1. Dr. DEDDY SAPUTRA SpBP-RE FK Unand/RSUP dr M Djamil PADANG
PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR
Dr. DEDDY SAPUTRA SpBP-RE
FK Unand/RSUP dr M Djamil
PADANG

2. 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 

3. Initial Assessment Airway Breathing Circulation Disability Exposure
Initial burn treatment: remove burn source
Airway
Breathing: PE
Circulation: pulses, IV, LR
Disability: rapid neurologic exam
Exposure: remove clothing, brush off dry chemicals

4. Prinsip Penatalaksanaan LB:
 Menjamin: Restorasi ABCDE
Airway dan Breathing bebas.
Perfusi normal.
Keseimbangan cairan & elektrolit.
Suhu tubuh Normal.

5. Airway & Breathing Inhalation Injury ~7% of patients bronchoscopy +/-
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

6. Airway disturbance

7. 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)

8. 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

9. 3 Zones of Thermal Injury
Hyperemia
Stasis
Coagulation

10. Burn Depth

11. “Superficial” Formerly “1st-degree” Essentially a sunburn Pink Painful
NO blisters
Will heal in < 1 week

12. “Partial-thickness” Formerly “2nd-degree” Pink Moist
Exquisitely painful
Blistered
Typically heals in < 2-3 weeks

13. “Full-thickness” Formerly “3rd-degree” Dry Leathery White to charred
Insensate
Will require E&G

14. “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

15. Calculate burn size Estimate %TBSA
Palmar surface of pts hand = 1% TBSA
Age-appropriate diagrams (e.g.- Berkow)
Rule of Nines

16. The Rule of Nines and Lund–Browder Charts
Arm = 9%
Leg = 18%
Ant trunk = 18%
Post trunk = 18%
Head = 9%
Palmar surface of hand = 1% TBSA
1st degree burns are not included
The size and depth of the burn is the basis for fluid resuscitation and care plans
Note: the burn evolves over 72 hours, so the initial calculation may be wrong
Orgill D. N Engl J Med 2009;360:

18. 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.

19. 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)

20. Escharotomies

21. 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

22. Escharotomy

23. 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

24. 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
Other factors that may affect the severity of the shock are:
- The voltage of the current.
- The presence of moisture
- The general health of the person prior to the shock.
Low voltages can be extremely dangerous because, all other factors being equal, the degree of injury increases the longer the body is in contact with the circuit.
The resistance of the body varies based on:
The amount of moisture on the skin (less moisture = more resistance)
The size of the area of contact (smaller area = more resistance)
The pressure applied to the contact point (less pressure = more resistance)
Muscular structure (less muscle = less resistance)

25. 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).

26. Electrical Injuries Factors Determining Severity
1. V = voltage 2. i = current 3. R = resistance
OHM’S LAW: i = V / R

27. 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/cm

28. Resistance of Body Tissues
Least
Nerves
Blood
Mucous membranes
Muscle
Intermediate
Dry skin
Most
Tendon
Fat
Bone

29. 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

30. 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

32. 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)

33. 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

34. Cutaneous Injuries & Burns
Extensive flash and flame burns
Hemodynamic, autonomic, cardiopulmonary, renal, metabolic and neuroendocrine responses

35. 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

36. Voltage >1,000,000 V
Currents of >200,000 A
Transformation of the electrical energy to heat generated temperatures as high as 50,000ºF.

38. 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

40. 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

41. Management of Electrical and Lightning Injuries
Overall fluid management should be judicious unless: SIADH

42. 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

43. Criteria for 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

44. Electric Shock: What Should You Do?
The victim:
Felt the current
pass through
his/her body
The current
passed through
the heart
Yes
Yes No No
Was held by the
source of the
electric current
Yes
1 second
or more
Yes No No
Lost
consciousness
Cardiac Monitoring
24 hours
Yes No
Touched a voltage
source of more
than volts

45. Direction Services de Sante
Electric Shock: What Should You Do?
Page 2.
Touched a voltage
source of more
than volts
Cardiac Monitoring
24 hours
Yes No
Yes
Has burn marks
on his/her
skin
The current
passed through
the heart
Evaluate and treat burns
(surgical evaluation,
look for myogolbinuria, etc.)
Yes No No
Was thrown from
the source
Evaluate trauma
Yes No
Is pregnant
Evaluate fetal
activity
Yes No
BENIGN SHOCK
Reassure and discharge
Direction Services de Sante
Hydro Quebec, 1995

46. 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
Eyes
Ears
Hand
Feet
Genitalia
Perineum
Sendi2 utama (Major joints)

47. Kriteria Rujukan Pasien LB
Grd 3 dg Luas LB> 5% BSA
LB listrik, petir & Zat Kimia
Trauma Inhalasi
Tdp Penyakit atau trauma penyerta

48. Kriteria Rujukan Pasien LB
Koordinasi dg dokter Pusat Rujukan.
Dirujuk dg:
Dokumentasi/ informasi yg lengkap.
Hasil Laboratorium.