SEVERE BURN

MANAGEMENT

POENGKI DWI POERWANTORO

BURN SURGEON
 BURN

 Expose of human body with heat, or something

that can induce heat by chemical and or physical
reaction.
 Severe Burn : 2nd Degree more than 40%, 3rd more
than 10%, children or pregnant women or special
trauma such as inhalation trauma or other trauma.
 Severe burn kasus yang kompleks dengan tingkat kematian
> 50%
 PROSES BURN INJURY

Since Day 1 have to

0-48 JAM FASE SUB be SIRS can be MODS FASE S/D 8-12 BULAN
FASE AKUT
DETERIORASI ABC AKUT must be control in day LANJUT REHABILITASI
21 or RIP

K E T: A : A I R W AY, B : B R E AT H I N G , C : C I R C U L AT I O N , S I R S : S Y S T E M I C
I N F L A M M AT O R Y R E S P O N S E S Y N D R O M E , M O D S : M U L T I - S Y S T E M O R G A N
DYSFUNGSION SYNDROME
ZONA KERUSAKAN

Zone of Zone of
Coagulation Stasis Zone of Hyperaemia

Jackson 1953
Infeksi, SIRS, dan Sepsis
 MASALAH Pada Severe Burn

 Kerusakan akut:
 Awal
Trauma inhalasi dengan atau tanpa stres pernafasan
Stres pernafasan karena adanya eschar melingkar
Syok hipovolemik
Hipotermia
 Lanjut
Systemic Inflammatory Response Syndrome (SIRS)
Multisystem Organ Dysfunction Syndrome (MODS)
Sepsis
 Trauma inhalasi

Inflamasi mukosa karena suhu

berlebih dan keracunan

Mukosa bengkak & Hipersekresi

Mukosa menjadi slough dan

terbentuk “plug”

Sumbatan jalan nafas

 Trauma inhalasi

 Treatment:
 Evacuation
 Secure the airway: endotracheal tube / emergency cricothyroidotomy
 Oxygen 2L + humidification
 Periodic suction
 Inhalation therapy: nebulizer w bronchodilator
 Broncho-Alveolar Lavage (BAL): bronchoscopic
 Respiratory rehabilitation
 Respiratory distress: encircled eschar

 Limitation of thoracic anterior wall expansion

 Encircled eschar
 Respiratory distress: encircled eschar

 Treatment:
 Emergency chest escharotomy
Pathology of the lumen

Lumen Obstruction
 MAJOR BURNS: INITIAL MANAGEMENT
TREATMENT SUMMARY
 STOP THE BURNING PROCESS
 Water for smoldering clothing
 Water for chemical burns
 Remove clothing – keep warm
 Cool water for small 2° burns only

 ASSURE ADEQUACY OF VENTILATION & OXYGENATION

 Provide oxygen for all burns to treat carbon monoxide
 Consider early endotracheal intubation with smoke inhalation injury

 INITIATE RESTORATION OF HEMODYNAMIC

STABILITY SYSTEMICALLY & LOCALLY
 Isotonic crystalloid infusion
 Remove any constricting items
 Consider Escharotomy for circumferential burns
 LOOK FOR OTHER TRAUMATIC INJURIES
 BURN WOUND LAST PRIORITY
 TREATMENT SUMMARY (0 TO 24 HOURS)

Facial Burns
Patient Acute airway problems
conscious, No Endocrineal inhalation (use % or larger size tube)
airway problem, CPAP or PEEP…begin at 5cm of H20
No deep facial Asses lower airways: obtain chest radiograph
burn baseline
-OR –
↓ Adequate Ventilation
Do not initiate standard treatment for smoke
Place on 100% exposure
oxygen by mask Do not use prophylactic antibiotics or
Contain blood corticosteriod
gases,
carboxyhemoglobin Adequate Ventilation
Consider bronchodilators
Initiate standard treatment for smoke exposure

If problem persists, increase PEEP, CPAP rule out

Restrictive defect
 Insidensi Sepsis
di Amerika Serikat
 Peranan Imunoglobulin (Ig)
Pada Keadaan Infeksi

 Mengenali mikroorganisme dan substansi yang

masuk dalam tubuh
 Opsonisasi bakteri
 Memberikan sinyal secara langsung atau
melalui jalur komplemen kepada sistem imun
non-spesifik
 Netralisasi toksin yang berasal dari bakteri

Berlot G, et al. Advance in Sepsis 2007;6(2):41=6

Peranan Imunoglobulin

Mackay I. NEJM 2000;343(2):108-17

Terapi IVIG :
 Menghambat / melemahkan respon awal
dengan cara melemahkan faktor pemicu
inflamasi :
 Berikatan dengan antigen.
 Faktor – faktor yang dilepaskan oleh mikroorganisme
(endotoksin, peptidoglikan, asam lipoteichoic).
 Inaktivasi langsung mediator sepsis / netralisasi
reseptor pada permukaan sel

Berlot G, et al. Advance in Sepsis 2007;6(2):41=6

Rasionalisasi Penggunaan IVIG
Pada Sepsis

Berlot G, et al. Advance in Sepsis 2007;6(2):41=6

Intravenous Immunoglobulin (IVIG)
 Terdaftar hanya dengan indikasi tertentu
 sering digunakan pada berbagai kasus
 Pemakaian IVIG berdasarkan penelitian:
 Keadaan imunodefisiensi
 Replacement therapy
 Umumnya : 200 – 400 mg/kg tiap 3 mgg

 Terapi autoimun
 Immunomodulator Umumnya :
2 g/kg
(Dosis besar)
 SIRS atau Sepsis 1- 1,5 g/kg

Blood Transfus 2009;7:216-34

Joles S et al. Clinical and Experimental Immunology 2005;14:1-11
Menilai efikasi IVIG terhadap kematian pasien
dengan penyakit kritis dengan sepsis
Hasil Penelitian :
 Kelompok yang diberikan IVIG menunjukan
angka mortalitas yang lebih rendah
dibandingkan kelompok plasebo atau tanpa
perlakuan (P = 0,001).

Turgeon , et al. Annals of Internal Medicine 2007;146:193-203

Kesimpulan :
 Dari 20 penelitian yang melibatkan 2621 pasien
sepsis, pemberian IVIG :
 Mengurangi angka kematian

 Kelebihan pemberian IVIG lebih menonjol

pada :
 Sepsis berat
 Dosis besar
 Durasi terapi yang lebih lama
 Morbidity Burns inpatient at
Pertamina Central Hospital

2004 2005 2006 2007 2008 2009 2010

Mod. Comb 39 29 23 40 37 22 27

Sev. Comb 15 6 11 8 7 17 20

Total 54 35 34 48 44 39 47

60
54

50 48 47
44
39 40 39
40 37
35 34
29 Mod. Comb
30 27
Sev. Comb
23 22
20 Total
20 17
15
11
10 8 7
6

0
2004 2005 2006 2007 2008 2009 2010

Average : Sev Burn : 20-40% of total pts, RSPP 28%.

 Mortality at Burn Unit Pertamina Central Hospital

2004 2005 2006 2007 2008 2009 2010

Total Sev Burn 12 10 11 8 7 17 20

Death among sev burn 7 5 5 2 0 6 9

Total Burn patients 54 35 34 48 44 39 47

Death/total (%) 12.96 14.29 14.71 4.17 0.00 15.38 19.15

% Death/Sev Burn ps 58.33 50.00 45.45 25.00 0.00 35.29 45.00

Pulmonary edema 7 5 4 1 0 3 5

% PE in Sev. Burn ps 58.33 50.00 36.36 12.50 0.00 17.65 25.00

 Mortality at Burn Unit Pertamina Central Hospital
70

Av = 37%
60 58.33
58.33

54

50.00
50.00
50 48
47
45.45 45.00
44

Total Sev Burn

40 39
Death among sev burn
36.36
35 35.29 Total Burn patients
34
% Death/total ps
% death/Sev Burn ps
30
Pulmonary edema
25.00 25.00
% PE in Sev. Burn ps

20
20 19.15
17 17.65
14.71 15.38
14.29
12.96 12.50 Av death among
12
11 Sev Burn RSPP
10
10 9 = 37%
8
7 7 7
6
5 5 5 5
4 4.17
3
2
1
0 0.00
0.0000.00
0
2004 2005 2006 2007 2008 2009 2010
MATUR
NUWUN
SANGET
HATUR NUHUN ARIGATO GO ZAIMASTE