BURN INJURY

dr. Nungki Ratna Martina, SpBP-RE

Bedah Plastik Rekonstruksi dan Estetik
RSU UKI

Kuliah Pakar, Oktober 2020

 INTRODUCTION
• Combustion, combustio
• Burn injury
 ETIOLOGY
• Fire
• Scalding (hot water)
• Conduction
• Chemical
• Electrical
• Radiation
 SKIN ANATOMY
• Epidermis :
– Stratum corneum
– Stratum lucidum
– Stratum granulosum
– Stratum spinosum
– Stratum germinativum (stratum basale)
• Dermis: papillary region and reticular region
• Skin appendages: roots, of the hair, sebaceous
glands, sweat glands, receptors, nail and blood
vessels.
 SKIN FUNCTION
• Protection
• Sensation
• Heat regulation
• Excretion
• Storage
• Synthesis
BURN DEPTH
 BURN DEPTH
• First degree burn (Superficial burn)
– Involves only the thinner outer epidermis layer
– Characterized by erythema and tenderness
– Resolves in 48 – 72 hours without leaving any
residual scarring
– Due to sunburn
• Second degree burn (partial thickness burn)
– Superficial partial thickness burn
• Involves epidermis and the upper third of the dermis
• Blister formations
• Extremely painful
• Heal in 10 – 14 days with minimal scarring
– Deep partial thickness burn
• Involves epidermis and most of the dermis as well
• Re-epithelialization is extremely slow (months)
• Blisters are usually not formed.
• Pain is present but to a lesser
• Dense scarring occurs if the wound is allowed to heal spontaneously
• Should be treated as a full thickness burn
• Third degree burn (full thickness burn)
– Destruction of whole thickness of skin elements
sometimes also involves underlying muscle,
tendon or bone.
– Appearance of waxy white in color or leathery
brown or black
– Hardened and dry skin
– Does not have any painful sensations
– Excision of the dead tissue is necessary as early as
possible, followed by coverage with skin grafting
or skin flap
 BURN EXTENT
• Uses the Wallace’s Principle of “Rule of Nine”
 PATHOPHYSIOLOGY OF BURN
Local Responses to Burn Injury
• Inflammatory reaction caused by local release
of inflammatory mediators
• Burn zones described by Jackson
– Zone of coagulation
– Zone of stasis
– Zone of hyperaemia
• Zone of Coagulation
– Necrotic area with cellular disruption
– Irreversible tissue damage
• Zone of Statis
– Moderate insult with decreased tissue perfusion
– Can survive or go on to coagulative necrosis
depending on wound environment
• Zone of Hyperemia
– Viable tissue, not at risk for further necrosis
Systemic Responses to Burn Injury
• 2nd degree Burn  Skin damage  Cell injury
 cytokines and inflammatory mediators at
the site of injury
• Cardiological Changes :
– Increased Capillary permeability
– Intravascular protein  fluids loss to the
interstitial compartment
– Systemic hypo perfusion  Blood pressure
decreased, Heart rate increased
• Hemo concentration  increased
haemoglobin level and haematocrit count
• Inflammation process  swelling, deformity,
tenderness, pain
• Stress/trauma  releasing of stress hormone
(insulin, epinephrine)  Increased basal
metabolic rates  Blood sugar level ↑
 PHYSICAL EXAMINATION
Primary Survey
• Airway: facial burn -, hoarseness -, stridor –
• Breathing: respiratory rate
• Circulation: pulse rate, blood pressure
• Disability
• Exposure
• Burn Evaluation
– History taking, weight
– Diagnosing the burn extent using the Rules of
Nines
– Diagnosing the burn Depth
– Evaluate the presence of circumferential burn
LABORATORY AND RADIOLOGIC EXAM
• Assess the peripheral blood test (Hb, Ht, WBC)
• Assess the blood sugar level, kidney function
test, electrolites
• Assess the chest radiographs (inhalation
trauma), other sites (as indication)
 MANAGEMENT
Initial management:
• Fluid resuscitation: Intra venous line, with
crystalloid solution (lactated ringer’s solution)
administration 
3-4 cc x body weight x % burn area
• Analgesic (NSAID) and antibiotic
• Evaluate/assess criteria for hospitalization
Definitive management:
• Wound care, debridement for deep partial
burn & 3rd degree burn
• Planned for secondary healing of the burn
wounds (2nd burn degree will heal within 5-21
days)
• Upper and lower Extremities Rehabilitation to
prevent joint contracture and stiffness
 CRITERIA FOR HOSPITALIZATION
• All ‘major’ burns
• Respiratory burns
• Deep burns of the scalp
• Burns of the eyes
• Crushing burns, especially of the hands or feet
• Burns of the buttock and/or perineum
• Deep dermal or full-thickness burns, especially to the
back of the hands, suitable for early excision and skin
grafting
• Circumferential burns of the chest which might impair
ventilation or of a limb which might embarrass
circulation
• Severe electric shock
• Patients whose home circumstances make it
impossible for them to be managed as outpatients.
• Burned patients with associated injuries, including
fractures and major blunt and penetrating trauma
• Burns of more than 10 % TBSA in patients under
the age of 10 years and over the age of 50 years
• Burns in patients with concomitant serious
medical diseases (e.g., diabetes mellitus, chronic
alcoholism, cirrhosis, heart disease, acquired
immunodeficiency syndrome)
• All children suspected of being victims of child
abuse or neglect
• Infected burns originally treated on an outpatient
basis
‘Major’ burns (American Burn Association): 
• Second degree burns – more than 15 % TBSA in an adult
• Third-degree burns – more than 5 % TBSA in an adult
• Second-degree burns – more than 10 % TBSA in a child
or more than 5 % TBSA in an infant
• Burns of the head, face, neck, feet, hands and perineum
• Respiratory burns or inhalation injury, including smoke
inhalation and carbon monoxide poisoning
• Electrical injuries
• Chemical burns (such burns require prolonged irrigation,
are deeply invasive, and usually are third-degree burns )
 EDUCATION
• Scars
– Hyperthropic scars
– Hypo/hyperpigmentation
– Contracture
– Function and appearance
THANK YOU