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

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Epidemiology

(ABC Burn, 2006)

Mortality

(ABC Burn, 2006)

2
 (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

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 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

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 Fungsi kulit
 Protection
against cold,  Absorption of  Regulation of
 Protection active agents
heat, radiation against circulation and
 Protection temperature
 Protection chemicals against
against pressure microbes
and friction

7 9
2 3
1 4 6 8
10

5 5

 Protection against loss  Sense of pressure, touch, pain

of temperature and water and temperature

Patofisiologi Luka Bakar

• Destruksi lokal
• Respon inflamasi sistemik (Systemic
inflamatory response)

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 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)

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 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)

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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

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 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

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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

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Derajat tiga

Luas luka bakar

Adult and Children >
10 y.o Children < 10 y.o

(ANZBA, 2013)

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 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

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

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

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Acute phase  Initial assessment

Rescusitation Airway
A: Look for signs of inhalation injury
Facial burns,
Soot in nostrils or sputum
Laryngoscope  edema, hyperemia
ET Better than TRACHEOSTOMY
Do not forget: C-Spine control

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 Acute phase
Rescusitation Breathing
Do not forget: Give O2 100% 15 L/minute (NRM)
B: Circumference Full thickness skin burn on the
chest wall  mechanical ventilation disturbance
 ESCHAROTOMY

Acute phase
Rescusitation Breathing
• Be aware of carbon monoxide poisoning
Patient may appear 'pink' (cherry red) with a
normal pulse oximeter reading
 administere 100% Oxygen
Perform intubation and artificial ventilation

(if needed)
(Do not believe pulse oxymetri saturation)
• Smoke injury  Soot in nostrils or sputum
 Nebulizer
Perform intubation, artificial ventilation and
bronchial toilet (if needed)

16
 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 β-HCG for pregnant woman)

Escharotomy on extremity
 Local :
Circumference Full thickness skin burn on extremity 
compartment syndrome  5P  ESCHAROTOMY

(Remember: escharotomy should be performed

after life-threatening was managed)

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Acute phase
Disability (D)
 GCS
 Lateral Sign

CO intoxication
Hipovolemic shock

Acute phase
Exposure and Environmental control
Log Roll Manuver
 Burn Size (% TBSA)
 Depth of Burn Wound
 temperature
 Other trauma

Beware : Hypothermia  blanket

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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

BAXTER / PARKLAND FORMULA

IVFD RL: 4 ml x BW (Kg) x BSA (%)

ANZBA  IVFD RL: 3-4 ml x BW (Kg) x BSA (%)

for children, + maintenance

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 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
(Pulse rate, respiration rate, blood presure, temperature)
• Urin Output  Adult 0,5-1,0 mL / Kg BW/ hour
Child 1,0-2,0 mL / Kg BW/ hour
• Breathing sound
• Severe burn (>40%) apply Central Venous Catheter

• Fluid theraphy adjustment hourly

• Deficiency  add 10%
• Overload  reduce 10%

Beware: myoglobinuria (haemochromogens)

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 Analgetic
Burns is painfull  need adequate analgetic
• Morphine : 0,05 – 0,1 mg/Kg BW (ANZBA, 2013)
• Fenthanyl : 1 μg/Kg BW

• Continue with maintenance dose

• (better using syringe pump)

Test
• ECG, Lateral Cervical, Thorax , Pelvical X-ray
• Hb, WBC, Plt, Hematocrit, Electrolite, Albumin, GDS
• Kidney Function, Liver Function, BGA

Tube
• Nasogastric tube production  beware of stress
ulcer
• Indweiling catheter  urine monitoring
• Central venous catheter

21
 Secondary survey
• History : A – M – P – L – E

• Head to toe examination

Emergency
burn
pathway

(ABC Burn, 2006)

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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)

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 (Mathes, 2006)

Pemberian Nutrisi

• Enteral
– Oral
– Nasogastric
– Nasoduodenal
• Parenteral
– Partial
– Total

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 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) 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
http://www.burnsurgery.org/Modules/

- 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)

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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

28
 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)

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 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)

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 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

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 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)

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 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)

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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% (utk luka bakar derajat III)
• Silver sulphadiazine 1% chlorhexidine digluconate 0.2%
(Flamazine Câ)
• Mafenide acetate 2% (Sulfamylonâ)
• Silver nitrate 0.5%
• Povidone iodine 10% (Betadineâ)
• Nitrofurazone (Furacinâ)
• Gentamycin sulphate (Garamycinâ)
• Bactracin with polymyxin B (Polysporinâ)
• Normal saline 0.9%
• Acetic Acid 0.5%
• Hydrogen peroxide, half-strength
• MEBO (utk luka bakar derajat II)
• Prontosan (utk mencuci luka)
• Hidrokortison+Gentamisin (utk luka granulasi)

37
 Laporan Pendahuluan
Penggunaan Hidrokostison+Gentamisin

Laporan Pendahuluan
Penggunaan Hidrokostison+Gentamisin

38
 Laporan Pendahuluan
Penggunaan Hidrokostison+Gentamisin

Laporan Pendahuluan
Penggunaan Hidrokostison+Gentamisin

39
 Laporan Pendahuluan
Penggunaan Hidrokostison+Gentamisin

Laporan Pendahuluan
Penggunaan Hidrokostison+Gentamisin

40
 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

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 Fase Bedah

• Tujuan:
– Meningkatkan kekuatan
• Menggunakan:
– Latihan motor aktif
– Fisioterapi dada
– mobilisasi

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

42
Ilustration

43
Case 1, Boy, 15 y.o.
Electric Burn

44
Case 2, Male, 30 y.o.
Chemical burn

45
Case 3, 1 year finger contracture
Release + FTSG

Case 4, 10 years axilla contracture

Local Skin Flap + STSG

46
Case 5, Arm electrical injury
LD MC Flap + Skin Graft

47
Case 6, Scalp electrical injury
LD Free Flap + STSG

Terima kasih
TERIMA KASIH

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