembuh mungkin diperlukan untuk
operasi rekonstruktif, manajemen luka, fisioterapi, terapi okupasi atau psikoterapi.

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LAMPIRAN 1

Penilaian Neurologik
Skoring Coma dari Glasgow
Respon Skor
Pembukaan mata Spontan 4
Untuk Nama 3
Untuk nyeri 2
Tidak ada 1
Tanggapan verbal terbaik Berorientasi 5
Bingung 4
Tidak tepat 3
Tidak dimengerti 2
Tidak ada 1
Tanggapan motor yang terbaik Mematuhi 6
Melokalisir 5
Penarikan 4
Abnormal Fleksi 3
Perpanjangan 2
Tidak ada 1
15
Gambar 2. 1

Cedera Kepala
Kategori GCS
Berat < 9
Sedang 9 12
Ringan 13 15
Gambar 2. 2

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LAMPIRAN 2

Protokol Tetanus
TabeL 3. 21. 1: Panduan untuk tetanus profilaksis dalam manajemen luka
Riwayat Waktu sejak Jenis luka DTPa, DTPa Tetanus
vaksinasi dosis kombinasi, dT, DTPA, immunoglobulin*
tetanus terakhir yang sesuai (TIG)
3 dosis <5 tahun Semua luka Tidak Tidak
3 dosis 510 tahun Luka ringan Tidak Tidak
3 dosis 510 tahun Semua luka Ya Tidak
yang lain
3 dosis >10 tahun Semua luka Ya Tidak
<3 dosis atau Luka ringan Ya Tidak
dak pas
<3 dosis atau Semua luka Ya Ya
dak pas yang lain

Dosis yang dianjurkan untuk TIG adalah 250 IU, diberikan melalui suntikan im menggunakan
jarum berukuran 21, sesegera mungkin setelah cedera. Bila lebih dari 24 jam telah berlalu, 500
IU harus diberikan.

penderita yang dak memiliki riwayat yang tercatat dari vaksinasi pertama (3 dosis) dengan
tetanus toksoid yang mengandung vaksin harus menerima semua dosis yang dilewati. Lihat
Bagian 1. 3. 5, diikuti.

(Sumber: Buku Panduan Immunisasi Australia (Edisi Sembilan) Halaman 288)

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LAMPIRAN 3

Rekomendasi untuk Sayatan Eskarotomi

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LAMPIRAN 4

Balutan
Produk Perawatan Fungsi Indikasi Aplikasi Catatan /
Luka Apa? Mengapa? Kapan? Bagaimana? Pencegahan
- Silikon / busa - Tidak patuh - Luka bakar - Dipakai untuk - Tidak boleh
- busa hidrofilik - Mematuhi superfisial membersihkan digunakan bila
poliuretan luka ada infeksi
- + Lapisan silikon - Tutup dengan
lembut balutan fiksasi
- +lapisan luar
tahan air
- Juga tersedia
dengan perak
- Hydrocolloid - Bantuan - Luka bakar - Batas 25cm - Tidak boleh
- Hydrocolloid autolisis yang superficial sekitar luka. digunakan bila
wafer jaringan hingga mid - Dapat tetap ada infeksi
- Menyediakan dermal utuk 23 hari
lingkungan - mengeluarkan - Wafer sampai 5
lembab eksudat rendah hari bila tidak
- Menyerap sampai sedang ada tanda
eksudat tanda infeksi.
- Kasa - Balutan - Luka bakar kulit - Digunakan - Rendam bila
- Vaseline yang antiseptik yang tebal langsung pada digunakan pada
dilapisi kasa - Mematuhi - Bagian luka dasar luka.
minyak pengcangkokan - 23 lapis untuk
dan donor emergensi
- Tutup dengan
balutan
sekunder
- Ganti setiap 1
3 hari
- Perak - Spektrum - Luka bakar - Digunakan - Kejenuhan
- Sodium antimikroba superficial untuk luka yang eksudat
carboxymethyc yang besar hingga dalam lembab. menunjukkan
ellulose (CMC) - fasilitas - Cukup - Memunkinkan indikasi
& 1. 2% ion Ag Debridement membersihkan 25 cm penggantian
pada bahan - Menyerap luka bersamaan balutan
berserat eksudat waktu
- Juga Contreet H - Tutup dengan
balutan kedua.
- Ulas 710 hari

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- Biarkan utuh
sampai sembuh

- Perak - Proteksi - Luka bakar - Basahi dengan - Hiperpigmentas


- Nanokristalin Spektrum dalam H2O; alirkan i temporer
Ag yang dilapisi antimikroba - Bagian dan terapkan - Hindari bila
dengan jala luas pengcangkokan sisi biru / perak alergi terhadap
Mengurangi dan donor menghadap ke perak
fpembentukane - Luka terinfeksi bawah. - Hindari
ksudat - Lembabkan hipotermia
balutan kedua
- Ganti 34 hari
or 7 hari
- Perak - Mengurangi - Luka yang - Pakailah jumlah - Tidak
- Silver infeksi terinfeksi yang benar direkomendasik
Sulfadiazin 1% - Luka bakar kulit - Gunakan an untuk semua
yang besar bila sarung tangan jenis luka bakar
tersedia - Terapkan karena
balutan perubahan
sekunder. pada
penampilan
luka dan
frekuensi
penggantian
balutan

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