Oleh:

Deonika Ariescieka Putri G99162116

KEPANITERAAN KLINIK SMF ILMU BEDAH

FAKULTAS KEDOKTERAN UNS/RSUD DR MOEWARDI

 PATIENT STATUS
Identity of The Patient
– Name : Mr. S
– Age : 51 years old
– Gender : Male
– Address : Talok
– Admission Date : April, 16th 2018
– Examination Date : April, 19th 2018
– MR Number : 01277XXX
 CHIEF COMPLAIN

Pain in the burn

 PRESENT ILLNESS

– The patients comes with pain throughout the body after

being exposed to electricity about two days before
come to the hospital. The pain occured when he was
fixing the tin roof, then suddenly he got hit by a roof
that was connected to electricity. He doesnt remember
exactly how it happened. He was taken to dr Oen
hospital by his family. He was hospitalized for 2 day to
cleaning the wound. After that, he is referred to RSDM
for further treatment.
PAST HISTORY

– Allergy/Asthma : denied
– Kongenital anomali : denied
– Trauma : denied
– Operation history : denied
FAMILY HISTORY

– Alergy/asthma : denied
– Trauma : denied
– Mallignancy : denied
 SYSTEMIC ANAMNESIS

Head : no complaints
Eyes : no complaints
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 120/70 mmHg, pulse 82
x/min
D. Disability : GCS E4V5M6, light reflex (+/+),
isochoric pupil
E. Exposure : temperature 36.7 ° C, injury (+) see
local examination
 Secondary Survey

Head : normal
Eyes : normal
Ear : normal
Nose : normal
Mouth : normal
Neck : normal
Thorax : injury (+), see local physical
examination
Abdomen : injury (+), see local physical
examination
Genitourinaria : normal
Extremity : injury (+), see local physical
examination
LOCAL PHYSICAL EXAMINATION
Regio Look

Regio palmar manus (D) Wound entry combustio grade III 0,2%

Regio dorsum manus (D) Combustio grade II 0,4%

Regio antebrachii (D) Combustio grade II 6%

Regio humeri (D) Combustio grade II 6,5%

Regio Thorax Anterior Combustio grade II 7%

Regio Thorax Posterior Combustio grade II 7%

Regio abdomen Combustio grade II 5%

Regio lumbal Combustio grade II 9%

Regio femur (D) Combustio grade II 10%, grade III eskar 1,5%

Regio femur (S) Combustio grade II 5%

Regio cruris (D) Combustio grade II 6%

Regio cruris (S) Combustio grade II 6%

Regio pedis (D) Combustio grade II 2%

Regio pedis (S) Combustio grade II 2%

CLINICAL PHOTO
 BlOOD EXAMINATION
Pemeriksaan Hasil Satuan Rujukan
HEMATOLOGI RUTIN

Hb 12.1 g/dl 13.5 – 17.5

Hct 34 % 33 – 45
AL 4,0 103/ L 4,5 – 11,0
AT 133 103 / L 150–450
AE 3,72 103/ L 4,50 – 5,90
HEMOSTASIS
PT 18,5 Detik 10,0 – 15,0
APTT 29,1 Detik 20,0 – 40,0
INR 1,560 -
ELEKTROLIT

Natrium darah 134 mmol/L 136 – 145

Kalium darah 3,8 mmol/L 3.3 – 5.1

Chlorida darah 108 mmol/L 98 – 106

ASSESSMENT 1
PLANNING 1

– Pro debridement emergency

ASSESSMENT 2
PLANNING 2

– O2 2 lpm
– Ampicilin sulbactam injection 1.5gr/8 jam
– Metamizol injection 1gr/8 jam
– Ranitidine injection 50mg/8 jam
– Keep an eye on condition of the patient and fluid balance
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 areclassified as high
voltage (≥1000V), low voltage (<1000V)
and those caused by lightning
• Low voltage: small partial thickness injury
• Hight voltage: large skin lessions 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
PATHOPHYSIOLOGY
 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 Deep partial

Epidermal Full thickness
partial thickness thickness
• only the • epidermis and • entire • the entire
epidermis is part of the epidermis and thickness of
involved and papillary the papillary the skin is lost,
sensation is still dermis is dermis is possibly with
intact damaged destroyed with deeper tissue
• Heal by itself • Heal for about part of the • They don’t heal
for about 7 14 days. reticular spontaneously;
days. • These take a skin graft is
about 14–21 needed if
days to heal 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
minutes to reduce
cool water
pain and oedema

give
Except in very small
mercurochrome or
burns, debride all
SSD or antibiotic to
bullae
the wound

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

Third degree burn

Full- thickness circumferential and near-circumferential skin burns result in

the formation of tough and inelastic mass of burt tissue /eschar

Eschar cause vascularization disorder, or

burn induced compartment syndrome
Prevent

ischemia
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