Dr DEDDY SAPUTRA SpBP RE FK Unand RSUP dr M Djamil PADANG LB Injuri kerusakan jaringan kulit amp jaringan tubuh yang disebabkan trauma thermal ID: 816207
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PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR
Dr. DEDDY SAPUTRA SpBP-REFK Unand/RSUP dr M Djamil PADANG
Slide2LB:
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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Slide3Initial Assessment
AirwayBreathingCirculationDisabilityExposureInitial burn treatment: remove burn source
Slide4Prinsip
Penatalaksanaan LB:
Menjamin: Restorasi ABCDEAirway dan Breathing bebas.Perfusi normal. Keseimbangan cairan & elektrolit. Suhu tubuh Normal. 4
Slide5Airway &
BreathingInhalation Injury ~7% of patientsHX: closed space fire, meth lab explosion, or petroleum product combustionUpper airway injury: acute mortality
facial/intraoral burns,
naso/oropharyngeal soot, sore throat, abnormal phonation, stridorLower airway injury: delayed mortalitydyspnea, wheezing, carbonaceous sputum, COHb, PaO2/FiO2bronchoscopy +/-Intubate EARLY!!! OrotrachealSurgical airway
Slide6Airway disturbance
Slide7Circulation
Typically burns 20% require IVF resuscitationResuscitate 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 + D5 Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids)
Slide8Calculate burn
size (%)Burn depthSuperficial Partial-thickness (PT)
Full-thickness (FT)
IndeterminateOnly partial-thickness (2nd degree), indeterminate, & full-thickness (≥3rd degree) injuries: count towards %TBSA
Slide93 Zones of Thermal Injury
Coagulation
Stasis
Hyperemia
Slide10Burn Depth
Slide11“Superficial”
Formerly “1st-degree”
Essentially a sunburn
PinkPainfulNO blistersWill heal in < 1 week
Slide12“Partial-thickness”
Formerly “2nd-degree”
Pink
MoistExquisitely painfulBlisteredTypically heals in < 2-3 weeks
Slide13“Full-thickness”
Formerly “3rd-degree”
Dry
LeatheryWhite to charredInsensateWill require E&G
Slide14“Indeterminate”
Unsure as to whether PT or FT
Observe for conversion b/t days 3-7
May or may not require E&GCan unpredictably increase LOS
Slide15Calculate burn size
Estimate %TBSAPalmar surface of pts hand = 1% TBSA Age-appropriate diagrams (
e.g.
- Berkow)Rule of Nines
Slide16The Rule of Nines and Lund–Browder Charts
Orgill D. N Engl J Med 2009;360:893-901
Slide1717
Slide18Disability
(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.
Slide19Everything else
Vascular access: PIV is preferableAnalgesia = IV opiates
Conservative & judicious sedatives,
prn onlyWood’s lamp eye exam for flash burns to faceEscharotomiesEarly enteral nutrition (≥ 20% TBSA)
Slide20Escharotomies
Slide21Indications
Circumferential 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
Slide22Escharotomy
Slide23ELECTRICAL 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
Slide2424
Shock SeveritySeverity 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 HAZARD
Slide25PRINCIPLES 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).
Slide26Electrical Injuries
Factors Determining Severity
1.
V = voltage2. i = current3. R = resistanceOHM’S LAW: i = V / R
Slide27Electrical Injuries
Factors Determining Severity
Mucous membranes
Vascular areas volar arm, inner thighWet skin SweatBathtubOther skinSole of footHeavily calloused palmSkin Resistivity - Ohms/cm2100300 - 10 0001 200 - 1 5002 50010 000 - 40 000100 000 - 200 0001 000 000 - 2 000 000
Slide28Resistance of Body Tissues
LeastNervesBloodMucous membranesMuscle
Intermediate
Dry skinMostTendonFatBone
Slide29Power lines range from:
Low: < 600 voltsUltrahigh: > 1 million voltsMost homes in US & Canada have a 120/240 V other countries (Europe, Asia..): 220 V
Slide30Immediate death may occur from:
1) Current-induced ventricular fibrillation2) Asystole3) Respiratory arrest secondary to:Paralysis of the central respiratory control system
Paralysis of the respiratory muscles
Slide31Slide32Electrical 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)
Slide332) DC: (Direct Current):
when electrons flow only in one directionUsed 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
Slide34Cutaneous Injuries & Burns
Extensive flash and flame burnsHemodynamic, autonomic, cardiopulmonary, renal, metabolic and neuroendocrine responses
Slide35LIGHTNING
Lightning is a form of DCOccurs 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 µsecLasts for only 1-2 sec
Slide36Voltage >1,000,000 V
Currents of >200,000 ATransformation of the electrical energy to heat generated temperatures as high as 50,000ºF.
Slide37Slide38Pathway 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 cord
Pathway through
the lower part of the body: local damage
Slide39Slide40Nervous System
Loss of conciousness, confusion & impaired recallPeripheral motor & sensory nerves : motor & sensory deficits
Seizures, visual disturbances & deafness
Hemiplegia, quadriplegia, spinal cord injuryTransient paralysis, autonomic instability hypertension, peripheral vasospasm due to lightning from massive release of catecholamines
Slide41Management of Electrical
and Lightning InjuriesOverall fluid management should be judicious unless: SIADH
Slide42Patient Monitoring
Most 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
Slide43Preexisting heart disease: monitor such patients for 24 hrs after the injury
Criteria for cardiac monitoring:Exposure to high voltageLoss of consciousnessAbnormal ECG at admission
Slide44Electric Shock
: What Should You Do?
The victim:
Felt the currentpass throughhis/her bodyThe currentpassed throughthe heart
Was held by the
source of the
electric current
Lost
consciousness
Yes
No
No
No
1 second
or more
Yes
No
Yes
Cardiac Monitoring
24 hours
Touched a voltage
source of more
than 1 000 volts
Yes
No
Yes
Slide45Electric Shock
:
What Should You Do?Page 2.Touched a voltagesource of morethan 1 000 volts
Cardiac Monitoring
24 hours
Has burn marks
on his/her
skin
The current
passed through
the heart
Yes
No
Yes
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
Yes
No
BENIGN SHOCK
Reassure and discharge
Direction Services de Sante
Hydro Quebec, 1995
Slide46Kriteria Rujukan Pasien LB
46Grade 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)
Slide47Kriteria Rujukan Pasien LB
Grd 3 dg Luas LB> 5% BSA
LB
listrik, petir & Zat Kimia Trauma Inhalasi Tdp Penyakit atau trauma penyerta 47
Slide48Kriteria Rujukan Pasien LB
Koordinasi dg dokter Pusat Rujukan. Dirujuk dg:Dokumentasi/ informasi yg lengkap.
Hasil Laboratorium.
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