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

Dr. DEDDY SAPUTRA SpBP-REFK 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.

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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, stridorLower 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 body

Amount 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

1. V = voltage2. i = current3. R = resistance

OHM’S LAW: i = V / R

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?

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

No 1 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.

Touched a voltagesource of more

than 1 000 voltsCardiac Monitoring

24 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 pregnant Evaluate fetal activity

No

Yes

Yes

NoBENIGN SHOCK

Reassure and dischargeDirection Services de Sante

Hydro 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

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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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