Manajemen luka bakar

Arie Kusumaningrum

Kesulitan

• Diagnosis Estimasi – ukuran dan kedalaman – Fluid resucitation n maintenance– Airway management – Vascular acces – Thermal maintenance

• Children: keterbatasan fisiologi psikologis dalam berespon

Mekanisme injury

• Luka bakar lokal– Nekrosis sel yang dihasilkan oleh panas – Koagulasi nekrosis pada jaringan – Pada permukaan tubuh – Derajat kedalaman

– Kerusakan sel lebih lanjut ditentukan:• Intensitas panas• Durasi pajanan • Jaringan terlibat

Thermal injury

• Direct heat • Exposure to caustic chemicals• Contact with electrical current

– Radiation ----- rare

• Flame, flash burn, scald, contact burn

Electrical injury

• Kontak listrik voltase tinggi – Area kontak kering, … . tertekan– Kerusakan jaringan yang dalam : edema

sufascial dan nekrosis jaringan– Fasciotomy dapat direkomendasikan

• menurunakan tekanan dalam compartment otot • mempertahankan aliran aliran darah

• Komplikasi – Neurologi– Renal – Cardiac– Skeletal – Terpajan aliran listrik di luar tubuh/lingkungan:

baju dan objek lain : flash –flame type

Chemical injury

Assessment and management

• Initial phase– Manajemen kegawatdaruratan

• FASE AKUT: – PENGKAJIAN DAN MANAJEMEN

Manajemen kegawatdaruratan

Initial assessment and management

Care at the scene of accident

First aid

Rapid primary and secondary assessment

Care in the emergency department

Primary assessment

Secondary assessment

Stabilization and transport

ABA criteria, Stabil prime dan sekunder

, Dokumentasi, Komunikasi dan

kolaborasi

Systemic response

Asessment and care

First aid

1. • Mengurangi kedalaman

luka• Mengurangi perluasan

luka• Mengeluarkan sumber

luka• Mengentikan proses

2• Tutup luka – kain kering,

bersih• Mengukur suhu tubuh• Kompres basah pada luka

kecil• Hindari air pada luka besar

dan anak kecil• Hindari air es/es pada luka

→

Rapid primary and secondary assessment

Prioritas •Siapkan Transportasi ke RS

Terkait dengan multipel organ•Kaji lebih lanjut cedera/trauma lain•Atasi trauma/cedera

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Primary assessment

Airway breathing

•Basic life support measure•Pengkajian dan manajemen oksigenasi: 100% FiO2, face mask,

•Spesial consideration: upper airway, lower airway = ET, MV

circulation•10% /> TBSA•IV resusitasi, 2 line, maintain, monitor•Skin color, sesnsation, CRT, elevasi ekstremitas area luka pada edema.•HR/jam 24 – 48 jam I pada deep burn/cir burn/elect burn.•Kateter urin

neurologic

•GCS/chlid •Level kesadaran

Expose and examin

•Lepas semua baju•Lepas perhiasan

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Secondary assessment

Pengakjian • Riwayat

luka bakar sekarang• Me

kanisme

• Durasi

• Keparahan

• Waktu

• Kaji “intentional injury”

Riwayat medis • AMPLE

• Allergy

• Medications

• Prevuous illnes

• Last meal/fluid

• Events related to the injury

Pemeriksaan fisik • Head to

toe• Severyt

y, type of burn• LU

AS• T

BSA• R

ULE OF ONES OR HAND RULE

• RULE OF NINE

• BERKOW

• HEIGHT AND WEIGHT NOMOGRAM

• Kedalaman• D

EPTH AND DEGREE of BURN

Diagnostic studi• ABGs• Carbox

yhemoglobin

• Hmt, Hb, elektrolit, albumin, urynalisis, BUN

• Chest radiographic

• ECG

Wound care• Emerge

ncy care: chemical burn

• Manual debridement

• Topical antimicroba

NPO• NGT

pada > 20% BSA

• intubasi

Victims and mechanisms of intentional and unitentional burns

• Perpetrator– Parent, guardian, partner of parent, sibling– Partner, carer (relative or professional)– Partner, carer (relative or professional) – Self (accomplice)– Government/civil authorities, kidnappers

VictimWho gets burnedChildrenElderlyInfirmSelfCaptives

Mechanism of burnScaldsContact (hot and cold)ChemicalElectricalFrictionSpill .splashImmersionFlame

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Rule of nine

→

The berkow

→

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Kedalaman lukaDegree Depth History Etiology Sensation Appearance Healing

1st Degree SuperficialEpidermis only 

Momentary Exposure

Sunburn Sharp, uniform pain

Blanches red, pink. Edematous, soft, flaking, peeling

± 7 days

2nd Degree Partial Thickness Epidermal and part of Dermal layer 

Exposure of Limited Duration to Lower Temperature (40-55°C)

Scalds, flash burn without contact, weak chemical

Dull or hyperactive pain, sensitive to air/temperature changes

Mottled, red blanches red/pink, blisters, edema, serous exudate, moist

14-21 days

3rd Degree Full Thickness Entire epidermis, dermis and subcutaneous tissue 

Long duration of exposure to high temperature

Immersion, Flame, Electrical, Chemical

Painless to touch and pinprick, May hurt at deep pressure

No blanching, pale white, tan charred, hard, dry, leathery, Hair absent

Granulates, Requires Grafting

4th Degree Underlying structures of muscle or bone

Prolonged duration of exposure to extreme heat

Electrical,Flame,Chemical 

Usually painless

Charred, Skeletonized

Requires Fasciectomy, Possible amputation

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ABA criteria

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Systematic response

kardiovaskuler

Pulmonary

Hematology

Gastrointestinal

Renal response

Metabolic

Imune and inflamatory response

hypotermia

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Luka bakar terkait perawatan• Cedera inhalasi (drief & endorf, 2013)

Pulmonary trauma

• caused by inhalation of thermal or chemical irritants.

classes:

1) heat injury 2) local chemical irritation

3) systemic toxicity inhalation of

carbon monoxide or cyanide

Assessment and care

Resusitasi cairan

10%/> TBSA infant,/15% pada yang lebih tua. Jika perlu akses femoral

Formula baxter: • 4 ml RLx %TBSAX BB kg = 24 jam volume

cairan• Dhitung pada saat terjadi burn

Hitung kebutuhan cairan harian pertahankan 15% dextrosa dlm ½ NS

Kristaloid, eletrolit, koloid, sodium, volume expander, dextrose

Pengkajian luka dan perawatan

Tujuan:• Mencegah infeksi• Memfasilitasi

penyembuhan luka• Meningkatkan

kenyamanan• Mempertahankan fungsi

optimal• Meminimalkan

deformitas

Wound assessment and care

Wound debridementTopical

preparation

Special care areas

ExsisiTemporary wound

coverage

Autograft

Donor site

Preventing graft loss

Wound debridement

• Mechanical debridement • Chemical debridement • Surgical debridement

– Tangential excision– Fulll thickness excision

Topical preparation

• 1% silver sufodiazene silvadene SSD thermazene

• Mafenide acetat cream• Bacitracin • 0.5% silvernitrat solution

Temporary wound coverage

• Hommograft – allograft • Heterograft or xenograft• Synthetehic dressing

autograft

• Split thickness autograft • Full thickness autograft• Sheet graft • Meshed autograft• Cultured epithelial autograft (CEA)

Perlindungan pada child abuse

•Semua•Pengkajian awal – karakteristi lukapengkajian

•Injury – further harm •Inform petugas : abuse / neglectedlaporan

•Advokat pasien dan keluarga: jujur/tdk menghindar•Komunikasi pada anak – anak jujur

Intervensi terapeutik

FASE AKUT: PENGKAJIAN DAN MANAJEMEN

• 3 day – minggu dimulai denga onset diuresis, edema intertisial pada luka bakar– Pulmonary care – Metabolic and nutritional support– Burn wound sepsis– Septic shock– Pain and anxiety assessment and management– Presure sore prevention strategies– Physical and occupational theraphy– Social and cultural assessment and care– Patient and family education

• trims