COMBUSTIO

DEFINITIONS:
A disease caused by heat, electric current or chemicals on the skin, mucosa and deeper tissue

Pathophysiology
The first result of burned is shock  and pain.  Capillaries are exposed to high temperatures damaged blood cells in it were damaged so that it can happen anemia.
The increased permeability causes edema and cause a bull with her electrolytes.  This results in reduced intra-vascular fluid volume.  The body loses fluid between.  % - 1%, "Blood Volume" for every 1% burned.  Skin damage due to burned cause additional fluid loss due to evaporation of excess (insensible water loss increases).

If the burn is more than 20% will occur hypovolemic shock with typical symptoms are: restlessness, pale cold sweat, pulse small, quick, low blood pressure and decreased urine production (kidney failure).
In  face area, the airway mucosal damage because of gas, smoke or steam heat.  The symptoms are shortness of breath, takipneu, stridor, hoarseness and a dark sputum as soot.  It can also happen CO gas poisoning or other toxic gases.  CO binds hemoglobin with a strong will so no longer able to bind oxygen.  Signs of mild poisoning is weak, confused, dizzy, nausea and vomiting.  In severe poisoning occurs coma.  When over 60% of hemoglobin bound to CO, the patient will die.
At a severe burned occur paralytic ileus.  Physiologic stress and burden that occurs in severe burned can cause ulcers in the stomach or duodenal mucosa with the same symptoms of peptic ulcer symptoms.  The disorder is known as the "ulcer Curling" a concern in this Curling is a bleeding ulcer that arise as hematesis melena.


EXAMINATION AND DIAGNOSIS
o Clinically
o Laboratory: hemoglobin, hematocrit, electrolit, LFT, RFT

COMPLICATIONS
1 Shock due to fluid loss.
2 Sepsis / toxic.
3 Renal Failure sudden
4 Pneumonia

prognosis:
1 Depending on the degree burned.
2 Surface Area
3 The affected area, perineum, axilla, neck and hands because of difficult treatment
and easy to contractures.
4 Age and health of patients.

PHASE of Combustio
To facilitate the treatment of burned in the history of the disease is divided into 3 phases of acute, subacute and phase chronic or next phase.  However, the division into three phases doesn't means there is a clear dividing line between these three phases.  Thus the frame of mind in the treatment of patients is not limited by the phase box and still be integrated.  Step management of the previous phase clinical implications in the next phase.
1.  The acute phase / phases of shock / early phase.
This phase began from the time of the incident until the patient is receiving treatment at the IRD / burned unit.  In this phase of the burn patients, like any other trauma patients, will face threats and harassment airway (airway), breathing (breathing mechanism) and impaired circulation (circulation).  Airway disorders not only can happen immediately or some time after the trauma, inhalation within 48-72 hours after trauma.  Inhalation injury is a cause death  in the acute phase.  In this phase can occur also circulatory disorders of fluid and electrolyte balance due to thermal injury / systemic effect of heat.  The existence of shock that is hipodynamic can continue with hyperdynamic state that is still connected due to instability problems of circulation.  Problems and treatment in this phase will be the main discussion in this paper.
2.  Subacute phase
This phase took place after the shock phase ends or can be resolved.  Injuries that occur can cause several problems, namely:
a.  The process of inflammation or infection.
b.  Problem wound closure
c.  Hipermetabolisme circumstances.
3.  Next Phase
This phase has been declared cured but the patient remains monitored through outpatient care.  Problems that appear in this phase is a complication of hypertrophic scar, celoid, pigmentation disorders, deformities and the occurrence of contracture.

Bullae

DEPTH OF DEGREES
The depth of tissue damage due to burned depends on the degree of heat sources, causes and duration of contact with the patient's body.  Dupuytren formerly divided over 6 levels, now more practical simply divided into 3 levels / degrees, as follows:
1.  First degree :
Damage limited to the epidermal layer (surperficial), hipermik form of erythematous skin, bullae are not found, felt pain because of nerve endings of sensory irritation.  Healing occurs spontaneously without specific treatment.
2.  Second degre
Damage includes the epidermis and some dermis, in the form of inflammatory reaction accompanied the process of exudation.  There bullae, pain due to nerve endings, sensory irritation.
Be divided into 2 (two) parts:
A.  Degree II shallow / superficial (IIA)
The damage of the epidermis and upper layers of the corium / dermis.  Organ - skin organ such as hair follicles, glands sebacea still a lot.  All these are the seeds of the epithelium.  Healing occurs spontaneously within 10-14 days without cicatrik formed.
B.  Degree II in / deep (IIB)
Damage on almost all parts of the dermis and the rest - the rest of epithelial tissue is low.  Organ - skin organ such as hair follicles, sweat glands, sebaceous glands is low.  Healing occurs over time and accompanied by scar hypertrophy.  Usually, healing occurs in more than a month.
3.  Third degree
The damage included the entire thickness of the skin and deeper layers until it reaches the subcutaneous tissue, muscle and bone.  Skin organ damage, there is no residual epithelial elements.  There were no bullae, burning skin gray and black paler until dry.  Protein coagulation occurs in the epidermis and dermis, known as the esker.  There were no pain and loss of sensation due to end - the end of sensory damage.  Healing was long because it does not happen spontaneously epithelialization.

BROAD Combustio
Wallace split the body of the part - 9% or multiples of 9 well-known as the Rule of Nine or the Rule of Wallace.
Head and neck: 9%
Arm: 18%

Rear Body: 18%
Limbs: 36%
Genitalia / perineum: 1%
Total: 100%

Grade of Combustio

In the calculation can be used to better facilitate broad palms patients is 1% of body surface area.  In children used Rule of Nine's modification according to Lund and Brower, which is emphasized at the age of 15 years, 5 years and 1 year.

CRITERIA severity
(American Burn Association)
1.  Light burned.
- Second degree burned <15%
- Second degree burned <10% in children - children
- Third degree burned are <2%
2.  Moderate
- Second degree burned on 15-25% of adults
- burned II 10-20 5 of the children - children
- Third degree burned <10%
3.  Severe burned
- Second degree burned of 25% or more in adults
- Second degree burned of 20% or more in children - children.
- Third degree burned of 10% or more
- burned on the hands, face, ears, eyes, legs and genitalia / perineum.
burned with inhalation injury, electricity, along with other trauma.

ACUTE COMBUSTIO MANAGEMENT.
On the treatment of trauma patients with severe burned, such as in patients with trauma - trauma to others should be handled carefully and systematically.
I.  First Evaluation (Triage)
A.  Airway, circulation, ventilation
The first priority patients who have sustained burned covering airway, ventilation and systemic perfusion.  If required endotracheal intubation immediately do, the installation of infusion to maintain circulating volume
B.  Physical examination overall.
On examination the patient must wear sterile gloves, free the people from the burning clothes, burn patients may also experience other trauma, for example in conjunction with abdominal trauma with internal bleeding or a fractured spine / spine.
C.  Anamnesis
The mechanism of trauma is important to note because, whether the patient was trapped in an enclosed space so that the suspicion of inhalation trauma that can cause airway obstruction.  When did it happened happened, and asked for the disease - a disease that never experienced before.
D.  Checking the burn
burned checked whether there is severe burned, burned moderate or mild.
1.  Widely prescribed burned.  Rule of Nine's used to determine the extent of the burn.
2.  Determined the depth of burn (degree of depth)
II.  Treatment in Emergency Room
1.  Required to wear sterile gloves when hand of patient examination.
2.  Free your clothes on fire.
3.  Carried out a careful and thorough examination to ensure there is another trauma that accompanies.
4.  Free your airway.  In burned with airway distress can be mounted endotracheal tube.  Traheostomy only when there is an indication.
5.  Installation of intraveneous catheters fairly large and not recommended  scalp vein.  Given the amount of fluid Ringer Lactate with 30-50 cc / hour for adults and 20-30 cc / hour for children - children over 2 years and 1 cc / kg / hour for children under 2 years.
6.  Performed installation of Foley catheter to monitor the amount of urine production.  Recorded amount of urine / hour.
7.  In doing installation nosogastric tube for gastric decompression with intermittent suction.
8.  To relieve severe pain may be given morphine intravenously and not intramuscularly.
9.  Weigh weight
10.  Given tetanus toxoid if needed.  Giving tetanus toxoid booster if the patient does not get it in the last 5 years.
11.  Injury Laundering in the operating room in a state of general anesthesia.  Wound debridement and in disinfection washed with salvon 1: 30.  Once clean cover with tulle and then spread with Silver Sulfa Diazine (SSD) until thick.  Treat covered with a thick sterile gauze.  On day 5 patients screened in the open and bathed with water mixed Salvon 1: 30
12.  Eschariotomy is a procedure or remove dead tissue (escar) with tangential excision technique of excision of necrotic tissue layer by layer until the surface got bloody.  Fasciotomy conducted on burned of the feet and hands
circular, for the distal necrosis is not due to stewing.
13.  Wound closure can occur or can be done when the wound bed preparation has been done which found the condition of the relatively more clean cuts and no infection.  Wounds can be closed without any surgical procedure.  In persekundam epithelialization process occurs at a relatively superficial burned.  For burned that are common in the choice of split skin grafting tickness.  Tickness Split skin grafting is a definitive action cover a wide wound.  Over the skin grafts done when the wound is not healed - healed within 2 weeks with a diameter> 3 cm.

CIRCULATION MANAGEMENT
In severe burned / major changes that will be followed by extrapasy xapiller permability fluid (plasma proteins and electrolytes) from the intravascular to the network interfisial hipovolemic resulted in intra-vascular and interstitial edema.  The balance of hydrostatic pressure and thus circulation gets oncotyc disorder distal obstructed, causing disruption perfusion / cell / tissue / organ.
In severe burned with changes in capillary permeability which is almost complete, there was a massive accumulation of fluid in the interstitial tissue causing hypovolemic conditions.  Intravascular fluid volume deficit, arising from the inability present transport process of oxygen to tissues.  This condition is known as shock.  Shock that arise must be addressed in a short time, to prevent damage to cells and organs from getting worse, because the real shock was significantly correlated with mortality.
In treatment the improved circulation in the burn known some following formula:
- Evans Formula
- Brooke Formula
- Parkland Formula
- Modifications Formula
- Monafo Formula

RESUSCITATION use FLUIDS
Baxter formula
Day One:
Adults: Ringer Lactate 4 cc x weight x% burn area per 24 hours
Children: Ringer Lactate: dextran = 17: 3
2cc x body weight x% of injury plus the physiologic needs.

Physiologic needs:
<1 Year: weight x 100 cc
1-3 Year: weight x 75 cc
2-5 Years: weight x 50 cc

½ the amount of fluid given in first 8 hours.
½ given 16 hours later.
The second day
Adult: First day
Children: given according to physiologic needs
According to Evans à Fluid Requirement:
1.  RL / NaCl = broad combustio ... ...% X BB / kg X 1 cc
2.  Plasma = broad combustio ... ...% X BB / kg X 1 cc
3.  Substitute lost due to evaporation D5 2000 cc
Day I = 8 x ½ hour
16 hours X-à ½
Day II à ½ dosage first day
Day II, the same as the second day


BREATHING MANAGEMENT
Inhalation trauma is a factor having a real correlation with mortality.  Deaths from inhalation trauma occurs in a short time the first 8 to 24 hours postoperatively.
On fires in confined spaces or where local burned about the face / face can cause the airway mucosal damage due to gas, smoke or steam heat that sucked.  Edema that occurs can cause disruption of the airway resistance due to edema of the larynx.
Direct thermal inhalation trauma is something that is very hot, products of incomplete burning of materials such as soot materials and special material which causes damage to the mucosa directly on trakheobronkhial branching.
Smoke poisoning caused by thermodegradation natural material and material produced. thermodegradation cause the formation of toxic gases such as hydrogen cyanide, nitrogen oxides, hydrogen chloride, akreolin and particles - particles suspended.  Acute effects of these chemicals cause irritation and bronchoconstriction in the airways.  Airway obstruction will become more intense due to the tracheal bronchitis and edema.
Intoxication effects of carbon monoxide (CO) resulting in tissue hypoxia.  Carbon monoxide (CO) has a strong affinity towards the binding ability of hemoglobin with 210-240 times more powerful than the ability of O2.  So the CO will separate the O2 from Hb resulting in tissue hypoxia.
Suspicion of inhalation trauma if the patient suffered severe burned following.
1.  History stuck in a closed room.
2.  Sputum mixed with charcoal.
3.  Perioral burned, including the nose, lips, mouth or throat.
4.  Impairment of consciousness including confusion.
5.  There are signs of breathing distress, like feeling of choking.  Choking, breathing or lazy
of wheezing or discomfort in the eyes or throat,
indicate the presence of mucosal irritation.
6.  The presence Tachypnoea or abnormalities on auscultation as Crepitation or ronchi.
7.  Shortness of breath or loss of voice.
Where there are 3 signs / symptoms of the above is sufficient suspicion of inhalation trauma.  Inhalation when treatment trauma patients without respiratory distress should be done trakheostomi.  Patients admitted to the emergency department resuscitation room until a stable condition.

 MONITORING ACUTE PHASE
Monitoring of the burn patient should be carefully followed.  Physical examination includes inspection, palpation patients, percussion and auscultation is the procedure to be performed on patient care.  Laboratory examination for monitoring were also performed to follow patients development circumstances.  Monitoring of our patients were divided into 3 situations, namely when the triage, during resuscitation (0-72 hours first) and post resusitation
I.  Triage - Emergency Intalasi
A.  ABC: By the time the patient comes to a hospital, should be assessed and be immediately solved the problem is there any airway, breathing, circulation is immediately overcome life-saving. Patient of combustio may also have suffered pneumothorax or thoracic trauma.
B.  VITAL SIGN: Monitoring and recording of blood pressure, respiration, pulse, rectal temperature.  Cardiac monitoring, especially in patients with electrical trauma, can happen until there is an arrhythmia or cardiac arrest.
C.  Urine OUTPUT: If urine can not be measured then it can be done installation of Foley catheter.  Urine production can be measured and recorded every hour.  Observation of urine checked the color of urine, especially in patients with third degree burned or electrical trauma, myoglobin, hemoglobin contained in the urine shows any great damage.

II.  MONITORING IN RESUSCITATION PHASE
(Up to 72 hours)
1.  Measuring urine production.  Urine production can be as an indicator of whether resuscitation is adequate or not.  In adults the amount of urine is 30-50 cc of urine / hour.
2.  Urine specific gravity.  Post-traumatic types of burned can be normal or elevated.  This situation can shows hydration state of the patient.  When the density increases associated with increased urine glucose levels.
3.  Vital Sign
4.  blood pH.
5.  Peripheral perfusion
6.  laboratory
a.  serum electrolytes
b.  plasma albumin
c.  hematocrit, hemoglobin
d.  urine sodium
e.  electrolyte
f.  liver function tests
g.  renal function tests
h.  total protein / albumin
i.  other tests as indicated
7.  Assessment of lung condition
Examination of lung conditions need to be observed every hour to determine the changes occurring include stridor, bronkhospam, the secret, wheezing, or dispneu that show impending obstruction.  Thoracic examination of this photo.  Examination of arterial blood gas.
8.  Gastrointestinal assessment.
Gastrointestinal Monitoring every 2-4 hours by auscultation for bowel sounds and checking knowing gastric secretion.  The presence of blood and a pH of less than 5 is a sign of Culing ulcer.
9.  Assessment of the burned.
When closed treatment, assessed whether wet gauze, there is fluid smell or no sign of her pussy then netting needs to be replaced.  When the net further treatment performed 5 days later.