Total Care

on Burn Patient
Rosadi Seswandhana
Unit Luka Bakar RSUP Dr Sardjito
Sub-Bagian Bedah Plastik
Bagian Bedah, Fakultas Kedokteran
UniversitasGadjah Mada

Epidemiology of Burn

ABA 2,2 juta pasien terbakar di USA setiap tahun

5500 meninggal karena luka bakar
60,000 dirawat.
$1 milyar, beaya yang dihabiskan
(Mathes Plastic Surgery, 2007)

Indonesia? Tidak ada data

Epidemiology

(ABC Burn, 2006)

Mortality

(ABC Burn, 2006)

(ABC Burn, 2006)

Skin Anatomy
Skin Constitution
Epidermis
Corium or Dermis
Subcutis
The total skin area
of adult humans covers approx.
1 to 2 square meters

Epidermis
Composition of the Epidermis
(1) Horny scales
(2) Horny layer (stratum corneum)
(3) Clear layer (stratum lucidum)
(4) Granular layer (stratum granulosum)
(5) Prickle-cell layer (stratum basale)
(6) Basal layer (stratum basale)
(7) Connective tissue fibres
(8) Melanocyte
(9) Arterial branch of capillary
(10)Venous branch of capillary
(11)Initial lymph vessel
(12)Meissner`s corpuscle
(13)Free nerve ending
(14)Excretory duct of sweat gland
Renewal of the epidermis occurs within 27 days.

Anatomi kulit

Fungsi kulit
Protection
against cold,
heat, radiation
Protection
against pressure
and friction

Protection
against
chemicals

Protection
against
microbes

Absorption of
active agents

Regulation of
circulation and
temperature

8
10

Protection against loss

of temperature and water

Sense of pressure, touch, pain

and temperature

Patofisiologi Luka Bakar

Destruksi lokal
Respon inflamasi sistemik (Systemic
inflamatory response)

Respon Lokal
Zone of

coagulation
Irreversible

Zone of stasis
Potensial
diselamatkan.
Zone of

hyperaemia
Biasanya sembuh

(ABC Burn, 2006)

Respon sistemik
LLB 20-30% pelepasan
faktor inflamasi sistemik
Peningkatan permeabilitas
kapiler
splanchnic vasoconstriction
Myocardial contractility
.
Fluid loss from the burn
wound hypoperfusion.
Respiratory changes
bronchoconstriction, ARDS
Metabolic changes.
Immunological

(ABC Burn, 2006)

Kebocoran kapiler
Menyebabkan permeabilitas kapiler
, cairan pindah dari intravaskular
ke interstisial:
hypovolemia intravaskular
menyebabkan edema

Electron microscopic exam

Tujuan resusitasi fase akut

Mempertahankan
perfusi oksigen di
perifer, terutama
organ vital (life
saving)
Mencegah
perburukan situasi
(meminimalkan
morbiditas)

Yang perlu diperhatikan

1. Etiologi
2. Derajat luka bakar
3. Luas luka bakar

ETIOLOGI / PENYEBAB
1. SUHU
PANAS ( API, UAP, AIR )
DINGIN ( FROST BITE )
2. LISTRIK

(4). RADIASI

3. KIMIA

(5). LASER

ASAM - BASA

KEDALAMAN LUKA BAKAR

DERAJAT SATU
Superficial Skin Burn
DERAJAT DUA
Partial Thickness Skin Burn
DERAJAT TIGA
Full Thickness Skin Burn

Derajat 1
Superficial Skin Burn

KEDALAMAN LUKA BAKAR

Luka Bakar
Derajat Satu

Derajat 2 Partial Thickness Skin Burn

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Derajat Dua

Derajat 3 Full Thickness Skin Burn

11

Derajat tiga

Luas luka bakar

Rule of Nines

12

TABEL
LUND &
BROWDER

PENANGANAN
PRE HOSPITAL

STOP - DROP - ROLL

Hilangkan Heat Restore

(Masih Efektif bila < 2 menit)

Luka bakar listrik putuskan

sumber listrik

Luka bakar kimia dilusi dengan air

mengalir

13

Assessment
Initial assessment ATLS
Managemen awal yang baik
mencegah morbiditas dan mortalitas

Primary Survey
A Airway
B Breathing
C Circulation / C-spine / Cardiac
status
D Disability / Neurologic Deficit
E Exposure and Examination
F Fluid Resuscitation

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Fase Akut Cari Masalah ABC

RESUSITASI
A:

Airway

Curiga Trauma Inhalasi

* Bila kejadian di ruang tertutup

* Bulu hidung terbakar
* Laryngoscope edema, hiperemis
ET LEBIH BAIK DARIPADA
TRACHEOSTOMY

15

Fase Akut
RESUSITASI A - B - C
B:

Luka Bakar Derajat 3 Melingkar Dinding Dada

ESCHAROTOMY

Fase akut
Rescusitation

Breathing

Waspada intoksikasi karbonmonoksida (CO)

'pink' (cherry red) with a normal pulse
oximeter berikan 100% Oxygen
intubasi and ventilator (bila perlu)
Smoke injury jelaga di lubang hidunfg dan
sputuum Nebulizer
intubasi and ventilator (bila perlu)

16

Fase akut
Rescusitation

Circulation (C)

Sistemik :
jika datang dg syok infus 2 jalur

IVFD RL 20 ml/Kg BW in 15-30

minutes (bisa sampai 2000 cc pada
dewasa)

Lokal:
Eskar melingkar di ekstremitas
compartment syndrome 5P
ESCHAROTOMY

Escharotomy pada
ekstremitas

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Fase akut
Disability (D)

GCS

Lateral Sign
CO intoxication
Hipovolemic shock

Fase Akut
Exposure (E)

Luas luka bakar(% TBSA)

Derajat luka bakar

Trauma lain

Cegah hipothermia

18

Acute phase
Fluid Resucitation (F)

(Mathes, 2006)

(Mathes, 2006)

19

Fase Akut
RESUSITASI Circulation (C)

Sistemik :
Pelepasan mediator inflamasi vasodilatasi +
kebocoran intravaskuler Hipovolemik
FORMULA BAXTER / PARKLAND
Infus RL: 4 cc x BB (Kg) x LUAS LB (%)

Kasus
Pasien dg BB 50 Kg dan 30% BSA
Cairan yang dibutuhkan : 4 x 50 Kg x 30 %

6000 cc RL
8 jam pertama 3000 ml 92 tetes/mnt
16 jam berikutnya 3000 ml 46 tetes/mnt

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Emergency
burn
pathway

(ABC Burn, 2006)

MONITORING

Vital Sign (TD, HR, RR, temp)

Urin Output Dewasa 30 ml / Jam

Anak 1-2 ml / Kg / Jam

Suara Nafas Waspadai edema pulmo

Pada LB berat (>40%) pasang CVP

Produk NGT Waspadai stress ulcer

Hb, WBC, Plt, Hematocrit, Elektrolit, Albumin,

GDR,
Fungsi ginjal, Fungsi live, BGA (AGD)

EKG, Thorax X-ray

21

INDIKASI RAWAT INAP

LB Derajat II > 15% Dewasa
> 10% Anak / Geriatri
LB Derajat III > 5% Dewasa

Trauma Inhalasi
Listrik / Kimia
LB di daerah muka, tangan, genital, perineal
LB dengan kelainan lain / trauma lain yang
berat

Nutrisi
Metabolisme basal 2-3 x:
Produksi glukosa ,
insulin resistance,
lipolysis,
Katabolisme protein otot.
Tanpa nutrisi yang adekuat
penyembuhan luka ,
Fungis imunitas ,
Penurunan berat badan
(Mathes, 2006)

22

(Mathes, 2006)

Pemberian Nutrisi
Enteral

Oral
Nasogastric
Nasoduodenal

Parenteral
Partial
Total

23

Pemberian Nutrisi
Enteral vs Parenteral
Oral vs Tube
Penggunaan tube terkadang lebih
menguntungkan dibandingkan dengan
intake oral regular

Pengendalian Nyeri
Nyeri yang berat dampak negatif
dalam penyembuhan
Dressing, regular bedside
debridement memerlukan sedatif
dan opiat dosis tinggi

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Tujuan merawat luka

Cegah konversi luka
Buang jaringan mati
Siapkan granulasi sehat
Minimalkan infeksi
Siap untuk autografting
Cegah kelainan parut dan kontraktur
WOUND CARE FOR THE ADULT BURN PATIENT
By Judy Knighton, RN, BScN, MScN

General Principles of Daily Care

If conversion is going to occur, it is typically several days (sometimes weeks) postburn

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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Perawatan awal
Hentikan proses kontak dg sumber
panas
Bersihkan luka
Tutup dengan balutan bersih, lembab,
dan tidak lengket
Analgesia
Debridement luka
Controversy: Blister debridement

Moist concept in wound

healing

Exposed method

Moist method

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PERAWATAN LUKA / SUB-AKUT

Derajat Satu
Derajat Dua

Cuci NaCl + Savlon

500 cc
5 cc
Dressing Moist dan Non Adherent
Tulle + Kassa Steril
(Biarkan Satu Minggu)
MEBO (4 6 x / hari)

PERAWATAN LUKA / SUB AKUT

Derajat Tiga Bahaya kolonisasi kuman
di bawah eskar sepsis
Cuci NaCl 500 cc + Savlon 5 cc
Debridement tiap hari
Dermazin / Burnazin
(Silver Sulfadiazin) tiap hari
K/P Escharectomy + Skin Graft

27

Burn Tank

Terapi bedah
Eksisi serial

Membuang jar nekrotik/debris harian

Escharectomy
Membuang eskar yang nyata (>10 hari)
Eksisi tangensial
Shaving the eschar dg pisau graft
+ skin
Biasanya 48-72 jam post burn
subtitute
Eksisi primer
Eksisi sampai level fasia secepatnya
Biasanya 48-72 jam post burn
(Achauer, 1987)

28

Skin Subtitutes
Autograft (beda lokasi sama individu)
Isograft (dari spesias yang genetically identical)

Biological dressing
Allograft (dari spesies yang sama=homograft)
Xenograft (heterograft, dari spesies lain)
Amnion
Kulit sintetik (silicone polymers / composite
membranes)
Kultur kulit (provide coverage, albeit fragile, for
large wounds)
Kombinasi

Skin Subtitutes
Ideal Properties
1. Menempel kuat
2. Aman (sterile, hypoallergenic, nontoxic,
nonpyrogenic)
3. Mampu mengontrol kehilangan cairan
4. Fleksibel
5. Tahan lama
6. Mampu menjadi barier kuman
7. Mudah digunakan dan dilepas
8. Availability mudah disimpan
9. Murah
10. Hemostatic
(Woodroof, 1984)

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Problem
Bagaimana menutup
luka yang luas?

Grafting Technique
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)

30

Skin Expansion 1
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)

Tanner Mesher

31

Skin Expansion 2
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)

Luka bakar listrik

Waspadai gangguan irama jantung
Waspadai kerusakan lebih berat dari
tampilan yang ada kerusakan otot
(Rhabdomyolisis)
Ancaman ekstremitas fasiotomi
Waspadai Gagal ginjal high urine output
fluid therapy 100 cc/hour (Manitol)
Tx: 2 amp Manitol (25 g) followed
immediately 2 amp bicarbonate, IV push

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Luka bakar kimia

Reaksi tetap berjalan
Waspadai kerusakan yang progresif
Waspadai cedera organ selain kulit
(mata, daun telinga, dll)
Prinsip dilusi 30 60 menit
Jangan menetralkan

Komplikasi
Sub-akut infeksi SIRS
SEPSIS MODS Death
Stress ulcer
Ulkus dekubitus
Lanjut kontraktur

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Sumber infeksi

(ABC Burn, 2006)

34

Uncontrolled Inflammation
Inflammatory trigger-

Sepsis, Infection (i.e. Pneumonia)

SIRS
Uncontrolled inflammatory response
Severe Shock

Risk for
ALI/ARDS

MODS- (Lungs fail first)

Death
MODS Multi Organ Dysfunction Syndrome

Terapi non bedah

Antibiotic prophylactic?
Sistemic vs Local
ATS Tetagam? 3rd O, large burn size
GIT protector
Antidecubital bed / care
Splinting
Antioxidant
Imunomodulator
Inotropic (if needed)

35

Bagaimana memilih agen topikal

Efikasi klinis
Antibacterial spectrum luas
Minimal Toksisitas, absorption baik
Kejadian superinfeksi
Mudah dan fleksibel digunakan
Murah
Diterima oleh pasien dan staf

Agen Topikal
Silver sulphadiazine 1% (Flamazine )
Silver sulphadiazine 1% chlorhexidine digluconate
0.2% (Flamazine C)
Mafenide acetate 2% (Sulfamylon)
Silver nitrate 0.5%
Povidone iodine 10% (Betadine)
Nitrofurazone (Furacin)
Gentamycin sulphate (Garamycin)
Bactracin with polymyxin B (Polysporin)
Normal saline 0.9%
Acetic Acid 0.5%
Hydrogen peroxide, half-strength

MEBO

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Fisioterapi & Splinting

Fase akut
Fase bedah
Fase rehabilitasi

Fase akut
Tujuan:
Menjaga paru tetap bersih
Mempertahankan fungsi
Meminimalkan udema
Menggunakan
Fisioterapi dada
Latihan pasif
Splinting

37

Ilustration

Fase Bedah
Tujuan:
Meningkatkan kekuatan
Menggunakan:
Latihan motor aktif
Fisioterapi dada
mobilisasi

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Rehabilitasi
Tujuan: mengembalikan pasien ke
tempat kerja
Menggunakan:
Latihan lebih menguatkan
Tugas2 yang spesifik

TERIMA
KASIH
Terima kasih

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