mita-pemicu 2 kgd
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Burn depth classification
Depth Appearance Surface Sensation Time to healing
1st
degree Epidermis Pink or red Dry Painful Days
2nd degree
(partial-thickness)
-Superficial
-Deep
Epidermis +
pars papilare
Epidermis +
pars retikulare
Pink, clear
blister
Pink,
hemorrhagic
blister, red
Moist
Moist
Painful
Painful
14-21 days
Weeks, or may
progress to 3rd
degree, require
graft
3rd degree (full-
thickness)
Epidermis +
dermis
White, brown Dry Insensate Require excision
4th degree Skin,
subcutaneos
fat, muscle,
bone
Brown,
charred
Dry Insensate Require excision
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Depth of Burn
• Superficial Burn
• Partial Thickness Burn
• Full Thickness Burn
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Burn Depth
• Superficial Burn:
1st Degree Burn
– Signs & Symptoms
• Reddened skin
• Pain at burn site
• Involves only
epidermis
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Burn Depth
• Partial-ThicknessBurn: 2nd DegreeBurn
–Signs & Symptoms• Intense pain
• White to red skin
• Blisters
•Involves epidermis& dermis
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Burn Depth
• Full-Thickness Burn:
3rd Degree Burn
– Signs & Symptoms
• Dry, leathery skin(white, dark brown, or
charred)
• Loss of sensation (little
pain)
• All dermal
layers/tissue may be
involved
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Determining Severity of Injury
• Size (surface area)
• Depth
• Prior status of health of victim
• Age
• Location of burn
• Severity of associated injury
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Classifications of burn injury
First-degree burns
• Painful, red, dry, and blanch with pressure
• Typically occur secondary to prolonged exposure tolow-intensity heat or short-duration flash exposure to aheat source
• Only a superficial layer of epidermal cells is destroyed
• They slough (peel away from healthy tissue underneaththe wound) without residual scarring
• Usually heal within 2 to 3 days
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Second-degree burns• Superficial partial-thickness burns
a) Characterized by blisters
b) Commonly caused by skin contact with the following:
(1) Hot but not boiling water
(2) Other hot liquids
(3) Explosions producing flash burns
(4) Hot grease(5) Flames
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c) Injury extends through the epidermis to the
dermis
(1) Basal layers of the skin are not destroyed
(2) Skin regenerates within a few days to a
week
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d) Edematous fluid infiltrates dermal-epidermal junction, creating blisters
e) Intact blisters provide a seal that protects the
wound from infection and excessive fluid lossf) Injured area is usually red, wet, and painful, andmay blanch when tissue around the injury iscompressed
g) In the absence of infection these woundsgenerally heal without scarring, usually within 14days
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2) Deep partial-thickness burns
a) Depth of burn involves the basal layer of the dermis
(1) Sensation in and around the wound may be diminishedbecause of the destruction of basal-layer never endings
b) Depending on the degree of vascular injury, wound mayappear red and wet, or white and dry
c) Major complications are wound infection and subsequentinfection
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d) If uncomplicated, injury generally heals within
3 to 4 weeks
e) Skin grafting may be necessary to promote
timely healing and to prevent scar tissue
formation
(1) Scar tissue may severely restrict joint
movements and cause persistent pain and
disfigurement
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Third-degree burns
1) Because the entire thickness of the epidermisand dermis is destroyed, skin grafts arenecessary for timely and proper healing
2) Injury is characterized by coagulation necrosis ofcells and appears pearly white, charred, orleathery
3) Definitive sign is a translucent surface in thedepths of which thrombosed veins are visible
4) Eschar is present in these injuries
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5) Sensation and capillary refill are absent because smallblood vessels and nerve endings are destroyed
a) Often results in large plasma volume loss, infection,and sepsis
6) Natural wound healing may produce contracturedeformity and severe scarring
7) Surgical intervention with skin grafting is necessary to:
a) Close full-thickness woundsb) Minimize complications
c) Allow restoration of maximal function
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Burn Severity
http://emcrit.org/030-064/056-thermal.burn.htm
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Lund & Browder Chart
http://www.medstudentlc.com/uploaded_images/Lund%20Browder%20Rakel.gif
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Pathophysiology
• Limit cell tolerance
• ≤ 44oC no significant damage
•> 51
o
C
tissue damage is very great speed• > 70oC although cellular damage in a very
short period of exposure
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Area burns
• Coagulation area area cells have been
damaged, the maximum damage points
• Static area damage and leakage of blood
vessels, are impaired perfusion, there are cells
that can still be saved
• Hyperemia area consists of cells damaged
and less money to complete recovery
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Pathogenesis
Increased capillary permeability
Isotonic fluid & protein transudation into extracapsuler
Reduction in circulating plasma volume
Edema Curah output ↓ Peripheral vascular resistance↑
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SYSTEMIC RESPONSE
Due to the release of cytokines and other inflammatory mediators at the site of injury
Cardiovascular
changes
• Capillary permeability ↑ loss of intravascular proteins and fluids
into the interstitial compartment
•Peripheral and splanchnic vasoconstriction occurs
• Myocardial contractility is << (due to release of TNF-α)
• These changes, coupled with fluid loss from the burn wound, result in
systemic hypotension and end organ hypoperfusion hypovolemic
shock
Respiratory changes • Inflammatory mediators bronchoconstriction
• In severe burns, ARDS can occur
Metabolic changes • BMR ↑ > 3x normal
• This, coupled with splanchnic hypoperfusion, necessitates early and
aggressive enteral feeding to decrease catabolism and maintain gutintegrity
Immunological
changes
• Non-specific down regulation of the immune response occurs,
affecting both cell mediated and humoral pathways
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Body’s Response to Burns
• Emergent Phase (Stage 1) – Pain response
– Catecholamine release
– Tachycardia, Tachypnea, Mild Hypertension, Mild Anxiety
• Fluid Shift Phase (Stage 2) – Length 18-24 hours
– Begins after Emergent Phase
• Reaches peak in 6-8 hours
– Damaged cells initiate inflammatory response
• Increased blood flow to cells
• Shift of fluid from intravascular to extravascular space
– MASSIVE EDEMA
– “Leaky Capillaries
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Body’s Response to Burns
• Hypermetabolic Phase (Stage 3)
– Last for days to weeks
– Large increase in the body’s need for nutrients
as it repairs itself
• Resolution Phase (Stage 4)
– Scar formation
– General rehabilitation and progression tonormal function
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Diagnose
• Calculation extensive burns and deep burns
• Lab and radiology tests (Chest X-Ray)
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Diagnostic
Anamnesis
• History of trauma / exposure
to the heat source (flame, hot
water, hot oil, chemicals,
electricity, radiation)• History trapped in a confined
space
• History of exposure to a blast
•History of falls from a certainheight after exposure to heat
sources
Physical examination
• Primary Survey : ABC
• Secondary Survey
Embed also:
1. The degree and extent of burns
2. Causes burns
3. As well as the problems that exist
at the time of the first inspection,
the example problem:
- inhalation injury
- Eskar around his chest
- shock
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• Lab. blood examination of peripheral blood (hemoglobin,
hematocrit, leukocyte count, platelet count), blood gas analyzer,
function system / organ (metabolic function, liver, kidney)
• Lab.urin urine specific gravity, pH, sediment
•Microbiological culture and resistance with the material from thewound, where entry intravenous line and catheter urine
• Radiology photo upright piston AP / half sit for pulmonary
evaluation:
– Detection of the ARDS and pulmonary edema (usually done after
the fifth day)
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Laboratory
• Hb, Ht pd every 8 hours the first 2 days and
then every 2 days to 10 days
• Liver and kidney function every week
• Examination of electrolytes each day duringthe first week.
• Examination of blood gases when
breathing> 32x/menit• Tissue culture on days I, III, VIII.
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Laboratory
• hemoglobin, hematocrit, electrolit (do as soon aspossible to repair the body fluids)
• Complete blood
• Renal function (BUN and creatinine)
• Liver function
• Blood gas analysis with carboxy hemoglobin levels(HbCO2)
•Profiles of blood clots
• Analysis of urine
• Creatine phosphokinase (CPK) and myoglobin urine
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Treatments Based on the Degree ofSeverity
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Systemic Complications
• Infection
– Greatest risk of burn is infection
• Organ Failure
– Release of myoglobin
• Special Factors
– Age & Health
• Physical Abuse
– Elderly, Infirm or Young
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Prognosis
• Will depend on depth of burn and the bodysurface area affected.
• Superficial burns usually heal within two
weeks without surgery.• Risk factors for death include age over 60
years, more than 40% of body surface areaaffected and inhalation injury.
• Death may result from severe extensive burnsor electric shock.
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Chemical burns
• Can result from exposure to acidic, alkaline orpetroleum products.
• Alkali burns tend to be deeper and more seriousthan acid burns.
• Immediately flush away the chemical with largeamounts of water for at least 20 to 30 minutes(longer for alkali burns). Alkali burns to the eyerequire continuous irrigation during the first eight
hours after the burn.• If dry powder is still present on the skin, brush it
away before irrigation with water.
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Electrical burns
• Are often more serious than they appear on thesurface.
• Rhabdomyolysis results in myoglobin release, whichcan cause acute renal failure. If the urine is dark, start
therapy for myoglobinuria immediately.
• Fluid administration should be increased to ensure aurinary output of at least 100 ml/hour in the adult.
• Metabolic acidosis should be corrected by maintainingadequate perfusion and adding sodium bicarbonate.
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Inhalation Injury
Toxic Inhalation Synthetic resin combustion
Cyanide & Hydrogen Sulfide
Systemic poisoning
More frequent than thermal inhalation burn
Carbon Monoxide Poisoning Colorless, odorless, tasteless gas
Byproduct of incomplete combustion of carbon products
Suspect with faulty heating unit 200x greater affinity for hemoglobin than oxygen
Hypoxemia & Hypercarbia
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Inhalation Injury
• Airway Thermal Burn – Supraglottic structures absorb heat and prevent lower airway
burns
• Moist mucosa lining the upper airway
– Injury is common from superheated steam
– Risk Factors
• Standing in the burn environment
• Screaming or yelling in the burn environment
• Trapped in a closed burn environment
– Symptoms
• Stridor or “Crowing” inspiratory sounds
• Singed facial and nasal hair
• Black sputum or facial burns
• Progressive respiratory obstruction and arrest due to swelling
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