patofisiologi luka bakar dan terapi nutrisi

Patofisiologi Luka Bakar dan Terapi Nutrisi

dr. Rauza Sukma Rita, Ph.D

Definisi Luka Bakarsuatu bentuk kerusakan dan atau kehilangan

jaringan disebabkan kontak dengan sumber yang memiliki suhu sangat tinggi.

Kerusakan akut yang disebabkan panas, listrik, dan zat kimia

InsidenSekitar 310.000 orang di seluruh dunia meninggal

karena luka bakar30 % diantaranya berusia di bawah 20 tahun

ETIOLOGI• Paparan api

• Flame• Benda panas

(kontak)• Scalds (air panas)• Uap panas• Gas panas

• Aliran listrik• Zat kimia• Radiasi • Sunburn

panas

listrikZat kimia

Zat radioakif laser

petir

ledakan

Kehidupan sehari-hari

Klasifikasi Luka BakarBerdasarkan derajat dan kedalaman luka bakar 1. Superficial (first-degree) 2. Deep (second-degree) 3. Full thickness (third and fourth degree)

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SUPERFICIAL BURNS (FIRST DEGREE)

• Epidermal tissue only affected• Erythema, blanching on pressure, mild swelling no vesicles or blister initially• Not serious unless large areas involved• i.e. sunburn

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DEEP (SECOND DEGREE)*Involves the epidermis and deep layer of the

dermisFluid-filled vesicles –red, shiny, wet, severe painHospitalization required if over 25% of body

surface involvedi.e. tar burn, flame

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FULL THICKNESS (THIRD/FOURTH DEGREE)

• Destruction of all skin layers• Requires immediate hospitalization• Dry, waxy white, leathery, or hard skin, no pain• Exposure to flames, electricity or chemicals can

cause 3rd degree burns

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Perhitungan Luas Permukaan Tubuh yang Terkena1.Metode permukaan telapak tanganarea permukaan tangan pasien (termasuk jari

tangan) adalah sekitar 1% total luas permukaan tubuh.

Digunakan pada luka bakar kecil

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Metode Permukaan Telapak Tangan

Perhitungan Luas Permukaan Tubuh yang Terkena2. Metode rule of nine Metode yang baik dan cepat menilai luka bakar menengah dan berat pada penderita berusia di atas 10 tahun.

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RULES OF NINES• Head & Neck = 9%• Each upper extremity (Arms) = 9%• Each lower extremity (Legs) = 18%• Anterior trunk= 18%• Posterior trunk = 18%• Genitalia (perineum) = 1%

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3. Metode diagram oleh Lund and Browder Metode yang paling akurat pada anak bila digunakan dengan benar.

Perhitungan Luas Permukaan Tubuh yang Terkena

Lund Browder Chart used for determining Body Surface Area (BSA)

29Evans, 18.1, 2007)

Patofisiologi Luka BakarRespon LokalSegera setelah kontak permukaan kulit dengan sumber panas nekrosis kulit yang terkena.Tiga zona luka bakar :1. Koagulasi2. Stasis 3. Hiperemis

1. Zona Koagulasi Area yang terkena kontak erat dengan sumber panasSel pada area ini mengalami nekrosis koagulasi dan

tidak membaikKehilangan jaringan bersifat irreversibel

2. Zona StasisArea konsentris yang kerusakan jaringannya lebih

sedikitDitandai penurunan perfusi jaringanJaringan pada zona ini berpotensi untuk

diselamatkan

3. Zona HiperemisZona terluar di mana perfusi jaringan meningkatSel pada area ini mengalami trauma minimalPada sebagian besar kasus akan membaik dalam 7-

10 hari

Zona Luka Bakar Menurut Jackson

Patofisiologi Luka BakarRespon SistemikTergantung luas luka bakarLuka bakar > 20 % total permukaan tubuh respon sistemikDua fase pada penderita luka bakar :1. Fase ebb terjadi 24 jam pertama

hipometabolisme2. Fase flow setelah 24 jam

peningkatan konsentrasi hormon katabolikKondisi hipermetabolik menyebabkan perubahan metabolism karbohidrat, lemak dan protein

Gangguan metabolism karbohidratPeningkatan gluconeogenesisResistensi insulin

Gangguan metabolism proteinTerjadi proteolysis yang bisa berlangsung 40-90

hari paska luka bakarPenurunan lean body mass hingga setahun paska

luka bakar

Patofisiologi Luka Bakar

Gangguan metabolism lemakPeningkatan lipolysis

Gangguan makronutrien Penurunan zat besi, seng, selenium, vitamin C,

tokoferol, retinol, dan vitamin A

Patofisiologi Luka Bakar

Respon metabolik terhadap luka bakar

Manifestasi Klinis Luka Bakar• Reaksi Lokal KemerahanBengkakNyeriPerubahan sensasi

Manifestasi Klinis Luka Bakar• Reaksi Sistemik pada luka bakar yang luasSyok hipovolemik luka bakar > 25 % luas

permukaan tubuhHipotermiaPerubahan metabolik

Terapi Luka Bakar1.Pertolongan emergency remove heat source avoid re-damage lessen contamination control pain manage combined injury

cold therapy

Terapi Luka Bakar2.Terapi Umum(1. Correct burn shock 2. Prevention and treatment of systemic infection 3. Nutritional support

(1) Correct burn shock ★ ◨ choice of fluid: water, crystalloid, colloid ◨ route for fluid administration: peripheral, central vein ◨ volume and rate of infusion: 24h volume = 1.5ml×%burn×weight (kg)

(2) Prevention and treatment of systemic infection ·control of wound infection ·systemic antibiotics ·support therapy

(3) Nutritional support in burned patients

• Burns are a tissue injury resulting in protein denaturation edema loss of intravascular fluid volume caused by chemical, thermal, radiation, or

electrical contact.

• There are three important reactions of the body to a burn injury, which include

Metabolic HormonalImmune Response

Nutrition in burned patients (cont.)

Feeding the burned patient • The first 24-48 hours of nutritional intervention

replaces lost fluid and electrolytes. • Initiation of feeding is recommended within 4-12

hours of hospitalization.

Nutrition in burned patients (cont.)

Calculation of energy needs • is usually based on the Curreri method:24 kcal × kg usual body weight + 40 kcal × % TBSA (with a maximum of 50% TBSA)• Adults are often calculated to need 35-40

kcal/kg/day.

Nutrition in burned patients (cont.)

Nutritional Requirements• CHO: Glucose administration at a rate of 5

mg/kg/min is optimum for adults. The child glucose requirement is 5-7 mg/kg/min.

• Lipid: 15% of energy requirements is sufficient.

Nutrition in burned patients (cont.)

• Protein: approximately 25% of total energy should come from protein.

• Adults : 1g protein /kg + 3g x % burn.• Children : 3g protein/kg + 1g x % burn.

Nutrition in burned patients (cont.)

Arginine• Is one amino acid important in the healing of burn wounds associated with:Reduced hospital stay & infection rate. It is also a precursor to nitric oxide, which increases blood flow to the wound and causes vasodilatation.

Glutamine• Another important amino acid has been shown

to Preserve integrity of the intestinal mucosa,Reduce infection and maintain immune

function in burn patientsDecrease the translocation of bacteria and

bacterial survival in animals.• Ornithine α-ketoglutarate, a precursor of

glutamate and glutamine, has been shown to be beneficial when administered to burn patients.

Vitamin requirements :•Vitamin A, which is important in proper immune function and epithelialization, in the amount of 10,000 IU/day and 5,000 IU/day in children under three years old.

•Vitamin C supplementation are 250 mg twice daily for children under 10 years old and 500 mg twice daily for adult.

Nutrition in burned patients (cont.)

Minerals • Are also important to monitor in the nutritional care

of burn patients. Supplementation of zinc, copper, and selenium during the first week.

• Calcium, phosphorus, magnesium, sodium, and potassium levels monitored cautiously.

Nutrition in burned patients (cont.)

Prevention:

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