CHAPTER I

CASE PRESENTATION

I. IDENTITY
th
Date of hospital entry : November 15 2012
Name : An. N
Age : 7 years
Gender : Female
Occupation :-
Addres : Wan Jaya
Religion : Islam
Marital status : Married

II. ANAMNESIS
Main complaint
Burns on the right thigh.
History of disease
The patient came to Arjawinangun Regional Hospital with complaints of burns due to
being scalded by hot water , ± 8 hour ago. the patient accidentally spills boiled hot water
and hits the patient's right thigh. There are red marks on the skin and a bubbly skin
filled with fluid
History of past disease
-
History of family disease
there is no family members with the same disease as patient.
III. PHYSICAL EXAMINATION
a. Present Status
Awareness : Compos mentis
Blood pressure : 120/80 mmHg
Pulse : 90 x/minute
Breathing : 20 x/minute
Temperature : 36,7 oC
 Head
Shape : Normocephale, symmetrical
Hair : Black
Eye : Pupil isokor Ø 3mm / 3mm, light reflex (+ / +), conjunctiva
inferior eyelid pale (- / -), sclera jaundice (- / -)
Ear : Normal shape, cerumen (-), intact thympany membrane

Nose : Normal shape, septum deviation (-), epitaxis(-/-)


Mouth : Within normal limits

Thorax

Lungs – pulmonary


Inspection : The chest is symmetrical both left and right


Palpation : Fremitus vocale and tactile are symmetrical,

crepitation (-), tenderness (-), rebound tenderness (-)

Percussion : Resonance sound in both lung fields


Auscultation : Vesicular and bronchial sound in the entire lung field, ronchi (-
/-), wheezing (-/-)
Upper Extremity : within normal limits

b. Localized Status
Abdomen
Inspection : Flat, follow the motion of breath, skin color is equal to about.
Darm Contour (-), Darm Steifung (-)
Auscultation : Peristaltic (+) decreased impression
Palpation : Mass Tumor (-), Pain Press (-)
Hepatic / Lien was not palpable.
Percussion : Timpani

Lower Extremity : Bullae (+) Basic pale red on right thigh

c. Laboratory Examination
EXAMINATION RESULTS REFERENCE
 Complete blood
hb 12.0 12-16
Ht 41.1 37-47
Leukocytes 7,500 4000-11000
platelets 331 000 150000-450000

Calculate Type leukocytes

eosinophils 2 1.0 to 3.0
basophils - 0-1.0
neutrophils 80 50.0 to 70.0
lymphocytes 15 20.0 to 40.0
monocytes 3 2.0 to 8.0

IV. DIAGNOSIS
Combutio grade II

V. TREATMENT
IVFD RL 15 tpm macro
Cef Oximeter 3 x 700 mg
Ketorolac ½ amp 2 x 15 mg
Ranitidin 2 x 1 5 mg
Bernadzin ointment

VI. PROGNOSIS
Ad vitam : ad bonam
Ad sanationam : ad bonam
Ad fungsionam : ad bonam
 CHAPTER II

LITERATURE REVIEW

DEFINITION
Burns are fairly common injuries. The type and weight show morbidity and a relatively high
degree of disability compared to injury due to other causes.

ETIOLOGY

 Flame in the body (flame)

 Flame to the body (flash)

 Exposed to hot water (scald)

 Touched by a hot object (hot contact)

 Due to electric shock

 Due to chemicals

 Sunburn (sun burn)

Burn area is expressed as a percentage of body surface area. To calculate quickly used Rule of
Nine from Wallace . Calculation of this method can only be applied to adults, because children
have different body proportions. For the purposes of medical records, used cards of burns
by way LUND & Browder. 1 , 8
Burn area calculation based on "Rule of Nine" by Polaski and Tennison from WALLACE:
1. Head and neck: 9%
2. Upper limb: 2 x 9% (left and right)
3. Thighs and calves: 4 x 9% (left and right)
4. Chest, stomach, back, buttocks: 4 x 9%
5. Perineum and genitalia: 1%

In an emergency, you can use the quick way by using the patient's palm. The principle is that
the area of the palm = 1% of the body area.
CLASSIFICATION
LB sufferers can be classified based on the depth of the burned tissue. This classification is
always associated with the surface area of the body that is burning and we know it as the degree
of burns. The degree of the burn is determined by the depth of body tissue damaged by heat
trauma and depends on the following 2 factors :
1. Intensity and duration of heat on the body.
2. Heat propagation in the network (influenced by the nature of the local network).

Tissues that are not able to propagate heat will suffer severe damage (necrosis)
otherwise the tissue that can carry heat to the surrounding tissue that contains enough water
will quickly lower the temperature so that the damage can be lighter.

"Pin
Damaged prick"
Classification Clinical Cured time Results
tissue Needle
Test

I Epidermis Hyperalgesi 7 days Normal

 Red
 Dry

II Most of the Pain red / Hyperalgesi 7-14 days Normal, pale,

Shallow dermis, yellow, wet, or normal spotted
follicles, bull
hair and
sweat glands
are intact

In Only sweat Pain red / Hypoalgesi 14 - 31 days Pale,

glands are yellow, wet, depigmented,
intact bull flat, shiny,
 hair (-),
cicatrix,
hypertrophy

III Whole Not sick, Analgesia 21 days of Cicatrix,

dermis white, brown, persekundam hypertrophy
black, dry

For the purposes of the clinic there is also a classification based on the thickness of the skin
damage wound and whether or not a LB sufferer receives intensive care, namely: 3
1. Partial - thickness burn burns.
2. Burns all over thick skin (full thickness burn).

PATHOPHYSIOLOGY

In burns, changes in temperature in the body occur either due to conditions of direct heat or
electromagnetic radiation. The degree of the burn is related to a number of factors, including
the condition of the tissue affected during contact with heat sources and surface
pigmentation. Nerves and blood vessels are structures that are less resistant to heat conduction,
while bones are the most resistant. Sources of electromagnetic radiation include X-rays,
microwaves, UV rays and visible light. This radiation can damage tissue either by heat
(microwaves) or ionization (X-rays).
The cells can withstand temperatures up to 44oC without significant damage. Between 44oC-
51oC, the speed of tissue damage multiplies for each degree of temperature rise and the limited
exposure time that can be tolerated. Above 51oC, the protein undergoes denaturation and tissue
damage is very severe. Temperatures above 70oC cause cellular damage very quickly and only
the irradiation period can be held. In the lower heat range, the body can release heat energy by
changing circulation, but at a higher heat range, this is ineffective.
Metabolism Response to Burns
Secretions of catecholamines, cortisol, glucagon, renin angiotensin, antidiuretic hormone, and
aldosterone are increased. Energy comes from the breakdown of glycogen deposits and the
anaerobic glycolysis process.
Hypermetabolism often occurs in the period after the burn. The signs are doubling the basala
rate.
Evaporation of water can reach 300 mL / m2 / hour (normal 15 mL / m2 / hour.

DIAGNOSIS
History:
A history of exposure to sunlight, fire, hot water, chemicals, electricity, radiation or cold
temperatures. It should be asked clearly the date, time and geographical location of the
injury. It is also necessary to know the patient's condition before illness, previous chronic
diseases, coronary artery disease, DM, chronic lung disease, cerebrovascular disease, and
AIDS , because they worsen the prognosis.

Physical examination :
The first proper observation can recognize difficulties such as severe inhalation injury, which
causes damage to the upper airway and obstruction, or carbon monoxide poisoning that is
approaching lethal. A thorough second observation can detect any other injuries that
accompany it.

Supporting examination :
Complete blood counts, electrolytes and standard biochemical profiles need to be obtained
immediately. AGD and carboxyhemoglobin need to be measured immediately because the
administration of oxygen can mask the severity of carbon dioxide poisoning experienced by
patients.

MANAGEMENT
The first attempt when burning is to put out the fire in the body, for example by covering and
covering the burned area to stop the supply of oxygen in the burning fire. Victims can try to
quickly drop themselves and roll over so that the burned parts do not expand. Contact with a
hot branch must also be quickly terminated, for example by dipping a burned part or throwing
yourself in cold water, or removing a hot-soaked shirt. The first aid after the heat source has
been removed is to soak the burn area in water or flush it with running water for at least fifteen
minutes. The process of coagulation of cell proteins in high-temperature exposed tissue
continues after the fire is extinguished so that destruction is rapidly spread. This process can
be stopped by cooling the burned area and maintaining this cold temperature in the first
hour. Therefore, immersing the burned part during the first fifteen minutes in water is very
beneficial for lowering the temperature of the tissue so that the damage is shallower and
minimized. Thus, the actual wound to second degree can stop at the first level. Dipping and
watering can be done with any cold water that does not need to be sterile.
The cooling of the burn must be done as soon as possible and is long enough . In mild baker
wounds, the principle of treatment is to cool the burned area with water, prevent infection and
allow the remaining epithelial cells to proliferate, and seal the wound surface. Wounds can be
treated closed or open. In severe burns, in addition to general treatment such as minor burns,
resuscitation is done immediately if the patient shows symptoms of shock, if the patient shows
symptoms of burning airways, given a mixture of moist air and oxygen. If laryngeal edema
occurs, endotracheal tube or tracheostomy is installed. Tracheostomy functions to free the
airway, reduce dead space, and facilitate the cleaning of the airway from mucus or dirt. If there
is suspicion of CO poisoning, pure oxygen is given. Local treatment is applying the wound
with an antiseptic and leaving it open for open treatment or covering it with a sterile dressing
for closed treatment. If necessary, the patient is bathed first, the patient is bathed
first. Furthermore, tetanus prevention is given in the form of ATS and / or toxoid. Analgesics
are given if the patient is in pain.

Resuscitation in Burn Patients

Basic therapy for patients with large burns by avoiding complications of fluid and electrolyte
deficiency in the early post-burn period. Determination of the percentage of TBSA wound
becomes the initial stage in calculating fluid requirements. Also the patient must be weighed
at the beginning of therapy to determine the basic weight as a guideline for therapy. Urine
catheters are used as an index of renal perfusion and to evaluate the effectiveness of fluid
resuscitation. In patients with pulmonary inhalation burns or in patients with cardiovascular
and pulmonary disease, central pressure monitoring with a Swan-Ganz catheter should be
carried out.
The two systems most commonly used in calculating fluid requirements today are the
Modification of Brooke and Parkland. Both of these formulas calculate fluid requirements
based on the area of the burns multiplied by the patient's weight in kilograms, multiplied by
the volume of RL solution to be given within 24 hours after the burn. In both calculations, half
the amount of fluid was given in the first 8 hours of resuscitation, a quarter of the total amount
originally given every 8 hours later. The recommended RL solution volumes in the modified
Brooke and Parkland formula are 4cc kg per burn and 2 cc per kg percent of large wounds ,
respectively. Both provide enough fluid for the initial calculation of resuscitation needs, as seen
with success in most patients. But doctors who participate in managing burn resuscitation
patients should be aware that each formula can be used only as a guide to determine fluid
requirements. Careful and careful monitoring of the sensorium, urine output, and central
vascular pressure with subsequent therapeutic changes in fluid therapy determined by the
patient's response, is an appropriate resuscitation method. Changes in consciousness in the
early post burns in patients with normal arterial blood gas, should make doctors aware of a
decrease in cerebrovascular flow. Urine output should be 30-50 cc per hour in people with
well-hydrated burns, with normal kidney function. If urine output is low or cardiovascular
instability in intravenous volumes that appear to be quite large, installation of Swan-Ganz
thermodiluted catheters to monitor left and right heart pressure and cardiac output is
appropriate. Although these catheters can cause vascular and septic complications, their
benefits often outweigh the risks of short-term use during initial resuscitation.
Resisutation in children requires parameter changes. The same formula can be used based on
body weight in kilograms multiplied by the TBSA percentage of a chart such as the Lund-
Bower chart. Overall fluid requirements for the first 24 hours 3 ml per kg per TBSA and given
half in the first 8 hours and a quarter in each subsequent hour. Sodium bicarbonate is added to
each liter of RL. Adequate fluid resuscitation can be checked by monitoring vital signs and
urine output. In children, weighing 30 kg or less, urine output must remain 1ml per kg per hour.
The best way to determine the initial fluid requirement for burn sufferers is to use 2-4ml per
kg, per TBSA. This range can be used as a guideline for administering fluids based on the
perfusion index.2

Post Resuscitation Period

24-hour intravenous fluids need to be accompanied by glucose and hypotonic saline
to replace losses caused by evaporation and plasma protein is also given to maintain adequate
circulation volume. Evaporation will continue to be considered until the wound has healed or
skin grafted. Can be estimated with (25 x% burn) x m2 TBS
The treatment aims to reduce the stimulation of catecholamines and provide enough calories to
counteract the effects of hypermetabolism. Hypothermia, pain and anxiety must be tightly
controlled. Hypovolemia must be prevented with adequate fluids.
Nutrition can be started as early as possible to maximize wound healing and minimize immune
deficiency.
Prophylaxis of penicillin in burn patients is controversial.
Vitamins A, E, C and Zinc are given until the wound is closed. Low doses of heparin may also
be beneficial as in patients with soft tissue injuries

Post Burn Injury Problems

After recovering from the wound, the next problem is due to scar tissue that can develop into
severe disabilities, skin contractures can interfere with function and cause joint stiffness, or
cause aesthetic disability that is very bad, especially if the scar is in the form of keloids. Joint
stiffness requires an intensive physiotherapy program and contractures that require surgery. In
severe aesthetic defects it may be necessary for a psychiatrist to restore the patient's confidence,
and help the reconstruction surgeon, especially if the defect involves the face or hands. If burns
damage the airway due to inhalation, ateletaxis, pneumonia, or post-traumatic lung
function insufficiency can occur .

Electric shock
Accidents due to electric currents can occur due to electric current flowing through the body,
due to current jumps or due to high voltage, among others due to lightning.

Electric current
Electric current causes abnormalities due to stimulation of nerves and muscles. The heat energy
that arises due to the resistance of the tissues through which the current causes burns on the
tissue. The heat energy from high voltage electric current jumps on the body will cause deep
burns because the temperature of electric sparks can reach 2,500 C. Strong tetanic spasms in
the muscles skeletons can cause vetebral compression fractures, in the chest muscles (m,
intercostal) this condition causes breathing movements to stop so that the patient can
experience asphyxia.
The tissue resistance sequence starts from the lowest is nerves, blood vessels, muscles, skin,
tendons and bones. The network with high resistance will be more flowed by the current and
higher heat. The heat that arises in the blood vessels will damage the intima so that thrombosis
occurs slowly, in an electric shock accident in the head region, the patient can faint long time
and can stop breathing, can also occur brain edema.
Treatment
First, before the patient is treated, the electric current must be disconnected, it must be
remembered that the patient contains an electric charge as long as it is still in contact with the
current source, if there is a need for cardiac resuscitation with cardiac massage and artificial
breath from the mouth of the mouth, generally need to give more fluid than expected because
often the damage is far more extensive than expected, if there is a lot of muscle damage, the
urine will be darkened by myoglobin: this patient needs to be given mannitol with an initial
dose of 25gr, followed by a regular dose of 12.5 grams / hour, if necessary mannitol is given
up to six times, if there is a brain edema given diuretics and corticosteroids.
In deep and severe burns, it is necessary to clean the dead tissue gradually, if the injury to the
extremities may need physiotomy on the first day to prevent compartment syndrome.

Struck by lightning
Pathogenesis, lightning voltage of 20-100 million volts and currents can reach 20,000 amperes
with core temperatures up to 30,000 kelvin, lightning accidents can occur in four ways.
The first way is when someone is openly in the field so that the person is reached by an electric
charge from the clouds before reaching the earth, this accident is called being struck directly.
The second method occurs when a person is in the farthest area two meters around the trunk of
a tree struck by lightning due to electric current jumps from the tree trunk, this is called side
struck.
The third method occurs when the victim rests on a tree or on a lake that is struck by lightning
which is called struck by contact
The fourth method occurs when stepping up, standing, or squatting near the ground struck by
lightning, this incident is called being struck by a step.
Usually in the event of being struck directly or struck by the side, electric current enters in the
head through the hole in the head, namely the ears, eyes or mouth, and reaches the earth through
the neck, body and legs. In the electrical current path there is a portion of the brain, respiratory
center, and heart so that the victim can faint, stop breathing, and stop the heart.
Resuscitation, usually people will regain consciousness in a certain, while the paralysis of the
breath center will also pass after five to ten minutes, usually asystolic will also recover if
artificial mouth mouth breathing is done adequately. Therefore, the victims will survive if
given resuscitation in the form of artificial breathing immediately after the accident.
Complications, early complications in direct lightning and side lightning accidents are
perforation of the tympanic membrane and conjunctivitis, and cataracts of the lens as prolonged
complications.
Prevention when there is thunder can be sought protection at home, buildings or faraday cages,
such as cars.
Chemical wounds
Injuries caused by chemicals are usually burns, this can occur due to carelessness, quarrels,
work accidents, and accidents in industry or laboratory, and due to the use of toxic jat as a
result of war
Chemicals such as chlorine, potassium permanganas, and chromic acid can be oxidizing,
corrosive, such as phenol and white phosphorus, and basic solutions, such as callium
hydroxide, cause protein denaturation. Denaturation due to salting can be caused by formic
acid, acetic acid, tannic, flouric, and chloride. Sulfuric acid damages cells because it attracts
water quickly. Gases used in warfare cause burns and cause cell anoxia when in contact with
skin or mucosa, fluoride and oxalic acid can cause hypocalcemia, tannic acid, chromate,
formates, picrats and phosphorus can damage the liver and kidneys if absorbed. Lysol causes
methhemoglobinemia.

treatment is generally handled by diluting chemicals massively, ie by flushing the patient with
running water while if necessary, efforts are made to clean it slowly mechanically. As a follow-
up action if necessary resuscitation to improve general conditions, as well as administration of
fluids and electrolytes. In accidents due to sam fluoride, administration of calcium gluconate
10% under the affected tissue helps prevent fluorine ions from penetrating the tissue and causes
decalcification of bone. Flour ions are bound to become insoluble calcium fluoride. If there are
deep wounds, debridement wounds may be followed by skin graft and reconstruction. The
chemical agent in the eye needs immediate emergency measures in the form of irrigation with
water or vice versa 0.9% salt solution continuously until the patient is hospitalized.

Cold temperature injury

Injuries due to cold temperatures mainly occur at the ends of the body which are directly
exposed to cold temperatures, such as toes and hands, ears, and nose. The factor of low
humidity and strong winds aggravate damage to areas that are not protected by clothing, such
as the nose, ears, and hands. Clothes and clothes that are tight and stiff, or which are moist and
wet, such as socks and wet shoes, have a bad effect. The severity of the damage is divided into
how many degrees, in the first degree hyperemia and edema are found, as in first-degree
burns. At the second degree there is skin necrosis and subcutis, there are also pains such as
burns which usually lasts for up to five weeks, then forming a black, peeling scab. The wound
is treated like a third degree burn. In the fourth degree there is damage to all tissues,
mummification occurs in which the body parts are black and shriveled, the dead tissue
boundary becomes clear and within one month the demarcation of the dead body can be seen
so that amputation can be performed.
Treatment of all tight clothing and clothes is loosened, the affected part is slowly warmed again
by soaking it in lukewarm water (about 30 C), then given treatment in ordinary burns.

COMPLICATIONS

• Acute kidney failure

• Acute respiratory failure

• Circulatory shock

• Compartment syndrome

• paralytic ileus

• Curling ulcer

PROGNOSIS
Prognosis in burns depends on the degree of burn, the surface area of the body affected by the
burn, the complications such as infection, and the speed of medical treatment. Minor burns can
heal 5-10 days without scarring. Moderate burns can heal within 10-14 days and may cause
scarring. Major burns require more than 14 days to heal and will form scar
tissue. Scarring will limit movement and function. In some cases, surgery is needed to remove
scar tissue.
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