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.
4
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 + D
5


Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids)
Calculate burn size (%)

Burn depth
Superficial
Partial-thickness (PT)
Full-thickness (FT)
Indeterminate

Only partial-thickness (2
nd
degree),
indeterminate, & full-thickness (3
rd
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 %TBSA
Palmar surface of pts hand = 1% TBSA
Age-appropriate diagrams (e.g.- Berkow)
Rule of Nines
The Rule of Nines and LundBrowder Charts

Orgill D. N Engl J Med 2009;360:893-
901
17
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
Woods lamp eye exam for flash burns to face
Escharotomies
Early enteral nutrition ( 20% TBSA)
Escharotomies
Indications
Circumferential FT extremity burns with
threatened distal tissue
Diminished or absent distal pulses via doppler
Any S/S of compartment syndrome.


Circumferential FT thoracic burn (Breathing
disturbance)
Elevated PIP or P
plateau

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 Injuries
Factors Determining Severity



1. V = voltage
2. i = current
3. R = resistance
OHMS LAW: i = V / R
Electrical Injuries
Factors Determining Severity

Mucous membranes
Vascular areas
volar arm, inner
thigh
Wet skin
Sweat
Bathtub
Other skin
Sole of foot
Heavily calloused palm
Skin Resistivity -
Ohms/cm
2

100
300 - 10 000


1 200 - 1 500
2 500
10 000 - 40 000
100 000 - 200 000
1 000 000 - 2 000 000
Resistance of Body Tissues

Least
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 I njuries & 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 sec
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
50,000F.


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 current
pass through
his/her body
The current
passed through
the heart
Was held by the
source of the
electric current
Lost
consciousness
Yes
No No
No
1 second
or more
Yes
No
Yes
Cardiac Monitoring
24 hours
Touched a voltage
source of more
than 1 000 volts
Yes
No
Yes
Electric Shock:
What Should You Do?
Page 2.
Touched a voltage
source of more
than 1 000 volts
Cardiac Monitoring
24 hours
Has burn marks
on his/her
skin
The current
passed through
the heart
Yes
No
Yes
Yes
Evaluate and treat burns
(surgical evaluation,
look for myogolbinuria, etc.)
No
Was thrown from
the source
Evaluate trauma
No
Is pregnant
Evaluate fetal
activity
No
Yes
Yes
No
BENIGN SHOCK
Reassure and discharge
Direction Services de Sante
Hydro Quebec, 1995
Kriteria Rujukan Pasien LB
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Grade 23
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.
48