Seminar Bang Lino Luka Bakaaaar (1)

8/13/2019 Seminar Bang Lino Luka Bakaaaar (1)

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Dr. Evangelino


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KU : Luka Bakar listrik di kedua lengan dantungkai

AK:

2 hari SMRS saat pasien sedang bekerjasambil memegang besi didaerah Padalarang,tiba-tiba besi yang dipegangnya mengenai kabellistrik sehingga pasien mengalami luka di kedualengan dan tungkainya. Riwayat pingsan (-)

muntah (-). Pasien kemudian dibawa ke RSCahya Kawaluyaan dirawat selama 2 hari namunbelum pernah dilakukan pembersihan luka diruang operasi. Pasien kemudian dirujuk ke RSHS.


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Primary survey:A: Clear + C-spine controlB: RR :20 x/m, Bentuk & gerak simetris, VBS ki=ka

C: N : 98x/m , T : 110/70 mmHgD: GCS E4M6V5=15 , Pupil bulat isokor ODS 3mm, RC +/+,parese -/-

Secondary survey:a/r palmar bilateral : luka masuk (+) gr III 2%

a/r antebrachii dekstra : luka bakar gr III 3,5%a/r antebrachii sinistra : luka bakar gr III 3,5%a/r ekstremitas inferior sinistra : luka keluar (+) gr III 9 %a/r ekstremitas inferior dextra : luka bakar gr III 9%

Total : luka bakar III 27% CRT (-), Pulsasi a. radialis dan a. ulnaris (-) pulsasi a. tibialis posterior dan a. dorsalis pedis (-)

Kedua lengan kontraktur (+)

c


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PT : 15

INR : 2

APTT : 24.8

Hb : 14.5

Ht : 42

L : 23.300

Tr : 159.000SGOT : 737

SGPT : 241

Ur : 77

Kr : 2.28

albumin : 2.4Protein total : 4,8

Na : 125

K : 5.3

AGD

pH : 7.381pCO2 : 34.7pO2 : 144.0HCO3 : 20.1TCO2 : 39.3BE : -8

Sat O2 : 99.0

Laktat : 0.8

Urinalisis : kuning keruh,kemerahan,protein urin 2+, Eritrosit banyak.

EKG : sinus rhytm


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DK/ :Luka bakar gr III 27% a/r palmaris bilateral, antebraciibilateral, ekstremitas inferior bilateral e.c listrik +Kompartemen syndrom + Sepsis berat.

Th/ :- EGDT

- Antibiotik

- Analgetik- ATS + TT

- R/ Nekrotomi Debridement + fasciotomi


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DO: (op. Dr. Ahmad H, Dr. Irzal)

a/r palmar bilateral : luka masuk (+)

gr III 2%

a/r antebrachii dekstra : luka bakar gr III 3,5%

a/r antebrachii sinistra : luka bakar gr III 3,5%

a/r ekstremitas inferior sinistra : luka keluar (+) gr III 9 %

a/r ekstremitas inferior dextra : luka keluar (+) gr III 9%

Total : luka bakar III 27%


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DK/ post op :Luka bakar listrik gr III 27% a/r palmaris bilateral,

antebracii bilateral, ekstremitas inferior bilateral e.c

listrik + kompartemen sindrom + Sepsis berat yang

telah dilakukan EGDT + nekrotomi debridement +Fasciotomi (79.63)

INA-DRG : 094103 IP MAJOR SKIN DISORDERS w/ MCC

ALOS : 18.6 days ISS : 75 RTS : 7.84 TRISS : 31.8 %


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Jam T N R S UO Keterangan13.00 110/70 98 24 37,4 20cc Thorax : B/G simetris, VBS ka=ki, Ro -/-,

wh -/-,

Abdomen : lembut, datar, BU(+), NT (-),NL (-),DM (-)

14.00 100/80 90 22 37,1 40cc Hb/Ht/L/Tr : 14,5/42/23.300/159..000SGOT/PT : 737/241 ; Ur/ Kr : 77/2,28 ; GDS: 155Na/K : 125/5,3Urinalisis : keruh, protein urin 2+, eritrosit

banyak.AGD :pH=7,381/pCO2=34,7/pO2=144/HCO3=20,1TCO2=39,3/BE=-8/Sat O2=97,7%, Laktat :2,8Diputuskan dilakukan EGDTSIO (-) karena biaya

16.00 100/80 94 24 37,8 30cc Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh-/-Abdomen : lembut, datar, BU(+), NT (-),NL (-), DM (-), SIO (-)

18.00 100/60 98 24 37,8 30cc Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh-/-Abdomen : lembut, datar, BU(+), NT (-),NL (-), DM (-), SIO (-)


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Jam T N R S UO Keterangan20.00 100/70 96 24 37,4 30cc Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh

-/-Abdomen : lembut, datar, BU(+), NT (-),NL (-), DM (-), SIO (+)dimulai EGDT

21.00 120/80 90 22 37,1 40cc Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh-/-Abdomen : lembut, datar, BU(+), NT (-),NL (-), DM (-)

AGD Vena :pH=7,334/pCO2=43,50/pO2=51/HCO3=22,5, TCO2=44,8/BE=-3, SO2=73,4%

22.00 110/70 92 22 36,8 40cc Thorax : B/G simetris, VBS ka=ki, Ro -/-,wh -/-,Abdomen : lembut, datar, BU(+), NT (-),NL (-),DM (-)

23.00 100/70 88 20 36,5 40cc Thorax : B/G simetris, VBS ka=ki, Ro -/-,wh -/-,Abdomen : lembut, datar, BU(+), NT (-),NL (-),DM (-)


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Jam T N R S UO Keterangan24.00 100/80 86 20 36,6 50cc Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh

-/-,Abdomen : lembut, datar, BU(+), NT (-),NL (-

),DM (-)Hb/Ht/L/Tr : 14,5/42/23.300/159..000SGOT/PT : 737/241 ; Ur/ Kr : 77/2,28 ; GDS :155Na/K : 125/5,3Urinalisis : keruh, protein urin 2+, eritrositbanyak.

01.00 110/70 88 20 36,5 60cc Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh-/-,Abdomen : lembut, datar, BU(+), NT (-),NL (-),DM (-)

02.00 110/70 80 20 36,6 60cc Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh-/-,Abdomen : lembut, datar, BU(+), NT (-),NL (-),DM (-)

PT/INR/APTT = 13,1/1,02/38,7Hb/Ht/Leu/Tr = 10,7/33/17.000/109.000AGD Vena:pH=7,339/pCO2=41,6/pO2=68,4/HCO3=22,2, TCO2=52,9/BE=-3,4/SO2=73,6%AGD Arteri:pH=7,349/pCO2=39,3/pO2=104,8/HCO3=21,5, TCO2=50,,9/BE=-3,8/SO2=97,9%

Laktet : 1,2Pasien naik OK.


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Apakah yang menjadipermasalahan utama pada pasientersebut?

Upaya apakah yang perludilakukan sebagai upaya damage/ source control?

Kapan perlu dilakukan amputasisebagai definitive surgery?


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Stop the Burning Process Neutralize the heat source Remove smoldering clothing


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Airway Assess patency of airway consider the presence of smoke inhalationinjury and carbon monoxide toxicity if smokeis presentBreathing Assess adequacy of breathing efforts electrical current impair the ability tobreatheInitiate respiratory assistance, if needed


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Circulation Electrical burn acts like a crush injury to muscle Assess adequacy of circulation IV placement and fluid administration Cardiac monitoring is indicated with electricalinjury Remove potentially constricting object, like

jewelry compartment syndrome


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An electrical current will produce

an array of injuries if the currentpasses through the body.

Most of the damage is beneath

the skin surface and the actualinjury can be underestimated.

There are often several possible

components to the injury.


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the injury caused by the electrical currentitself.

The current generates intense heat often inexcess of 2000F along its path through thebody, can lead to severe muscle, nerve andblood vessel damage.


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the injury from arcing .= Ionization of air particles associated with avoltage drop is called arcing. The heat generated in the arc can be as highas 4,000C and can vaporize metal. his process frequently causes a patients

clothing to ignite and cause flame burns.


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is traumatic injury caused by the intensemuscle spasm with the current or from a fall. There is also a variety of cardiac, lungmuscle, nerve and internal organ injurieswhich can occur, some being immediately lifethreatening.


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= defined as exposure to a voltage of 1000volts or greater (damage beneath the surfaceshould be suspected). High-voltage injuries characteristically occurin an outdoor environment near powersources and lines. Electrical current can arc (jump) 1 inch from a

power source or line for every 10,000 voltsbeing carried, so that a person does notactually have to touch the source to sustaininjury.


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The dark nearly black urine on the left iscaused by the muscle damage and pigmentrelease. The urine gradually gets clearer over24 to 48 hours with fluid resuscitation,however, kidney failure can result.


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Immediate cardiac arrest is the most commoncause of death after electrical injury. The process is due to both the direct alterationof rhythm by the current, fibrillation or to the

depression of respiration and subsequenthypoxia. Hand to hand passage of a high voltage currenthas a reported immediate mortality of 60%. Theinitial heart problems are often reversible withCPR. High blood pressure is also quite commonimmediately after injury.


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Impairment of the brain centers stimulationof breathing and severe central nervoussystem damage lack of breathing, Decreased muscle activity in the chest wallcaused by a chest burn, muscle damage, orsecond-degree blunt traumatic injuries canmarkedly impair breathing.


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Acute central nervous systemdamage with coma, seizures,motor and, to a lesser extent,sensory deficits are welldescribed.

Many of these abnormalities arepermanent.


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Orthopedic injuries occur as a result of threeprocesses: The most common orthopedic injury occursas a result of severe immediate musclespasm, long bone fractures and dislocationat major joints. Heat necrosis of local periosteum withsubsequent production of non-viable

bone and sequestrum formation vascular injury


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Conjunctival and corneal burnscataract ruptured ear drums


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FIRST DEGREE [I]Epidermal layer

Pink, painful, and edematous

Heals 3-5 days w/o scarring

Causes: Flame

Sun

Flash from explosion


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SUPERFICIAL SECOND DEGREE [IIA] Epidermis and papillary region of

dermis

Blisters, bullae, serous fluid

Cherry red moist appearing Painful, sensation intact

Edematous

Heals in 7-28 days with minimal scarring

Cause: flame,


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DEEP SECOND DEGREE [IIB] Epidermis and reticular region

of dermis

Blisters, bullae, serous fluid

Pale ivory moist appearing Painful, sensation intact

Edematous

Heals in 7-28 days with variable scarring

Cause: flame, flash, scald, contact


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THIRD DEGREE A full thickness burn destroys all

three layers of skin Extends into subcutaneous tissue, loss of not only the skin but also the

hair follicles, sweat glands, and the regionwhere new skin cells are formed White, yellow, brown leathery appearance Thrombosed vessels, loss of elasticity, marked

edema Possible escharotomy

Painless to touch Requires grafting Causes: flame, electricity, chemicals, prolonged

exposure May take 2-3 days to fully present true depth


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FOURTH DEGREE Extends to muscle

Loss of function

Black, charred appearance

May require amputation May require escharotomy and

fasciotomy

Causes: very prolonged

exposure to flame, chemicals,

and high voltage


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If the extremity is ischemia without apulse, anesthetic, and maintained in a

flexed and contracted position amputation.


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Seminar Bang Lino Luka Bakaaaar (1)

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