2. Etiology
• Flame common in adults
• Scald common in children
• Contact
• Chemical alkaline > acid
• Friction
• Electrical
• Frostbite
3. Pathophysiology
• Zone of coagulation
• Cell necrosis
• Zone of stasis
• Cells are still alive
• Microcirculation damage
vasoconstriction
• Critical can progress into
coagulation
• Zone of hyperemia
• Vasodilation
• Systemic 10% (children), 20%
(adults)
4. Systemic reaction
• Happened in >20% TBSA burns
• Fluid and electrolyte balance
• Vasodilation + cytokines release increased capillary permeability
increased molecules transport (diffusion, filtration, molecule transfer)
albumin transport to interstitial edema
• Transport of Na into the cell + K out of cell
• Dissolve of intercell substances increased osmotic pressure in interstitial
• Fluid and protein leak into interstitial hypovolemia
• Hypermetabolic state release of stress hormones protein degradation,
catabolism state
12. Burn Area Estimation
• Only 2nd and 3rd burn degree
• Methods:
• Palmar surface method
• Rules of Nine
• Lund and Browder Chart
• Palmar surface method
• Use patient’s palm (including fingers) = 0,78% TBSA
• For <15% or >85% burns
13. Rules of Nine
• Adult & children >10 years old
• Children 1 year old
• Increase in 1 year extract 1% from head
divide 0,5% to each legs
16. Burn Classifications (American Burn
Association)
• Major burn
• 2nd – 3rd degree >20% <10 or >50 yo
• 2nd – 3rd degree >25% 10-50 yo
• Burns at face, ears, hands, feet, perineum
• Inhalation injury, high-voltage electrical burn
• With other trauma
• High risk patients
• Moderate burn
• 3rd degree <10%
• 15-25% in adult
• 10-20% in <10 or >40 yo
• No face, hands, feet, perineum involvement
• Minor burn
• <15% burns in adult
• <10% burns in children and geriatric
• <2% burns in all ages, no face, hands, feet, perineum involvement
23. Burn Wound Healing
• Reepitelization
• Superficial thickness epidermal reconstruction from skin adnexa
• Deep thickness repigmentation
• Scar formation
• Fibrose formation could develop into contracture, keloid, hypertrophic scar
• Contracture
• Wound contraction
• Especially at loose skin
24. Management
• Prehospital/ first aid
• Water irrigation
• Flowing water for 20 minutes
• Max 1-3 hours after burn
• Take clothes off + cover with clean covers
25. Primary Survey
• Use personal protective
equipments
• Airway + C-spine
• Breathing
• Circulation + hemorrhage
control
• Disability : AVPU + pupils
• Exposure + environmental
control
• Fluids rescucitation
• Analgesics morphines 0,05-
0,1 mg/kg IV
• Tests blood test, blood gas
analysis, imaging
• Tubes NGT
27. Fluid rescucitation
• Intravenous access
• 2 peripheral IV lines (16G)
• Central line larger burns, significant inhalation injury
• IV >15-20% burns
• Parkland formula : 3-4 cc x weight (kg) x %TBSA
• Children <15 kg + maintenance with dextrose containing fluids
• ½ fluid in the first 8 h ½ fluid in the rest 16 h
• Target: UO 0,5-1 cc/kg/hour (adult), >1 cc/kg/hour (children)
• IV fluid is titrated based on UO
28. Fluids
• Crystalloid
• Ringer Lactate is used hypotonic, contains Na, K, C, Cl, lactate
• NS not used risk of inducing hyperchloremic acidosis
• Colloid
• Increase intravascular oncotic pressure minimize capillary leak and draw
fluid back intravascularly
• Not to be used in early burn leakage into interstitial aggravate tissue
edema
• Albumin is the most used
29. Escharotomy
• Eschar : protein coagulation from full thickness burn constrict
extremity/ trunk impair perfusion/ breathing
• Indicated: full thickness circumferential burns of extremity/ chest wall
• Compartment syndrome: 6P, USG Doppler
• Bedside/ OR
• Adequate release: eschar separates, popping sound perfusion
improves
• Avoid major superficial nerves
30.
31. Secondary Survey
• Full examination : head to toe
• History
• A – allergy
• M – medicine
• P – past illness
• L – last meal
• E – Event
• Mechanism of Injury
• Documentation
• Reevaluation of primary survey
32. Burn Wound Management
• Burn disrupt skin functions
• Thermal regulation
• Sensation regulation
• Immune response
• Bacterial invasion protection
• Fluid regulation (evaporation)
• Metabolic function
• Psychology, esthetic function
• Principal of management:
• Stop burn process stop, drop,
roll
• Decreasing the temperature
water irrigation
• Clean the wound (soap + water)
• Debridement
• Topical burn wound treatment
• Silver sulfadiazine
33. Surgical management
• Early burn excision + skin grafting
• Decreasing infection rate
• Increasing survival
• Decreasing hospital stay
• Early staged excision begins on postburn day 3
• Technique:
• Tangential excision
• Fascial excision
• Control blood loss
34. Tangential excision
• Sequential removal of layers of
eschar and necrotic tissue
reaching layer of viable,
bleeding tissue support skin
graft
• Watson/ Goulian blades
Fascial excision
• Excision of burned tissue +
subcutaneous tissue until
muscle fascia
• Electrocauter
35. Skin grafting
• Survives on recipient bed through process of diffusion of nutrients
• Revascularization process begin 48 hours after graft replacement
• Neovascularization
• Inosculation direct biologic anastomosis of cut ends of recipient vessels in
graft bed with graft
• Classification
• Split thickness skin graft
• Full thickness skin graft
• Fixation of graft
• Staples, suturing
• Dressing
36. Burn management
• Nutritional support
• Initiated soon oral/ enteral
• Parenteral for paralytic ileus, bowel
obstruction
• Stress ulcer prophylactic
• Antibiotics based on culture
• Pain management
• Elevation of the wound
• Vaccination tetanus vaccinated
• Rehabilitation, contracture prevention
37. Burn Center Referral Criteria (ABA)
• Partial thickness burns greater than 10% total body surface area (TBSA)
• Burns that involve the face, hands, feet, genitalia, perineum, or major joints
• Third degree burns in any age group
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn injury in patients with preexisting medical disorders that could complicate management,
prolong recovery, or affect mortality
• Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses
the greatest risk of morbidity or mortality
• Burned children in hospitals without qualified personnel or equipment for the care of children
• Burn injury in patients who will require special social, emotional, or rehabilitative intervention.
38. References
• Wardhana A. Panduan Praktis Manajemen Awal Luka Bakar. Jakarta:
Lingkar Studi Bedah Plastik Foundation. 2014.
• Emergency Management Of Severe Burns (EMSB). [North Sydney, N.S.W.]:
Australian and New Zealand Burn Association.
• Grabb, W., Smith, J. and Chung, K., 2020. Grabb And Smithʼs Plastic
Surgery. Philadelphia [etc.]: Wolter Kluwers.
• Roth JJ, Hughes WB. The Essential Burn Unit Handbook. USA: CRC Press.
2016.
• Foncerrada G, Culnan DM, Capek KD, Gonzalez-Trejo S, Cambiaso-Daniel J,
Woodson LC. Inhalation injury in the burned patient. Ann Plast Surg. 2018;
80: S98-S105.
• Hettiaratchy S, Dziewulski P. Pathophysiology and types of burns. BMJ.
2004; 328: 1427-1429.
