Transcript luka bakar,listrik dan petir

PENATALAKSANAAN AWAL
KEGAWAT DARURATAN BEDAH:
LUKA BAKAR,LISTRIK DAN PETIR
Dr. DEDDY SAPUTRA SpBP-RE
FK Unand/RSUP dr M Djamil
PADANG
LB: Injuri / kerusakan jaringan kulit & jaringan tubuh
yang disebabkan trauma thermal.
Penyebab:
Api, Air panas, Zat kimia, Listrik, Petir,
Ledakan dan Radiasi.
MORBIDITAS & MORTALITAS: 1. Penyebab dan Lama kontak.
2. Sudah terjadi sejak fase awal LB.
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Initial Assessment
•
•
•
•
•
Airway
Breathing
Circulation
Disability
Exposure
• Initial burn treatment: remove burn source
Prinsip Penatalaksanaan LB:
 Menjamin: Restorasi ABCDE
• Airway dan Breathing bebas.
• Perfusi normal.
• Keseimbangan cairan & elektrolit.
• Suhu tubuh Normal.
4
Airway & Breathing
• Inhalation Injury ~7% of patients
 HX: closed space fire, meth lab explosion, or
petroleum product combustion
 Upper airway injury: acute mortality
• facial/intraoral burns, naso/oropharyngeal soot, sore
throat, abnormal phonation, stridor
 Lower airway injury: delayed mortality
• dyspnea, wheezing, carbonaceous sputum, COHb,
PaO2/FiO2
• bronchoscopy +/• Intubate EARLY!!!  Orotracheal
• Surgical airway
Airway disturbance
Circulation
• Typically burns 20% require IVF resuscitation
• Resuscitate w/ kristaloid.
Adult(Baxter/Parkland Formula)
= 4 cc/ kg/ % burn
• 1/2 over 1st 8 hr from time of burn
• 1/2 over subsequent 16 hr
Child (<20 kg)  3 cc/kg/% burn + D5
Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids)
Calculate burn size (%)
• Burn depth
Superficial
Partial-thickness (PT)
Full-thickness (FT)
Indeterminate
• Only partial-thickness (2nd degree),
indeterminate, & full-thickness (≥3rd degree)
injuries: count towards %TBSA
3 Zones of Thermal Injury
Hyperemia
Stasis
Coagulation
Burn Depth
“Superficial”
• Formerly “1st-degree”
•
•
•
•
•
Essentially a sunburn
Pink
Painful
NO blisters
Will heal in < 1 week
“Partial-thickness”
• Formerly “2nddegree”
•
•
•
•
•
Pink
Moist
Exquisitely painful
Blistered
Typically heals in < 23 weeks
“Full-thickness”
• Formerly “3rddegree”
•
•
•
•
•
Dry
Leathery
White to charred
Insensate
Will require E&G
“Indeterminate”
• Unsure as to whether
PT or FT
• Observe for
conversion b/t days
3-7
• May or may not
require E&G
• Can unpredictably
increase LOS
Calculate burn size
• Estimate %TBSA
Palmar surface of pts hand = 1% TBSA
Age-appropriate diagrams (e.g.- Berkow)
Rule of Nines
The Rule of Nines and Lund–Browder Charts
Orgill D. N Engl J Med 2009;360:893901
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Disability
(from other injuries)
• Primary & secondary surveys are
important!!!
• R/O non-thermal trauma … ~5% have
concomitant non-thermal injury
• Management of non-thermal trauma
typically supercedes burn management,
except for the resuscitation.
Everything else
• Vascular access: PIV is preferable
• Analgesia = IV opiates
• Conservative & judicious sedatives, prn only
• Wood’s lamp eye exam for flash burns to face
• Escharotomies
• Early enteral nutrition (≥ 20% TBSA)
Escharotomies
Indications
• Circumferential FT extremity burns with
threatened distal tissue
 Diminished or absent distal pulses via doppler
 Any S/S of compartment syndrome.
• Circumferential FT thoracic burn (Breathing
disturbance)
 Elevated PIP or Pplateau
 Worsening oxygenation or ventilation
Escharotomy
ELECTRICAL INJURY
• Zeus, the ruler of the ancient
Greek gods, was
characteristically depicted
holding thunderbolts,which he
used as warning or punishment
against those who disobeyed
him.
• The first electrical fatality
recorded in France in 1879
Shock Severity
• Severity of the shock depends on:
Path of current through the
body
Amount of current flowing
through the body (amps)
Duration of the shocking
current through the body,
• LOW VOLTAGE DOES NOT
MEAN LOW HAZARD
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PRINCIPLES OF ELECTRICITY
• Electricity is the flow of electrons (the negatively
charged outer particles of an atom) through a
conductor.
• when the electrons flow away from this object
through a conductor, they create an electric
current, which is measured in Amperes (I).
• The force that causes the electrons to flow is the
voltage, and it is measured in Volts (V).
• Anything that impedes the flow of electrons
through a conductor creates resistance, which is
measured in Ohms (R).
Electrical Injuries
Factors Determining Severity
OHM’S LAW: i = V / R
1.
2.
3.
V = voltage
i = current
R = resistance
Electrical Injuries
Factors Determining Severity
Mucous membranes
Vascular areas
• volar arm, inner
thigh
Wet skin
• Sweat
• Bathtub
Other skin
Sole of foot
Heavily calloused palm
Skin Resistivity Ohms/cm2
100
300 - 10 000
1 200 - 1 500
2 500
10 000 - 40 000
100 000 - 200 000
1 000 000 - 2 000 000
Resistance of Body Tissues
Least
• Nerves
• Blood
• Mucous membranes
• Muscle
Intermediate
• Dry skin
Most
• Tendon
• Fat
• Bone
• Power lines range from:
– Low: < 600 volts
– Ultrahigh: > 1 million volts
• Most homes in US & Canada have a 120/240 V
other countries (Europe, Asia..): 220 V
Immediate death may occur from:
1) Current-induced ventricular fibrillation
2) Asystole
3) Respiratory arrest secondary to:
– Paralysis of the central respiratory control
system
– Paralysis of the respiratory muscles
• Electrical current exists in 2 forms:
1) AC: (Alternating Current): when
electrons flow back and forth through a
conductor in a cyclic fashion
• It is used in household and offices and is
standardized to a frequency of 60
cycles/sec (60 Hz)
2) DC: (Direct Current): when electrons
flow only in one direction
• Used in certain medical equipment:
defibrillators, pacemakers, electrical
scalpels
• AC is far more efficient and also more
dangerous than DC (~ 3 times): tetanic
muscle contractions that prolong the
contact of victim with source
Cutaneous Injuries & Burns
• Extensive flash and flame burns
• Hemodynamic, autonomic,
cardiopulmonary, renal, metabolic and
neuroendocrine responses
LIGHTNING
• Lightning is a form of DC
• Occurs when electrical
difference between a
thundercloud and the
ground overcomes the
insulating properties of the
surrounding air
• Current rises to a peak in
about 2 µsec
• Lasts for only 1-2 sec
• Voltage >1,000,000 V
• Currents of >200,000 A
• Transformation of the electrical energy to
heat generated temperatures as high as
50,000ºF.
Pathway of the current through the body:
– Vertical pathway parallel to the axis of the
body is the most dangerous. It involves all the
vital organs; central nervous system, heart,
respiratory muscles, in pregnant women the
uterus and fetus
– Horizontal pathway from hand to hand: the
heart, respiratory muscles and spinal cord
– Pathway through the lower part of the body:
local damage
Nervous System
• Loss of conciousness, confusion & impaired recall
• Peripheral motor & sensory nerves : motor & sensory
deficits
• Seizures, visual disturbances & deafness
• Hemiplegia, quadriplegia, spinal cord injury
• Transient paralysis, autonomic instability 
hypertension, peripheral vasospasm due to lightning
from massive release of catecholamines
Management of Electrical and
Lightning Injuries
Overall fluid management should be
judicious unless: SIADH
Patient Monitoring
• Most severe cardiac complications present
acutely
• Very unlikely for a patient to develop a
serious or life-threatening dysrhythmia
hours or days later
• Asymptomatic normal ECG do not need
cardiac monitoring
• Preexisting heart disease: monitor such
patients for 24 hrs after the injury
• Criteria for cardiac monitoring:
– Exposure to high voltage
– Loss of consciousness
– Abnormal ECG at admission
Electric Shock:
What Should You Do?
The victim:
Felt the current
pass through
his/her body
Yes
No
Was held by the
source of the
electric current
The current
passed through
the heart
Yes
No
Yes
1 second
or more
No
Yes
No
Lost
consciousness
No
Touched a voltage
source of more
than 1 000 volts
Yes
Cardiac Monitoring
24 hours
Electric Shock:
What Should You Do?
Page 2.
Touched a voltage
source of more
than 1 000 volts
Cardiac Monitoring
24 hours
Yes
No
Yes
Has burn marks
on his/her
skin
Yes
The current
passed through
the heart
No
Evaluate and treat burns
(surgical evaluation,
look for myogolbinuria, etc.)
No
Was thrown from
the source
Yes
Evaluate trauma
No
Is pregnant
Yes
Evaluate fetal
activity
No
BENIGN SHOCK
Reassure and discharge
Direction Services de Sante
Hydro Quebec, 1995
Kriteria Rujukan Pasien LB
Grade 2–3




Luas LB>10% BSA pd semua umur.
Umur <10 and > 50 thn
Luas LB >20% BSA
Mengenai area :
• Face
• Hand
• Perineum
• Eyes
• Feet
• Ears
• Genitalia
• Sendi2 utama (Major
joints)
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Kriteria Rujukan Pasien LB




Grd 3 dg Luas LB> 5% BSA
LB listrik, petir & Zat Kimia
Trauma Inhalasi
Tdp Penyakit atau trauma penyerta
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Kriteria Rujukan Pasien LB


Koordinasi dg dokter Pusat Rujukan.
Dirujuk dg:
• Dokumentasi/ informasi yg
lengkap.
• Hasil Laboratorium.
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