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

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Presentation on theme: "PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR Dr. DEDDY SAPUTRA SpBP-RE FK Unand/RSUP dr M Djamil PADANG."— Presentation transcript:

1 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.  2

3 Initial Assessment Airway Breathing Circulation Disability Exposure Initial burn treatment: remove burn source

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

5 A irway & B reathing 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

6 Airway disturbance

7 C irculation 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 + D 5  Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids)

8 C alculate burn size (%) Burn depth  Superficial  Partial-thickness (PT)  Full-thickness (FT)  Indeterminate Only partial-thickness (2 nd degree), indeterminate, & full-thickness (≥3 rd degree) injuries: count towards %TBSA

9 3 Zones of Thermal Injury Coagulation Stasis Hyperemia

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 C alculate 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 Orgill D. N Engl J Med 2009;360:

17 17

18 D isability (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 E verything 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 P plateau  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 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

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

31

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.

37

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

39

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 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 Was held by the source of the electric current Lost consciousness Yes No 1 second or more Yes No Yes Cardiac Monitoring 24 hours Touched a voltage source of more than volts Yes No Yes

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

46 Kriteria Rujukan Pasien LB 46 Grade 2–3  Luas LB>10% BSA pd semua umur.  Umur 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 47

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


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