FIFTY TWO YEARS OLD MAN WITH

BURN WOUND (COMBUSTIO) 48%

STAGE II CAUSED BY GAS EXPLOTION

Pembimbing:
dr. Amru Sungkar, Sp. B, Sp.BP-RE (K)

Oleh:
Risna Annisa Mardiyati G991906029

KEPANITERAAN KLINIK SMF ILMU BEDAH

FAKULTAS KEDOKTERAN UNS/RSUD DR MOEWARDI
 PATIENT STATUS

Name : Mr. Sub

Age : 52 years old
Gender : Male
RM no : 014xxxxx
Address : Gemolong, Sragen
Admission Date : July, 31st 2019
Examination Date : August 5th 2019
Chief Compliment

 Burn wound (combutio) on several body.

 PRESENT ILLNESS
The patient came to the emergency room Dr. Moewardi with
burns in several parts of the body. Burns were obtained 4 hours
ago from the explosion of the gas cylinder while the patient was
operating a diesel engine. Patients complaints of burning pain
feeling hot all over the body. Patient burns on the face, neck,
back, hands, legs, and stomach. Fainting after being hit by a gas
explosion was denied. Nausea (-) vomiting (-) convulsions (-).
Previously the patient was brought helper to the Yarsi Hospital
emergency room. Due to limited facilities, the patient was
referred to RSUD Dr. Moewardi Surakarta.
 PAST HISTORY

Allergy/Asthma : denied
Kongenital anomali : denied
Trauma : denied
 FAMILY HISTORY

Alergy/asthma : denied
Trauma : denied
Keloid : denied
Hipertension : denied
Diabetes mellitus : denied
 SYSTEMIC ANAMNESIS
Head : no complaints
Eyes : icteric sklera (+/+) pale conjungtiva (+/+)
Mouth : no complaints
Respiratory system : no complaints
Cardiovascular system : no complaints
Gastrointestinal system : no complaints
Genitourinaria system : no complaints
Upper extremity : wound (+/+), pain (+/+)
Lower extremity : wound (+/+), pain (+/+)
 PRIMARY SURVEY
A. Airway : clear
B. Breathing : 20 times/min
Palpation : normal
Percussion : normal
Auscultation : normal
C. Circulation : blood pressure 130/90 mmHg, pulse 82
x/min
D. Disability : GCS E4V5M5, light reflex (+/+),
isochoric pupil
E. Exposure : temperature 36.9 ° C, injury (+) see
local examination
 SECONDARY SURVEY

Head : normal
Face : hiperemis (+) scar (+)
Eyes : pale (+) ikterik (+)
Ear : normal
Nose : normal
Mouth : normal
Neck : normal
Thorax : normal
Abdomen : normal
Extremity : injury (+), see local physical
examination
 LOCAL PHYSICAL
EXAMINATION
Face: 3.5% degree II burns
Neck: 1% degree II burns
Thorax: 5% degree II burns
Abdomen: 5% degree II burns
Extremities: Superior
Antebrachii dextra 5% degree II burns
Antebrachii sinistra burns 5% degree II burns
Inferior dextra 12% degree II burns
Inferior sinistra 12% degree II burns
CLINICAL PHOTO (Eks. Superior)
CLINICAL PHOTO (Eks.
Inferior)
CLINICAL PHOTO (Face)
BLOOD EXAMINATION
 ASSESSMENT

 Burn wound (combustion) 48% II degree

 PLANNING
 O2 3 lpm
 Monitoring vitalsign
 IVFD NaCl 0,9% fluid resuscitation :
improvement 8 hours 6240 cc
for the next 12 hours 6240 cc
 Injection ranitidin 50 mg /12 hours
 Injection metamizol 1 gram/8 hours
 Injection ATS
 Injection ampisilin sulbactam 1,5 gr
LITERATURE REVIEW
 INTRODUCTION

Burn wound is a tissue damaging or loss

due to extreme heat source, cold source,
electric source, chemical compounds, light,
radiation, or friction.

Burns still constitute one of the main accidents in

homes and industry, and are also linked to social
and economic risk factors.
ETIOLOGY
Thermal
• Scald
• Flash
• Flam

Radiation BURNS Chemical

Electrical
 ETIOLOGY
Thermal burns

• Flash and flame burns affected main population.

Flames produce deep burns especially if clothes have
been on fire and usually associated with inhalational
injury and trauma
• Scalds usually caused by spilling hot water or by using
too hot water for bathing. Scalds also caused by grease
or hot oils, which produce deeper burns
• Contact burns usually caused by hot metal, plastic,
glass and coal.
 ETIOLOGY

Chemical Burns

• Sodium hypochloride : strong alkaline solution that

cause protein coagulation and when ingested
oesophageal constriction and perforation of stomach.
• Phenol (carbolic acid): superficial burns caused by
phenol produce light grey lesion, deep burns produce
black lesion
• White phosphorous: produce painful thermal burn
• Sulphuric acid: Deep dermal burns have a bronzed
leathery appearance with deep ulceration underneath.
 ETIOLOGY

Electrical burns
• Electrical burns are classified as high
voltage (≥1000V), low voltage (<1000V)
and those caused by lightning
• Low voltage: small partial thickness injury
• Hight voltage: large skin lession with
necrosis at the contact point and even
deeper
 ETIOLOGY

Radioactive burns
• Burn cause by exposed to radioactive
source
• Clinical symptomps: hair loss, burns,
desquamation, cutaneous necrosis
and ulseration
PATHOPHYSIOLOGY
Zone of coagulation

• Cells in the immediate area of contact die and the

surrounding tissue coagulates and denatures.
• No blood circulation in this area.

Zone of stasis

• Blood perfusion is decreased

• Increased damage could occur because of prolonged
hypoperfusion
PATHOPHYSIOLOGY

Zone of hyperaemia

• This is the outermost zone; perfusion

is increased and tissue here will
recover unless there is another insult
such as sepsis or hypoperfusion
DEGREES OF BURN
 DEGREES OF BURN
Depth of wounds are categorized in four parts:

Superficial partial Deep partial

Epidermal Full thickness
thickness thickness

• only the • epidermis and • entire epidermis • the entire

epidermis is part of the and the thickness of the
involved and papillary dermis papillary dermis skin is lost,
sensation is still is damaged is destroyed possibly with
intact • Heal for about with part of the deeper tissue
• Heal by itself for 14 days. reticular • They don’t heal
about 7 days. • These take spontaneously;
about 14–21 a skin graft is
days to heal needed if depth
exceeds >1 cm.
DEGREES OF BURN
HOW TO ASSES THE DEGREE
OF BURN ?
HOW TO MEASURE BURN
AREA ?
 HOW TO MEASURE BURN
AREA ?
Palmar surface—The surface area of a patient's
palm (including fingers) is roughly 0.8% of total
body surface area. Palmar surface are can be used
to estimate relatively small burns (< 15% of total
surface area) or very large burns (> 85%, when
unburnt skin is counted). For medium sized burns,
it is inaccurate.
Wallace rule of nines—This is a good, quick way of
estimating medium to large burns in adults
SEVERITY OF BURN INJURY
MANAGEMENT
 MANAGEMENT
Emergent Phase
• Begins with the burn injury, assessing severity, initial care
and ends when the patient is stable and begins to diurese
and no longer requires fluid therapy

Acute Phase
• Return of fluid from the cells (intracellular fluid) and
between the cells (interstitial fluid) to the intravascular
space and continuous care of the wounds to promote
grafting, prevent infections, and promote healing (Weeks to
months)
 MANAGEMENT
Rehabilitation Phase
• Begins with the burn injury, assessing severity,
initial care and ends when the patient is stable and
begins to diurese and no longer requires fluid
therapy
• Helping the patient return to previous or optiminal
level of functioning. Many aspects of rehabilitation
begins at the time of emergent care and continue
through the phases.
MANAGEMENT
 MANAGEMENT OF BURN
INJURY
immerse the site in
drench the burn
cold water for 30
thoroughly with cool
minutes to reduce
water
pain and oedema

give mercurochrome Except in very small

or SSD or antibiotic burns, debride all
to the wound bullae

Dress the burn with

gauze
 WOUND MANAGEMENT
Biological Wound Phsyological Wound
Topical Oinments Wound Dressing
Dressing Dressing

• Silver sulfadiazine: is • maximal support for • treatment of choice for • Synthetic dressings
the most common wound healing excised burn wounds are an excellent
ointment used. • „maximal protection is an autograft alternative for covering
• Mafenida : is another against infection • cheaper alternative to burn wounds
ointment often used for • „minimal pain during this biological dressing • Their function is to
full-thickness burns; it dressing changes is a cultured epidermal stimulate skin
has a bacteriostatic without anaesthesia autograft in patients in regeneration and act
action • „minimal cost. whom a considerable as a barrier to prevent
• Silver nitrate : An surface area is infections. Therefore
alternative version of affected, donor site synthetic dressings do
• The most basic and may be very limited. not work properly on
this compound common wound burn full-thickness burn
(Acticoat) was dressing is gauze injuries
developed using silver covered with soft
nanoparticles. paraffin
WOUND MANAGEMENT BASED
ON DEGREEOF BURNS
First degree

• Drench the burn thoroughly with cool water

• Topical antibiotik
• Analgesic: NSAID (Ibuprofen, Acetaminophen)

Second Degree (Superficial)

• Need routine care of the wound

• Dress with antibiotic and gauze
• Temporary coverage: allograft or xenograft

Second Degree (Deep) dan Third Grade

• Early exicision and grafting

 EARLY EXICISION AND
GRAFTING (E&G)
This technique is important because early excision and skin grafting
reduces the presence of necrotic and infected tissue

Eschar is removed operatively then the wound is covered with skin

graft (allograft or autograft)

Early excision and grafting can be done 3-7 days after the injury
EARLY EXICISION AND
GRAFTING (E&G)
 ANTIMICROBIAL THERAPY

Burn >> remove barrier of skin >> infection

Can be administered:
Topically
Systemically
Topical teraphy: Silver sulfadiazine,
Mafenide acetate, Silver nitrate, Povidone-
iodine, Bacitracin (biasanya untuk luka
bakar grade I), Neomycin, Polymiyxin B,
Nysatatin, mupirocin , Mebo.
THANK YOU