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Superficial partial-thickness
Deep partial-thickness
Full-thickness
Very painful, dry, red burns which blanch with pressure. They usually
take 3 to 7 days to heal without scarring. Also known as first-degree
burns. The most common type of first-degree burn is sunburn. First-
degree burns are limited to the epidermis, or upper layers of skin.
Very painful burns sensitive to temperature change and air exposure.
More commonly referred to as second-degree burns. Typically, they
blister and are moist, red, weeping burns which blanch with pressure.
They heal in 7 to 21 days. Scarring is usually confined to changes in skin
pigment.
Blistering or easily unroofed burns which are wet or waxy dry, and are
painful to pressure. Their color may range from patchy, cheesy white to
red, and they do not blanch with pressure. They take over 21 days to
heal and scarring may be severe. It is sometimes difficult to differentiate
these burns from full-thickness burns.
Burns which cause the skin to be waxy white to a charred black
and tend to be painless. Healing is very slow, if at all, and may
require skin grafting. Severe scarring usually occurs.
Burn depth classification
2nd degree
(partial-thickness)
-Superficial Epidermis + Pink, clear Moist Painful 14-21 days
pars papilare blister
Epidermis +
-Deep pars retikulare Pink, Moist Painful Weeks, or may
hemorrhagic progress to 3rd
blister, red degree, require
graft
3rd degree (full- Epidermis + White, brown Dry Insensate Require excision
thickness) dermis
4th degree Skin, Brown, Dry Insensate Require excision
subcutaneos charred
fat, muscle,
bone
Burn Severity
http://emcrit.org/030-064/056-thermal.burn.htm
Signs and Symptoms
• Inhalation injury:
– Facial burns
– Carbonaceous sputum
– Pharyngeal injection
– Wheezing
– Hoarseness
– Singed nasal hair
History
• Information from emergency medical services
(EMS), family, friends, or witnesses may be
required.
• Medical history, surgical history, medications,
allergies, social history, tetanus immunization
status
• Carbon monoxide poisoning with exposure to
combustion
• Cyanide poisoning from burning wool, silk, nylon,
and polyurethane found in furniture and paper
Physical Exam
• Focus on airway, breathing first, then head-to-toe
secondary survey for concurrent injuries.
• Evaluate face and oropharynx for signs of
inhalation injury.
• Assess need for immobilization of cervical spine.
• Eye examination for corneal burns
• Determine severity of partial- and full-thickness
burns by assessing size and depth of burn:
– Estimate surface area involved
Lab
• For severe burns, obtain CBC, serum
electrolytes, glucose, BUN, creatinine, and
PT/PTT, type and cross-match, pregnancy test
(female)
• Blood gas with carbon monoxide level for
closed space or inhalation exposures
• Cyanide level if suspected
Imaging
• Chest radiograph
• Fiber optic bronchoscopy to assess inhalation
injury
Differential Diagnosis
• Electrical injury
• Chemical injury
• Associated trauma or intoxication
Treatment
Pre Hospital
• Stop the burning process, remove smoldering
clothes/jewelry.
• Establish patent airway; frequent reassessment:
– Intubate early for signs of respiratory distress.
• Initiate early IV fluid therapy.
• Relieve pain.
• Protect the wound with clean sheets.
• Transport to burn center (for major burns) if transport
time shorter than 30 minutes.
• Immobilize spine if decreased sensorium or trauma.
Initial Evaluation
• Airway management
• Evaluation of other injuries
• Estimation of burn size
• Diagnosis of carbon monoxide and cyanide
poisoning
INITIAL TREATMENT – BURN INJURY
MANAGEMENT OF BURNS
• stop the burning process and to protect the
patient from additional injury
– If chemical injury has occurred, immediate and
copious dilution of the chemical agent with tap
water and prompt removal of all involved clothing
are necessary
– If clothing is burning, extinguish the flames with
water or smother the flames with a blanket and
gently remove the involved clothing.
• The suspected inhalation injury or carbon
monoxide intoxication 100% oxygen
delivered by a non-rebreather mask
• Prehospital infusion of intravenous fluid is
beneficial in those patients with extensive
burns (greater than 20% TBSA)
• Wash all burned clothing and skin with cool
water
• Patients may need a tetanus toxoid booster
(dT or aPdT toxoid 0.5 mL IM) with tetanus
immune globulin
Algoritme Management of burns
Cooling of the Burn
• The optimal cooling temperature is around
10° to 25° C
• tap water at 12° to 18° C was used least
necrosis and fastest healing
• treatment began up to 30 minutes after injury
• Ice and ice water may lead to increased tissue
injury and are contraindicated
Burn Dressings
• protect the wound, to reduce pain, to absorb
wound exudate, and, finally, to reduce vaporative
heat loss
• first-degree burns is not required other than
optional topical anesthetics, aloe vera, and/or
topical (NSAIDs).
• second-degree burns:
– the open method, which consists of topical
antimicrobials
– the closed method, which uses synthetic occlusive
dressings
Dressing
CATEGORY EXAMPLES ADVANTAGES DISADVANTAG
ES
Absorptive
Gauze, Telfa Nonadherent, Requires daily
nonadherent inexpensive dressing
changes
Occlusive
Hydrocolloid Duoderm , Absorbs Opaque, no
Tegasorb exudates, antimicrobial
protective properties
cushioning of
wound
Alginate Seasorb, Absorptive Frequent
Algiderm dressing
changes
Nanocrystallin Acticoat,Aquac Need to keep Need to keep
e silver el Ag dressing dressing
moist moist
Hydrogel Curagel , Rehydrates dry Nonabsorptive
Flexigel Nu- wounds
GeL
Polyurethane Tegaderm , Transparent, Nonabsorptive
foam Opsite inexpensive
Escharotomy
• Releasing the constriction of a burn eschar
with a scalpel or cautery at the bedside
• The procedure is performed by making a
longitudinal incision down to the fat in the
constricting eschar
• Circumferential burn eschar may lead to
neurovascular compromise:
– Monitor pulses; may need Doppler flow probe.
– Elevate burned extremity.
EMERGENCY DEPARTMENT
MANAGEMENT OF BURNS
• Airway Management Endotracheal intubation
• General Measures for Moderate to Severe Burns
intravenous access
• Circulation and Fluid Resuscitation Fluid
resuscitation
• recognizing Inhalation Injury (soot, charring, and
mucosal inflammation, edema, or necrosis)
endotracheal intubation and mechanical
ventilation
Treatment of the burn wound
• Silver sulfadiazine
• Mafedine acetate
• Silver nitrate
• Nearly healed: bacitracin, neomycin,
polymyxin B
Indications for Endotracheal Intubation and
Mechanical Ventilation
Upper airway obstruction
Inability to handle secretions
Hypoxemia despite 100% O2
Patient obtundation
Muscle fatigue suggested by a high or low respiratory rate
A - Airway
B - Breathing
C - Circulation
D - Disability
E - Expose The Patient
http://www.uic.edu/labs/lightninginjury/treatment.html
Lightening Injuries
Patofisiologi
Electrical Burns - Lightening Injuries
• Management
– Primary Survey
– Assess Injury
• History (Other Trauma, Cardiac Arrest)
• Physical Exam (Include Thorough Neurologic Exam)
– Maintain Airway
– Cardiac Monitoring
• ECG On Admission
• Continuous Cardiac Monitor For 24 Hours
Electrical Burns - Lightening Injuries
• Management
– Resuscitation
• Increased Fluid Requirements Due To Underlying
Muscle Damage
• Foley Catheter
• Analyze Urine For Myoglobin
– Maintenance Of Peripheral Circulation
• Frequent Monitoring
• Decompress With Escharotomy Or Fasciotomy
Electrical Burns - Lightening Injuries
• Low Voltage Common
– Usually Minimal Cutaneous Injury
– No Muscle Damage
• Injuries To Oral Commissure
– Look Worse Than They Really Are
– No Immediate Debridement
– Watch For Delayed Bleed With Eschar Separation
Chemical Injuries
• These chemicals, which include acids, alkalis,
and other highly reactive substances
Alkali Burn Acid Burn
Frequently full thickness Usually partial-thickness
injuries injuries
Appear pale Erythema
Basah & kasar erosion
http://www.anatomyatlases.org/firstaid/Burns.shtml
Inhalation injury
• Smoke inhalation caused injury in 2 ways:
– Direct heat injury to the upper airways
– Inhalation of the combustion products intothe lower airways
• Direct injury to the upper airways airways swelling
maximal edema in the first 24 to 48 hours after injury
require short course of endotracheal intubation for airway
protection
• Lower airway injury combustion products found in smoke,
mos commonly from synthetic substance burned in structural
fires direct mucosal injury mucosal sloughing, edema,
reactive broncoconstriction obstruction of the lower
airways
• Treatment of inhalation injury consist of supportive
care.
– Agressive pulmonary toilet
– Routine use of bronchodilators (eg. Albuterol) are
recomended
• Inhaled nitric oxide may also be useful as a last effort
in burn patients with severe lung injury for whom
other means of ventilatory support has failed
• The use of steroids tradiitionally has been avoided
due to worse outcomes in burn patients
Complication
• Ventilator associated pneumonia
• Abdominal compartement syndrome
• Deep vein thrombosis
• Heparin-induced thrombocytopenia
• Catheter-related bloodstream infections
Rehabilitation
• Patients that are unable to participate due to
mechanical ventilation or other reasons
should have passive range of motion done at
least twice a day
• Patients with foot and extremity burns should
be instructed to walk independently without
the help of crutches to prevent extremity
swelling
Prognosis
• Highest predictive value for mortality:
– Age
– Percent TBSA
– Inhalation injury
– Coexistent trauma
– Pneumonia
Prevention
• Smoke alarm
• Regulation of hot water heater temperatures
Patient Education
PENCEGAHAN
• Dekontaminasi sal cerna m↓ insidens pneumonia
nosokomial.
• Dekontaminasi usus
• Membatasi transmisi organisme dari / antar pasien
dgn cara mencuci tgn
• Tindakan asepsis dan antisepsis didlm RS
• AB empiris yg tepat dan memadai m↓ angka
kematian HAP (hospital acquired pneumonia)
KOMPLIKASI
EKSTRAVASASI Cairan infus masuk ke jar sekitar insersi
(infiltrat) kanul
PENYUMBATA Infus tdk berfungsi tanpa dpt dideteksi
N adanya g3 lain
FLEBITIS Trdpt pembengkakan, kemerahan, dan nyeri
spjg vena
TROMBOSIS Pembengkakan, spjg vena yg mghambat
aliran infus
KOLONISASI Bila sdh dpt dibiakkan MO dr bag kanula yg
KANUL ada dlm PD
SEPTIKEMIA Jk kuman menyebar hematogen dr kanul
SUPURASI Jk tjd bentukan pus disekitar insersi kanul
Systemic Inflammatory
Response Syndrome
(SIRS)
SEPSIS and It’s Disease spectrum
• Various stages of disease
– Bacteremia
– SIRS
– Sepsis syndrome
– Sepsis shock : early and refractory
Definition
• Infection
– Presence of microorganisms in a normally
sterile site.
• Bacteremia
– Cultivatable bacteria in the blood stream.
• Sepsis
– The systemic response to infection.
If associated with proven or clinically
suspected infection, SIRS is called “sepsis”.
American College of Chest Physicians/Society of Critical Care Medicine Consensus
Conference Committee. Crit Care Med. 1992;20:864-874.
SIRS (Systemic
Inflammatory Response Syndrome)
Microbial Products
(exotoxin/endotoxin)
Cellular Responses
Platelet Coagulation Kinins Cytokines
Activation Activation Oxidases Complement TNF, IL-1, IL-6
Coagulopathy/DIC
Vascular/Organ System Injury
Multi-Organ Failure
Death
Normal Systemic Response to
Infection and Injury (1)
• Leukocytosis Mobilizes neutrophils into the
circulation
• Tachycardia Increases cardiac output, blood flow to
injuried tissue
• Fever Raises core temperature; peripheral
vasoconstriction shunts blood flow to
injuried tissue. Occurs much more
often when infection is the trigger for
systemic responses
Mandell et al. Principals and Practice of Infectious Diseases6th ed;906:906-926.
Normal Systemic Response to
Infection and Injury (2)
• Acute-Phase Responses
– Anti-infective
• Increases synthesis of complement factors, microbe
pattern-recognition molecules(mannose-binding lectin,
LBP, CRP, CD14, Others)
• Sequesters iron (lactoferrin) and zinc (metallothionein)
• Aids
– P aeuginosa (if neutropenic), S aureus, PCP
pneumonia
• Intravascular devices
– S aureus, S epidermidis
• Nosocomial infections
– MRSA, Enterococcus species, resistant gram-
negative, Candida species
• Septic patients in NE of Thailand
– Burkholderia pseudomallei
MacArthur RD, et al. Mosby, 2001:3-10.
Wheeler AP, et al. NEJM 1999;340:207-214.
Chaowagul W, et al. J Infect Dis 1989;159:890-899.
Diagnosis
• Physical Examination
– essential
– In all neutropenic patients and in patients
with as suspected pelvic infection the
physical exam should include rectal, pelvic,
and genital examinations
• perirectal, and/or perineal abscesses
• pelvic inflammatory disease and/or
abscesses, or prostatitis
• Fluid resuscitation
• Appropriate cultures prior to antibiotic
administration
• Early targeted antibiotics and source control
• Use of vasopressors/inotropes when fluid
resuscitation optimized
Surviving Sepsis Campaign Management Guidelines Committee. Crit Care Med 2004; 32:858-873.
Sepsis management bundle
Surviving Sepsis Campaign Management Guidelines Committee. Crit Care Med 2004; 32:858-873.
Infection Control
Surviving Sepsis Campaign Management Guidelines Committee. Crit Care Med 2004; 32:858-873.
Early Goal-Directed
Therapy
CVP : central
venous
pressure
MAP : mean
arterial
pressure
ScvO2: central
venous
oxygen
saturation
NEJM 2001;345:1368-77.
Antibiotic use in Sepsis (1)