PENATALAKSANAAN AWAL

KEGAWAT DARURATAN BEDAH

dr Sulistyo Budiman,Sp.B
 LUKA BAKAR,LISTRIK
DAN PETIR

OSHA Office of Training & Education 2

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.

3
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.

5
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 + D5

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 (2nd degree),
indeterminate, & full-thickness (3rd
degree) injuries: count towards %TBSA
3 Zones of Thermal Injury
Hyperemia

Stasis

Coagulation
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
18
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 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
 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 25
 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
Electrical Injuries
Injuries
Factors
Factors Determining
Determining Severity
Severity

OHMS LAW: i = V / R

1. V = voltage
2. i = current
3. R = resistance
 Electrical
Electrical Injuries
Injuries
Factors
Factors Determining
Determining Severity
Severity
Skin Resistivity -
Ohms/cm2
Mucous membranes
100
Vascular areas
300 - 10 000
volar arm, inner
thigh
Wet skin
Sweat 1 200 - 1 500
Bathtub 2 500
Other skin 10 000 - 40 000
Sole of foot 100 000 - 200 000
Heavily calloused palm 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 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 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::
Electric Shock
What
What Should
Should You
You Do?
Do?
The victim:
Felt the current The current
pass through Yes
passed through Yes
his/her body the heart

No No

Was held by the

Yes
source of the
electric current
1 second Yes
No
or more

No

Lost Yes Cardiac Monitoring

consciousness 24 hours

No

Touched a voltage
source of more
than 1 000 volts
 Electric Shock::
Electric Shock
What
What Should
Should You
You Do?
Do?
Page
Page 2.
2.

Touched a voltage
Yes Cardiac Monitoring
source of more
24 hours
than 1 000 volts

No
Yes

Has burn marks The current Evaluate and treat burns

Yes No
on his/her passed through (surgical evaluation,
skin the heart look for myogolbinuria, etc.)

No

Was thrown from Yes

Evaluate trauma
the source

No

Yes Evaluate fetal

Is pregnant
activity

No
BENIGN SHOCK Direction Services de Sante
Reassure and discharge Hydro Quebec, 1995
 Kriteria Rujukan Pasien LB
Grade 23
Luas LB>10% BSA pd semua
umur.
Umur <10 and > 50 thn
Luas LB >20% BSA
Mengenai area :
Face Hand Perineum
Eyes Feet Sendi2 utama (Major
Ears Genitalia joints)
47
Kriteria Rujukan Pasien LB
Grd 3 dg Luas LB> 5% BSA
LB listrik, petir & Zat Kimia
Trauma Inhalasi
Tdp Penyakit atau trauma penyerta

48
Kriteria Rujukan Pasien LB

Koordinasi dg dokter Pusat Rujukan.

Dirujuk dg:
Dokumentasi/ informasi yg lengkap.
Hasil Laboratorium.

49
Acute Abdomen
 Acute Abdomen
General name for presence of signs,
symptoms of inflammation of peritoneum
(abdominal lining).
Determining exact cause is irrelevant in
pre-hospital medicine.
Important factor is recognizing acute
abdomen is present and providing proper
patient care.
Abdominal Anatomy
Exam Quadrants
 Anatomic Landmarks
Divided in quadrants
RUQ, LUQ, RLQ,
LLQ
Anatomic:
Epigastrium
Umbilical
Suprapubic
(hypogastrium)
 6 Dermatomal Pain Syndrome
Due to poorly localizing visceral innervation, diseases can present in
vague, confusing manner
Pneumonia
Acute MI
GERD
Biliary Colic
PUD
Pancreatitis
Hepatitis
Clinical Diagnosis
Location of pain by
organ
RUQ
Gallbladder
Epigastrum
Stomach
Pancreas
Mid abdomen
Small intestine
Lower abdomen
Colon, GYN pathology
Clinical Diagnosis
Differential Diagnosis
 Abdominal Aortic Aneurysm
Localized weakness of
blood vessel wall with
dilation (like bubble on
tire)
Pulsating mass in
abdomen
Can cause lower
back pain
Rupture shock,
exsanguination
 Appendicitis
Pain begins periumbilical; moves to RLQ
Nausea, vomiting, anorexia, fever
Patient lies on side; right hip, knee flexed
Pain may not localize to RLQ if appendix in
odd location
Sudden relief of pain = possible perforation
 Bowel Obstruction

Blockage of inside of intestine

Interrupts normal flow of contents
Causes include adhesions, hernias,
fecal impactions, tumors
Cramping abdominal pain, nausea,
vomiting (often of fecal matter),
abdominal distension
 Cholecystitis
Inflammation of gall
bladder
Commonly associated
with gall stones
More common in 30 to 50
year old females
Nausea, vomiting; RUQ
pain, tenderness; fever
Attacks triggered by
ingestion of fatty foods
 Diverticulitis
Pouches become
blocked and infected
with fecal matter
causing inflammation.
Pain, perforation,
severe peritonitis.
 Peptic Ulcer Disease
Steady, well-localized
epigastric or LUQ pain
Described as a burning,
gnawing, aching
Increased by coffee,
stress, spicy food,
smoking
Decreased by alkaline
food, antacids
 Peptic Ulcer Disease
Erosion of the lining of the stomach,
duodenum, or esophagus
May cause massive GI bleed
Patient lies very still with complaint of
intense, steady pain, rigid abdomen with
exam, suspect perforation
 Ectopic Pregnancy
Fertilized egg is
implanted outside the
uterus.
Growth causes rupture
and can lead to
massive bleeding.
Patient c/o of severe
RLQ or LLQ pain
with radiation.
 Esophageal Varices
Dilated veins in
lower part of
esophagus
Common in EtOH
abusers, patients
with liver disease
Produce massive
upper GI bleeds
 Gastroesophageal Reflux
Also known as GERD
Signs and symptoms
can mimic cardiac
pain.
Usually onset after
eating.
Typically resolved
with medication.
 Inguinal Hernia
Protrusion of the
intestine through a tear
in the inguinal canal.
Usually identified by
abnormal mass in
lower quadrant, with
or without pain.
Strangulation can lead
to necrosis.
 Kidney Stone
Mineral deposits form in
kidney, move to ureter
Often associated with
history of recent UTI
Severe flank pain
radiates to groin, scrotum
Nausea, vomiting,
hematuria
Extreme restlessness
 Pancreatitis
Inflammation of pancreas
Triggered by ingestion of
EtOH; large amounts of
fatty foods
Nausea, vomiting;
abdominal tenderness;
pain radiating from upper
abdomen straight through
to back
Signs, symptoms of
hypovolemic shock
 Pelvic Inflammatory Disease
Inflammation of the
fallopian tubes and
tissues of the pelvis
Typically lower
abdominal or pelvic
pain, nausea, vomiting
 Splenic Trauma
Blunt force trauma is
typical MOI.
Signs and symptoms
may not developed
until 24 hours later.
Pain usually LUQ but
may present atypical
to other quadrants.
 Assessment

BSI/Scene Safety
Initial Assessment: Sick/Not Sick
Focused Exam
Detailed Exam
Assessment
Plan/treatment
 Signs and Symptoms
Local/diffuse Anorexia, nausea,
abdominal pain or vomiting
tenderness Abdominal
Guarding distension
Rapid, shallow Constipation or
breathing bloody stool
Referred pain Tachycardia
Rebound tenderness Hypotension
Fever
 History (S)
Where do you hurt?
Know locations of major organs
But realize abdominal pain locations do not
correlate well with source
 History (S)
Was onset of pain gradual or sudden?
Gradual = peritoneal irrigation or hollow organ
distension
Sudden = perforation, hemorrhage, infarct
What does pain feel like?
Steady pain - inflammatory process
Crampy pain - obstructive process
 History (S)
Does pain radiate (travel) anywhere?
Right shoulder, angle of right scapula = gall
bladder, liver, spleen
Around flank to groin = kidney, ureter
Referred Pain Locations
 History (S)

Duration?
Nausea, vomiting? Bloody? (Coffee
grounds emesis?)
Change in urinary habits? Urine
appearance?
Change in bowel habits? Melena (Dark,
tarry stools?)
Regular food/water intake?
 History (S)

Females
Last menstrual period?
Abnormal bleeding?

In females, abdominal pain =

GYN problem until proven otherwise
 Physical Exam (O)
General Appearance
Lies perfectly still suspect inflammation,
peritonitis
Restless, writhing suspect obstruction
Abdominal distension?
Ecchymosis around umbilicus, flanks?
Obvious bleeding noted?
 Physical Exam (O)
Vital signs
Tachycardia ? Early shock (more
important than BP)
Rapid shallow breathing peritonitis
Postural changes may indicate internal
bleeding
Signs of shock?
 Physical Exam (O)
Palpate each quadrant
Work toward area
of pain
Warm hands
Patient on back,
knee bent (if
possible)
Note tenderness,
rigidity, guarding,
masses
 Special Considerations

In adults > 30, consider possibility of

referred cardiac pain.
In females, consider possible gyn problem,
especially tubal ectopic pregnancy
Geriatric patients may present with atypical
signs and symptoms
Never underestimate injury from trauma
 ALS Indicators
Shock signs & symptoms:
Poor skin signs (pale, diaphoresis)
Sustained tachycardia
Hypotension
Unstable vital signs
Positive postural changes
Evidence of on-going bleeding
Severe, unremitting pain
 Patient Care

Medics?
Airway management/suctioning
Patient position of comfort
Provide O2
Maintain body temperature
Calm & reassure
Monitor vital signs every 5 minutes
 Labs & Imaging
Test Reason Test Reason
CBC w diff Left shift can be KUB SBO/LBO,
very telling Flat & Upright free air,
BMP N/V, lytes, stones
acidosis,
dehydration Ultrasound Choly, jaundice
GYN pathology
Amylase Pancreatitis,
perf DU, bowel
ischemia
CT scan Anatomic dx
LFT Jaundice,hepati
Case not
tis -Diagnostic
accuracy straightforward
UA GU- UTI, stone,
hematuria

Beta-hCG Ectopic
 CT scan

What is the diagnosis? Acute appendicitis

 Non-Surgical Causes by Systems
System Disease System Disease
Cardiac Myocardial infarction Endocrine Diab ketoacidosis
Acute pericarditis Addisonian crisis

Pulmonary Pneumonia Metabolic Acute porphyria

Pulmonary infarction Mediterranean fever
PE Hyperlipidemia
GI Acute pancreatitis Musculo- Rectus muscle
Gastroenteritis skeletal hematoma
Acute hepatitis
GU Pyelonephritis CNS Tabes dorsalis (syph)
PNS Nerve root
compression

Vascular Aortic dissection Heme Sickle cell crisis

 Decision to operate
Peritonitis
Tenderness w/ rebound, involuntary guarding
Severe / unrelenting pain
Unstable (hemodynamically, or septic)
Tachycardic, hypotensive, white count
Intestinal ischemia, including strangulation
Pneumoperitoneum
Complete or high grade obstruction
 Take Home Points
Careful history (pain, other GI symptoms)
Remember DDx in broad categories
Narrow DDx based on hx, exam, labs, imaging
Always perform ABC, Resuscitate before Dx
If patients sick or toxic, get to OR (surgical emergency)
Ideally, resuscitate patients before going to the OR
Dont forget GYN/medical causes, special situations
For acute abdomen, think of these commonly (below)

Perf DU Appendicitis Diverticulitis Bowel

+/- perforation +/- perforation obstruction
Cholecystitis Ischemic or Ruptured Acute
perf bowel aneurysm pancreatitis
Thank you
OSHA Office of Training & Education 94