dr. rosadi - burn injury, an update

8/17/2019 Dr. Rosadi - BURN INJURY, An Update

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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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*

(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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*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

dr. rosadi - burn injury, an update

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