CRITICAL CARE CRITICAL CARE IN BURN PATIENTIN BURN PATIENTCRITICAL CARE CRITICAL CARE

IN BURN PATIENTIN BURN PATIENT

Bali, Bali, Oktober 2002Oktober 2002

Mariott Hotel, JakartaMariott Hotel, JakartaAgustus 2003Agustus 2003

Kuningan, Jakarta, Kuningan, Jakarta, September 2004September 2004

CRITICAL CARE IN BURN PATIENT

BURN : • DEF/ :

INJURY OR DAMAGE OF TISSUE (SKIN AND TISSUE DEEPER THAN SKIN) CAUSE BY HEAT.

• ET/ :

FIRE,SCALD,CHEMIST,ELECTRIC,RADIATION

• MORBIDITY & MORTALITY SINCE INITIAL PHASE.

PROBLEMS IN BURN • INITIAL PHASE/SHOCK PHASE/ACUTE: DISTURBANCES OF FLUID & ELECTROLITE

• SUB ACUTE PHASE (DAY 2 – DAY 21) - HYPERMETABOLISM - HIGH REACTION INFLAMATION

- HEALING PROCESS - INFECTION

- SIRS- MODS

• LATE PHASE : HYPERTHROPIC SCAR,KELOID & CONTRACTURE PROBLEMS

CLASSIFICATION BASE ON DAMAGE THE TISSUE

GRADE I

GRADE II DEPEND ON AETIOLGY & CONTACT

GRADE III

SKIN ANATOMY

SKIN ANATOMY

ZONES IN BURN WOUND

1. COAGULATION ZONE :

PROTEIN COAGULATION (DIRECT)

2. STATIC ZONE :

DAMAGE OF ENDOTHEL,ERY,LEUCO,THROMBOCYT

CAPILER PERMEABILITY DISTURBANCE

3. HYPEREMIA ZONE:

VASODILATATION WITHOUT CELLULAR REACTION

BURN WOUND ZONE

Zone 1

Zone 2

Zone 3

1

2

3

CLASSIFICATION OF SEVERITY BURN

SEVERE BURN DEGREE II > 25 % TBSA DEGREE III > 10 % DEGREE III OR II CIRCUMFERENTIAL AT FACE, HAND, LEG. INHALATION INJURY

BURN WITH ASSOCIATED INJURYELECTRICAL BURN

MODERATE BURN

DEGREE II 15 –25 %

DEGREE III < 10 % MINOR BURN

DEGREE II < 15 %

DEGREE III < 2 % ALL OF THE FIRST DEGREE

PATOPHYSIOLOGIPATOPHYSIOLOGI

Release MediatorRelease Mediator InflamationInflamation

Increase MicrovascularIncrease MicrovascularPermeabilityPermeability

Decrease Myocardial Decrease Myocardial ContractilityContractility

Early ExcisionEarly ExcisionThermal InjuryThermal Injury

Capillary LeakCapillary Leak

Massive ExtravasasionMassive Extravasasion

hipovolemiahipovolemia edemaedema

Cellular perfusion Cellular perfusion disorderdisorder

Macro circullatoryMacro circullatorydisorderdisorder

acidosisacidosis

ischemiaischemia

necrosisnecrosis

hipoperfussionhipoperfussion

RenalIschemiaRenalIschemia

Cardiovascular collapsCardiovascular collaps

Fluid Fluid ressusciationressusciation

PATOPHYSIOLOGICAL CHANGES

HYPERMETABOLISM

HORMONAL CHANGES : CORTISOL,INSULIN

IMMUNOLOGICAL IMPAIRMENT

INCREASED INTESTINAL PERMEABILITY

Organ Injury

Inflamation“Fighting”

Pro Inflamation

Healing

Anti Inflamation(compentation)

ImmunosupressionSIRSSIRS

time

HOW TO MANAGE THE BURN PATIENT

PREHOSPITAL

- PUT PATIENTS FAR TO SOURCE OF THE HEAT

- REMOVE ALL OF THE CLOTHES & ACCESORIES

- EARLY COOLING WITH WATER, NO ICE

- BURN MORE THAN MODERATE IN SEVERELY

SEND TO THE HOSPITAL

20 % TBSA IV LINE IF POSSIBLE

- THE PATIENT WITH CLEAN CLOTHES COVER

PRIMARY ASSESMENTIDENTIFY IMMEDIATE LIFE THREATENING CONDITION

• AIRWAY : - OXYGEN

- PROGRESSIVE OBSERVATION

• BREATHING : - EXPANSION OF THE CHEST

- CIRCUMFERENTIAL BURN IN

CHEST ESCHAROTOMY

• CIRCULATION :

- PULSE AND BLOOD PRESSURE

• C – SPINE IMMOBILITATION

CHEMISTRY BURN

• WATER IRRIGATION, DON’T NETRALISIR

ELECTRIC BURN• OBSERVATION VENTRICLE VIBRILATION

SECONDARY ASSESMENT

• WOUND EVALUATION

• FLUID RESUSCITATION

• CLOSE MONITORING

• GIT DECOMPRESSION : NGT

WOUND EVALUATION• WOUND TOILET ASSESS DEPTH & EXTENT OF BURN• EXTREMITY

CHECK PULSATION ESCHAROTOMY• DEBRIDEMENT GENERAL ANESTHESIA

FLUID RESUSCITATION

• FORMULA DOESN’T ABSOLUTE.

• CLINICAL MONITORING FROM TIME TO TIME

• BAXTER : 4 ml/Kg BB/ % TBSA

• DIURESIS MONITORING

• BURN 40 % CVP

NUTRITION

• 8 HOUR’S ENTERAL FEEDING NURITION : IF THE GUT WORK USE IT

• PARENTERAL NUTRITION (PN) ONLY IF THERE ISCONTRAINDICATION OR INTOLERANCE TO EN

• HIGH CALORY HIGH PROTEIN

Normal Energy Intake

Energy needed in a normal activity

LimitedEnergy intake

Energy needed in a normal activity

Energy needed in a inflamation conditions

Energy needed in a regenera

tion process

IMMUNONUTRITION• IS SUBSTANCES THAT ENHANCE THE IMMUNE SYSTEM EFFECTS :

- FEWER INFECTIONS COMPLICATION- SHORTER TIME IN VENTILATOR- LOW OF STAYING HOSPITAL

MOST IMPORTANT

• ARGININE, GLUTAMINE,NUCLEOTIDE

& OMEGA 3

• RECOMMENDED 7 DAYS, MINIMUM 3 DAYS

ADMINISTRATION

HOW TO MANAGE BURN DISSASTER

• NO DIFFERENT IN SUPPORT & LIFE THREATENING• NEED MANY PROFESIONAL’S AND

HIGH SKILL IN BURN MANAGEMENT• NEED SPESIFIC SUPPORT FOR :

- ACCOMODATION EVACUATION - TECHNIQUE TO ATTACT THE FIRE - ABLS (ADVANCE BURN LIFE SUPPORT)

THANK YOUTHANK YOU