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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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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
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Prinsip Penatalaksanaan LB:
Menjamin: Restorasi ABCDE
Airway dan Breathing bebas. Perfusi normal.
Keseimbangan cairan & elektrolit.
Suhu tubuh Normal.
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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, sorethroat, abnormal phonation, stridor
Lower airway injury: delayed mortality
dyspnea, wheezing, carbonaceous sputum, COHb,
PaO2/FiO2
bronchoscopy +/-
Intubate EARLY!!! Orotracheal
Surgical airway
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Airway disturbance
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Circulation Typically burns 20% require IVF resuscitation
Resuscitate w/ kristaloid.
Adult(Baxter/Parkland Formula)
= 4cc/ kg/ % burn
1/2 over 1st 8 hr fromtime of burn
1/2 over subsequent 16 hr
Child (
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Calculate burn size (%)
Burn depth
Superficial
Partial-thickness (PT)
Full-thickness (FT)
Indeterminate
Only partial-thickness (2nddegree),
indeterminate, & full-thickness (3rddegree)injuries: count towards %TBSA
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3 Zones of Thermal Injury
Coagulation
Stasis
Hyperemia
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Burn Depth
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Superficial
Formerly 1st-degree
Essentially a sunburn
Pink Painful
NOblisters
Will heal in < 1 week
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Partial-thickness
Formerly 2nd-
degree
Pink
Moist
Exquisitely painful
B l istered
Typically heals in < 2-
3 weeks
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Full-thickness
Formerly 3rd-
degree
Dry Leathery
White to charred
Insensate
Will require E&G
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Indeterminate
Unsure as to whether
PT or FT
Observe forconversion b/t days
3-7
May or may notrequire E&G
Can unpredictably
increase LOS
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Calculate burn size
Estimate %TBSA
Palmar surface of pts hand = 1% TBSA
Age-appropriate diagrams (e.g.- Berkow)
Rule of Nines
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The Rule of Nines and LundBrowder Charts
Orgill D. N Engl J Med 2009;360:893
901
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Disability(from other injuries)
Primary & secondary surveys areimportant!!!
R/O non-thermal trauma ~5% haveconcomitant non-thermal injury
Management of non-thermal trauma
typically supercedesburn management,except for the resuscitation.
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Everything else
Vascular access: PIV is preferable
Analgesia = IV opiates
Conservative & judicious sedatives,prnonly
Woods lamp eye exam for flash burns to face
Escharotomies
Early enteralnutrition ( 20% TBSA)
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Escharotomies
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Indications
Circumferential FT extremity burns withthreatened 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
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Escharotomy
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ELECTRICAL INJURY
Zeus, the ruler of the ancient
Greek gods, wascharacteristically depicted
holding thunderbolts,which he
used as warning or punishment
against those who disobeyed
him.
The first electrical fatality
recorded in France in 1879
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Shock Severity
Severity of the shock depends on:
Path of current through thebody
Amount of current flowingthrough the body (amps)
Duration of the shockingcurrent through the body,
LOW VOLTAGE DOES NOTMEAN LOW HAZARD
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PRINCIPLES OF ELECTRICITY
Electricity is the flow of electrons (the negativelycharged outer particles of an atom) through aconductor.
when the electrons flow away from this object
through a conductor, they create an electriccurrent, which is measuredin Amperes (I).
The force that causes the electrons to flow is thevoltage, and it is measured in Volts (V).
Anything that impedes the flow of electronsthrough a conductor creates resistance, which ismeasured in Ohms (R).
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Electrical Injuries
Factors Determining Severity
1. V= voltage
2. i = current
3. R= resistance
OHMS LAW: i = V / R
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Electrical Injuries
Factors Determining Severity
Mucous membranes
Vascular areas volar arm, innerthigh
Wet skin
Sweat
Bathtub
Other skin
Sole of foot
Heavily calloused palm
Skin Resistivity -Ohms/cm
2
100
300 - 10 000
1 200 - 1 500
2 500
10 000 - 40 000
100 000 - 200 000
1 000 000 - 2 000 000
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Resistance of Body TissuesLeast
Nerves Blood
Mucous membranes
Muscle
Intermediate
Dry skin
Most Tendon
Fat
Bone
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Power lines range from:
Low: < 600 volts
Ultrahigh: > 1 million volts
Most homes in US & Canada have a 120/240 Vother countries (Europe, Asia..): 220 V
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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
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Electrical current exists in 2 forms:
1) AC: (Alternating Current):when
electrons flow back and forth through aconductor in a cyclic fashion
It is used in household and offices and isstandardized to a frequency of 60
cycles/sec (60 Hz)
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2) DC: (Direct Current):when electrons
flow only in one direction
Used in certain medical equipment:
defibrillators, pacemakers, electricalscalpels
AC is far more efficient and also moredangerous than DC (~ 3 times): tetanic
muscle contractions that prolong the
contact of victim with source
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Cutaneous I njur ies & Burns
Extensive flash and flame burns
Hemodynamic, autonomic,
cardiopulmonary, renal, metabolic and
neuroendocrine responses
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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 sec
Lasts for only 1-2 sec
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Voltage >1,000,000 V
Currents of >200,000 A
Transformation of the electrical energy toheat generated temperatures as high as
50,000F.
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Pathway of the current through the body:
Vertical pathwayparallel 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 theuterus and fetus
Horizontal pathwayfrom hand to hand: the
heart, respiratory muscles and spinal cord
Pathway through the lower part of the body:
local damage
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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
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Management of Electrical and
Lightning Injuries
Overall fluid management should bejudicious unless: SIADH
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Patient Monitor ing
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
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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:
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Electric Shock:What Should You Do?
The victim:
Felt the currentpass throughhis/her body
The currentpassed through
the heart
Was held by thesource of the
electric current
Lostconsciousness
Yes
No No
No1 secondor more
Yes
No
Yes
Cardiac Monitoring24 hours
Touched a voltagesource of more
than 1 000 volts
Yes
No
Yes
Electric Shock:
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Electric Shock:What Should You Do?
Page 2.
Touched a voltagesource of morethan 1 000 volts
Cardiac Monitoring24 hours
Has burn markson his/her
skin
The currentpassed through
the heart
Yes
No
Yes
YesEvaluate and treat burns
(surgical evaluation,look for myogolbinuria, etc.)
No
Was thrown fromthe source
Evaluate trauma
No
Is pregnantEvaluate fetal
activity
No
Yes
Yes
No
BENIGN SHOCKReassure and discharge
Direction Services de SanteHydro Quebec, 1995
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Kriteria Rujukan Pasien LB
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Grade 23 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)
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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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