Adi, Oki, Irawadi, Ita, Ati, Maul, Tizi

KASUS
IDENTITAS
Nama : Nn. YY
Umur : 25 tahun
Masuk RSCM : 14 Maret 2006
Di rujuk dari RS Mitra Keluarga Bekasi
dengan Luka bakar Gr II-III 64%
KASUS
ANAMNESIS
• Keluhan Utama:
Luka bakar api sejak 8 jam SMRS
• Riwayat Penyakit Sekarang:
– 8 jam SMRS pasien boncengan motor, bawa jerigen bensin,
tabrakan dengan motor lain dari depan, jatuh dengan posisi
bahu kiri di bawah, jerigen meledak membakar tubuh pasien
– 6 jam SMRS pasien dibawa ke RS MK
• infus RL 7 buah
• Rantin 1 amp
• Petidin 50 mg
• Tetragram 1 amp
• Seftriakson 2 g
• Pasang kateter urin
• Pasien dirujuk ke RSCM
KASUS
PEMERIKSAAN FISIK
Primary Survey: BB 50 kg; TB 155 cm
A : Sadar, sesak, suara disfoni, bulu hidung terbakar,
edema labialis superior dan inferior, mukosa oral dan
orofaring hiperemis  INTUBASI
B : Spontan, simetris, RR 28 x/mnt
C : TD 110/70 mmHg, HR 110 x/mnt reguler, cukup,
akral hangat, kateter urin keluar 600 cc
D : GCS = 15
KASUS
STATUS LOKALIS
Regio Femur Dextra:
L : Medial Femur VL 25 x 10 cm
F : Dasar lunak, bone expose – NT + Krep –
M: ROM terbatas karena nyeri + edema, skor ?
KASUS
STATUS LUKA BAKAR
Kepala dan leher : 8%
Trunkus ant : 8%
Trunkus post : 9%
Genital : 0%
Lengan dext : 6%
Lengan sin : 4%
Tungkai sup dext : 9%
Tungkai sup sin : 9%
Tungkai Inf dext : 9%
Tungkai inf sin : 9%
Anterior Posterior
Total : 71%
KASUS
Secondary Survey :
Kepala: jejas – deformitas –
Wajah : Terintubasi, alis, bulu mata dan bulu
hidung terbakar, edema seluruh wajah
Mata : sulit dinilai, edema palpebra
Thoraks : Simetris I/E, jejas –
Cor : BJ I-II Murni, murmur – gallop –
Pulmo : Vesikuler, sonor, Rhonki -/- mengi-/-
Abdomen : Jejas – lemas, datar, BU+N, NT –
Ekstremitas : Status lokalis.
KASUS
DIAGNOSIS:
1. Combustio gr. II – III 71% + Trauma inhalasi
2. Vulnus Laseratum Femur dextra
KASUS
SIKAP
• Telah terpasang ETT : O2 4 L/mnt
• IVFD Res. Parkland: 4 x 58 x 71=14200
– 7100 cc jam 01.00-09.00 masuk 3500 cc
– RL 1500 cc  urin ½ cc/Kg/jam dilanjutkan D5% + Dobu
20 tts mikro/mnt
– HAES 500 cc/24 jam
– D5% 1500 cc/24 jam
• Eskarotomi
KASUS
SIKAP
• Kateter: 600 cc jernih tidak pekat
• CVP
• NGT
• Inhalasi: RL+Dexa+SA tiap 6 jam
• Suction
• Diet cair
• Novalgin 3 x I
• Scaven 3 x II
• Omega_3 3 x I
• Cek laboratorium lengkap
15/3/2006 16/3/2006 17/3/2006 18/3/2006 19/3/2006
O2 via ETT O2 via ETT O2 via Tracheostomi O2 via O2 via
Tracheostomi Tracheostomi Tracheostomi

D5 :RL 1L:1L/24 D5:RL=1:1/24 j D5 2L/24 j D5 2L/24 j D5+Dobu

jam + Dobu + Dobu D5+Dobu D5+Dobu Dx 5 1000 cc/24 j
PRC I PRC II Haes 6% 50 cc/inj D5 1000 cc/24 j Haes 500cc/24 j
PRC III Haes 500cc/24 j

Ceftriaxon Ceftriaxon Ceftriaxon Ceftriaxon Ceftriaxon

Navalgin Navalgin Novalgin Novalgin Novalgin
Inpepsa Inpepsa Inpepsa Inpepsa Inpepsa
Ca glukonas Ca glukonas Ca glukonas
Scaven Scaven Scaven
Omega 3 Omega 3 Omega 3

Inhalasi Inhalasi Inhalasi SA:RL:DeXa Inhalasi Inhalasi

Suction SA:RL:Dexa Suction SA:RL:DeXa SA:RL:DeXa
NGT spooling Suction NGT Spool Suction Suction
dingin, diit NGT Spool dingin+diit NGT Spool NGT Spool
dingin+diit dingin+diit dingin+diit
20/3/2006
01.45: O2 5L/mnt + Lasix
02.45: nitrogliserin 5 L/5mg
04.45: apneu  RJP  Meninggal
TANGGAL 14 17 18 19 20
pk 15.10 pk15.04 pk 08.00 pk 02.45
DPL
Hb 14,6 8 9 10,4
Ht 43% 24,8 26,8 30,1
Leukosit 32100 11700 10200
Trombosit 283000 50000 27000

KIMIA DARAH
Protein total 5 4,3
Albumin
Globulin
2,8
2,2
1,75
2,55
Hipoalbuminemia
GDS 129 156
SGOT 32 75
SGPT 18 49
Ureum 16 42 68
Kreatinin 0,6 0,5 1,2

AGD
pH 7,39 7,41 7,39 7,18
PCO2 24,7 40,7 24,60 31,70
PO2 99,1 87,2 64,30 60,80 Asidosis
HCO3
TCO2
14,5
15,3
25,7
27,6
14,70
15,40
12,10
13,00
Metabolik
BE -8,2 1,6 -9,60 -16,40
Sat O2 97,9 92,1 93,00 84,90

Na 137 131 136 136

K 4 3 3 3 Hipokalemia
Cl 105 94 98 100
Monitoring

15 16 17 18 19

Input

IVFD 1800 2012 3300 2240 2616

Oral 140 600 7150 1100 880

1940 2612 10450 3370 3496

Output
Cairan
Urine 145 1180 1216 775 680

NGT 350 2520 0 0 0

IWL 840 1535 2520 2520 2520

1335 5235 3736 3295 3200

Balance 605 -2623 6714 75 296

CVP - 2 6 16 16
SIRS Trauma

Shock

Catabolism Tissue damage

Toxins Infection
Inadequate
blood flow

Cerebral Cardiac Pulmonary Splanchnic Renal Muscles Skin

Patient’s Problem…Early Period
• Burn Injury  Open Wound
– >> IWL
– >> Inflammation
• Inhalation Injury  Compromise Airway
and Breathing
• Shock
Patient’s Problem… Late Period
• Hypoalbuminemia
• Hypokalemia
• Metabolic Acidosis
• Infections
• Pulmonary Oedema
• Wound Healing Impairment
Burn Management

What to do?

Early Phase Second Phase Late Phase

0 – 48(72)hrs to 14-21days to 8-12months

ABC Resuscitation Early Excision Rehabilitation

Early Respiratory Early Skin Grafting
Rehabilitation
Early Enteral Nutrition Rehabilitation
Pre-hospital Care

• Remove from area! Stop the burn!

• If thermal burn is large--FOCUS on the
ABC’s
– A=airway-check for patency, soot around
nares, or signed nasal hair
– B=breathing- check for adequacy of
ventilation
– C=circulation-check for presence and
regularity of pulses
Other precautions...
• Burn too large--don’t immerse in water
due to extensive heat loss
• Never pack in ice
• Pt. should be wrapped in dry clean
material to decrease contamination of
wound and increase warmth
Cool Burn
• Within 30 minutes
• Inhibits lactate production and acidosis
• Promotes catecholamine function and
cardiovascular homeostasis
• Inhibits burn wound histamine release
• Blocks histamine mediated increased vascualr
permeability
• Minimizes edema formation
• Suppresses thromboxane
– mediator of vascular occlusion
– progressive dermal ischemia
Initial Assessment
• Perform ABCDEF primary survey
A-Airway, B-Breathing, C-Circulation
D-Disability, E-Exposure, F-Fluid
• Asses burn size and depth
• Establish good IV access, give fluids
• Give Analgesia
• Catheterise patients, fluid balance monitoring
• Take baseline blood sample
• Dress Wound
• Perform Secondary Survey, reassess, exclude or treat
associated injuries
 The Airway and Breathing resuscitation

 The insertion of tracheal tube / tracheostomy

 Ventilator is usually needed
 Periodically suction of secrets to maintain the airway keep
clear
 Bronchial washing and pulmonary toilet (broncho-alveolar
lavage)
 Inhalation therapy
 Oxygen supply (2-4 liter per minutes)
 Nebulizer (humidification treatment)
 Bronchodilator  ?
 Early respiratory rehabilitation (the chest physiotherapy and
pts positioning)
 Escharotomies
 The Fluid Resuscitation

• GOAL
– Restore effective plasma volume
– Maintain vital organ function
• Watch Out
– Hypovolemia / renal failure-complications
– Pulmonary edema
• Monitoring
– Assess adequacy by Urine output
 The Fluid Resuscitation
Resuscitation Formulas
Crystalloid in Second
Formula Fluid in First 24 Hours Colloid in Second 24-Hours
24-Hours
20-60% estimated Titrated to urinary output of 30
Parkland RL at 4 mL/kg per percentage burn
plasma volume mL/h

NS at 1 mL/kg per percentage 50% of first 24-hour

Evans (Yowler, 2000) burn, 2000 mL D5W*, and colloid volume plus 2000 mL 50% of first 24-hour volume
at 1 mL/kg per percentage burn D5W

RL at 2 L/24 h plus fresh frozen

Slater (Yowler, 2000)
plasma at 75 mL/kg/24 h
RL at 1.5 mL/kg per percentage
50% of first 24-hour
burn, colloid at 0.5 mL/kg per
Brooke (Yowler, 2000) volume plus 2000 mL 50% of first 24-hour volume
percentage burn, and 2000 mL
D5W
D5W
Modified Brooke RL at 2 mL/kg per percentage burn
1 U fresh frozen plasma for
RL solution with 50 mEq sodium
MetroHealth Half NS titrated to urine each liter of half NS used plus
bicarbonate per liter at 4 mL/kg per
(Cleveland) output D5W as needed for
percentage burn
hypoglycemia
250 mEq/L saline titrated to urine
output at 30 mL/h, dextran 40 in
NS at 2 mL/kg/h for 8 hours, RL
Monafo hypertonic One-third NS titrated to
titrated to urine output at 30 mL/h,
(Demling) urine output
and fresh frozen plasma 0.5 mL/h
for 18 hours beginning 8 hours
postburn
 The Fluid Resuscitation

• PARKLANDS FORMULA
4ml x body weight (kg) x % burns
• Regimen:
- 1st 8 hours: ½ the calculated volume
- Next 16 hours: remaining ½ calculated volume

* 1st 8 hrs. started from the time of injury *

• Fluid to use:
- Use predominantly crystalloid in the first 12-24 hrs
- Add on colloids after 24 hrs
 The Fluid Resuscitation
Crystalloid vs Colloid
• Increase in permeability at the site of injury
and microvasculature causes tremendous shift
of fluid from plasma to interstitial fluid

• This decrease in intravascular volume is

pronounced in the first 24hr and is typically
replaced with crystalloids

• After 24-48hr, capillary integrity returns to

normal, and colloid solutions will remain
intravascular
 The fluid resuscitation

The Role of Albumin

• The effects of colloids to the osmotic
pressure
• The role of hypoalbuminemia
– Pulmonary edema (<2.5g/dl) and cerebral
edema (<2.0g/dl)
– Delayed healing
 The Fluid Resuscitation
Fluids for this patient
• RL
• Dextrose 5%
• HAES 6%
• PRC

LDD Anti inflammatory agent

7.100ml crystalloid 7.100ml crystalloid 2.000ml
4750ml 2350ml glucose
8hr
1-2hr 16hr 24hr
 The fluid resuscitation

Caution
• Ringer’s Lactate lead to large interstitial edema
formation
• Hypertonic saline lead to electrolytes dis-configuration
followed with hypernatremic state acidosis
• Colloids should be handle with care (still controversial)
 The fluid resuscitation

The Role of Vaso-active agent

• Vaso-active agent (dopaminergic) is
needed to resuscitate the peripheral
vasoconstriction

• Low Dose Dopamine is administered in

the first 1-2hr of 1-3µg/kgBW/minutes
(renal dose) diluted in 5% Glucose is
administered per infuse
 The fluid resuscitation

Assessment of adequacy of fluid

replacement
• Urinary output is most commonly used parameter
• urine OP-30-50 cc/hr in an adult
• cardiopulmonary factors- BP (systolic 90-100 mmHg, pulse less
than 100, resp 16-20 breaths per min. (BP more accurate with
arterial line)
• sensoruim-alert, oriented to time, place, & person
Nutritional Therapy
• Fluid replacement takes priority over
nutritional needs in the initial emergent phase
• NG tube is inserted and connected to low
intermittent suction for decompression. When
bowel sounds return (48-72 hrs) after injury,
start with clear liquids and progress up to a
diet high in proteins and calories
Why Nutritional Therapy?
• Hypermetabolism in varying intensity and duration
• During the flow phase, energy requirements approach
physiological limits exceeding by as much as 100% basal energy
required normally
• This increased energy expenditure contributes to malnutrition
with severe weight loss and negative nitrogen balance
• Severely burned patient  > 40 g N/d loss of protein
– Protein exudation through the burned skin
– Catabolic stress  body protein are used for the production of 15-
20% total energy required
• Consequently, patient with burn on > 20% body surface should
received nutritional support specifically tailored for each
individual; also for less severe burns with malnutrition
Shift of Energy Source
• Increase catecholamine, cortisol and glucagon;
normal/slightly elevated insulin
• Increased proteolysis and lipolysis with the release of
large amounts of amino acids (alanine and
glutamine), glycerol and FFA
– AA and glycerol  gluconeogenesis (Glucagon > Insulin);
glucose is the preferred energy substrate of cell
(macrophages, leukocytes and fibroblasts)
– FFAs are used as an alternative energy source (skin and
muscle) or metabolized via Cyclooxigenase or Lipoxygenase
 eucosanoid compounds
The Decrease in Immune Response
• Systemic Response  activation of macrophages and
neutrophils, the arachidonic acid and complements,
cytokines and proteases and stimulation of metabolic
responses
• All may adversely affect immune function
• Immunologic response also is impaired due to
– Protein Energy Malnutrition
– Specific Micronutrient deficiency
Nutritional Support
• Enteral rather than parenteral
– Maintains trophism of GI tract by promoting release of
intestinal hormones and growth factors
– Parenteral route increases infectious complication
• Individualized amounts of energy and protein to
accelerate muscle and visceral protein synthesis and
to reduce proteolysis
• High Protein diets (1,5 – 3 g/kg/day) with a non
protein energy to g N ratio of 100:1
• Pharmacological nutrition included
– Specific Amino Acids (glutamine, arginine) and fatty acids
(n-3 fatty acids) or combination
• Avoid Overfeeding
Infection in Burns

• Skin damage bacterial invasion infection immunosuppression

sepsis
• Coagulation zone  circulation  immune humoral  bacterial growth
• Grade II infection  progressive bacterial proliferation  perivascular
reaction  thrombosis Grade III
• Without early topical antibiotic   streptococcus, staphylococcus
• Nosocomial  gram -
• sepsis : 105 bacterial colony /gr tissue
• (+) Bacterial culture only in secondary infection
Infection prevention

• Aseptic
• Dilution & wound toilet
• Necrotomy & debridement
• Topical & systemic antibiotics
• Rational Profilactic antibiotics  30 minutes pre-
necrotomy / debridement 1x IVAb iv 24 hour
post treatment
 Next : the wound care procedure

• Wound toilet in a proper manner

• Occlusive dressing
• Rational application of antimicrobial cream /
solution
• Early excision
o Less extensive burn 3-4 days post trauma
o More extensive burn 7-10days post trauma
• Early skin grafting
Topical antimicrobial
• Silver nitrate 0.5%
• Mafenide acetate 10%
• Silver sulfadiazine 1%
Be Ware of:
• Bone marrow suppression
• Leukopenia
• Hypochloremic
• Hypersensitive reaction

• Gentamicyn sulfate
 REHABILITATION

• Respiratory rehabilitation
– Respiratory tract clean-up
– Inspiration-expiration mechanism
– Proper position
• Rehabilitation of the joints, etc
Possible Cause of Death
• In-Adequacy of Fluid Resuscitation
• Development of Sepsis, SIRS and MODS
• Respiratory Distress due to:
– Progression of Inhalation Injury
– Development of Pulmonary Edema
– Metabolic Acidosis
– ARDS, MODS
Duh cape-nya…