BURN INJURY

Budhi Arifin Noor, Dion Ade Putra, Oktaviati, Ridho Ardhi Syaiful, Rizky Amaliah, Mursid

Translator: Adrian Salim, Andrio Wishnu Prabowo, Arnetta Naomi L. Lalisang, Julistian, Muliyadi, Sony Sanjaya, Stefanny, Zamzania Anggia Shalih.

General Surgery Department, FKUI/RSCM, Jakarta, Indonesia, May 2011.

CASE ILLUSTRATION

A man, 43 years old came with complaint of burn injury 8 hours before hospital admission. The patient was exposed to flame sparks on the face, body and both upper trunk while working as a construction worker. Patient was holding steel when the steel was exposed to electrical wires and caused fire. The patient was unconscious for 5 minutes and taken to a private hospital, there patient treated with MEBO, RL 1 kolf infusion, urinary catheters, anti-tetanus and analgesics. The patient was then referred to the RSCM due to limited facility.

The primary survey during physical examination was clear airway, spontaneous breathing, vital signs was within normal limits, with GCS 15 (E4M6V5), and on secondary survey there was found burn wounds on the face, neck and chest (see local status). Other physical examinations were within normal limits with height 165 cm, and weight 62 kg. Laboratory tests result showed hemoglobin level of 12.2 g / dL, hematocrit 35%, leukocytes 10,480 / ul, 82.2 fl platelets, albumin 2.2, random blood glucose 152 mg / dl, procalsitonin 16.06 and other laboratory results within normal result. The diagnosis for this patient was second degree burn injury 37.5% wide.

Patient was treated with fluid resuscitation (37.5 x 4 x 62) 9300 ml, 4650 ml within the first 8 hours, and continued with 4650 ml in the next 16 hours and then titrated until the urine output reached 0.5 to 1 ml / kg / hour. Patients were also given co-amoksiklav injection of 3 x 1 gram, ketorolac injection of 3 x 300 mg, ranitidine injection of 3 x 150 mg, and vitamin E injection of 1 x 400 mg. Patients were then consulted to anesthesiologist for CVP installation. After 1 day of treatment in the ER patients were then moved to the RSCM Burn Unit.

LITERATURE REVIEW

Burn injuries can be caused by fire, exposure to high temperature such as the sun, electrocution, chemicals and radiation. Most of burn injuries admitted to RSCM are caused by fire with 56% of the total case, 40% of boiling water, 3% of electrocution and 1% of chemicals.⁵

I.                PATHOPHYSIOLOGY
Areas of burn wounds are divided into three zones, which are coagulation zone, stasis zone and hyperemic zone.^1,2

a.       Coagulation zone
          The tissue in this zone is irreversibly damaged during traumatic burn.
b.       Stasis zone
          There are moderate perfusion disturbances in the area surrounding the necrotic zone. In the stasis zone, there is vascular damage thus causes vascular leakage. 
c.       Hyperemic zone  
          The character of the hyperemic zone is vasodilatation due to
                                                       inflammation process.

 Burn Injury Phases⁵

• Acute Phase / shock phase. The patients may experience disturbance in the airway, breathing and circulation.

• Sub-acute phase, which takes place after the shock phase is resolved. Lost or damaged tissue resulting from contact with the heat source will cause inflammatory process with exudation of plasma protein and infection that can cause sepsis.

• Late Phase occurred after wound closure until maturation. The problem that arises during this phase are scarring, contractures and deformities due to the fragility of tissue or structured organ.

 II.              DIAGNOSIS

a.       Total burn surface area can be evaluated with:

i.      Palmar surface method : the patient’s palmar (including the fingers)  

      measured as 1% of Total Body Surface Area (TBSA).

ii.     Wallace’s Rule Of Nine

iii.   Lund and Browder charts: to measure body shape differences in patient 

       age and asses precise score in burn children.

b.       Age : Infant, children, and adult

c.       Burn Wound Depth

d.       Circumferential Grade II and III Burn Injury cause blood flow restriction at 

        extremities, disturb respiration process if located at chest, therefore 

        escharotomy is needed.

Table 1. Classification of Burn Wound Depth in United States.³

          

        III.         BURN INJURY MANAGEMENT.^4,6

                      Burn injury wound care could be divided into 3 major steps, which are

                      emergency/resuscitation phase, acute phase, and rehabilitation phase.

  Table 2. Categorization of Burns.

1. Acute/shock phase :  to protect patient from the source of burn injury, ABC evaluation, evaluation of any other trauma, fluid resuscitation, urine catheter, nasogastric tube, vital sign and laboratory, pain management, tetanus prophylaxis, administration of antibiotics and wound care.
2. Sub acute phase started when patient is hemodinamically stable. Management for acute phases:  to prevent infection, wound care, and nutrition.
3. Phase rehabilitation : to increase self-sufficiency through the achievement of improved full                                                                                                         functionality.

III.1. Fluid resuscitation.^5,6

III.2. Indication for fluid therapy

Grade 2 or 3 > 25% in adult, burn injury in the face with inhalation trauma and if the patient can not drink. Whereas in children and elderly burn injury grade II or III >15%, the intravenous fluid resuscitation is generally required.

•  Baxter formula  

              First day : TBSA x body weight (kg) x 4 cc (RL)

Second day : coloid : 500-2000cc + glucose 5% to maintain the fluid.

Half the fluid volume is given in the first 8 hours and another halfis given  in the next 16 hours.

III.3. Indications  for hospitalization

-          Grade  2 over 15% in adults and over 10% in children

-          Grade 2 on the face, hands, feet and perineum

-          Grade 3 more than 2% in adults and every grade 3 in children

-          Burns with viscera trauma, bones and airway

III.4. Wound management.^5,7

First burn wound should be washed with a solution of dilute detergent (baby soap), debride the skin that has been damaged. Dry the wound and apply mecurochrom or silver sulfa diazine. In handling the wound required protective material to create an optimal environment for wound healing, protect the wound from bacteria, from the friction and absorb the exudat, this is what we called dressing. There are many kinds of dressings, starting from the traditional (honey) conventional/passive occlusive dressing (opened: mebo cream, silversulfadiazine cream; closed: wet gauze, dry gauze, pembebatan) modern dressing/active occlusive dressing (absorbent cellulosic material, tulle grass dressing and film dressing).

IV. DISCUSSION

In this patient, the diagnosis of Burn injury Grade II A-B was upheld on the grounds that the injuries occurred on dermis; there were blisters, and reddish white colored injury that were very painful. Total burn surface area was 37,5%, it was determined by Lund and Browder charts.

The patients treatment was consist of fluid resuscitation with baxter formula (TBSA x body weight (kg) x 4 cc (RL) in 24 hours), in this case, patient was given 9300 cc for 24 hours, divided into 4650 cc or 50% in the first 8 hours, then 4650 cc or 50% in the next 16 hours. Urine production is needed to be monitored in the resuscitation fluid because it describes the circulation of the fluid and the adequacy of fluid given. Nomally, urine production is 0.5 cc / kg / hour. Installation of CVP is indicated to monitor systemic circulation of fluid resuscitation and to access other solution.

First Day

  

Wound dressing

After seventh day (1)

After seventh day (2)

There is no indication in giving antibiotic for burn injury patients, but this patient was given injections of co-amoksiklav  3 x 1 gram. Analgesic is recommended in burn injury, in this case, the patient was given intravenous ketorolac 3 x 300 mg. Indication for hospitalization on these patients is second-degree burns over 15% and there were wounds on his face and hands.

V. REFERENCES

1. Gallagher JJ, Wolf SE, Herndon DN. Burns. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Editors. Sabiston Textbook of Surgery. 18th Ed. Philadelphia: Saunders Elsevier. 2008.
2. Gibran NS. Burns. In: Mulholland MW, Lillemoe KD, Doherty GM, Gerard M, Ronald V, Upchurch GR. Editors. Greenfield’s Surgery: Scientific Principles and Practice. 4th Ed. Philadelphia: Lippincott Williams and Wilkins. 2006.
3. Klein MB. Thermal, Chemical and Electrical Injuries. In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL. Editors. Grab and Smith’s Plastic Surgery. 6th Ed. Philadelphia: Lippincott Williams and Wilkins. 2007.
4. Hettiaratchy S, Dziewulsky P. ABC Burns. BMJ 2004; 328: 1427-9.
5. Reksoprodjo S dkk (ed). Kumpulan Kuliah Ilmu Bedah. Jakarta: Binarupa Aksara Publisher.
6. Herndon, David N. Total Burn Care 3rd edition. Saunders Elsevier.
7. Grunwald TB, Garner WL. Acute Burns Plast Reconstr Surg. 2008(121):311.