PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR Dr. DEDDY SAPUTRA SpBP-RE...
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Transcript of PENATALAKSANAAN AWAL KEGAWAT DARURATAN BEDAH: LUKA BAKAR,LISTRIK DAN PETIR Dr. DEDDY SAPUTRA SpBP-RE...
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:
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
Initial Assessment
• Airway• Breathing• Circulation• Disability• Exposure
• Initial burn treatment: remove burn source
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, sore
throat, abnormal phonation, stridor
Lower airway injury: delayed mortality• dyspnea, wheezing, carbonaceous sputum, COHb,
PaO2/FiO2
• bronchoscopy +/-• Intubate EARLY!!! Orotracheal• Surgical airway
Airway disturbance
Circulation• 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 + D5
Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids)
Calculate burn size (%)
• Burn depthSuperficial Partial-thickness (PT)Full-thickness (FT)Indeterminate
• Only partial-thickness (2nd degree), indeterminate, & full-thickness (≥3rd degree) injuries: count towards %TBSA
3 Zones of Thermal Injury
Coagulation
Stasis
Hyperemia
Burn Depth
“Superficial”
• Formerly “1st-degree”
• Essentially a sunburn• Pink• Painful• NO blisters• Will heal in < 1 week
“Partial-thickness”
• Formerly “2nd-degree”
• Pink• Moist• Exquisitely painful• Blistered• Typically heals in < 2-
3 weeks
“Full-thickness”
• Formerly “3rd-degree”
• Dry• Leathery• White to charred• Insensate• Will require E&G
“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
Calculate burn size
• Estimate %TBSAPalmar surface of pts hand = 1% TBSA Age-appropriate diagrams (e.g.- Berkow)Rule of Nines
The Rule of Nines and Lund–Browder Charts
Orgill D. N Engl J Med 2009;360:893-901
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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.
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)
Escharotomies
Indications
• 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 Pplateau
Worsening oxygenation or ventilation
Escharotomy
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
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Shock 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 HAZARD
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).
Electrical InjuriesFactors Determining Severity
Electrical InjuriesFactors Determining Severity
1. V = voltage
2. i = current
3. R = resistance
OHM’S LAW: i = V / R
Electrical Injuries Factors Determining Severity
Electrical Injuries Factors Determining Severity
Mucous membranesVascular areas
• volar arm, inner thigh
Wet skin • Sweat• Bathtub
Other skinSole of footHeavily calloused palm
Skin Resistivity - Ohms/cm2
100300 - 10 000
1 200 - 1 5002 500
10 000 - 40 000100 000 - 200 000
1 000 000 - 2 000 000
Resistance of Body TissuesLeast• Nerves• Blood• Mucous membranes• Muscle
Intermediate• Dry skin
Most• Tendon• Fat• Bone
• 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
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
• 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)
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
Cutaneous Injuries & Burns• Extensive flash and flame burns
• Hemodynamic, autonomic, cardiopulmonary, renal, metabolic and neuroendocrine responses
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
• Voltage >1,000,000 V
• Currents of >200,000 A
• Transformation of the electrical energy to heat generated temperatures as high as 50,000ºF.
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
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
Management of Electrical and Lightning Injuries
Overall fluid management should be judicious unless: SIADH
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
• 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: What Should You Do?
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: What Should You Do?
Page 2.
Electric Shock: What Should You Do?
Page 2.
Touched a voltagesource of more
than 1 000 volts
Cardiac Monitoring24 hours
Has burn markson his/her
skin
The currentpassed through
the heart
Yes
NoYes
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
Kriteria Rujukan Pasien LB
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Grade 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)
Kriteria Rujukan Pasien LB
Grd 3 dg Luas LB> 5% BSA LB listrik, petir & Zat Kimia Trauma Inhalasi Tdp Penyakit atau trauma penyerta
47
Kriteria Rujukan Pasien LB
Koordinasi dg dokter Pusat Rujukan. Dirujuk dg:
• Dokumentasi/ informasi yg lengkap.
• Hasil Laboratorium.
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