ambulatory management of burns
TRANSCRIPT
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Ambulatory Management of Burns
ERIC D. MORGAN, MAJ, MC, USA, Esen!o"er Army Me#$al Center, %ort Gor#on,
Georga
SCO&& C. B'EDSOE, C(&, MC, USA, )ee# Army Communty *os+tal, %ort Ir"n,
Calforna
JANE BARER, C(&, MC, USA, Mon$ref Army Communty *os+tal, %ort Ja$-son,
Sout! Carolna
Am %am (!ys$an. /// No0 1234567/189/3.
See relate# +atent nformaton !an#outs on ta-ng $are of burns an#+re0entng burns, "rtten by t!e aut!ors of t!s art$le.
Burns often !a++en une:+e$te#ly an# !a0e t!e +otental to $ause #eat!, lfelong
#s;gurement an# #ysfun$ton. A $rt$al +art of burn management s assessng
t!e #e+t! an# e:tent of n
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!os+tal@aton an# m+lementng measures to +romote !ealng, +re0ent nfe$ton
an# rele0e +an. Durng follo"9u+ $are, t!e fo$us s!fts to lmtng #s;gurement
from s$arrng an# #ysfun$ton from $ontra$tures. Alt!oug! most +atents "t!
burns $an be manage# by famly +!ys$ans, some re?ure surg$al referral for
s-n graftng an# s$ar re!abltaton.
A$ute Management of Burns
It s of +aramount m+ortan$e to #etermne "!et!er a +atent "t! a burn n
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%IGURE .
Dee+ +artal9t!$-ness burns on t!e trun- an# e:tremtes of a young $!l#. &!ese
burns are ty+;e# by easly unroofe# blsters t!at !a0e a "a:y a++earan$e an#
#o not blan$! "t! +ressure.
e" 'arge
%IGURE .
%ull9t!$-ness burn on a "omans left Fan-. Burn areas of t!s ty+e are
$!ara$terst$ally nsensate an# "a:y "!te or leat!ery gray n $olor.
e" 'arge
&AB'E 1 Class;$aton of Burns Base# on De+t!
e" &able
Derentatng a #ee+ +artal9t!$-ness burn from a full9t!$-ness burn $an be
?ute #H$ult ntally.,8,3 Re0sons of burn9#e+t! estmatons are often
ne$essary n t!e ;rst to !ours8 an# may be re?ure# t!roug! t!e ;rst t"o
or t!ree "ee-s. %or nstan$e, alt!oug! a full9t!$-ness burn ty+$ally !as a "!te
or $!arre# a++earan$e, t $an be re# after a s$al# n s a++ro+rate for use n all a#ults an# "!en a ?u$- assessment s
nee#e# for a $!l#.
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More a$$urate met!o#s are re?ure# for #e;nt0e estmaton of t!e e:tent of
burns n $!l#ren. &!e 'un# an# Bro"#er met!o# $o0ers all age grou+s an# s
$ons#ere# t!e most a$$urate met!o# to use n +e#atr$ +atents 4%gure 86.,K
C!art for Estmatng Area of Burns
%IGURE 8.
Mo#;e# 'un# an# Bro"#er $!art for estmatng t!e area of burns. &!s a++roa$!
s $ons#ere# t!e most a$$urate for use n +e#atr$ +atents. &!e ;gures $an be
$olore# n "t! re# for full9t!$-ness burns an# blue for +artal9t!$-ness burns.
4n# L se$on#9#egree burn2 r# L t!r#9#egree burn2 &BSA L total +er$entage of
bo#y surfa$e area6
A#a+te# "t! +ermsson from Mertens DM, Jen-ns ME, )ar#en GD. Out+atent
burn management. Nurs Cln Nort! Am 155273, an# 'un# C, Bro"#er N.
&!e estmaton of areas of burns. Surg Gyne$ol Obstet 152578K.
e" 'arge
&!e surfa$e area of a +atents +alm $an also be use# to estmate t!e e:tent of
small or +at$!y burns. Class$ally, t!e +alm !as been $ons#ere# to re+resent 1
+er$ent of t!e &BSA.,3 *o"e0er, a re$ent stu#y #emonstrate# t!at t!e +alm
more a$$urately re+resents /. +er$ent of t!e &BSA, an# t!e entre !an#
re+resents /.K +er$ent of t!e &BSA.5
IN(A&IEN& &REA&MEN& AND BURN UNI& RE%ERRA'
(atents $ons#ere# to !a0e mo#erate burns base# on t!e gra#ng system
#e0elo+e# by t!e Amer$an Burn Asso$aton 4ABA6 s!oul# be a#mtte# for
ntra0enous !y#raton an# surg$al $are of t!er "oun#s 4&able 6.3,1/ Be$ause
of t!e ntal #H$ultes n #erentatng #ee+ +artal9t!$-ness burns from full9
t!$-ness burns, famly +!ys$ans s!oul# strongly $ons#er obtanng a surg$al
$onsultaton for "!at a++ears to be a #ee+ +artal9t!$-ness burn ae$tng more
t!an +er$ent &BSA.
&AB'E Amer$an Burn Asso$atons Gra#ng System for Burn Se0erty an#
Ds+oston of (atents
e" &able
(ulmonary nsuH$en$y s res+onsble for more t!an 8 +er$ent of ;re9relate#
#eat!s.1 Be$ause of t!e +ossblty of +rogress0e e#ema, +atents "t!sus+e$te# n!alaton n
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*stor$al or +!ys$al ;n#ngs t!at rase $on$ern about n!alaton n
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Management of Burns
%gure 3.
Algort!m for t!e management of +atents "t! burns.
A#a+te# from (eate )%. Out+atent management of burns. Am %am (!ys$an
15528713.
e" 'arge
A systemat$ a++roa$! to t!e ambulatory management of burns s
$on$e+tual@e# by t!e s: =Cs>7 $lot!ng, $oolng, $leanng, $!emo+ro+!yla:s,
$o0erng an# $omfortng 4.e., +an relef6.
Clot!ng. Any $lot!ng t!at s !ot or burne# s!oul# be remo0e# mme#ately from
t!e +atents bo#y. Clot!ng t!at !as been e:+ose# to $!em$als s!oul# also be
remo0e# to a0o# e:+osng t!e s-n to $ontnue# burn nsult. If $lot!ng #oes not
remo0e easly, nona#!erent materal s!oul# be $ut a"ay, "t! a#!erent $lot!ng
left for remo0al n t!e $leanng +!ase.
Coolng. I#eally, burns s!oul# be $oole# mme#ately after t!ey o$$ur. Alt!oug!
most tssue !as alrea#y $oole# by t!e tme +atents "t! burns +resent to a+!ys$an, furt!er $oolng #urng t!e ;rst se0eral !ours after n
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&ar an# as+!alt res#ues s!oul# ne0er be #ebr#e#82 nstea#, t!ey $an be
remo0e# "t! a m:ture of $ool "ater an# mneral ol. A++lyng $o+ous
amounts of +olymy:n Bba$tra$n @n$ ontment 4(olys+orn6 o0er se0eral #ays
s!oul# emulsfy an# remo0e res#ual tar.18 Embe##e# bts of $lot!ng or ot!er
materals s!oul# be remo0e# by $o+ous rrgaton usng a large9gauge syrnge.
&o mnm@e nfe$ton, ne$rot$ tssue from +artal9 an# full9t!$-ness burns s!oul#
be remo0e# manually or "t! "!rl+ool #ebr#ement. &!e latter met!o# ten#s to
be better tolerate# by +atents. &!e yello" es$!ar $!ara$terst$ of +artal9
t!$-ness burns nee# not be remo0e#.
Ru+ture# blsters s!oul# be remo0e#. Many e:+erts re$ommen# unroo;ng
blsters f t!ey $ontan $lou#y Fu# or are l-ely to ru+ture mmnently 4e.g.,blsters lo$ate# o0er
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use# to +re0ent burn nfe$tons. &!s agent s!oul# ne0er be use# on t!e fa$e or
n +atents "t! sulfonam#e !y+ersenst0ty. Be$ause of t!e rs- of sulfonam#e
-ern$terus, sl0er sulfa#a@ne s!oul# not be use# n +regnant "omen, ne"borns
or nursng mot!ers "t! nfants younger t!an t"o mont!s of age.
Ba$tra$n s an alternat0e to+$al +ro+!yla$t$ antbot$. &!s agent s!oul#
al"ays be use# aroun# mu$ous membranes. Be$ause of t!e #e$rease# $ost,
se0eral aut!ors fa0or usng ba$tra$n rat!er t!an sl0er sulfa#a@ne for any
su+er;$al +artal9t!$-ness burn. No stu#es $om+arng t!e eH$a$es of
ba$tra$n an# sl0er sulfa#a@ne !a0e yet been +ubls!e#.
Alternat0es to to+$al antbot$s n$lu#e bolog$ #ressngs 4+gs-n, !uman
allograft6 an# bsmut!9m+regnate# +etroleum gau@e or Bobrane #ressngs. &!ea#0antage of t!ese #ressngs s t!at t!ey are a++le# only on$e. As a result,
+atents are s+are# t!e +an t!at ty+$ally a$$om+anes #ressng $!anges.
Bolog$ #ressngs are asso$ate# "t! lo"er nfe$ton rates an# faster !ealng
rates t!an sl0er sulfa#a@ne. *o"e0er, t!ese #ressngs are e:+ens0e, #H$ult to
a++ly an# not al"ays rea#ly a0alable.1 If use#, bolog$ #ressngs s!oul# be
a++le# "t!n t!e ;rst s: !ours after t!e burn s sustane#. &!e ntal
a++l$aton may loosen by t!e follo"ng #ay, ne$esstatng rea++l$aton.
&!ereafter, t!ese #ressngs gra#ually +eel o as s-n e+t!elal@es un#erneat!t!em. Early se+araton of t!e #ressng from t!e s-n n#$ates t!e +resen$e of a
#ee+er "oun# 4re?urng surg$al treatment6 or an nfe$ton.8
Bsmut!9m+regnate# +etroleum gau@e an# Bobrane #ressngs a++ear to be
a#0antageous treatments an# are a$$e+table for use n young $!l#ren "t!
su+er;$al +artal9t!$-ness burns.1,8 Bot! of t!ese #ressngs are a++le# as a
sngle layer o0er t!e burn an# are t!en $o0ere# "t! a bul-y #ressng. &!e bul-y
#ressng s!oul# be $!ange# e0ery ot!er #ay, ty+$ally n a +!ys$ans oH$e, "t!
$lose assessment of t!e "oun# for sgns of nfe$ton.
Co0erng. Dogmat$ re$ommen#atons regar#ng t!e ty+e an# #uraton of
#ressng $annot be ma#e be$ause of t!e +au$ty of stu#es on t!e sub
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Su+er;$al burns #o not re?ure "oun# #ressngs. Use of a sm+le s-n lubr$ant
4e.g., aloe 0era $ream6 s suH$ent, an# +atents s!oul# be nstru$te# to see t!er
+!ys$an f any blsters #e0elo+.
All +artal9 an# full9t!$-ness burns s!oul# be $o0ere# "t! sterle #ressngs. A
;ne mes! gau@e 4e.g., &elfa6 s!oul# be a++le# after t!e burn !as been $leane#
an# a t!n layer of to+$al antbot$ !as been a++le#. Cr$ulatory m+arment s
mnm@e# by a++lyng t!s nona#!erent #ressng n su$$ess0e str+s, rat!er
t!an "ra++ng t aroun# t!e "oun#.13 &!e #ressng s !el# n +la$e "t! a
tubular net ban#age or lg!tly a++le# gau@e "ra+s. &ubular net ban#ages $ome
n a 0arety of s@es. &!s ban#age s e:$ellent for use on e:tremtes, an# t $an
be mo#;e# to ;t t!e trun- of a younger $!l#.
Re$ommen#e# fre?uen$es for #ressng $!anges range from t"$e #aly to on$e a
"ee-.3 Dressngs s!oul# be $!ange# "!ene0er t!ey be$ome soa-e# "t!
e:$ess0e e:u#ate or ot!er Fu#s.8 At ea$! #ressng $!ange, t!e to+$al
antbot$ s!oul# be remo0e# as $om+letely as +ossble usng gentle "as!ngs.
S$rubbng an# s!ar+ #ebr#ement are not ne$essary.8
Comfortng. Analges$s s!oul# be g0en aroun# t!e $lo$- to $ontrol =ba$-groun#>
+an. A$etamno+!en 4&ylenol6 an# nonstero#al ant9nFammatory #rugs 4alone
or n $ombnaton "t! o+o#s6 are often a++ro+rate for use n +atents "t!small burn "oun#s.3 As+rn +ro#u$ts s!oul# be a0o#e# be$ause of +latelet
n!bton an# t!e rs- for blee#ng.
(atents "t! burns often re?ure a =res$ue> me#$aton 4e.g., a$etamno+!en
"t! $o#ene &ylenol ) Co#eneP or a stronger nar$ot$ e.g., mor+!neP6 before
#ressng $!anges an# #urng n$rease# +!ys$al a$t0ty.3 Nar$ot$ me#$atons
$an be use# n $!l#ren as "ell as a#ults.1,13,
A +atents "orst +an s$ore s!oul# be less t!an 8 4on a s$ale of @ero to 1/6.
S$ores of 8 or !g!er nterfere "t! slee+, a$t0ty an# moo#.K
%ollo"9U+ Care for Burns
%ollo"9u+ $are n0ol0es sur0eyng +atents "t! burns for sgns of nfe$ton,
s$arrng an# $ontra$ture. &o mnm@e furt!er #amage, nfe$ton s best manage#
n a !os+tal. S$arrng an# $ontra$tures $onnote long9term #s;gurement an##sablty, bot! of "!$! are n#$atons for s+e$al@e# $are.
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%O''O)9U( IN&ERA'S
(atents "t! burns "!o are beng manage# as out+atents s!oul# be seen agan
on t!e #ay after n &!s s not ne$essarly t!e $ase
"t! burns. Alt!oug! t!e t!reat of nfe$ton an# t!e magntu#e of +an #mns!
"t! tme, t!e +ros+e$ts for long9term s$arrng an# #sablty often be$ome more
a++arent. *y+ertro+!$ s$arrng s t!oug!t to be ne0table "!en e+t!elal@aton
ta-es longer t!an t"o "ee-s n bla$-s an# young $!l#ren, or longer t!an t!ree
"ee-s n all ot!er +atents.5
A++l$aton of +ressure to burn "oun#s s generally re$ommen#e# to mnm@e
!y+ertro+!$ s$arrng, alt!oug! o+tmal +ressure an# #uraton !a0e not yet been
#etermne# n $ontrolle# trals./ A 0arety of te$!n?ues are use#, but all are
$om+le: an# $ostly. &!erefore, famly +!ys$ans often refer +atents at rs- for
s$arrng to a burn s+e$alst. Be$ause +ressure +re0ents s$ars but #oes not treat
t!em on$e t!ey #e0elo+, referral s!oul# be ntate# +rom+tly at t!e ;rst sgn of
!y+ertro+!$ s$arrng or f a "oun# msses $ertan e+t!elal@aton mlestones
4&able 6.1
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&AB'E )oun# E+t!elal@aton Mlestones
e" &able
Alt!oug! +ressure #oes lttle to remo#el e:stng !y+ertro+!$ s$ars, t!e
a++l$aton of sl$one gel s!eetng !as been foun# to sgn;$antly re#u$e
establs!e# s$ars as late as 1 years after n
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It$!ng s a $ommon +roblem #urng t!e !ealng +ro$ess. (rurtus s often
trggere# or "orsene# by en0ronmental e:tremes 4es+e$ally !eat6, +!ys$al
a$t0ty an# stress.3 &!e t$!ng usually #mns!es gra#ually an# e0entually
sto+s after $om+lete "oun# !ealng.3 Untl t!en, a number of measures $an be
em+loye# to $ontrol t$!ng. System$ ant!stamnes are usually tre# ;rst, "t!
#+!en!y#ramne 4Bena#ryl6 use# most fre?uently.8,3 Cy+ro!e+ta#ne 4(era$tn6
an# !y#ro:y@ne 4Atara:6 are alternat0es.3 'o$al measures n$lu#e b$arbonate
of so#a bat!s an# mostur@ng lotons.8 Many +atents +refer to "ear loose, soft,
$otton $lot!ng.3
In a##ton to !el+ng +atents $o+e "t! long9term +!ys$al #s$omfort, famly
+!ys$ans s!oul# be alert for +sy$!olog$ ssues. (atents "!o !a0e sustane#
burns are at n$rease# rs- for an:ety, #e+resson an# +ost9traumat$ stress
#sor#er. %amly #ynam$s $an also $!ange #ramat$ally. %amly members may be
str$-en "t! gult, an# +atents are sus$e+tble to #e+en#en$y ssues be$ause of
t!e a##tonal !el+ re?ure# for #aly a$t0tes "!le !ealng s o$$urrng. If a
+sy$!olog$ ssue s not$e#, a++ro+rate treatment s!oul# be m+lemente#.
&!e Aut!ors
ERIC D. MORGAN, MAJ, MC, USA, s res#en$y #re$tor for t!e De+artment of
%amly an# Communty Me#$ne at Esen!o"er Army Me#$al Center, %ort
Gor#on, Ga. *e re$e0e# !s me#$al #egree from 'oma 'n#a 4Calf.6 Un0ersty
S$!ool of Me#$ne an# $om+lete# a famly +ra$t$e res#en$y at &r+ler Army
Me#$al Center, *onolulu. *e also earne# a master of +ubl$ !ealt! #egree from
t!e Un0ersty of )as!ngton, Seattle, an# $om+lete# a fa$ulty #e0elo+ment
fello"s!+ at Ma#gan Army Me#$al Center, %ort 'e"s, )as!.
SCO&& C. B'EDSOE, C(&, MC, USA, s a sta +!ys$an at t!e %amly (ra$t$e
Cln$, )ee# Army Communty *os+tal, %ort Ir"n, Calf. *e gra#uate# from
r-s0lle 4Mo.6 College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly
+ra$t$e res#en$y at Esen!o"er Army Me#$al Center.
JANE BARER, C(&, MC, USA, s a sta famly +!ys$an at t!e %amly *ealt!
Center, Mon$ref Army Communty *os+tal, %ort Ja$-son, S.C. S!e gra#uate#
from r-s0lle College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly
+ra$t$e res#en$y at Esen!o"er Army Me#$al Center.
A##ress $orres+on#en$e to Er$ D. Morgan, MAJ, MC, USA, Res#en$y Dre$tor,
De+artment of %amly an# Communty Me#$ne, Esen!o"er Army Me#$al
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Center, %ort Gor#on, GA /5/89838/ 4e9mal a##ress7
Er$.MorganQse.ame##.army.ml6. Re+rnts are not a0alable from t!e aut!ors.
&!e o+nons an# assertons $ontane# !eren are t!e +r0ate 0e"s of t!e
aut!ors an# are not to be $onstrue# as oH$al or as reFe$tng t!e 0e"s of t!e
Army Me#$al De+artment or t!e Army Ser0$e at large.
&!e +!otogra+!s n ;gures 1 t!roug! "ere +ro0#e# by Ste0e Bra$$ of t!e
Jose+! M. Stll Burn Center at Do$tors *os+tal, Augusta, Ga.
&!s art$le s #e#$ate# to Elsabet! Morgan, t!e #aug!ter of Dr. Er$ D. Morgan.
Elsabet! sustane# a se0ere s$al# n
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3. *artfor# CE. Care of out+atent burns. In7 *ern#on DN, e#. &otal burn $are.
(!la#el+!a7 Saun#ers, 155371K/.
. *emba$! D, Mann R, Engra0 '. E0aluaton of t!e burn "oun#. Management
#e$sons. In7 *ern#on DN, e#. &otal burn $are. (!la#el+!a7 Saun#ers, 15537K1
.
K. 'un# C, Bro"#er N. &!e estmaton of areas of burns. Surg Gyne$ol Obstet.
152578K.
5. (erry RJ, Moore CA, Morgan DB, (lummer D'. Determnng t!e a++ro:mate
area of a burn7 an n$onssten$y n0estgate# an# re9e0aluate#. BMJ.15532171K.
1/. *os+tal an# +re!os+tal resour$es for o+tmal $are of +atents "t! burn
n
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1. (us!-ar NS, San#ormns-y B(. Col# treatment of burns. Burns In$l &!erm In
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K. Cleelan# CS, Ryan M. (an assessment7 global use of t!e Bref (an
In0entory. Ann A$a# Me# Snga+ore. 1552715K.
5. Det$! EA, )!eela!an &M, Rose M(, Clot!er J, Cotter J. *y+ertro+!$ burn
s$ars7 analyss of 0arables. J &rauma. 15K27K58K.
/. Muller MJ, *ern#on DN. &!e $!allenge of burns. 'an$et. 1552713/.
1. Carr9Collns JA. (ressure te$!n?ues for t!e +re0enton of !y+ertro+!$ s$ar.
Cln (last Surg. 1552157.
. A!n S&, Monafo )), Mustoe &A. &o+$al sl$one gel for t!e +re0enton an#
treatment of !y+ertro+!$ s$ar. Ar$! Surg. 15512137558/.
. unn J. Sl$one gel n s$ar treatment. Burns In$l &!erm In
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Mana
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'u-a ba-ar #a+at meng!an$ur-an lu-a yang menga-bat-an -ematan atau lu-a
seumur !#u+, $a$at #an #sfungs. 'u-a ba-ar a#ala! +enyebab utama -etga
-ematan -arena -e$ela-aan # Amer-a Ser-at 4setela! ns#en yang melbat-an
-en#araan bermotor #an sen
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Gambar 1.
'u-a ba-ar su+er;sal +a#a batang #an lengan -anan #ar ana- mu#a. Basanya,
n a#ala! lu-a ba-ar mera! yang memut!-an #engan te-anan.
'!at besar
Gambar .
Su+er;$al +artal9t!$-ness memba-ar lutut -anan +ra. &er- lu-a yang
memut!-an #engan te-anan meru+a-an -ara-terst- #ang-al +arsal9-etebalan
lu-a ba-ar. 'u-a n
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'UAS A BURN
'uasnya lu-a ba-ar #nyata-an sebaga +ersentase total luas +ermu-aan tubu!
4&BSA6 ter-ena $e#era. Estmas a-urat #ar &BSA #ar lu-a ba-ar sangat +entng
untu- membmbng mana
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(asen #angga+ meml- lu-a ba-ar mo#erat ber#asar-an sstem +enlaan yang
#-embang-an ole! Amer$an Asso$aton Ba-ar 4ABA6 !arus #a-u untu- !#ras
ntra0ena #an +era"atan be#a! lu-a mere-a 4&abel 6 .3,1/ arena -esultan
a"al #alam membe#a-an +artal9 #alam -etebalan lu-a ba-ar #ar full9t!$-ness
lu-a ba-ar, #o-ter -eluarga !arus mem+ertmbang-an men#a+at-an -onsultas
be#a! untu- a+a yang tam+a-nya men
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ba-ar Immerson a#ala! lu-a ba-ar -las- #alam +ele$e!an ana-, teta+
+ele$e!an !arus #$urga #engan $e#era mele+u!, terutama
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ba-ar saat !a#r untu- #o-ter, +en#ngnan leb! lan
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emo+ro;la-ss. Imunsas tetanus !arus #+erbaru +a#a +asen #engan lu-a
leb! #alam #ar burn. +arsal9-etebalan #ang-al
Men#agnoss nfe-s +a#a +asen #engan lu-a ba-ar menantang. 'u-a ba-ar
menmbul-an +era#angan, yang meng!asl-an rngan ertema, e#ema, rasa sa-t
#an nyer. J-a tan#a9tan#a n ter
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Dressng bologs ber!ubungan #engan tng-at nfe-s yang leb! ren#a! #an
tng-at +enyembu!an leb! $e+at #ar sulfa#a@n +era-. Namun, #ressng n
ma!al, sult untu- menera+-an #an t#a- selalu mu#a! a0alable.1 J-a
#guna-an, #ressng bologs !arus #tera+-an #alam enam
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#engan e-su#at yang berleb!an atau Fu#s.8 lannya (a#a seta+ +eruba!an
ras, antbot- to+-al !arus #!a+us seleng-a+ mung-n mengguna-an
+embasu!an lembut. S$rubbng #an #ebr#ement ta
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$m, +asen !arus #ru
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ontra-tur S$ar menyebab-an $a$at #an $a$at. J-a ter#ete-s #n, $ontra$ture
#a+at #obat #engan ss+an sl-on #an te-anan. J-a $ontra$ture leb! ma
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Selan membantu +asen mengatas -et#a-nyamanan ;s-
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%oto9foto #alam ang-a 1 sam+a yang #se#a-an ole! Ste0e Bra$$ #ar Jose+!
M. Mas! Burn Center # Ruma! Sa-t Do-ter, Augusta, Ga.
Art-el n ##e#-as-an untu- Elsabet! Morgan, +utr Dr Er$ D. Morgan.
Elsabet! mengalam $e#era +ara! mele+u! lama setela! ulang ta!un
+ertamanya. Mes-+un -ult Elsabet! +ermanen men$ermn-an trage#
-e$ela-aan #an tela! selamanya +e-a aya! #o-ternya #engan -engeran lu-a
ba-ar, -euletan nya, 0taltas #an su-a$ta bag -e!#u+an a#ala! bu-t
-emam+uan -e!en#a- manusa #an -e+rba#an untu- men
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K 'un# C, Bro"#er N. Estmas #aera! lu-a ba-ar. Surg Gyne$ol Obstet. 152 57
89K.
5. (erry RJ, Moore CA, Morgan DB, (lummer D'. Menentu-an ta-sran luas lu-a
ba-ar7 n-onsstens #sel#- #an re9e0aluas. BMJ. 15532 17 1K.
1/ Ruma! Sa-t #an sumber #aya +ra9ruma! sa-t untu- +era"atan o+tmal
+asen #engan lu-a ba-ar7 +e#oman untu- +engembangan #an +engo+erasan
+usat lu-a ba-ar. Amer-a Ba-ar Asso$aton. J Ba-ar (era"atan Re!abl. 155/2
117 5K91/.
11. Monafo )). Mana
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1K. All"oo# JS. Mana
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5. Det$! EA, )!eela!an &M, Rose M(, Clot!er J, Cotter J. *y+ertro+!$ be-as
lu-a ba-ar7 analss 0arabel. J &rauma. 15K2 7 K589K.
/. Muller MJ, *ern#on DN. &antangan lu-a ba-ar. 'an$et. 1552 7 139/.
1. Carr9Collns JA. &e-n- te-anan untu- +en$ega!an +arut !+ertro;-. Cln (last
Surg. 1552 157 9.
. A!n S&, Monafo )), Mustoe &A. Gel sl-on to+-al untu- +en$ega!an #an
+engobatan be-as lu-a !+ertro;-. Ar$! Surg. 15512 137 5598/.
. unn J. Gel sl-on #alam +engobatan be-as lu-a. &ermasu- lu-a ba-ar
&!erm In
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See relate# +atent nformaton !an#outs on ta-ng $are of burns an#
+re0entng burns, "rtten by t!e aut!ors of t!s art$le.
Burns often !a++en une:+e$te#ly an# !a0e t!e +otental to $ause #eat!, lfelong
#s;gurement an# #ysfun$ton. A $rt$al +art of burn management s assessng
t!e #e+t! an# e:tent of n
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a$$urate #etermnaton of t!e #e+t! an# e:tent of t!e "oun#4s6, as "ell as
$ons#eraton of $rt$al ssues su$! as s-n t!$-ness, burn lo$aton an#
$omorb# $on#tons.
DE(&* O% A BURN
&!e tra#tonal $lass;$aton of burns as ;rst, se$on# or t!r# #egree s beng
re+la$e# by t!e #esgnatons of su+er;$al 4%gure 16, su+er;$al +artal t!$-ness
4%gure 6, #ee+ +artal t!$-ness 4%gure 6 an# full t!$-ness 4%gure 6. Burn
#e+t! !as an m+a$t on !ealng tme, t!e nee# for !os+tal@aton an# surg$al
nter0enton, an# t!e +otental for s$ar #e0elo+ment. Alt!oug! a$$urate
$lass;$aton s not al"ays +ossble ntally, t!e $auses an# +!ys$al
$!ara$terst$s of burns are !el+ful n $ategor@ng t!er #e+t! 4&able 16.
Gambar 1.
Su+er;$al burns on t!e trun- an# rg!t arm of a young $!l#. &y+$ally, t!ese are
re# burns t!at blan$! "t! +ressure.
'!at besar
%IGURE .
Su+er;$al +artal9t!$-ness burn on a mans rg!t -nee. Blsterng "oun#s t!at
blan$! "t! +ressure are $!ara$terst$ of su+er;$al +artal9t!$-ness burns.
&!ese "oun#s are also ty+$ally most an# "ee+ng.
'!at besar
%IGURE .
Dee+ +artal9t!$-ness burns on t!e trun- an# e:tremtes of a young $!l#. &!ese
burns are ty+;e# by easly unroofe# blsters t!at !a0e a "a:y a++earan$e an#
#o not blan$! "t! +ressure.
'!at besar
%IGURE .
%ull9t!$-ness burn on a "omans left Fan-. Burn areas of t!s ty+e are$!ara$terst$ally nsensate an# "a:y "!te or leat!ery gray n $olor.
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'!at besar
&AB'E 1 Class;$aton of Burns Base# on De+t!
'!at &abel
Derentatng a #ee+ +artal9t!$-ness burn from a full9t!$-ness burn $an be
?ute #H$ult ntally.,8,3 Re0sons of burn9#e+t! estmatons are often
ne$essary n t!e ;rst to !ours8 an# may be re?ure# t!roug! t!e ;rst t"o
or t!ree "ee-s. %or nstan$e, alt!oug! a full9t!$-ness burn ty+$ally !as a "!te
or $!arre# a++earan$e, t $an be re# after a s$al# n s a++ro+rate for use n all a#ults an# "!en a ?u$- assessment s
nee#e# for a $!l#.
More a$$urate met!o#s are re?ure# for #e;nt0e estmaton of t!e e:tent of
burns n $!l#ren. &!e 'un# an# Bro"#er met!o# $o0ers all age grou+s an# s
$ons#ere# t!e most a$$urate met!o# to use n +e#atr$ +atents 4%gure 86.,K
C!art for Estmatng Area of Burns
%IGURE 8.
Mo#;e# 'un# an# Bro"#er $!art for estmatng t!e area of burns. &!s a++roa$!
s $ons#ere# t!e most a$$urate for use n +e#atr$ +atents. &!e ;gures $an be
$olore# n "t! re# for full9t!$-ness burns an# blue for +artal9t!$-ness burns.
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4n# L se$on#9#egree burn2 r# L t!r#9#egree burn2 &BSA L total +er$entage of
bo#y surfa$e area6
A#a+te# "t! +ermsson from Mertens DM, Jen-ns ME, )ar#en GD. Out+atent
burn management. Nurs Cln Nort! Am 155273, an# 'un# C, Bro"#er N.
&!e estmaton of areas of burns. Surg Gyne$ol Obstet 152578K.
'!at besar
&!e surfa$e area of a +atents +alm $an also be use# to estmate t!e e:tent of
small or +at$!y burns. Class$ally, t!e +alm !as been $ons#ere# to re+resent 1
+er$ent of t!e &BSA.,3 *o"e0er, a re$ent stu#y #emonstrate# t!at t!e +alm
more a$$urately re+resents /. +er$ent of t!e &BSA, an# t!e entre !an#
re+resents /.K +er$ent of t!e &BSA.5
IN(A&IEN& &REA&MEN& AND BURN UNI& RE%ERRA'
(atents $ons#ere# to !a0e mo#erate burns base# on t!e gra#ng system
#e0elo+e# by t!e Amer$an Burn Asso$aton 4ABA6 s!oul# be a#mtte# for
ntra0enous !y#raton an# surg$al $are of t!er "oun#s 4&able 6.3,1/ Be$ause
of t!e ntal #H$ultes n #erentatng #ee+ +artal9t!$-ness burns from full9
t!$-ness burns, famly +!ys$ans s!oul# strongly $ons#er obtanng a surg$al
$onsultaton for "!at a++ears to be a #ee+ +artal9t!$-ness burn ae$tng more
t!an +er$ent &BSA.
&AB'E Amer$an Burn Asso$atons Gra#ng System for Burn Se0erty an#
Ds+oston of (atents
'!at &abel
(ulmonary nsuH$en$y s res+onsble for more t!an 8 +er$ent of ;re9relate#
#eat!s.1 Be$ause of t!e +ossblty of +rogress0e e#ema, +atents "t!
sus+e$te# n!alaton n
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*os+tal a#msson s ne$essary for +atents "!o !a0e $r$umferental +artal9
t!$-ness or full9t!$-ness burns, +atents "!o !a0e burn n
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A systemat$ a++roa$! to t!e ambulatory management of burns s
$on$e+tual@e# by t!e s: =Cs>7 $lot!ng, $oolng, $leanng, $!emo+ro+!yla:s,
$o0erng an# $omfortng 4.e., +an relef6.
Clot!ng. Any $lot!ng t!at s !ot or burne# s!oul# be remo0e# mme#ately from
t!e +atents bo#y. Clot!ng t!at !as been e:+ose# to $!em$als s!oul# also be
remo0e# to a0o# e:+osng t!e s-n to $ontnue# burn nsult. If $lot!ng #oes not
remo0e easly, nona#!erent materal s!oul# be $ut a"ay, "t! a#!erent $lot!ng
left for remo0al n t!e $leanng +!ase.
(en#ngn.I#eally, burns s!oul# be $oole# mme#ately after t!ey o$$ur.Alt!oug!
most tssue !as alrea#y $oole# by t!e tme +atents "t! burns +resent to a
+!ys$an, furt!er $oolng #urng t!e ;rst se0eral !ours after n
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be better tolerate# by +atents. &!e yello" es$!ar $!ara$terst$ of +artal9
t!$-ness burns nee# not be remo0e#.
Ru+ture# blsters s!oul# be remo0e#. Many e:+erts re$ommen# unroo;ng
blsters f t!ey $ontan $lou#y Fu# or are l-ely to ru+ture mmnently 4e.g.,
blsters lo$ate# o0er
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su+er;$al +artal9t!$-ness burn. No stu#es $om+arng t!e eH$a$es of
ba$tra$n an# sl0er sulfa#a@ne !a0e yet been +ubls!e#.
Alternat0es to to+$al antbot$s n$lu#e bolog$ #ressngs 4+gs-n, !uman
allograft6 an# bsmut!9m+regnate# +etroleum gau@e or Bobrane #ressngs. &!e
a#0antage of t!ese #ressngs s t!at t!ey are a++le# only on$e. As a result,
+atents are s+are# t!e +an t!at ty+$ally a$$om+anes #ressng $!anges.
Bolog$ #ressngs are asso$ate# "t! lo"er nfe$ton rates an# faster !ealng
rates t!an sl0er sulfa#a@ne. *o"e0er, t!ese #ressngs are e:+ens0e, #H$ult to
a++ly an# not al"ays rea#ly a0alable.1 If use#, bolog$ #ressngs s!oul# be
a++le# "t!n t!e ;rst s: !ours after t!e burn s sustane#. &!e ntal
a++l$aton may loosen by t!e follo"ng #ay, ne$esstatng rea++l$aton. &!ereafter, t!ese #ressngs gra#ually +eel o as s-n e+t!elal@es un#erneat!
t!em. Early se+araton of t!e #ressng from t!e s-n n#$ates t!e +resen$e of a
#ee+er "oun# 4re?urng surg$al treatment6 or an nfe$ton.8
Bsmut!9m+regnate# +etroleum gau@e an# Bobrane #ressngs a++ear to be
a#0antageous treatments an# are a$$e+table for use n young $!l#ren "t!
su+er;$al +artal9t!$-ness burns.1,8 Bot! of t!ese #ressngs are a++le# as a
sngle layer o0er t!e burn an# are t!en $o0ere# "t! a bul-y #ressng. &!e bul-y
#ressng s!oul# be $!ange# e0ery ot!er #ay, ty+$ally n a +!ys$ans oH$e, "t!$lose assessment of t!e "oun# for sgns of nfe$ton.
Co0erng. Dogmat$ re$ommen#atons regar#ng t!e ty+e an# #uraton of
#ressng $annot be ma#e be$ause of t!e +au$ty of stu#es on t!e sub
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tubular net ban#age or lg!tly a++le# gau@e "ra+s. &ubular net ban#ages $ome
n a 0arety of s@es. &!s ban#age s e:$ellent for use on e:tremtes, an# t $an
be mo#;e# to ;t t!e trun- of a younger $!l#.
Re$ommen#e# fre?uen$es for #ressng $!anges range from t"$e #aly to on$e a
"ee-.3 Dressngs s!oul# be $!ange# "!ene0er t!ey be$ome soa-e# "t!
e:$ess0e e:u#ate or ot!er Fu#s.8 At ea$! #ressng $!ange, t!e to+$al
antbot$ s!oul# be remo0e# as $om+letely as +ossble usng gentle "as!ngs.
S$rubbng an# s!ar+ #ebr#ement are not ne$essary.8
Comfortng. Analges$s s!oul# be g0en aroun# t!e $lo$- to $ontrol =ba$-groun#>
+an. A$etamno+!en 4&ylenol6 an# nonstero#al ant9nFammatory #rugs 4alone
or n $ombnaton "t! o+o#s6 are often a++ro+rate for use n +atents "t!small burn "oun#s.3 As+rn +ro#u$ts s!oul# be a0o#e# be$ause of +latelet
n!bton an# t!e rs- for blee#ng.
(atents "t! burns often re?ure a =res$ue> me#$aton 4e.g., a$etamno+!en
"t! $o#ene &ylenol ) Co#eneP or a stronger nar$ot$ e.g., mor+!neP6 before
#ressng $!anges an# #urng n$rease# +!ys$al a$t0ty.3 Nar$ot$ me#$atons
$an be use# n $!l#ren as "ell as a#ults.1,13,
A +atents "orst +an s$ore s!oul# be less t!an 8 4on a s$ale of @ero to 1/6.
S$ores of 8 or !g!er nterfere "t! slee+, a$t0ty an# moo#.K
%ollo"9U+ Care for Burns
%ollo"9u+ $are n0ol0es sur0eyng +atents "t! burns for sgns of nfe$ton,
s$arrng an# $ontra$ture. &o mnm@e furt!er #amage, nfe$ton s best manage#
n a !os+tal. S$arrng an# $ontra$tures $onnote long9term #s;gurement an#
#sablty, bot! of "!$! are n#$atons for s+e$al@e# $are.
%O''O)9U( IN&ERA'S
(atents "t! burns "!o are beng manage# as out+atents s!oul# be seen agan
on t!e #ay after n
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to +ro0#e +ro+er "oun# $are, t!e +atent s!oul# be seen on a #aly bass untl
$om+lete e+t!elal@aton o$$urs.,3
If "oun# e+t!elal@aton !as not begun after t"o "ee-s or f subse?uent
e0aluatons re0eal t!e +resen$e of a full9t!$-ness burn more t!an $m n
#ameter, t!e +atent s!oul# be referre# to a surgeon "t! e:+ertse n burn
$are.,3,18 &ny o+ales$ent slan#s of e+t!elum t!roug!out t!e "oun# n#$ate
e+t!elal@aton, "t! t!e "oun# ty+$ally !ealng $om+letely n se0en to 1/
#ays.3
After e+t!elal@aton !as o$$urre#, +atents are seen e0ery four to s: "ee-s to
assess for e0#en$e of !y+ertro+!$ s$ar formaton an# to montor $o+ng
me$!ansms.
*(ER&RO(*IC SCARRING AND CON&RAC&URES
It !as been sa# t!at =tme !eals all "oun#s.> &!s s not ne$essarly t!e $ase
"t! burns. Alt!oug! t!e t!reat of nfe$ton an# t!e magntu#e of +an #mns!
"t! tme, t!e +ros+e$ts for long9term s$arrng an# #sablty often be$ome more
a++arent. *y+ertro+!$ s$arrng s t!oug!t to be ne0table "!en e+t!elal@aton
ta-es longer t!an t"o "ee-s n bla$-s an# young $!l#ren, or longer t!an t!ree
"ee-s n all ot!er +atents.5
A++l$aton of +ressure to burn "oun#s s generally re$ommen#e# to mnm@e
!y+ertro+!$ s$arrng, alt!oug! o+tmal +ressure an# #uraton !a0e not yet been
#etermne# n $ontrolle# trals./ A 0arety of te$!n?ues are use#, but all are
$om+le: an# $ostly. &!erefore, famly +!ys$ans often refer +atents at rs- for
s$arrng to a burn s+e$alst. Be$ause +ressure +re0ents s$ars but #oes not treat
t!em on$e t!ey #e0elo+, referral s!oul# be ntate# +rom+tly at t!e ;rst sgn of
!y+ertro+!$ s$arrng or f a "oun# msses $ertan e+t!elal@aton mlestones
4&able 6.1
&AB'E )oun# E+t!elal@aton Mlestones
'!at &abel
Alt!oug! +ressure #oes lttle to remo#el e:stng !y+ertro+!$ s$ars, t!e
a++l$aton of sl$one gel s!eetng !as been foun# to sgn;$antly re#u$e
establs!e# s$ars as late as 1 years after n
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res+on#ers from nonres+on#ers. S#e ee$ts of +rurtus an# ras! $an be
mnm@e# by "as!ng t!e s$ar an# a++lyng sl$on gel #aly.
S$ar $ontra$tures result n #s;gurement an# #sablty. If #ete$te# early, a
$ontra$ture $an be treate# "t! sl$one nserts an# +ressure. If t!e $ontra$ture s
more #e0elo+e#, a $ontnuously "orn stat$ s+lnt s a##e# to mantan sustane#
stret$!. On$e full range of moton s a$!e0e#, s+lntng $an be re#u$e# to
ng!ttme use untl t!e s$ar fully matures. Surg$al nter0enton s!oul# be
$ons#ere# f t!e $ontra$ture s not $om+letely re#u$e#.1
RO'E O% SURGER
Surg$al e:$son an# s-n graftng begnnng less t!an !ours after n
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of so#a bat!s an# mostur@ng lotons.8 Many +atents +refer to "ear loose, soft,
$otton $lot!ng.3
In a##ton to !el+ng +atents $o+e "t! long9term +!ys$al #s$omfort, famly
+!ys$ans s!oul# be alert for +sy$!olog$ ssues. (atents "!o !a0e sustane#
burns are at n$rease# rs- for an:ety, #e+resson an# +ost9traumat$ stress
#sor#er. %amly #ynam$s $an also $!ange #ramat$ally. %amly members may be
str$-en "t! gult, an# +atents are sus$e+tble to #e+en#en$y ssues be$ause of
t!e a##tonal !el+ re?ure# for #aly a$t0tes "!le !ealng s o$$urrng. If a
+sy$!olog$ ssue s not$e#, a++ro+rate treatment s!oul# be m+lemente#.
&!e Aut!ors
ERIC D. MORGAN, MAJ, MC, USA, s res#en$y #re$tor for t!e De+artment of
%amly an# Communty Me#$ne at Esen!o"er Army Me#$al Center, %ort
Gor#on, Ga. *e re$e0e# !s me#$al #egree from 'oma 'n#a 4Calf.6 Un0ersty
S$!ool of Me#$ne an# $om+lete# a famly +ra$t$e res#en$y at &r+ler Army
Me#$al Center, *onolulu. *e also earne# a master of +ubl$ !ealt! #egree from
t!e Un0ersty of )as!ngton, Seattle, an# $om+lete# a fa$ulty #e0elo+ment
fello"s!+ at Ma#gan Army Me#$al Center, %ort 'e"s, )as!.
SCO&& C. B'EDSOE, C(&, MC, USA, s a sta +!ys$an at t!e %amly (ra$t$eCln$, )ee# Army Communty *os+tal, %ort Ir"n, Calf. *e gra#uate# from
r-s0lle 4Mo.6 College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly
+ra$t$e res#en$y at Esen!o"er Army Me#$al Center.
JANE BARER, C(&, MC, USA, s a sta famly +!ys$an at t!e %amly *ealt!
Center, Mon$ref Army Communty *os+tal, %ort Ja$-son, S.C. S!e gra#uate#
from r-s0lle College of Osteo+at!$ Me#$ne an# re$ently $om+lete# a famly
+ra$t$e res#en$y at Esen!o"er Army Me#$al Center.
A##ress $orres+on#en$e to Er$ D. Morgan, MAJ, MC, USA, Res#en$y Dre$tor,
De+artment of %amly an# Communty Me#$ne, Esen!o"er Army Me#$al
Center, %ort Gor#on, GA /5/89838/ 4e9mal a##ress7
Er$.MorganQse.ame##.army.ml6. Re+rnts are not a0alable from t!e aut!ors.
&!e o+nons an# assertons $ontane# !eren are t!e +r0ate 0e"s of t!e
aut!ors an# are not to be $onstrue# as oH$al or as reFe$tng t!e 0e"s of t!eArmy Me#$al De+artment or t!e Army Ser0$e at large.
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&!e +!otogra+!s n ;gures 1 t!roug! "ere +ro0#e# by Ste0e Bra$$ of t!e
Jose+! M. Stll Burn Center at Do$tors *os+tal, Augusta, Ga.
&!s art$le s #e#$ate# to Elsabet! Morgan, t!e #aug!ter of Dr. Er$ D. Morgan.
Elsabet! sustane# a se0ere s$al# n
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K. 'un# C, Bro"#er N. &!e estmaton of areas of burns. Surg Gyne$ol
Obstet.152578K.
5. (erry RJ, Moore CA, Morgan DB, (lummer D'.Determnng t!e a++ro:mate
area of a burn7 an n$onssten$y n0estgate# an# re9e0aluate#.
BMJ.15532171K.
1/. *os+tal an# +re!os+tal resour$es for o+tmal $are of +atents "t! burn
n
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15. (ur#ue G%, 'ayton &R, Co+elan# CE. Col# n
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/. Muller MJ, *ern#on DN.&!e $!allenge of burns. 'an$et.1552713/.
1. Carr9Collns JA. (ressure te$!n?ues for t!e +re0enton of !y+ertro+!$ s$ar.
Cln (last Surg. 1552157.
. A!n S&, Monafo )), Mustoe &A. &o+$al sl$one gel for t!e +re0enton an#
treatment of !y+ertro+!$ s$ar. Ar$! Surg. 15512137558/.
. unn J. Sl$one gel n s$ar treatment. Burns In$l &!erm In &!s art$le s one n a seres $oor#nate# by t!e De+artment of
%amly an# Communty Me#$ne at Esen!o"er Army Me#$al Center, %ort
Gor#on, Ga. Guest e#tor of t!e seres s &e# D. E++erly, CO', MC, USA