I. LUKA BAKAR = COMBUSTIO

Definisi Burn : penyakit yang disebabkan oleh panas , arus , listrik , bahan kimia yang mengenai kulit , mukosa , jaringan tubuh manuasia.Sampai saat ini, Luka Bakar ( LB ) masih merupakan problem yang berat. Perawatan + rehabilitasi masih sukar, biaya tenaga >> di Negara majupun masih merupakan tantangan.

Untuk kita, dapat mengetahui perawatan yang ideal / mendekati, sehingga tidak timbul penyulit.

DERAJAD LB

PROSENTASE LB

LB RINGAN : - TK II : < 15% - TK III : 5%

LB SEDANG : - TK II : 15 30% - TK III : 5 10% (KECUALI MENGENAI : MUKA , TANGAN , GENITAL)

LB BERAT : - TK II > 30%- TK III > 10%PEDOMAN LAZIM UNTUK MENENTUKAN MRS PEMBERIAN CAIRAN , OBSERVASI KETATLB GRADE SEDANG + BERATLB TERUTAMA PADA LEHER , KEPALALB DAERAH GENITALLB GRADE I > 75%LB DENGAN PENYULIT PERNAFASAN , FRAKTUR + KERUSAKAN JARINGAN LUNAK LUAS

PATOFISIOLOGI LB 1. SEGERA SETELAH TERJADI LB , MAKA OEDEM YANG TERJADI PADA DAERAH ITU AKAN MEMBAWA AKIBAT : MOBILISASI AIR , ELEKTROLIT , PROTEIN KELUAR HIPOVOLEMIK

( SELAIN OLEH KARENA RASA SAKIT )DILATASI KAPILER( FASE AKUT )2. ANEMIA : PANAS ERITROSIT PECAH3. HIPONATREMIA : Na KELUAR KE DAERAH LUKA4. HIPERKALEMIA : K OLEH KARENA PECAHNYA ERITROSIT DAN KERUSAKAN JARINGAN5. ASIDOSIS METABOLIK : OLEH KARENA METABOLISME ANAEROBIK (TISSUE ANOXIA ) DAN KELUARNYA ASAM- ASAM ORGANIK DARI SEL-SEL TERBAKAR6. HIPOCALSEMIA7. HEMOGLOBINURIA8. HEMOCONCENTRASI9. PERUBAHAN FAAL ENDOKRIN10. NITROGEN BALANS YANG NEGATIFSHOCK

PENATALAKSANAAN LB DIBAGI DALAM 3 PERIODE :1. PERIODE AKUT2. PERIODE SUPPORTIVE3. PERIODE REHABILITASI1. PERIODE AKUTPERKIRAAN CAIRAN YANG HILANG PADA SAAT ITU ADALAH SUKAR.KEHILANGAN CAIRAN DALAM 6 JAM PERTAMA AKAN MEMPENGARUHI BALANS CAIRAN.SEBAGAI ANCAR-ANCAR :FASE HIPOVOLEMIK : HARI I IIFASE HIPOPROTEINEMI : HARI III

Perlu DiperhatikanLuka bakar wajah = InhalasiTermasuk immediate life saving, tanda yang diwaspadai :Luka di wajah = leherTerbakarnya alis + rambut bulu mataKarbon deposite di oropharyngSputum ada karbonnya ( kehitaman )HoarsenessLedakan pada kepala dan leher, wajahOedema mucosa seluruh nafas sehingga terjadi gangguan airwaySuara nafas : obstruksi jalan nafas ada stridor = inhalasi segera misal : - menghisap uap panas - uap bertekanan tinggi pertimbangan tracheostomi Shock akibat nyeri analgetik / narkotika hipovol cairan

* UNTUK LUKA SP 30 MENIT POST TRAUMA DINGINKAN DENGAN AIR DINGIN (KRAN) 15 MENIT , INI UNTUK MENURUNKAN PANAS DI JARINGAN LUNAK CUCI LUKA BAKAR YANG KOTOR : - NaCl 0,9% (PZ) - AIR STERIL - SAVLON ENCER - PERHIDROL 1%DILAKUKAN DEBRIDEMENT

RAWAT TERBUKA / RAWAT TERTUTUPDAERAH TANGAN / KAKI FASIOTOMI (KP) SEMUA DILAKUKAN SECARA STERIL

DENGAN PERAWATAN TERBUKA SEBENARNYA DIHARAPKAN DARI EXUDAT YANG KERING AKAN BERFUNGSI SEBAGAI PELINDUNG LUKA.LUKA TIDAK DIBERI APA-APA.TETAPI KENYATAAN BERBEDA , ESCHAR (KRUSTA = KERAK) YANG TERJADI TIDAK TERTUTUP RAPI PECAH DIMANA-MANA DAN DIBAWAH ESCHAR BERSARANG KUMAN / PUS.OLEH KARENA ITU PEMBERIAN OBAT LOKAL SUDAH MENJADI KEHARUSAN.

OBAT YANG DIANJURKAN CREAM SILVER SULFA DIAZIM (SSD) DERMAZIN , BURNAZIN , SILVADENT (MERUPAKAN TOPICAL TERPILIH DI DUNIA) CRUSTA = ESCHAR YANG TERBENTUK TIPIS , MUDAH DIBERSIHKAN , TIDAK NYERI EFEKTIF 2 3 HARI DIOLESKAN TIAP 2 3 HARI LAR. PERAK NITRAT 0,5% TIAP HARI MENYEBABKAN GANGGUAN ELEKTROLIT , BERCAK HITAM GARAMICIN CREAM 0,1% TIAP HARI EFEKTIF TAPI MAHAL POVIDON IODINE (BETADIN)EFEKTIF DIBERIKAN 2 3 KALI/HARI MAHAL , NYERI , ESCHAR KAKU , KERAS MERCHUROCHROMCATATAN : BIOPLASENTON TIDAK DIANJURKAN KARENA TERBENTUK ESCHAR KAKU SEPERTI KACA.

SELAMA PERAWATAN LUKA : FISIOTERAPI DILAKUKAN SEDINI MUNGKINBILA SEBAGIAN LUKA SUDAH MEMBAIK ( 4 7 HARI) , PENDERITA BOLEH DIMANDIKAN EVALUASI DERAJAD LUKA LAGI UNTUK KEMUNGKINAN SKIN GRAFTING

2. PERIODE SUPORTIFSETELAH FASE AKUT (HIPOVOL) TERATASI , MAKA TERAPI SUPORTIF DIBERIKAN - DIET TKTP , VITAMIN B / C (LUNAK)- ANTASIDA UNTUK CEGAH CURLING ULCERKEBUTUHAN KALORI : 30 KCAL /BBTERDIRI :50% KARBOHIDRAT30%PROTEIN20% LEMAKPENDERITA YANG TIDAK MUNGKIN PER ORALDIBERI PER SONDE- ANTIBIOTIK : - GOLONGAN PENICILIN - GOLONGAN AMINOGLICOSIDESEPSIS PSEUDOMONASAMIKIN 3 x 500 mg / HR- ANALGETIK- TRANSFUSI DARAH : PERTAHANKAN Hb 12 gr%- MONITORING LABORATORIUM- Hb- Ht- ELEKTROLIT- PRODUKSI URINE

3. PERIODE REHABILITASIDILAKUKAN SEDINI MUNGKIN :- FISIOTERAPI SENDI-SENDI OLEH : - DOKTER- PERAWAT- FISIOTERAPIST- SKIN GRAFT : - LUKA > 3 CM- TIDAK BISA MENUTUP- SUDAH TBTK GRANULASI , TIDAK ADA INFEKSI- RELEASE KONTRAKTURBL LB SUDAH MEMBAIK

KOMPLIKASI LUKA BAKARSHOCKKGM AKUT TUBULER NECROSIS (ATN)SEPSISPNEUMONIACARDIAC ARRESTKONTRAKTUR

MDF= MYOCORDIAL DEPRESAN FAKTOR IDENTIK DENGAN K+PROGNOSADIRAMALKAN JELEK : BILA LUAS LUKA BAKAR DITAMBAH UMUR PENDRITA > 80

PEMBERIAN CAIRAN PADA LUKA BAKAR PEDOMAN PEMBERIAN CAIRAN MENURUT EVANS YAITU JUMLAH CAIRAN = 2 cc/kg BB /% LBTD : - PLASMA - CAIRAN ELEKTROLIT - CAIRAN GULA KESELURUHAN DIBAGI DLAM PEMBERIAN50% DALAM8 JAM I50% DALAM 16 JAM BERIKUTHARI IHARI II: JUMLAH ITU DIBERIKAN MERATA 24 JAMHARI III: HANYA CAIRAN GULA SP SELESAI PEMBERIAN PAR- ENTERAL

METODE BAXTER LAZIM DIPAKAICAIRAN KRISTALOID (RINGER LAKTAT)SEBANYAK : 4 cc/ kgBB / % LBHARI I: RL 50%8 JAM I50%16 JAM BERIKUT

HARI II: KRISTALOID DAN KOLOID DALAM SAMARL = 1 = 2 3 TERGANTUNG KONDISI PENDERITAD5 1 2 3

HARI III : MAINTANCE : CAIRAN ELEKTROLIT GULAKOLOID RL : D5 : KOL

CONTOH : 50 kg LB 45%PERHITUNGAN CAIRAN :4 x 50 x 45 = 9000 cc / 24 JAMHARI I: 8 JAM ~ RL = 4500 cc16 JAM ~ RL = 4500 ccHARI II: RL = D5 SESUAI KEBUTUHAN

METODE MONCRIEFUNTUK ANAK - ANAK2 cc / kg BB / % LB + KEBUTUHAN CAIRAN FAALIDENGAN PERBANDINGAN : KRISTALOID : KOLOID = 17 : 350% 8 JAM I50% 16 JAM BERIKUTCATATAN : KEBUTUHAN FAAL< 1 TH = 100 cc/kg BB1 3 TH = 75 cc/kg BB3 5 TH = 50 cc/kg BB

CONTOH : 3 TH . LB 30% . BB 15 kg . KEBUTUHAN CAIRAN FAALI 60 cc / kg BBPERHITUNGAN CAIRAN :2 x 15 x 30 + 3 x 60 = 900 + 180 = 1080 24 jamKRISTALOID (RL) = 17 x 1080 = 918 cc 20KOLOID (D5) = 3 x 1080 = 62 cc 20

PEMBERIAN 8 JAM I RL = 918 = 459 cc 2 D5 = 62 = 31 cc 21 HARI

Perawatan Luka Bakar terkini LB derajad sedang dan berat : rehidrasi dengan Metode Baxter atau Moncreaf pada hari pertama Segera dilakukan bulektomi / debrideman dengan Narkose umum setelah KU stabil dilanjutkan dengan pemberian topical AB ( Dermazin ) cukup tebal dan dibalut rapat, dievaluasi 3 4 hari ( posisi anggota anatomis ) Pada daerah genital : mutlak dipasang Dower kateter untuk mencegah striktur uretra ( pada laki-laki )Pada daerah leher : pertimbangkan segera tracheostomi

Kontraktur Ada 3 macam : - Dermogen : kulit tertarik - Tendogen : tendon / otot tertarik - Osteogen: tulang-tulang melekat satu dengan lainnya

Skin graftDefek kulit 3 cm tidak bias ditutup primerSyarat skin graftLuka tidak infeksiSudah ada jaringan granulasiTidak diatas tulang atau fascia

II. INJURIES DUE TO COLD

Trauma dingin, terjadi bila suhu sekitar < 0 Celcius atau kedinginan berkepanjangan.Ada 3 macam traumanya :Fronsip : yang banyak terjadi di darah tinggi, salju, nyeri, pucat, rasa sensi hilang.Hal ini masih reversible bila segera dilakukan penghangatan Frost bite : Pembekuan jaringan dilanjut sampai terbentuk kristal formasi intraseluler dan microvaskuler occlusi sehingga hipoxia jaringan, sehingga jaringan nekrosis Non freezing injury : Disebabkan kerusakan endotel micro sirkulasi, sehingga terjadi sumbatan vaskuler.

Hal ini terjadi pada kegiatan fisik tertentu misalnya :PelautTentaraPemancing, pendaki gunung, petaniKarena kontak dengan suhu dingin yang terus menerus Gejala : papula kemerahan, gatal-gatal, nodul-nodul, scar, diakhiri dengan fibrosis

Sistemik hipotermia Mild : suhu tubuh 35 - 32CModerate : suhu tubuh 32 - 30C Severe : suhu tubuh < 30C Perabaan :biru, sianosis, dingin, RR , tensi , nadi Hambatan jantung terganggu sampai arrest Pentalaksanaan Segera dihangatkan : lnfus hangatSuhu sekitar hangatOksigenasiBantu nafas, jantung

Daftar PustakaBuku Ajar Bedah : Wim de Yong dkk.Emergency Surgery : H. Bailey.Abdominal Operation : Manigot.Smiths : General urologyDasar-dasar urologi Ed Kedua : Basuki B PurnomoAtlas Anatomy Physiology Plastic SurgeryATLS. American Collage of Surgery, Committee on Trauma

TRIAGE SCENARIO IIITRAILER HOME EXPLOSION AND FIRE

Not all trauma centers manage burn injuries. Consequently, patients with burns should be managed at facilities with burn capability and trauma patients at trauma facilities. Therefore, the primary doctor at the small institution must recognize which burn patient has traumatic injuries. Furthermore, the major problem with burn patients is respiratory in nature. Therefore, inhalation injury must be recognized early. The burned patient needs fluids initiated and sustained until the patient gets to the net institution. The first 1 to 2 hours should not be a challenge. Intravenous lines need to be initiated and fluids administered, as would be for any injured patient. The tertiary care facility can initiate the appropriate fluid formula.Scenario : An explosion and fire, due to a faulty gas line, has involved 1 trailer in a nearby trailer park. Because of the close proximity of the incident to the hospital, the prehospital personnel transport the patients directly to the hospital without prior notification. The 5 patients, all members of the same family, are immobilized on long spine boards when they arrive at your small hospital emergency department. The injured patients are :

Patient A A 45 year old man is coughing and expectorating carbonaceous material. Hairs on his face and head are singed. His voice is clear and he is complaining about pain in his hands, which have erythema and early blister formation.VS : BP 120 mmHg systolic, HR 100, and RR 30

Patient B A 6 year old girl appears frightened and is crying. She complains of pain from burn ( erythema / blister ) over her back, buttocks, and both legs posteriorly. VS : BP 110/70 mmHg, HR 100, and RR 25

Patient C A 70 year old man is coughing wheezing, and expectorating carbonaceous material. His voice is hoarse and he responds only to painful stimuli. There are erythema, blisters, and charred skin to the anterior chest and abdominal walls, and circumferential burns of both thighs. VS : BP 80/40 mmHg, HR 140, and RR 35

Patient D A 19 year old woman is obtunded but responds to pain when her right humerus and leg are moved. There is no obvious deformity of the arm, and the thigh is swollen while in a traction splint.VS : BP 140/90 mmHg systolic, HR 110, and RR 32

Patient E A 45 year old man is pale and spontaneously complaining of pain in his pelvis. There is clinical evidence of fracture with abdominal distention and tenderness to palpation. There is erythema and blister of the anterior chest and abdominal walls and thighs. He also has a laceration to the forehead. VS : BP 130/90 mmHg, HR 90, and RR 25

TRIAGE SCENARIO VCAR CRASH

Scenario : You are the only doctor available in a 100-bed community emergency department. One nurse and 1 nurses aide are available to assist you. Ten minutes ago you were notified by radio that ambulances would be arriving with patients from a single motor vehicle crash. No further report is received. Two ambulances arrive with 5 patients who were occupants in an automobile traveling at 60 mph ( 96 kph ) before it crashed. The injured patients are :

Patient A A 45 year old man was the driver of the car. He apparently was not wearing a seat belt. Upon impact, he was thrown against the windscreen. On admission, he is notably in severe respiratory distress. The prehospital personnel provide the following information to you after preliminary assessment. Injuries include (1) severe maxillofacial trauma with bleeding from the nose and mouth, (2) an angulated deformity of the left forearm, and (3) multiple abrasions over the anterior chest.VS : BP 150/80 mmHg, HR 120, RR 40, and GCS Score = 8

Patient A A 45 year old man was the driver of the car. He apparently was not wearing a seat belt. Upon impact, he was thrown against the windscreen. On admission, he is notably in severe respiratory distress. The prehospital personnel provide the following information to you after preliminary assessment. Injuries include (1) severe maxillofacial trauma with bleeding from the nose and mouth, (2) an angulated deformity of the left forearm, and (3) multiple abrasions over the anterior chest.VS : BP 150/80 mmHg, HR 120, RR 40, and GCS Score = 8

Patient B A 38 year old woman passenger was apparently thrown from the front seat and found 30 feet ( 9 meters ) from the car. On admission she is awake, alert, and complains of abdominal and chest pain. The report you are given indicates that on palpating her hips, she complains bitterly of pain and fracture related crepitus is felt.VS : BP 110/90 mmHg, HR 140, and RR 25

Patient C A 48 year old male passenger was found under the car. You are told that on admission he is confused and responds slowly to verbal stimuli. Injuries include multiple abrasions to his face, chest, and abdomen. Breath sounds are absent on the left, and his abdomen is tender to palpation.VS : BP 90/50 mmHg, HR 140, RR 35, and GCS Score = 10

Patient D A 25 year old hysterical woman was extricated from the back seat of the vehicle. She is 8 months pregnant and complains of abdominal pain. Injuries include multiple abrasions to her face and anterior abdominal wall. You are told that her abdomen is tender to palpation. She is in active labor.VS : BP 120/80 mmHg, HR 100, and RR 25

Patient E A 6 year old boy was extricated from the floor of the rear seat. At the scene, he was alert and talking. He now responds to painful stimuli by only crying out. Injuries include multiple abrasions and an angulated deformity of the right lower leg. There is dried blood around his nose and mouth.VS : BP 110/70 mmHg, HR 180, and RR 35