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Rosadi Seswandhana
Plastic Surgery
DR Sardjito General Hospital
Faculty of Medicine, Gadjah Mada University
*
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*
*Worldwide, burns cause significant morbidity
and mortality
*Dramatic decrease in the case fatality rate of
burns over the past 50 years
*Majority of burns are not life-threatening and
can be managed in the ED and primary care
settings*Early appropriate assessment is needed to
provide adequate treatment
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*
*Firstly, to determine whether situations are
life-threatening or not
*In disaster event, triage is the most important
to make several priority level
*If the victim is pediatric, sign of abuse is
mandatory to be looked for
*One of the most important aspects of burn careis determination of the extent and depth of the
injury
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* PRE-HOSPITAL MANAGEMENT
• STOP - DROP - ROLL
• Prevent Heat Restore• Electric injury breaking
down the voltage
• Chemical dilution
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*
*Burn mass casualty triage is similar to
typical mass incident triage.
*In the face of limited resources, patients
who are the most salvageable should
receive priority; Not the most severely
injured
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*
*severity of injury can be determined rapidly by
1. considering total extent of burn,
2. age of patient and
3. the presence or absence of inhalationinjury or
4. associated severe mechanical trauma
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*
*Super f i cia l Ski n Burn (1 st O )
*Pain, Erythema, epidermal slough 1-4 days later
*Par t i al Thickness Ski n Burn (2 nd O )
*Pain, Blisters within 1-6 hours, erythema,tenderness, good capillary refill
*Ful l Thi ckness Ski n Bur n (3 r d O ) *Insensate, leathery, thrombosed vessels, nocapillary refill
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*
Superficial Skin Burn
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The prototype is a sunburn with erythemaand mild edema.
The area involved is tender and warm.
There is rapid capillary refill after pressure is
applied.
All layers of the epidermis and dermis are
intact; no topical antimicrobial is necessary.
Uncomplicated healing is expected within
five to seven days.
*
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Partial Thickness Skin Burn
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Initially they may be quite difficult todiagnose accurately
The hallmark of the partial-thickness
burn is blister formation and pain.
Confusion may result, however, when partial-thickness burns are examined
after blisters have been ruptured and
uncovered pin prick test
*
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*
Full Thickness Skin Burn
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Full-thickness burns have a relatively
characteristic clinical appearance.
Little discomfort for the patient.
They may be of almost any color
because of the breakdown of
hemoglobin.
The appearance of the skin may bewaxy and translucent.
Visible thrombosed vessels beneath
translucent skin are pathognomonic
for full thickness injury.
*
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*
Rule of Nine’s
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TABEL
LUND &BROWDER
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*
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*
*A – Airway
*B – Breathing
*C – Circulation / C-spine / Cardiac status
*D – Disability / Neurologic Deficit
*E – Exposure and Examination
*F – Fluid Resuscitation
(Modified ATLS)
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*
A: Look f or si gns of i nhal at i on i nj ur y
*Facial bur ns,*Soot in nost r i l s or sput um
*Laryngoscope edema, hyper emia
*ET Bet t er t han t r acheost omy( lat er i f pr olonged ET )
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*
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* Breathing
• Be aware of carbon monoxide poisoning
Patient may appear 'pink' (cherry red) with a normalpulse oximeter reading
administere 100% Oxygen
Perform intubation and artificial ventilation
(if needed)
• Smoke injury Soot in nostrils or sputum
Nebulizer
Perform intubation, artificial ventilation andbronchial toilet (if needed)
(merapi eruption material volcano ash)
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Systemic :
If patient arrived with shock condition
2 IV-line
Drirectly IVFD RL 20 ml/Kg BW
combine with colloid (fast drip)
Local :
Ci r cumf erence Full t hi ckness ski nbur n on ext r emi t y compar t ment
synd r ome 5P ESCHAROTOMY
* Ci r culat i on (C)
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*
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GCS
Lat era l Sign
CO int oxi cat ion
Hipovolemic shock
* Di sabi l i t y (D)
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Bur n Si ze (% TBSA)
Dept h of Burn Wound
Ot her t r auma
* Exposur e (E)
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(Mathes, 2006)
* Flui d Resuci t at i on (F)
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(Mathes, 2006)
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Syst emic :
The release of cytokines and other inflammatory mediators
Increase of capillary permeability let the intravascular fluid
shifted to the interstitial space
hypovolemia
BAXTER / PARKLAND FORMULA
IVFD RL: 4 ml x BW (Kg) x BSA (%)
* Flui d Resuci t at i on (F)
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*MONITORING
*Vital Sign
*(Pulse rate, respiration rate, blood presure, temperature)
*Urin Output Adult 0.5 - 1 ml / hour
Child 1-2 ml / Kg / hour
*Breathing sound
*Severe burn (>40%) apply Central Venous Catheter
*Nasogastr ic tube production beware of stress ulcer *Hb, WBC, Plt, Hematocrit, Electroli te, Albumin, RBG,
*Kidney Function, Liver Function, BGA
*ECG, Thorax X-ray
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*
*Monitoring of urinary production is important
to evaluate the adequacy of resuscitation.
*Wardhana in 2011, defined that volume fluidresuscitation should be adjustable regarding
urinary output per kilogram bodyweight per
hour.
*If urine production ≤ 1 ml/kg BW/hour
+ 10%
* If urine production = 1 ml/kg BW/hour
* If urine production ≥ 1 ml/kg BW/hour - 10%
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*
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*Criteria for burn
center referral
•2nd Degree Burn > 15% Adult
> 10% Child
•3rd Degree Burn> 5%
•Electric/Chemical
•Burn Wound on the face, hand, genital
and perineal•Other trauma or sistemic disease
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*Electrical injury
*Beware of cardiac rythm abnormality closed ECG evaluation in the first 2 days
*Beware of extensive rhabdomyolisis
*Beware compartment syndrome fasciotomy
*Beware of renal failure
high urine outputfluid therapy 100 cc/hour (Manitol)
*Tx: 2 amp Manitol (25 g) followed immediately 2 ampbicarbonate, IV push
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*
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*Chemical injury
*Beware of Progresive Destruction
*Beware of organ injury (eye, ear etc)
*Principle dilution
*Do not try neutralized acid with base, evenin vice versa
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*
*After the initial resuscitation, up to 75% ofmortality in burns patients is related toinfection.
*Gram positive organisms colonised with largenumbers within 48 hours. Gram negativebacteria appear from three to 21 days after theinjury. Invasive fungal infection is seen later
*Preventing infection, recognizing it when itoccurs, and treating it successfully presentconsiderable challenges
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*
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*
(ABC Burn, 2006)
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Inflammatory trigger -
Uncontrolled inf lammatory response
Severe Shock
MODS- (Lungs fail first)
MODS – Multi Organ Dysfunction Syndrome
SIRS
Risk for
ALI/ARDS
Sepsis, Infection (i.e. Pneumonia)
Uncontrolled InflammationUncontrolled Inflammation
Death
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*
*To this end, aggressive surgery and the use of
topical antimicrobial agents are effective.
*silver sulfadiazine is the most frequently used
*Early closure of the burn wound by surgical
techniques
*Prophylactic use of systemic antibiotics is
controversial
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*
*Surface swabs and cultures cannot distinguish
wound infection from colonisation
*Wound biopsy, followed by histologicalexamination and quantitative culture, is the
definitive method
*relies heavily on clinical parameters, with the
aid of blood, surface, or tissue cultures toidentify likely pathogens
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*
*β haemolytic streptococci to
*resistant Gram negative organisms including
pseudomonas,
*resistant Gram positive organisms,
*and fungi
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*
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*
*Avoid wound conversion
*Remove devitalized tissue
*Bed granulation preparation*Minimal level of infection
*Autografting preparation
*Scar abnormality and contrature prevention
WOUND CARE FOR THE ADULT BURN PATIENT By Judy Knighton, RN, BScN, MScN
General Principles of Daily Care
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If conversion is going to occur, it is typically several days (sometimes weeks)post-burn
•Continue monitoring if indicated•Avoid hypothermia
- warm room- warm water
- do not expose entire body at once
•Avoid Cross-Contamination
- Wear caps, masks, gown, gloves wash hands before and after- Expose, clean, and rewrap less infected areas first- Look for sources of bacteria in equipment used
•Assure Adequate Control of Pain, Anxiety, Fever
- Pre-indication with narcotics and short-acting sedative- Use intravenous route
- Consider antipyretic pre-treatment pre-burn care
•Wound Dressing
- Use comfortable but no immobilizing dressing, as muscle activity is important!(exception: new grafts) http://www.burnsurgery.org/Modules/
*
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*
*Stop the burning process
*Clean the wound
*Cover. Clean, moist, nonadherent dressing
*Analgesia
*Wound debridement
Controversy: Blister debridement
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*
Exposed method Moist method
*
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**1st O no specific treatment
*2nd O
Cleansed with NaCl + Savlon
500 ml 5 ml
Tule + sterile thick gauzeor Biological dressing
(Observation in one week)
MEBO
Sponge derivate dressing (Allevyn, Wundress)
Silver impragnated dressing (Acticoat, Mepilex-Ag)
Controversy: Usage of Silver Sulfadiazin
(Deep 2nd O)
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*
*
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*
*3 r d O
Cleansed wi t h NaCl 500 ml + Sav lon 5 ml
Dai l y debr i dement
Dai ly Si lv er Sul f adi azin (Dermazin® /Burnazin®)
Si l ver impr agnat ed dr essi ng
Plus Surgi cal Tr eat ment
*
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*
*
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*
*Sequent i al excisi on
Dai l y r emoval of loose debr is
*Eschar ect omy
Exci se t he obvi ous f ull t hickness bur n
About 10 days post -bur n
*Tangent i al exci si on Shav i ng t he eschar w i t h sk i n gr af t kni ves + ski n subt i t ut e
Usuall y done 48 t o 72 hours post -burn
*Pr imar y excisi on
Excision t o t he fascia l level acut ely
Usuall y done 48 t o 72 hours post -burn
(Achauer, 1987 )
*
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*
*Aut ogr a f t (d i f f er ent locat ion wi t hin t he same indiv i dua l )
*Isogr a f t (f r om a genet ica l l y ident ical donor t o t herec ip ient)
Biological dr essi ng
*Al l ogr af t (homogr af t in older t erminology)
*Xenogr a f t (het er ogr a f t in older t erminology)
*Amnion
*Synt het i c ski n (si l i cone polymer s / composi t e
membranes) *Cult ur ed epi t hel i um (provi de cover age, al bei t f r agi l e,f or lar ge wounds)
Combination
*
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*Ideal Properties
1. Adherence2. Safety (sterile, hypoallergenic, nontoxic,
nonpyrogenic)
3. Controls evaporative water loss
4. Flexible5. Durable6. Bacterial barrier7. Ease of application and removal8. Availability easy to store9. Cost effective10.Hemostatic
(Woodroof, 1984)
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*
How to resurface wide
area of skin burn ?
*
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*
*Hand dermatome require
most skill to use
(Watson, Cobbett)
*Electric dermatom,relatively can be use by
inexperienced surgeon
(Padgett, Reese)
*Drum dermatome usually
yield a wider graft
(Brown)
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*Expanding graft by meshing (Tanner mesher)
*Postage stamp secured by nylon netting
*Mesh graft stapled, covered with nylon netting,
antibiotic dressing, synthetic skin, xenograft,or allograft
(Achauer, 1987)
*
*
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*
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*Combination between large sheet of allograft and
small pieces of autografts (used in China)
*Alexander et al widely mesh graft covered with
allograft*Application of strips of autograft (3-4 mm wide
alternating with strips of allograft (15-22 mm wide)
*Alternative for alternating autograft: xenograft,
synthetic skin, amnion, cultured epithelium
(Achauer, 1987)
*
*
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*
*Prevent contracture
Splinting
*Prevent pseudosyndatily
individual dressing on
every-finger
*To develop good scar
pressure garment,
moisturize the new skin
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*
* Wach TL and McQueen KAK, Burn Management in disaster and humanitarian crises. In Herndon DN [Ed]:
Total Burn Care. Third Edition. 2007. p43-66.
* Young DM. Burn and Electrical Injury. In Mathes SJ [Ed]: Plastic Surgery. 2nd Edition. 2006. P811-833
*Singer AJ. Thermal Burns: Rapid Assessment And Treatment. Emerg.Med.Pract. Sep 2000. Vol 2[9]
* Dale S.Vincent, Benjamin W. Berg, Keiichi Ikegami, Mass-Casualty Triage Training for International
Healthcare Workers in the Asia-Pacific Region Using Manikin-Based Simulations. Prehospital and Disaster
Medicine. May – June 2009. http://pdm.medicine.wisc.edu
* Stewart C. Wang. Michigan’s Plan for Burn Mass-Casualty Incidents. Director, U of Michigan Burn Center
Director, State of Michigan Burn Coordinating Center. File presentation.
* Smith S, Duncan M, Mobley J, et al. Emergency room management of minor burn injuries: a quality
management evaluation. J Burn Care Rehabil 1997;18:76-80. (Retrospective;791 patients)
* Hettiaratchy S, Dziewulski P. ABC of burns. BMJ 2004;329:504–6
* Wardhana A. Adjustable volume of fluid resuscitation for burn injury. Plastic Annual Meeting. 2011
* Burn Injuries. HDM Course. Society of Critical Care Medicine, 2007
* Judy Knighton, WOUND CARE FOR THE ADULT BURN PATIENT
*Preuss S. Breuing KH, Eriksson E. Plastic Surgery Techniques. In [eds] Achauer BM et al. PLASTICSURGERY – Indications, Operations, and Outcomes. Mosby. 2000:147-162