Presentation on theme: "Dr. DEDDY SAPUTRA SpBP-RE FK Unand/RSUP dr M Djamil PADANG"— Presentation transcript:
1Dr. DEDDY SAPUTRA SpBP-RE FK Unand/RSUP dr M Djamil PADANG PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIRDr. DEDDY SAPUTRA SpBP-REFK Unand/RSUP dr M DjamilPADANG
2LB: 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
7Circulation Typically burns 20% require IVF resuscitation Resuscitate w/ kristaloid.Adult(Baxter/Parkland Formula)= 4 cc/ kg/ % burn1/2 over 1st 8 hr from time of burn1/2 over subsequent 16 hrChild (<20 kg) 3 cc/kg/% burn + D5Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids)
13“Full-thickness” Formerly “3rd-degree” Dry Leathery White to charred InsensateWill require E&G
14“Indeterminate” Unsure as to whether PT or FT Observe for conversion b/t days 3-7May or may not require E&GCan unpredictably increase LOS
15Calculate burn size Estimate %TBSA Palmar surface of pts hand = 1% TBSAAge-appropriate diagrams (e.g.- Berkow)Rule of Nines
16The Rule of Nines and Lund–Browder Charts Arm = 9%Leg = 18%Ant trunk = 18%Post trunk = 18%Head = 9%Palmar surface of hand = 1% TBSA1st degree burns are not includedThe size and depth of the burn is the basis for fluid resuscitation and care plansNote: the burn evolves over 72 hours, so the initial calculation may be wrongOrgill D. N Engl J Med 2009;360:
18Disability (from other injuries) Primary & secondary surveys are important!!!R/O non-thermal trauma … ~5% have concomitant non-thermal injuryManagement of non-thermal trauma typically supercedes burn management, except for the resuscitation.
19Everything else Vascular access: PIV is preferable Analgesia = IV opiatesConservative & judicious sedatives, prn onlyWood’s lamp eye exam for flash burns to faceEscharotomiesEarly enteral nutrition (≥ 20% TBSA)
21IndicationsCircumferential FT extremity burns with threatened distal tissueDiminished or absent distal pulses via dopplerAny S/S of compartment syndrome.Circumferential FT thoracic burn (Breathing disturbance)Elevated PIP or PplateauWorsening oxygenation or ventilation
23ELECTRICAL INJURYZeus, the ruler of the ancient Greek gods, was characteristically depicted holding thunderbolts,which he used as warning or punishmentagainst those who disobeyedhim.The first electrical fatality recorded in France in 1879
24Shock Severity Severity of the shock depends on: Path of current through the bodyAmount of current flowing through the body (amps)Duration of the shocking current through the body,LOW VOLTAGE DOES NOT MEAN LOW HAZARDOther 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)
25PRINCIPLES 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).
26Electrical Injuries Factors Determining Severity 1. V = voltage 2. i = current 3. R = resistanceOHM’S LAW: i = V / R
28Resistance of Body Tissues LeastNervesBloodMucous membranesMuscleIntermediateDry skinMostTendonFatBone
29Power lines range from: Low: < 600 voltsUltrahigh: > 1 million voltsMost homes in US & Canada have a 120/240 V other countries (Europe, Asia..): 220 V
30Immediate death may occur from: 1) Current-induced ventricular fibrillation2) Asystole3) Respiratory arrest secondary to:Paralysis of the central respiratory control systemParalysis of the respiratory muscles
32Electrical current exists in 2 forms: 1) AC: (Alternating Current): when electrons flow back and forth through a conductor in a cyclic fashionIt is used in household and offices and is standardized to a frequency of 60 cycles/sec (60 Hz)
332) DC: (Direct Current): when electrons flow only in one direction Used in certain medical equipment: defibrillators, pacemakers, electrical scalpelsAC is far more efficient and also more dangerous than DC (~ 3 times): tetanic muscle contractions that prolong the contact of victim with source
34Cutaneous Injuries & Burns Extensive flash and flame burnsHemodynamic, autonomic, cardiopulmonary, renal, metabolic and neuroendocrine responses
35LIGHTNING Lightning is a form of DC Occurs when electrical difference between a thundercloud and the ground overcomes the insulating properties of the surrounding airCurrent rises to a peak in about 2 µsecLasts for only 1-2 sec
36Voltage >1,000,000 VCurrents of >200,000 ATransformation of the electrical energy to heat generated temperatures as high as 50,000ºF.
38Pathway 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 fetusHorizontal pathway from hand to hand: the heart, respiratory muscles and spinal cordPathway through the lower part of the body: local damage
40Nervous System Loss of conciousness, confusion & impaired recall Peripheral motor & sensory nerves : motor & sensory deficitsSeizures, visual disturbances & deafnessHemiplegia, quadriplegia, spinal cord injuryTransient paralysis, autonomic instability hypertension, peripheral vasospasm due to lightning from massive release of catecholamines
41Management of Electrical and Lightning Injuries Overall fluid management should be judicious unless: SIADH
42Patient MonitoringMost severe cardiac complications present acutelyVery unlikely for a patient to develop a serious or life-threatening dysrhythmia hours or days laterAsymptomatic normal ECG do not need cardiac monitoring
43Criteria for cardiac monitoring: Preexisting heart disease: monitor such patients for 24 hrs after the injuryCriteria for cardiac monitoring:Exposure to high voltageLoss of consciousnessAbnormal ECG at admission
44Electric Shock: What Should You Do? The victim:Felt the currentpass throughhis/her bodyThe currentpassed throughthe heartYesYesNoNoWas held by thesource of theelectric currentYes1 secondor moreYesNoNoLostconsciousnessCardiac Monitoring24 hoursYesNoTouched a voltagesource of morethan volts
45Direction Services de Sante Electric Shock: What Should You Do?Page 2.Touched a voltagesource of morethan voltsCardiac Monitoring24 hoursYesNoYesHas burn markson his/herskinThe currentpassed throughthe heartEvaluate and treat burns(surgical evaluation,look for myogolbinuria, etc.)YesNoNoWas thrown fromthe sourceEvaluate traumaYesNoIs pregnantEvaluate fetalactivityYesNoBENIGN SHOCKReassure and dischargeDirection Services de SanteHydro Quebec, 1995
46Kriteria Rujukan Pasien LB Grade 2–3Luas LB>10% BSA pd semua umur.Umur <10 and > 50 thnLuas LB >20% BSAMengenai area :FaceEyesEarsHandFeetGenitaliaPerineumSendi2 utama (Major joints)
47Kriteria Rujukan Pasien LB Grd 3 dg Luas LB> 5% BSALB listrik, petir & Zat KimiaTrauma InhalasiTdp Penyakit atau trauma penyerta
48Kriteria Rujukan Pasien LB Koordinasi dg dokter Pusat Rujukan.Dirujuk dg:Dokumentasi/ informasi yg lengkap.Hasil Laboratorium.