IN HOUSE TRAINING :

INTEGRATED MANAGEMENT OF BURN INJURY

RS YARSI – 28 AGUSTUS 2019

CHRONIC PHASE OF BURN :

BURN WOUND ASSESSMENT,
PREVENTION AND RELEASE OF CONTRACTURE

Dr. Prasasta Adhistana, SpBP-RE

Plastic Reconstructive & Aesthetic Surgeon
Penampang Kulit Normal
Kulit merupakan organ tubuh yg paling luar dan melapisi
seluruh tubuh dgn karakteristik sbb :
▪ Luas kulit : 0.025 m2 pada bayi baru lahir dan
1.8 m2 pada orang dewasa
▪ Berat kulit : 4.5 - 5 kg (15% dari total berat badan)
▪ Tebal kulit : 0.5 mm – 6 mm
Fungsi Kulit :
1. Proteksi
2. Termoregulasi
3. Organ Sensoris
4. Respon Imun
5. Pengontrol Kehilangan Cairan (Evaporasi)
6. Fungsi Metabolik
7. Fungsi Psikososial (Penampilan)
Definisi Luka Bakar :
Kerusakan kulit tubuh yang disebabkan
oleh air panas, listrik, bahan kimia, radiasi
dan trauma dingin (frost bite).
KLASIFIKASI KLINIS
PASIEN LUKA BAKAR BERDASARKAN ATAS :

1. PENYEBAB LUKA BAKAR

2. DERAJAT KEDALAMAN LUKA BAKAR
3. LUAS LUKA BAKAR THD PERSENTASE LUAS BADAN
(TBSA : TOTAL BODY SURFACE AREA)
 KLASIFIKASI BERDASARKAN
PENYEBAB UTAMA LUKA BAKAR :

1. API (FLAME BURNS)

2. AIR ATAU MINYAK PANAS (SCALD BURNS)
3. BAHAN KIMIA (CHEMICAL BURNS)
4. LISTRIK DAN PETIR (ELECTRICAL BURNS)
Data dari RSCM tahun 2012-2013

PENYEBAB LUKA BAKAR

LUKA BAKAR KARENA API
(FLAME BURNS)
 LUKA BAKAR
KARENA AIR PANAS ATAU
MINYAK PANAS (SCALD BURNS)
LUKA BAKAR KIMIA
(CHEMICAL BURNS)
 LUKA BAKAR LISTRIK
(HIGH-VOLTAGE ELECTRICAL BURNS)
 Lichtenberg Pattern

LUKA BAKAR AKIBAT PETIR

(ELECTRICAL BURNS)
 KLASIFIKASI BERDASARKAN
DERAJAT KEDALAMAN LUKA BAKAR :

GRADE 1 (EPIDERMAL BURNS)

GRADE 2 : 2A & 2B (DERMAL BURNS)

2A – SUPERFICIAL DERMAL BURNS
2B – DEEP DERMAL BURNS

GRADE 3 (FULL THICKNESS BURNS)

Grade 1 Grade 2 Grade 3
LUKA BAKAR GRADE 1 : SUN BURN

Luka Bakar terbatas pada lapisan Epidermis

Kulit berwarna kemerahan
Terasa perih atau nyeri
Tidak didapatkan gelembung cairan (Bullae)
Sembuh sempurna dalam waktu 3-5 hari
LUKA BAKAR GRADE 2
LUKA BAKAR GRADE 2 DANGKAL (2A) :

Terdapat gelembung cairan (Bullae)

Terasa nyeri
Tampak basah dan berwarna kemerahan
Sembuh dalam waktu 10-21 hari secara spontan
Jaringan Parut atau Scar : Minimal

LUKA BAKAR GRADE 2 DALAM (2B) :

Tidak terdapat gelembung cairan (Bullae)

Berwarna kemerahan namun lebih dominan pucat
Rasa nyeri kadang tidak dirasakan lagi oleh pasien karena ujung-ujung
syaraf rusak terbakar
Diperlukan operasi cangkok kulit (Skin Graft) untuk penyembuhan luka
Jaringan Parut atau Scar : Sering Terjadi
LUKA BAKAR DERAJAT 3

Seluruh bagian kulit terbakar

Jaringan tampak menghitam, kering dan teraba keras (Eschar)
Sensai Nyeri sudah hilang sama sekali akibat kerusakan
seluruh ujung syaraf perasa
Sangat Potensial mengakibatkan Jaringan Parut
CARA MENGHITUNG LUAS LUKA BAKAR

PALMAR SURFACE AREA

RULES OF NINE
LUND BROWDER CHART
PALMAR SURFACE
AREA OF THE
PATIENTS’ HAND :
EQUAL 1%
RULES OF NINE
LUND AND BROWDER
CHART
 KLASIFIKASI BERDASARKAN
BERAT RINGANNYA LUKA BAKAR MENURUT ABA
(AMERICAN BURN ASSOCIATION) :

LUKA BAKAR RINGAN

LUKA BAKAR SEDANG
LUKA BAKAR BERAT
LUKA BAKAR RINGAN :

▪ LUAS < 15% GR.2AB PADA ORANG DEWASA

▪ LUAS < 10% GR.2AB PADA ANAK DAN USIA LANJUT
▪ LUAS < 2% GR.3 PADA SEGALA USIA YG TIDAK
MENGENAI MUKA, TANGAN DAN PERINEUM
LUKA BAKAR SEDANG : :
▪ LUAS 15-25% PADA DEWASA dgn DERAJAT 3 <10%
▪ LUAS 10-20% PADA ANAK-ANAK, DAN/ATAU LUKA BAKAR
DERAJAT 3 < 10%
▪ DERAJAT 3 < 10% PADA ANAK ATAU DEWASA,
TIDAK MENGENAI MUKA TANGAN KAKI DAN PERINEUM
LUKA BAKAR BERAT :
▪ GR.2 DAN GR.3 LUAS >20% DGN USIA <10 THn ATAU >50 THN
▪ GR.2 DAN GR.3 LUAS >25%
▪ LUKA BAKAR PADA MUKA, TELINGGA, TANGAN, KAKI, DAN
PERINEUM (BERAPAPUN DERAJATNYA)
▪ LUKA BAKAR DGN TRAUMA INHALASI
▪ LUKA BAKAR LISTRIK TEGANGAN TINGGI
▪ LUKA BAKAR DGN TRAUMA LAIN, MIS : FRAKTUR MULTIPEL,
PNEUMOTHORAX
▪ LUKA BAKAR PADA PASIEN DENGAN RESIKO TINGGI (COMORBID) :
DIABETES MELLITUS, IMMUNOCOMPROMISED
KRITERIA RUJUKAN PASIEN KE BURN UNIT
ATAU BURN CENTER (1) :
▪ Luka Bakar Gr 2AB >15-20% TBSA pada Dewasa
▪ Luka Bakar Gr 2AB >10-15% TBSA pada Anak
▪ Luka Bakar Derajat 3 luas> 5%
▪ Luka bakar pada daerah wajah, tangan, kaki, genitalia,
perineum, sendi utama (axilla,elbow, wrist, poplitea, ankle)
dan luka bakar yang mengelilingi ekstremitas dan dada.
KRITERIA RUJUKAN PASIEN KE BURN UNIT
ATAU BURN CENTER (2) :
▪ Luka bakar dengan Trauma Inhalasi
▪ Luka bakar Listrik
▪ Luka bakar karena Zat Kimia
▪ Luka bakar dengan Penyakit Penyerta (DM, Hipertensi, Stroke)
▪ Luka bakar dengan Trauma Multiple
▪ Luka bakar pada anak, orang tua dan wanita hamil
Wound Bed Preparation
and Wound Dressing
Principles of Wound Bed Preparation
The aim : to bring back the wound to the physiological
pathway of wound healing.
HOW to achieve the aim :
1. Provision of well-vascularized wound bed
2. Stable wound bed
3. Minimal exudate
4. Infection Control
 BACTERIAL LOAD
DEBRIDEMENT MANAGEMENT

WOUND BED PREPARATION

MOISTURE
CONTROL
 NECROTIC BACTERIAL
EXUDATE
TISSUE LOAD

WOUND HEALING

IMPAIRED WOUND HEALING

Wound Bed Preparation - Anesthesia
Topical Anesthesia :
◦ Solution or paste
◦ EMLA
Local Anesthesia :
◦ Direct infiltration
◦ Lidocaine with or without epinephrine
◦ Bupivacaine for longer acting anesthesia
Regional Block :
◦ Local infiltration proximally in order to avoid tissue disruption
◦ Smaller amount of anesthesia required
General Anesthesia
Wound Irrigation :
Local anesthesia prior to irrigation
Do not soak the wound
Use normal saline
Use syringe with needle to create turbulent spray
DO NOT use iodine, peroxide or detergents
USE Baby Soap or Chlorhexidine 2-4%
Wound Bed Preparation – Debridement
Removes foreign matter & devitalized tissue
Preserving normal structures and
neurovascular integrity
Respect skin lines
 Current State of Wound

Necrotic Infected Sloughy Granulating Epithelizing

Antibiotics
Infections occur in 3-5% of traumatic wounds seen in the ER.
Factors that increase risk :
◦Heavily contaminated wound, especially with soil
◦Immunocompromised patients
◦Diabetics
Most important prevention → adequate irrigation & debridement
Dry vs Moist Wound Healing
Moist wound environment has been accepted by wound experts to support wound healing and reduce the risk of infection

Dry Wound Healing Moist Wound Healing

Dry wound healing → scab/crust • Wound heals faster and better in moist environment
• Scab protects the wound from contamination • Moist wound environment prevents the formation of scab
• However, scab also delays wound healing because • Less scar, therefore a better cosmetic result
it becomes a physical barriers for cell proliferation

Surgery supplement. Keep wounds moist or dry? Available at: http://www.surgerysupplements.com/keep-wounds-moist-or-dry. Accessed on: 19/03/2015.
 MOISTURE CONTROL
TYPES OF EXUDATE AND ITS INTERPRETATION
EXUDATE TYPE EXUDATE APPEARANCE COMPONENTS OF EXUDATE
SEROUS Thin, watery, clear Bacteria may presents
FIBRINOUS Thin, cloudy Contain Fibrins Strands
PURULENT Thin or Thick, Milky, Opaque to Yellow Contain inactive bacteria and
inflammatory cells
HEMOPURULENT Viscous, Sticky, Dark, Blood Stained If dermal capillary breaks, damage
leads to the the presence of red blood
cells
HEMORRHAGIC Thin, Bright Red Dominated by red blood cells
THE DRESSING
Superficial to Mid Dermal Thickess >> biologically compatible dressing (Biobrane,
Opsite (Transparent Film Dressing), Duoderm)

Deep Dermal or Full Thickness Burns >> Topical Antimicrobial Agent (Silver
Sulfadiazine) and Thick Gauze (occlusive dressing)

Care should be taken to ensure that the dressings are not too tight and check the
limbs on appropriate sensation and circulation distally.

IF BURN WOUND EXTENT TO THE JOINT >> SPLINTING IS MANDATORY

TO PREVENT CONTRACTURE
IDEAL CHARACTERISTIC OF WOUND DRESSING

Maintains a moist wound environment

Absorbs excess exudate
Eliminates dead space
Does not harm the wound
Provides thermal insulation
Provides bacterial barrier
Promotes Epithelialization

Seaman S. Dressing selection in chronic wound management. J Am Podiatr Med Assoc. 2002;92(1):24-25
 SCAR HIPERTROFI DAN
KONTRAKTUR PASCA LUKA BAKAR
SCAR
Scar is a fiber tissue which has an abnormal
structure of collagen.
Scar has a poor quality compare to healthy
tissue.
 HYPERTROPHIC SCAR VS KELOID

A B C
LUKA BAKAR derajat 2 dalam (Deep Dermal Burn) atau
derajat 3 (Full Thickness Burn) jika sembuh spontan, biasanya
akan mengakibatkan komplikasi scar hipertrofi dan kontraktur.

KONTRAKTUR LUKA BAKAR adalah keterbatasan gerak sendi

pada pasien luka bakar akibat skar luka bakar yang menarik
sehingga mengakibatkan pemendekan sudut gerak sendi pada
area yang terkena luka bakar.

KONTRAKTUR biasanya terjadi di persendian utama seperti

leher, jari-jari tangan, siku, pergelangan tangan, lutut dan
pergelangan kaki atau jari-jari kaki.
SCAR HIPERTROFI DAN
KONTRAKTUR LEHER
PASCA LUKA BAKAR API
NECK CONTRACTURE POPLITEAL CONTRACTURE
WRIST CONTRACTURE FOOT CONTRACTURE
HAND CONTRACTURE
 PERAWATAN SCAR DAN
PENCEGAHAN KONTRAKTUR
PASCA LUKA BAKAR
ANTI-CONTRACTURE
POSITIONING
FLEXION CONTRACTURE OF THE NECK → PILLOW UNDER SHOULDER
CLAW HAND → LUMBAR POSITION SPLINT
FLEXION CONTRACTURE OF THE AXILLA → AXILLARY SPLINT (AEROPLANE SPLINT)
PRESSURE TAPING

SILICONE SHEET PRESSURE GARMENT

CARA MEMBALUT LUKA BAKAR PADA TANGAN UNTUK MENCEGAH KONTRAKTUR DAN WEBBING

1 2

3 4
 Hand and Wrist Splinting:
Lumbrical (Intrinsic) Plus Position
FOOT AND ANKLE SPLINTING
HARD COLLAR BRACE FOR NECK SPLINTING
Aeroplane Splint to Prevent Axilla Contracture
 PERAWATAN LUKA &
OPERASI REKONSTRUKSI BEDAH PLASTIK
PADA PASIEN LUKA BAKAR
 BULLAE : KEEP IT OR BREAK IT ?

BULLAE = EPIDERMOLYSIS = NON VITAL TISSUE = NECROTIC TISSUE

SO, IT’S BETTER TO DEBRIDE THE BULLAE AND GIVE PROPER DRESSING TO FACILITATE WOUND HEALING
DEBRIDEMENT AND EARLY TANGENTIAL EXCISION
 POST BURN
CONTRACTURE RELEASE
AND SKIN GRAFT
NECK CONTRACTURE AND HYPERTROPHIC SCAR
HAND CONTRACTURE AND HYPERTROPHIC SCAR ON FACE
SKIN GRAFT – MESH GRAFT
H+5 POST FTSG
Terima Kasih
prasastaadhistana@gmail.com