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Initial

Burn Management
Andik Kusbiantoro
SMF Ilmu Bedah RSUD.Dr.R.Soedjono Selong
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BURN PHASES
1. Acute / shock / early phase
- Immediate / emergency room
- Airway & fluid problem
- Wound

2. Subacute phase
- During admission
- Wound, infection, sepsis problem

3. Late phase
- After discharged
- Scar & contracture problems

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INITIAL BURN MANAGEMENT
1. Pre hospital care
2. Emergency Department care
Primary survey
Secondary survey
Assessment
Fluid resucitation
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Pre Hospital care
Quickly identify and remove life-threatening
conditions
Usual trauma care approach
A Airway
B Breathing, 100% O
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C Circulation, C-spine control
Remove patient from burning process
Remove burning clothing or constriction
Rings, watches, belts
Retain heat & act like a tourniquet
Wound dressing
Transfer to emergency department
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Emergency Department care
PRIMARY SURVEY :

IV, O
2
, Monitors
ABCs reassessed and stabilized
A Airway 100% O
2


+/- ET Intubation
B Breathing
C Circulation IV access & fluids
Heart rate
Capillary refill
Mental status
Urinary output
Blood pressure
C Cervical spine evaluation
D Disability / Neurologic deficit
E Expose and Evaluate
F Fluid resuscitation
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Emergency Department care
SECONDARY SURVEY :
A. History taking
Burning agent ?
Chemicals involved ?
Duration of exposure ?
Open or enclosed space fire ?
Contact with electricity ?
Any other trauma ?
AMPLE (T) A Allergies
M Medications
P Past medical history
L Last meal
E Events prior to or during burn
T Tetanus immunization
B. Physical examination / head to toe examination
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Assessment
Etiology
1. Fire
2. Chemical substances
3. Electric & radiation
4. Sunburn
5. Stove / gas explosion
6. Bomb explosion
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Assessment
Wound depth
1. 1
st
Degree, epidermis
caused : sunburn
appearance: red, slight swelling
surface: dry
sensation: painful

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Assessment
Wound depth
1. 2
nd
degree
- Superficial dermis
caused: hot liquid or solid
appearance: red, moist blebs
surface: wet
sensation: very painful

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Assessment
Wound depth
1. 2
nd
degree
- Deep dermis
caused: hot liquid, flash flame to clothing
appearance: red, blebs, edematous
surface: wet
sensation: hipoesthesi

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Assessment
Wound depth
3. 3
rd
Degree
- Extends through the entire skin thickness
caused: prolonged contact with hot liquid,
flame, chemical, and electrical
appearance: white/brown, contracted
surface: dry
sensation: anesthetize

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Assessment
Percentage of burn wound
head and neck 9% BSA
anterior body 18% BSA
posterior body 18% BSA
upper extremity@ 9% BSA
lower extremity@ 9% BSA
genitalia 1% BSA
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Burn Size: The Rule of Nines
(ADULT)

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Burn Size (Juvenile)

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9 9
18 18
18 18
9 9
18 18
16 16
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18 18
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10 14
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Assessment
Burn Severity Criteria
1. Mild
- 2
nd
Degree < 15%
- 2
nd
Degree < 10% In Juveniles
- 3
rd
Degree < 1%
2. Moderate
- 2
nd
Degree 15-25% In Adults
- 2
nd
Degree 10-20% In Juveniles
- 3
rd
Degree < 10%

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Assessment
Burn severity criteria
3. Severe
- 2
nd
degree >25% in adults
- 2
nd
degree >20% in juveniles
- 3
rd
degree >10%
- Affecting hands, face, ears, eyes, feet, and
genital / perineum
- Inhalation injury, electric injury, or associated
with other traumas

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Indication for admission
- 2
nd
and 3
rd
degree burns >10% body surface
area in patients <10 or >50 y.o
- 2
nd
and 3
rd
degree burns >20% BSA in other
groups.
- 2
nd
and 3
rd
degree burns with serious threat of
functional or cosmetic impairment that involve
face, hands, feet, genitalia, perineum, and
major joints.
- Any burn patient with concomitant trauma (for
example fractures)

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Indication for admission
- 3
rd
degree burns >five% BSA in any age group.
- Electrical and chemical burns with serious
threat of functional or cosmetic impairment.
- Inhalation injury with burn injury.
- Circumferential burns with burn injury.
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FLUID RESUSCITATION
BAXTERS FORMULA
ADULT: RL 4 CC X KG BW X %WOUND SURFACE / 24 HRS
CHILD: RL : DEXTRAN = 17 : 3
2 CC X KG BW X %WOUND SURFACE+MAINTENANCE
MAINTENANCE :
< 1 YR : BW X 100 CC
1-3 YRS : BW X 75 CC
3-5 YRS : BW X 50 CC

IN FIRST 8 HRS
NEXT 16 HRS
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MONITORING FLUID RESUSCITATION
Urinary production per hour
Adult : 0,5 cc/bw/hr (30-50 cc/hr)
Juvenile : 1 cc/bw/hr
Blood pressure
Heart rate
Haematocrite
Haemoglobin
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WOUND MANAGEMENT
- Initial wound debridement and dressing
- The topical agent of choice is applied
- Dressings must not be constricting; distal
extremities must be available for neurovascular
monitoring
- Open the wound dressings at day 5 unless there
is any sign of infection
- Perform under general anaesthesia
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WOUND MANAGEMENT
Deep circumferential burns limbs
May compromise distal circulation
Escharotomy may be required
Incise Midlateral line of extremity to expose fat

Deep circumferential burns chest
May cause mechanical respiratory restriction
Escharotomy may be required
Incise anterior axillary line Rib
2
to Rib
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Join these incisions with two (2) transverse incisions
to allow chest wall expansion



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Electrical Injury
Internal burning, bleeding and trauma are often
associated with electrical burns. Therefore
continuous monitoring of vital signs and patient
complaints is important
Cardiac disrhythmias are a second characteristic
of electrical burns. Continuous cardiac
monitoring is indicated (ECG)
Cervical trauma is associated with the patient
who falls or is thrown back.

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Inhalation Injury
Main cause of mortality
Associated with closed space fires
Associated with decreased mentation
Overdose, alcohol/drug use
Head injury
Smoke exposure heat, toxic gases
Thermal injury upper airway only
Toxic inhalants
Carbon monoxide
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Chemical Burns
All chemical burns are similar (pathophysiologically)
Skin has a limited toxic response
Burns may appear superficial
Factors of absorption
Body site
Integrity of skin
Nature of chemical
Occlusive contact
Majority are acids & alkalis
Alkali more destructive
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THANK YOU FOR YOUR
PATIENCE
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