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PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR

PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR. Dr. DEDDY SAPUTRA SpBP -RE FK Unand /RSUP dr M Djamil PADANG. LB: Injuri / kerusakan jaringan kulit & jaringan tubuh yang disebabkan trauma thermal. Penyebab :

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PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR

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  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 / kerusakanjaringankulit & jaringantubuh yang disebabkan trauma thermal. Penyebab: Api, Air panas, Zatkimia, Listrik, Petir, LedakandanRadiasi. MORBIDITAS & MORTALITAS: 1. Penyebabdan Lama kontak. 2. Sudahterjadisejakfaseawal LB.

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

  4. PrinsipPenatalaksanaan LB:  Menjamin:Restorasi ABCDE • Airway dan Breathing bebas. • Perfusi normal. • Keseimbangancairan & elektrolit. • Suhutubuh Normal.

  5. 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, 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) = 4cc/ kg/ % burn • 1/2 over 1st 8 hrfromtime of burn • 1/2 over subsequent 16 hr • Child (<20 kg)  3cc/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 Orgill D. N Engl J Med 2009;360:893-901

  17. 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.

  18. 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)

  19. Escharotomies

  20. 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

  21. Escharotomy

  22. ELECTRICAL INJURY • Zeus, the ruler of the ancient Greek gods, was characteristically depicted holding thunderbolts,whichhe used as warning or punishment against those who disobeyed him. • The first electrical fatality recorded in France in 1879

  23. 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

  24. 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).

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

  26. 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/cm2 100 300 - 10 000 1 200 - 1 500 2 500 10 000 - 40 000 100 000 - 200 000 1 000 000 - 2 000 000

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

  28. 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

  29. 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

  30. 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)

  31. 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

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

  33. 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

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

  35. 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

  36. 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

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

  38. 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

  39. 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

  40. 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 1 000 volts

  41. Electric Shock:What Should You Do? Page 2. Touched a voltage source of more than 1 000 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 Direction Services de Sante Hydro Quebec, 1995 BENIGN SHOCK Reassure and discharge

  42. Grade 2–3 Luas LB>10% BSA pd semua umur. Umur <10 and > 50 thn Luas LB >20% BSA Mengenai area : Kriteria Rujukan Pasien LB • Face • Eyes • Ears • Hand • Feet • Genitalia • Perineum • Sendi2 utama (Major joints)

  43. Kriteria Rujukan Pasien LB • Grd 3 dg Luas LB> 5% BSA • LB listrik, petir& Zat Kimia • Trauma Inhalasi • TdpPenyakitatau trauma penyerta

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

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