Emergency Management

of Severe Burn
dr. Sandro, SpB, FINACS
Departemen Bedah
FK UNIB – RSUD M YUNUS
adapted from

18th Edition, December

2016
 1
Epidemiology and
Etiology
 Epidemiology

Burn injuries may result from:

• accidents
• carelessness or ina ention
• pre-existing medical condition
• alcohol or drug abuse
• military burns
 Common location where
burn injuries are sustained

Children Adult
 Etiology

Children Adult
 2
Respon Lokal dan
Sistemik pada Luka Bakar
More than 10% in children or 20% in adults of TBSA, the zone of
hyperemia may involve virtually the whole of the body, be coming
analogous to a systemic inflammatory response.
 • Pelepasan sistemik mediator inflamasi
• Meningkatkan permeabilitas kapiler
Hipo
volemia • Kebocoran cairan dan proterin ke jaringan interstitial

• Sekresi hormon Stress + Supresi Hormon Anabolik

Hiper
metabolik

• Depresi dari berbagai pintu mekanisme imun

Imuno
supresi

• Syok 🡪 Hipoperfusi usus

Translokasi
Bakteri

• Respon inflamasi sistemik

ARDS
• Terjadi tanpa harus cedera inhalasi
 3
Pemeriksaan dan
penanganan Emergency
• Patensi Jalan Nafas
• Bicara
• Trauma inhalasi ?
• Jaw trust
• Intubasi

• Kontrol Cervikal
• Imobilisasi
• Cervikal Collar
 PERHATIKAN
RR <10 / > 30

• Buka bagian Dada

• IPPA

• Kecepatan, Kedalaman, Asimetris Luka bakar

Sirkumferensial
• Oxymetri
• Eksklusi trauma thoraks

• O2 15l/m NRM

Keracunan
Sistemik
 Pulasasi, CRT,
Temp. (ELevasi)

• Nadi (Central VS Perifer)

• External
• Bebat tekan • TD & HR

• Torniket • IV Line 16 G + Sampel darah

• Internal
• Thoraks • Resusitasi Cairan

• Abdomen • Syok Perdarahan ?

• Pelvis • Cari & Kontrol Perdarahan

• Tulang Panjang
•AVPU

•Pupil

•RC

•Ekstra Cranial

•Hipoksia + Syok

•Intra Cranial ?
• Hitung TBSA

• Lepaskan Semua

• Log Roll

• Selimut cegah Hipotermi

Modifik
asi,
3xTBS
A+BB
+Mainte
Morfin
nance
0.05 s/d
0.1
mg/Kg
ECG,F
AST,RO
DR,DK,
βHcG
Cathtet
er, NGT
(Gastro
paresis)
, ETT
Air ?
mengali
r 20
Menit
(<3jam)
Medikasi, Past
Illnes, Last
Meal, Event
Visus, Timpani,
Extremitas
(NVD?)

ATS & TT

List Kontrol &

ISBAR

Tutup luka
Cling Warp (<8
Jam)
Support
Edukasi &
Empati
 4
Cedera Inhalasi
1. Cedera jalan nafas atas laring
2. Cedera jalan nafas bawah laring
3. Keracunan Sistemik
Cedera jalan nafas atas laring
Karena Udara Panas
Terperangkap pada ruangan tertutup
Overload Cairan
Cedera jalan nafas bawah laring
Karena inhalasi produk pembakaran
Karbon sulfur fosfor dan nitrogen, dll
Reaksi Asam-Basa
Alveoli Rusak
Desaturasi 🡪 Penurunan kesadaran
Keracunan Sistemik
CO 🡪 COHb
Gangguan kesadaran jika COHb > 15%
Merah chery jarang ditemukan
Oxymetry tidak dapat membedakan
Blood gas analysers

Sianida 🡪 Plastik/lem
 5
Penilaian Luka
Burn Wound Percentage
- Rule of Nine -
1st degree

2nd a degree

2nd b degree

3re degree
 Depth of Burn

1. 1st Degree
- Epidermis

2. 2nd Degree
- 2a: Superficial
- 2b: Deep

3. 3rd Degree
- Subdermal
- Extension to muscle, bone
Depth of Burn
 6
Syok Luka Bakar dan
Resusitasi Cairan
Estimation of Resuscitation
Fluids Needs
Modified Parkland Formula:

3 x kg body weight x percent (%) burn

½ -> first 8 hours

½ -> 16 hours
 Maintenance Fluids in Children
(< 16 years)
Maintenance fluids for children are calculated as ml/kg/hr using:
“4:2:1” rule

4 ml/kg/hr up to 10 Kg
+
2 ml/kg/hr from 11-20 kg
+
1 ml/kg/hr for each kg over 20 kg

fluid choice: 0,9% NaCl + 5% Dextrose

 Monitoring Fluid
Resuscitation
1. Urinary production per hour
Adult : 0,5 - 1 cc/bw/hr (30-50 cc/hr)
Children : 1 cc/bw/hr
2. Oliguria
Associated with systemic vascular resistance & cardiac output recuction
3. Blood pressure
4. Heart rate
5. Haematocrite & haemoglobin
35
 Signs of Adequate
Fluid Resuscitation

•Allert
•Pulse < 120 beats per minute
•Urine output for adults 0,5 - 1 cc/kg/hour, pediatric 1-2
cc/kg/hour
•Systolic blood pressure > 100 mm Hg, MAP > 65

36
Jika Tidak Tercapai ???

• RL
• Bolus 5-10 mg/kg

• RL
• 150 % dari ½ Parkland (Loading 1 Jam)
• Manitol
• 12.5g + 1 lt RL
 7
Tatalaksana Luka
• Hentikan Proses
• Stop Drop Cover (face) Roll
• Lepas Pakaian

• Dinginkan Luka
• Mengurangi sitokin
• Viabilitas Zona stasis

• Cegah Hipotermia
• Area Spesial
• Jalan Nafas
• Perineum, Katerer
• Kepala Leher, Head Up
• Extremitas, Elevasi
 Wound Management
•Wound cleansing, debridement, & desinfection with savlon 1 : 30
•Moist dressing, tulle -> epidermal to mid-dermal burn
•Topical silver sulfadiazine (ssd) -> deep dermal to full-thickness burn
•Thick sterile gauze / elastic bandage
•Open the wound dressings at day 5 unless there is any sign of
infection
•Perform under general anaesthesia (in the operating theatre)
41
 Burn Wound Surgery

Burn Wound escharec

STSG
Injury tomy

Postage stamp
Meshed STSG STSG
 8
Rujukan
Kriteria Rujukan
 9
Luka Bakar Pada Anak
Kepala – umur
🡪 Tungkai
½ ½
KASUS
 10
Luka Bakar Listrik
2. Mr. Apriansyah / ♂ / 22 years old.
Admitted on Monday, July 7th 2014 at 22.30 pm

ANAMNESIS
Electric burn injury
He got electrical injury on face, chest and both leg while he was working
About 12 hours before admission
Referred from M. Rabain Muara Enim Hospital
PRIMARY SURVEY
A. Good
B. RR : 22 x/min
C. BP : 119/69 mmHg
PR : 105 x/mnt
SECONDARY SURVEY

There were burn injury (flash) on

Head and neck : 8%
Chest + Abdomen : 27 %
Right leg : 12 %
Left leg : 13 %
Total : 60 %
Electrocardiography
Sinus rhytme
LABORATORY FINDINGS

Hb : 15,1 gr/dl (N:12-16 gr/dl)

Ht : 43 Vol% (N:37-43 Vol%)
Leukosit : 14.000 /nL ( 4,5 – 11.0 10 ³/mm ³)
Na : 145 ( 135 – 155 mEq/L)
K : 3,8 ( 3,6 – 5,5 mEq/L )
Ureum : 17 ( 16.6 – 48,5 mg/dL)
Creatinin : 0,48 ( 0.50 – 0.90 mg/dL )
SGOT : 228 ( 0 – 32 mg/dL )
SGPT : 69 ( 0 – 31 mg/dL )
CKNA : 270 IU/L
CKMB : 6947 IU/L
DIAGNOSIS
Electric burn injury grade 2B 76 % (T21.2)

MANAGEMENT
- Fluid Resusitation 🡪 Baxter Formula ( 4800 cc /12 hours
= gtt C /m ) (00.45)
- Ceftriaxon injection 1 x 2 g (99.21)
- Ranitidin Injection 2 x 150 mg
- Ketorolac injection 3 x 30 mg (99.21)
- ATS injection 1500 IU (99.21)
- Debridement (86.28)

Patient was treated in the ward

IO
Tu
lan
•Resisten
Kug •Konduktor

lit
Le •Joule Effect

m
ak
Sa
raf
Ot
Caot
ira
n
Lichtenberg Flower
Disritmia
• EKG 24
• Tinggi

• Hilang kesadaran

• Riwayat EKG abnormal

• Riwayat Penyakit Jantung

Hemokromogenuria
Jernihkan Urine 1-2/kg/jam atau
>2ml/Kg/Jam pada anak

• RL
• Bolus 5-10 mg/kg

• RL
• 150 % dari ½ Parkland (Loading 1 Jam)
• Manitol
• 12.5g + 1 lt RL
 11
Luka Bakar Kimia
 2. Mrs.Neli / ♀ / 28 years old
Admitted on Thusrday, march 6th 2013 at 09.34 am

ANAMNESIS
Chemical burn injury
She complained that her face and leg got splashed by her husband using chemical fluid.
(About 1 hours before admission)

PRIMARY SURVEY
A. Good
B. RR : 20 x/m
C. BP : 120/80 mmHg
PR : 86 x/m
SECONDARY SURVEY
There was chemical burn injury on
head : 3 %
neck : 2 %
Right arm :1%
Right tight :3%

Total : 8 %

On Occuli dextra region :

I : chemosis (+)
SECONDARY SURVEY

Before irrigation After irrigation

LABORATORY FINDINGS
Hb : 13.9 gr/dl (N : 14 – 18 gr/dl)
Ht : 41 % (N : 40 – 46 %)

DIAGNOSIS
Chemical burn injury grade III 8% (T22)

THERAPY
- IVFD RL gtt XX/m (1800 cc/day)(38.92)
- Inj Ceftriaxon 1x2 g(99.21)
- Inj ATS 1500 IU (99.38)
- Inj Ketorolac 3 x 30 mg (05.31)
- Irrigation using aquadest
- Joint care with ophtalmologic department

The patient was treated in the ward

• Asam
• pH < 7
• Nekrosif koagulatif
• Membentuk koagulum yang dapat membatasi penetrasi

• Basa
• pH > 7
• Nekrosis Liquefaktif
• Saponifikasi (Melunakan)
• Lambat dan Dalam
 Lepaskan Pakaian
Kontaminasi

Irigasi Air mengalir

(Jangan Menggenang)

Target pH Netral,
minimal 30 Menit

Bahan kimia bersifat

basa dan aspal irigasi
selama minimal 1 Jam
 12
Tatalaksana Rawat Jalan
Luka Bakar Minor
 <10 % atau <5%
pada anak (Max
Midermal)

Irigasi 20 – 30
menit air mengalir

Analgetik Antibiotik

Akut berikan Lar

Chlorhexidine 0.1
atau 0.2 %
Bulla <2 cm
biarkan, Bulla
besar >2 cm
tegang, di sendi,
kontamisasi,
pecahkan
• Epidermis
• Tanpa bula
• Sun burn
• Krim pelembab

• Dermis
• Ada Bulla
• Balutan SSD
• Evaluasi 3 hari
 13
Fross bite dan
Hiponatremia
 14
Tatalaksana Bencana
›TERIMAKASIH