Perawatan Darurat Luka Bakar Mata Kimia Dan Termal

8/12/2019 Perawatan Darurat Luka Bakar Mata Kimia Dan Termal

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Perawatan darurat luka bakar mata kimia dan termal Ralf Kuckelkorn, Norbert Schrage, Gabriela Keller dan Claudia Redbrake Pasal pertama kaliditerbitkan secara online: 20 MAR 2002

ABSTRAK. Kimia dan luka bakar mata termal account untuk sebagian kecil tapi signifikan dari trauma

okular. Kecepatan di mana irigasi awal mata dimulai, memiliki pengaruh terbesar pada prognosis dan

hasil dari luka bakar mata. Air umumnya direkomendasikan sebagai cairan irigasi. Namun, air adalah

hipotonik ke stroma kornea. Osmolaritas gradient menyebabkan masuknya air meningkat ke kornea

dan invasi zat korosif ke dalam struktur kornea yang lebih dalam. Oleh karena itu kami

merekomendasikan osmolaritas lebih tinggi untuk pembilasan awal untuk memobilisasi air dan korosif

terlarut dari jaringan bakaran. Sistem universal seperti solusi amfoter, yang memiliki mengikat tidak

spesifik dengan basa dan asam, memberikan solusi yang nyaman untuk netralisasi darurat. Kedua

terapi anti-inflamasi konservatif dan intervensi bedah segera sangat penting untuk mengurangirespon inflamasi dari jaringan yang terbakar. Pada luka bakar mata yang paling parah, tenonplasty

kembali menetapkan-permukaan konjungtiva dan vaskularisasi limbal dan mencegah segmen

anterior necrosis.

Penelitian terbaru menempatkan kejadian cedera kimia dan termal mata pada 7,7% -18% dari semua

trauma okular ( Watz & Reim 1973 ; . Pfister et al 1984 ; Liggett 1989 , MacEwen 1989 ; . Zagelbaum

et al, 1993 ). Sebagian besar cedera ini sepele dan tidak menyebabkan lesi abadi, yang lain

mengakibatkan gangguan penglihatan unilateral atau bilateral permanen dan kehidupan

ketergantungan (Kuckelkorn et al. 1993 ). Sebagian besar korban masih muda dan paparan terjadi di

rumah, tempat kerja dan dalam hubungan dengan serangan kriminal ( Keeney 1974 ; . Morris et al

1987 ; . Thielsch et al 1989 ). Alkali cedera lebih sering daripada cedera asam terjadi (Pfister

1983 , Morgan 1987 ), mata luka bakar yang disebabkan oleh deterjen dan agen termal menjadi

kurang sering lagi ( Kuckelkorn et al 1995. ). Para agen yang paling umum yang menyebabkan luka

bakar alkali adalah amoniak (NH 3), alkali (NaOH), kalium hidroksida (KOH) dan kapur (CaOH2). Sulfat

(H2SO 4), belerang (H2SO 3), fluorida (HF) dan klorida (HCL) asam adalah penyebab paling umum dari

luka bakar asam. Tabel 1 daftar data dari 191 pasien dengan 260 mata parah terbakar yang dirawat

di mata pusat RWTH Aachen antara tahun 1980 dan 1995. Ada insiden tinggi cedera bilateral dan

sebagian besar cedera terjadi di rumah atau selama kegiatan rekreasi.

TABEL 1. berat mata kimia dan termal membakar di Departemen Ophthalmology dari RWTH

Aachen (1985-1995): 191 pasien (260 mata).

Aksi alkali dan asam Tingkat keparahan cedera mata berkaitan dengan jenis bahan kimia, volume dan konsentrasi (pH)

dari solusi dan durasi paparan (Hughes 1946 ). Alkalis menembus lebih cepat daripada asam. The

hydroxylion (OH) saponifies komponen asam lemak dari membran sel dengan gangguan sel berturut-

turut dan kematian sel, sedangkan kation bertanggung jawab untuk proses penetrasi alkali tertentu
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Perawatan darurat Segera irigasi adalah sangat penting setelah luka bakar kimia atau termal ( Lbeck & Greene

1988 , Cohen & Hyndiuk 1978 ; . Rodeheaver et al 1982 ). Dalam kebanyakan kasus korban

dinonaktifkan oleh blepharospasm reflectory berat dengan berikutnya disorientasi. Dalam situasi ini

para korban tampaknya tidak akan mampu mencapai tubuh terdekat atau mata shower dan perlu

penyelamat yang menghapus mereka dari daerah berbahaya dan menerapkan cepat dan efisien

membantu mata dan tubuh mereka (Morgan 1987 ).

Pertolongan pertama yang efektif melibatkan mengetahui bagaimana mengatasi blepharospasm oleh

pembukaan pasif tutup dan bagaimana melakukan irigasi yang efektif mata. Semua aspek

konjungtiva dan kornea harus diairi, dan pasien harus diminta untuk melihat ke segala arah ( Tannen

& Marsden 1991 ). Tetes anestesi topikal dapat diterapkan untuk mengurangi rasa sakit dan untuk

memfasilitasi irigasi. Menurut American National Standards Institute (ANSI) standar (Z358.1-1990)

luka bakar mata berat harus dibilas selama 15 menit. Setidaknya 500-1000 ml cairan irigasi dengan

demikian diperlukan. Solusi amfoter atau buffered dapat menormalkan pH dari ruang anterior dalam

waktu itu ( Schrage et al. 1996 ). Partikel kadang-kadang terjebak dalam fornizes atau di bawah

kelopak mata atas. Oleh karena itu, ectropinisation dan pembersihan intensif cul-de-sac adalah wajib

setelah setiap luka bakar. Bahan yang mengandung kalsium oxid (kapur, debu semen) bereaksi rajin

dengan air untuk menghasilkan larutan kalsium hidroksida dengan pH 12,4 ( Moon & Robertson

1983 ). Sebuah aplikator kapas-tipped direndam dalam EDTA 1% (EDTA, di-sodium-etilen-

diamintetra-acetat) dapat digunakan untuk memfasilitasi pembersihan cul-de-sac dari kalsium

hidroksida ( Pfister 1983 ). Segera irigasi juga penting dalam luka bakar termal, karena inimendinginkan permukaan mata ( Schrage et al. 1997 ). Irigasi terus menerus juga menghilangkan zat

inflamasi dari permukaan okular ( Reim 1990 ; Reim & Kuckelkorn 1995 ).

Pertolongan pertama dengan irigasi intensif segera setelah cedera memiliki pengaruh yang

menentukan pada kursus klinis dan prognosis mata tersebut ( Saari & Parvi 1984 ; Luka bakar &

Paterson 1989 ). Perbandingan antara hasil visual yang lebih baik dari 1/50 dengan kurang dari 1/50

mengungkapkan perbedaan yang sangat signifikan, dengan hasil yang jauh lebih baik setelah irigasi

langsung.Ketajaman visual dari> 1/50 memungkinkan pasien untuk bergerak tanpa bantuan. Jumlah

operasi dan lama tinggal di bangsal secara signifikan berkurang untuk mata yang menerima irigasi

prompt ( Tabel 3; . Kuckelkorn et al, 1995 ).

Tabel 3. Nilai terapi pembilasan langsung terhadap hasil klinis pada luka bakar yang parah mata (101 pasien, 131 mata).

Pilihan cairan irigasi Luka bakar yang disertai dengan hilangnya epitel kornea dalam beberapa detik. Kornea akut dibakar

mengambil substansi terbakar oleh pasukan osmolar menghasilkan osmolaritas tinggi. Salah satu

tujuan terapi pembilasan adalah untuk menghapus beban kimia ini.
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5/7

Air umumnya direkomendasikan sebagai cairan irigasi. Ini tersedia hampir di mana-mana, dan jumlah

berlebihan air mempunyai efek dilutif. Namun, air adalah hipotonik ke stroma kornea dan lingkungan

intraokular. Dalam pengukuran osmolaritas, Schrage et al. (Tidak dipublikasikan) menemukan stroma

kornea untuk memiliki osmolaritas 420 mOsm / L. Jaringan kornea diencerkan dengan membilasnya

dengan air dan ini disertai dengan peningkatan serapan air tambahan dan difusi korosif ke lapisan

lebih dalam dari kornea. Sehingga kami merekomendasikan penggunaan cairan irigasi dengan

osmolaritas lebih tinggi untuk pembilasan awal untuk mencegah masuknya air ke dalam kornea dan

untuk memungkinkan mobilisasi air dan korosif terlarut dari jaringan bakaran.

Salin normal (NS), yang sering direkomendasikan sebagai cairan irigasi, juga memiliki osmolaritas

lebih rendah dari cairan air mata. Ini gagal untuk menormalkan pH dari ruang anterior bahkan setelah

irigasi berkepanjangan ( Tabel 4 ).

Tabel 4. Pada permukaan kornea dan di ruang anterior setelah berkumur dengan cairan irigasi yang berbeda (burn mata eks/1n NaOH).

Dapar fosfat sering disebut sebagai larutan buffer ideal ( Thiel 1965 ; . Laux et al 1975 ; Poser

1983 , Roth 1993 ). Untuk alasan ini, ada meluasnya penggunaan penyangga ini di banyak

pabrik. Namun, dalam sebuah studi eksperimental kalsifikasi lengkap dari stroma superfisial terjadi

pada 100% dari semua hewan setelah pembakaran dengan 1 n NaOH selama 30 s dan pembilasan

langsung dengan 500 mL dapar fosfat. (Schrage et al., Tidak dipublikasikan). Kami menyarankan

bahwa eksogen diterapkan fosfat bereaksi dengan kalsium endogen dilepaskan dari sel pecah untukmenghasilkan kompleks kalsium-phophate.

Saat ini, ada penelitian eksperimental yang sedang berlangsung untuk menemukan cairan irigasi

dengan osmolaritas mirip dengan stroma kornea. Saat ini tersedia cairan yang cocok untuk irigasi

steril, laktat Ringer (LR) dan larutan garam seimbang (BSS; . Herr et al, 1991 ). Ringer laktat adalah

larutan buffer dan mungkin lebih efektif daripada normal saline. Osmolaritas BSS adalah mirip

dengan aqueous humor; pH yang netral dan mengandung natrium asetat dan citrat ( McDermott et al.

1988 ). Menurut Pfister, isotonik buffer sitrat memulai chelat-kompleks dan mengikat logam-ion tidak

spesifik berasal dari korosif ( Pfister et al 1981. ; . Pfister et al 1984 ). Larutan garam seimbang

memiliki kapasitas buffer yang disempurnakan; mencegah kornea dari pembengkakan dan

mempertahankan endothelium kornea ( McNamara et al. 1987 ).

The pH, osmolaritas dan penyangga kapasitas aqueous humor, stroma kornea dan beberapa cairan

irigasi yang tercantum dalam Tabel 5 .

Tabel 5 .. pH, osmolaritas, konstituen dan penyangga kapasitas aqueous humor, stroma kornea dan cairan irigasi yang berbed

Sebuah solusi amfoter baru yang cocok untuk irigasi Diphoterine (Previn , Fa. Prevor). Cairan ini

baru synthetisized mampu mengikat kedua alkali dan asam. 0,4% Diphoterinehas pH 7,4 dan

osmolaritas 820 mosml / L. PH dalam kantung konjungtiva dan dalam stroma kornea berkurangsecepat setelah irigasi dengan dapar fosfat. Konstituen dari Diphoterine tercantum dalam Tabel 6 .
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6/7

Masalah transportasi Sebagai asam kuat dan basa menembus dalam hitungan detik atau menit dan tetap selama berjam-

jam ( Grant & Kern 1955 ), irigasi tidak boleh terganggu selama transportasi ke unit perawatan mata

profesional. Rekomendasi untuk kali irigasi minimum berkisar dari 15 menit (standar ANSI; Lubeck &

Greene 1988 ) 2-4 h ( Pfister 1983 ; . Saari et al 1984 ). Kami merekomendasikan penggunaan infus

set intravena untuk memasok setidaknya 500-1000 ml cairan irigasi. Seperti dijelaskan di atas, salah

satu penyelamat harus memegang kelopak mata terbuka sementara penyelamat kedua flushes mata

dengan aliran ringan, directable dan terkendali cairan. Tetes anestesi lokal harus diberikan berulang

kali jika diperlukan untuk meringankan pasien dari rasa sakit dan untuk memfasilitasi irigasi.

Beberapa penulis mendukung penggunaan sistem irigasi yang dirancang khusus ( Naumann

1964 ; Girard & Soper 1966 ; Schulze & Tost 1967 , Tan 1970 , Morgan 1971 ; Lau

1979 ). Sedangkan sistem ini memberikan irigasi terus menerus mata, mereka gagal untuk menyiram

permukaan mata homogen dan appropiately, terutama cul-de-sac. Sebuah risiko lebih lanjut dengan

kapur atau semen burnsis bahwa partikel dipertahankan di bawah kelopak mata tidak terdeteksi dan

dihapus setelah loop atau lensa telah diterapkan.Selain itu, tim penyelamat asing dengan

penanganan sistem ini akan kehilangan waktu yang berharga ketika menginstal sling atau lensa,

yang dapat menyebabkan kerusakan tambahan untuk mata.

Efektivitas terapi pembilasan dapat dinilai dengan menggunakan kertas indikator universal

menentukan pH dari mata eksternal. Irigasi harus dilanjutkan selama pH tetap di luar kisaran

normal. Jika irigasi lama tidak mencapai normalisasi pH, kita harus mempertimbangkan kemungkinan

bahwa masih ada partikel di superior atau inferior cul-de-sac.

Perawatan berikutnya Perawatan selanjutnya luka bakar mata tergantung pada tingkat keparahan cedera. Prosedur

therapeutical lebih lanjut diterapkan sesuai dengan tingkat kerusakan. Jika cedera ringan (kelas I dan

II) dan irigasi mulai segera, sebagian besar mata akan sembuh tanpa kerusakan permanen dalam

beberapa hari ( Moon & Robertson 1983 , Morgan 1987 ; Beare 1990 ; . Kuckelkorn et al,

1993 ). Steroid / antibiotik topikal tetes dan salep ditambah bantalan mungkin cukup untuk

pengobatan luka bakar ringan. Tindak lanjut pengobatan dalam waktu 24 jam adalah wajib.

Parah luka bakar mata okular (kelas III dan IV) sulit untuk mengobati dan proses penyembuhan

sering membutuhkan waktu beberapa bulan. Dalam kasus ini, klasifikasi akurat sehubungan dengan

memperpanjang (limbal) iskemia dan kedalaman kerusakan jaringan sangat penting. Pemeriksaan

dengan mikroskop operasi dengan demikian wajib. Parabulbar atau anestesi umum kadang-kadang

diperlukan jika pasien menderita rasa sakit dan tetes anestesi lokal tidak cukup.

Luka bakar mata kurang parah (grade III) yang ditandai dengan iskemia superfisial dari jaringan

konjungtiva. Dalam kasus ini di mana struktur ruang anterior biasa yang diawetkan dan tidak ada

kerusakan pada iris, ectropium uveae atau exsudation fibrinous, manajemen selanjutnya mengambil
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bentuk terapi yang lebih konservatif. Masuk ke dan pengobatan di klinik mata lokal sehingga cukup

( Reim & Kuckelkorn 1995 ).

Luka bakar mata yang paling parah (grade IV) menyebabkan iskemia limbal signifikan dan nekrosis

bulbar konjungtiva tarsal dan serta dari jaringan episcleral sampai ke forniks. Dalam kasus dengan

nekrosis superfisial, pembuluh episcleral mendalam masih perfusi sedangkan nekrosis jaringan

episcleral lebih dikaitkan dengan trombosis pembuluh episcleral. Dalam kasus yang parah, kekeruhan

kornea adalah umum dan struktur ruang anterior dikaburkan. Aspek keabu-abuan dari iris, ectropium

uveae dan pemecahan hambatan berair darah dengan exsudation fibrinous ke ruang anterior

mengkonfirmasi penghancuran segmen anterior yang mendalam. Tutup dan aspek konjungtiva tarsal

sering terlibat. Banyak masalah muncul pada fase akut luka bakar. Masalah yang paling halus adalah

mencegah mata dari mencair awal.

Nekrosis konjungtiva dan jaringan subconjunctival disertai dengan exsudation besar leucozytes (PMN

itu). Leucozytes ini melepaskan sejumlah besar enzim lisosomal. The matriks metaloproteinase

(MMP), kolagenase (MMP-1 dan MMP-8; . Itoi et al 1969 ; kait et al 1971. ;Newsome & Gross

1977 , Johnson-Muller & Gross 1978 ; . Kuter et al 1989 ; Fini & Girard 1990 ), gelatinase (MMP-2,

MMP-9) ( Collier et al 1988. ; Fini & Girard 1990 ; . Huhtala et al 1990 ), dan stromelysin (MMP-3, .

Collier et al 1988 ; . Chin et al 1995 ) khususnya bertanggung jawab untuk pemisahan molekul

kolagen dan pengembangan corneoscleral dan kornea ulserasi, karakteristik 4-6 minggu setelah

kecelakaan itu.

Prinsip dasar dalam pengobatan mata ini adalah untuk mengurangi respon inflamasi yang

disebabkan oleh jaringan nekrotik. Andalan tradisional terapi adalah aplikasi awal dan intensifkortikosteroid ( Donshik et al 1978. ; Leibowitz 1980 ; Reim & Schmidt-Martens 1982 ,Kenyon

1985 , Reim 1987 ). Selain itu, antibiotik lokal yang diperlukan untuk mencegah infeksi microbiobal

sampai permukaan okular telah reepithelialized ( Girard et al 1970. ; . Kuckelkorn et al 1987 ; Beare

1990 ). Turunan tetrasiklin memainkan peran penting karena mereka telah terbukti dapat

menghambat Metallo-proteinase ( Brion et al 1985. ; . Golup et al 1987 ; . Seedor et al 1987 ; . Luka

bakar et al 1989 ; . Perry et al, 1993 ) secara independen dari mereka sifat anti-mikroba.

Selain terapi konservatif, intervensi bedah aktif dengan debridemen jaringan nekrotik konjungtiva dan

subkonjungtiva diperlukan dalam rangka untuk menghapus nidus peradangan lanjutan dari bahan

kaustik dipertahankan, meskipun juga setiap akumulasi PMN dan untuk mencegah pelepasan

berkelanjutan enzim yang merusak mereka. Pendekatan khusus rekonstruksi seperti tenonplasty

memungkinkan sclera avascular gundul ditutupi dengan jaringan ikat penting dibuat dari khatulistiwa

dari dunia ( Reim & Teping 1989 ; Reim 1992 ; Reim & Kuckelkorn 1992, 1995; Kuckelkorn & Reim

1993 ; Reim & Leber 1993 ; . Kuckelkorn et al, 1995 ). Keuntungan utama dari jaringan ini adalah

bahwa hal itu memungkinkan rekonstruksi matriks konjungtiva dan vaskularisasi limbal. Intervensi ini

mencegah anterior segmen nekrosis dan / atau ulserasi steril dan mata tersebut

diawetkan. Dianjurkan untuk mengakui kasus ini ke klinik mata khusus dalam pengobatan mata ini

dan akrab dengan prosedur khusus dalam rekonstruksi plastik.
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Perawatan Darurat Luka Bakar Mata Kimia Dan Termal

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