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Skin Anatomy
Skin Constitution
Epidermis
Corium or
Dermis
Subcutis
Zone of stasis —
decreased tissue perfusion.
Potentially salvageable.
Zone of hyperaemia —
tissue perfusion is
increased.
Usually Recover
Systemic response
The release of cytokines and
other inflammatory mediators at
the site of injury has a systemic
effect once the burn reaches 30%
of total body surface area
Capillary permeability
Splanchnic vasoconstriction
Myocardial contractility
Fluid loss
Respiratory changes
Bronchoconstriction, ARDS
Metabolic changes, BMR 3x
•Immunological changes—Non-specific
down regulation of the immune response
occurs, affecting both cell mediated and
humoral pathways.
Pathophysiology
Burn = Coagulative destruction of the skin or
mucous membrane
Caused by heat, chemical or irradiation
Thermal damage occurs above 48 ºC
Extent of necrosis is related to temperature and
duration of contact
Intravascular fluid shifting
intravascular
inflammatory
mediators hypovolemia
Interstitiel /
extravascular
edema
Burns can result in:
Increased capillary permeability and fluid loss
Hypovolaemia and shock
Increased plasma viscosity and microthrombosis
formation
Haemoglobinuria and renal damage
Increased metabolic rate and energy metabolism
The Goals in the acute situation
To maintain oxygen
perfusion to the
vital organs;
acutely, heart and
brain (life saving)
To prevent a
worsening of the
situation (minimize
morbidity)
The question............??
How the oxygen
can be deliveried
to the cell?
Breathing
To allow oxygen
flow into the lung
To allow carbon
dioxide flow out of
the lung
Circulation
To distribute
oxygen rich blood
from the lung to the
peripheral tissue
To collect oxygen
poor blood from
peripheral tissue to
the lung
Cell metabolism
Cell metabolism is the
process (or really the
sum of many ongoing
individual processes)
by which living cells
process nutrient
molecules and
maintain a living state.
Important Consideration
1. Etiology
2. The depth of skin burn
3. Size and extent of the burn wound
Etiology
1. Temperature
High ( Fire, Boiled Water, Steam, hot cloud, lava )
Low ( Frost Bite )
2. Electric
3. Chemical
Base – Acid
4. Radiation
5. LASER
The Depth of Burn Wound
Superficial Skin Burn (1st O)
Pain, Erythema, epidermal slough 1-4 days later
Partial Thickness Skin Burn (2nd O)
Pain, Blisters within 1-6 hours, erythema,
tenderness, good capillary refill
Full Thickness Skin Burn (3rd O)
Insensate, leathery, thrombosed vessels, no
capillary refill
Superficial Skin Burn
Superficial Skin Burn
Superficial Skin Burn
The prototype is a sunburn with erythema
and mild edema.
The area involved is tender and warm.
There is rapid capillary refill after pressure is
applied.
All layers of the epidermis and dermis are
intact; no topical antimicrobial is necessary.
Uncomplicated healing is expected within
five to seven days.
Partial Thickness Skin Burn
Partial Thickness Skin Burn
Initially they may be quite difficult to
diagnose accurately
The hallmark of the partial-thickness
burn is blister formation and pain.
Confusion may result, however, when
partial-thickness burns are examined
after blisters have been ruptured and
uncovered pin prick test
Full Thickness Skin Burn
Full Thickness Skin Burn
Full Thickness Skin Burn
Rule of Nine’s
TABEL
LUND &
BROWDER
Management
PRE HOSPITAL
• STOP - DROP - ROLL
• Prevent Heat Restore
• Electric injury breaking
down the voltage
• Chemical
decontamination / dilution
Assessment
Initial assessment should be by ATLS
principles
Good early management is required to
prevent morbidity or mortality
Primary Survey
A – Airway
B – Breathing
C – Circulation / C-spine / Cardiac status
D – Disability / Neurologic Deficit
E – Exposure and Examination
F – Fluid Resuscitation
Acute phase Initial assessment
Rescusitation Airway
CO intoxication
Hipovolemic shock
Acute phase
Exposure (E)
Burn Size (% TBSA)
Depth of Burn Wound
Other trauma
Acute phase
Fluid Resucitation (F)
(Mathes, 2006)
(Mathes, 2006)
Acute phase
Fluid Resucitation (F)
Systemic :
The release of cytokines and other inflammatory mediators
Increase of capillary permeability let the intravascular fluid shifted
to the interstitial space hypovolemia
BSA = 1,5
MFR = ((35+30)x1,5x24)+(1500x1,5)
= 2340 + 2250
= 4590 mL /24 hour 190 mL / hour
Hourly adjusment
Urine output < 1 mL/hour/Kg BW 10%
Urine output > 2 mL 10%
Wound Care
1st O no spesific treatment
2nd O
Cleansed with NaCl + Savlon
500 ml 5 ml
Tule + sterile thick gauze
or Biological dressing
(Observation in one week)
MEBO
(Mathes, 2006)
Electrical injury
Beware of cardiac rythm abnormality closed
ECG evaluation in the first 2 days
Beware of extensive rhabdomyolisis
Beware compartment syndrome fasciotomy