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First management of
Burn Injury:
GP Must Do and Dont
Rosadi Seswandhana
Plastic Surgery Division, Dept of Surgery, GMU
Burn Unit DR Sardjito General Hospital
Problems
09/02/2014
Mortality
09/02/2014
Etiology
Pathophysology
Local response
Systemic response
(Jackson, 1947)
(Hettiaratchy & Dziewulski, 2004)
09/02/2014
Severity of Burns
Age
Children
Adult
Older
Mild
Moderate
10-20% TBSA
Full-Thickness < 10%
TBSA
(none critical area)
15-25% TBSA
Full-Thickness < 10%
TBSA
(none critical area)
10-20% TBSA
Full-Thickness < 10%
TBSA
(none critical area)
Severe
>20% TBSA
Full-Thickness > 10%
TBSA
Critical areal*
Complicated burns**
>25% TBSA
Full-Thickness > 10%
TBSA
Critical area*
Complicated burns**
>20% TBSA
Full-Thickness > 10%
TBSA
Critical area*
Complicated burns**
Severity
(Singer, 2000)
09/02/2014
09/02/2014
09/02/2014
09/02/2014
(ANZBA, 2013)
09/02/2014
Management
09/02/2014
First aid
Stop burning
process
Cooling
treatment
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09/02/2014
EMSB Structure
L
O
O
K
D
O
A
I
R
W
A
Y
C
spine
B
R
E
A
H
I
N
G
O2
C
I
R
C
U
L
A
T
I
O
N
Haemorraghe
control
I.V.
D
I
S
A
B
I
L
I
T
Y
E
X
P
O
S
U
R
E
AVPU
& Pupils
Environmental
control
FLUIDS
AM PLE
History
ANALGESIA
Head to Toe
Examination
TESTS
Tetanus
TUBES
Document &
Transfer
Support
Primary Survey
First Aid
Secondary
Survey
(ANZBA, 2013)
A:
Airway
11
09/02/2014
Acute phase
Rescusitation
Breathing
ESCHAROTOMY
12
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Acute phase
Rescusitation
Breathing
Nebulizer
Perform intubation, artificial ventilation and
bronchial toilet (if needed)
Acute phase
Rescusitation
Circulation (C)
Examine:
Central pressure
Blood pressure
Central and periphery capillary refill
Systemic :
If patient arrived with shock condition 2 IV-line
First IVFD RL 20 ml/Kg BW in 15-30 minutes
(Do not forget blood test sample complete
blood count, blood group, chemical analysis,
BGA, and -HCG for pregnant woman)
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09/02/2014
Escharotomy on extremity
Local :
Circumference Full thickness skin
burn on extremity compartment
syndrome 5P ESCHAROTOMY
Acute phase
Disability (D)
GCS
Lateral Sign
CO intoxication
Hipovolemic shock
14
09/02/2014
Acute phase
Exposure and Environmental control
Log Roll Manuver
temperature
Other trauma
Acute phase
Fluid Resucitation (F)
(Mathes, 2006)
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(Mathes, 2006)
Acute phase
Fluid Resucitation (F)
Systemic :
The release of cytokines and other inflammatory mediators
Increase of capillary permeability let the intravascular fluid shifted
to the interstitial space hypovolemia
16
09/02/2014
Case
Patient with 50 Kg BW and 30% BSA
Fluid Needed : 4 x 50 Kg x 30 %
6000 mL RL
First 8 hours 3000 mL 92 drops/mnt
Next 16 hours 3000 mL 46 drops/mnt
MONITORING
Vital Sign
Breathing sound
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09/02/2014
Analgetic
Burns is painfull need adequate analgetic
Morphine : 0,05 0,1 mg/Kg BW (ANZBA, 2013)
Fenthanyl : 1 g/Kg BW
Continue with maintenance dose
(better using syringe pump)
Test
Tube
Nasogastric tube production beware of stress
ulcer
Indweiling catheter urine monitoring
Central venous catheter
18
09/02/2014
Secondary survey
History : A M P L E
Head to toe examination
Electrical injury
Beware of cardiac rythm abnormality closed ECG
evaluation in the first 2 days
Beware of extensive rhabdomyolisis
Beware compartment syndrome need fasciotomy
19
09/02/2014
Chemical injury
Wound Care
1st O no spesific treatment
2nd O Cleansed with NaCl + Savlon
500 ml
5 ml
Film transparan
Foam
Silver impregnated foam
Calcium alginate
Cellulosa
Antibiotic ointment
MEBO
Controversy:
Usage of Silver Sulfadiazin
20
09/02/2014
Wound Care
3rd O
Cleansed with NaCl 500 ml + Savlon 5 ml
Daily debridement
Daily Silver Sulfadiazin (Dermazin
/ Burnazin) ,
Silver contained dressing (Acticoat / Mepilex-Ag)
Plus Surgical Treatment
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Referral criteria
Partial thickness burns greater than 10% total body surface area (TBSA).
Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
Third degree burns in any age group.
Electrical burns, including lightning injury.
Chemical burns.
Inhalation injury.
Burn injury in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality.
8. Any patient with burns and concomitant trauma (such as fractures) in which the
burn injury poses the greatest risk of morbidity or mortality. In such cases, if
the trauma poses the greater immediate risk, the patient may be initially
stabilized in a trauma center before being transferred to a burn unit. Physician
judgment will be necessary in such situations and should be in concert with the
regional medical control plan and triage protocols.
9. Burned children in hospitals without qualified personnel or equipment for the
care of children.
10. Burn injury in patients who will require special social, emotional, or
rehabilitative intervention
(ABA-ABLS, www.ameriburn.org)
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Fluid Maintenance
Maintenance Fluid Requirements
=
35 + % 24 + 1500
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09/02/2014
Nutrition
(Mathes, 2006)
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09/02/2014
Splinting
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09/02/2014
Thank you
28