baru kegawat lb listrik petir

5/20/2018 Baru Kegawat Lb Listrik Petir

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PENATALAKSANAAN AWAL

KEGAWAT DARURATAN BEDAH:

LUKA BAKAR,LISTRIK DAN PETIR

Dr. DEDDY SAPUTRA SpBP-RE

FK Unand/RSUP dr M Djamil

PADANG


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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


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Initial Assessment

Airway

Breathing

Circulation

Disability

Exposure

Initial burn treatment: remove burn source


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Prinsip Penatalaksanaan LB:

Menjamin: Restorasi ABCDE

Airway dan Breathing bebas. Perfusi normal.

Keseimbangan cairan & elektrolit.

Suhu tubuh Normal.

4


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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, sorethroat, abnormal phonation, stridor

Lower airway injury: delayed mortality

dyspnea, wheezing, carbonaceous sputum, COHb,

PaO2/FiO2

bronchoscopy +/-

Intubate EARLY!!! Orotracheal

Surgical airway


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Airway disturbance


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Circulation Typically burns 20% require IVF resuscitation

Resuscitate w/ kristaloid.

Adult(Baxter/Parkland Formula)

= 4cc/ kg/ % burn

1/2 over 1st 8 hr fromtime of burn

1/2 over subsequent 16 hr

Child (


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Calculate burn size (%)

Burn depth

Superficial

Partial-thickness (PT)

Full-thickness (FT)

Indeterminate

Only partial-thickness (2nddegree),

indeterminate, & full-thickness (3rddegree)injuries: count towards %TBSA


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3 Zones of Thermal Injury

Coagulation

Stasis

Hyperemia


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Burn Depth


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Superficial

Formerly 1st-degree

Essentially a sunburn

Pink Painful

NOblisters

Will heal in < 1 week


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Partial-thickness

Formerly 2nd-

degree

Pink

Moist

Exquisitely painful

B l istered

Typically heals in < 2-

3 weeks


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Full-thickness

Formerly 3rd-

degree

Dry Leathery

White to charred

Insensate

Will require E&G


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Indeterminate

Unsure as to whether

PT or FT

Observe forconversion b/t days

3-7

May or may notrequire E&G

Can unpredictably

increase LOS


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Calculate burn size

Estimate %TBSA

Palmar surface of pts hand = 1% TBSA

Age-appropriate diagrams (e.g.- Berkow)

Rule of Nines


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The Rule of Nines and LundBrowder Charts

Orgill D. N Engl J Med 2009;360:893

901


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Disability(from other injuries)

Primary & secondary surveys areimportant!!!

R/O non-thermal trauma ~5% haveconcomitant non-thermal injury

Management of non-thermal trauma

typically supercedesburn management,except for the resuscitation.


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Everything else

Vascular access: PIV is preferable

Analgesia = IV opiates

Conservative & judicious sedatives,prnonly

Woods lamp eye exam for flash burns to face

Escharotomies

Early enteralnutrition ( 20% TBSA)


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Escharotomies


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Indications

Circumferential FT extremity burns withthreatened 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


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Escharotomy


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ELECTRICAL INJURY

Zeus, the ruler of the ancient

Greek gods, wascharacteristically 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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24

Shock Severity

Severity of the shock depends on:

Path of current through thebody

Amount of current flowingthrough the body (amps)

Duration of the shockingcurrent through the body,

LOW VOLTAGE DOES NOTMEAN LOW HAZARD


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PRINCIPLES OF ELECTRICITY

Electricity is the flow of electrons (the negativelycharged outer particles of an atom) through aconductor.

when the electrons flow away from this object

through a conductor, they create an electriccurrent, which is measuredin Amperes (I).

The force that causes the electrons to flow is thevoltage, and it is measured in Volts (V).

Anything that impedes the flow of electronsthrough a conductor creates resistance, which ismeasured in Ohms (R).


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Electrical Injuries

Factors Determining Severity

1. V= voltage

2. i = current

3. R= resistance

OHMS LAW: i = V / R


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Electrical Injuries

Factors Determining Severity

Mucous membranes

Vascular areas volar arm, innerthigh

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


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Resistance of Body TissuesLeast

Nerves Blood

Mucous membranes

Muscle

Intermediate

Dry skin

Most Tendon

Fat

Bone


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Power lines range from:

Low: < 600 volts

Ultrahigh: > 1 million volts

Most homes in US & Canada have a 120/240 Vother countries (Europe, Asia..): 220 V


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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


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Electrical current exists in 2 forms:

1) AC: (Alternating Current):when

electrons flow back and forth through aconductor in a cyclic fashion

It is used in household and offices and isstandardized to a frequency of 60

cycles/sec (60 Hz)


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2) DC: (Direct Current):when electrons

flow only in one direction

Used in certain medical equipment:

defibrillators, pacemakers, electricalscalpels

AC is far more efficient and also moredangerous than DC (~ 3 times): tetanic

muscle contractions that prolong the

contact of victim with source


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Cutaneous I njur ies & Burns

Extensive flash and flame burns

Hemodynamic, autonomic,

cardiopulmonary, renal, metabolic and

neuroendocrine responses


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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


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Voltage >1,000,000 V

Currents of >200,000 A

Transformation of the electrical energy toheat generated temperatures as high as

50,000F.


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Pathway of the current through the body:

Vertical pathwayparallel 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 theuterus and fetus

Horizontal pathwayfrom hand to hand: the

heart, respiratory muscles and spinal cord

Pathway through the lower part of the body:

local damage


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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


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Management of Electrical and

Lightning Injuries

Overall fluid management should bejudicious unless: SIADH


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Patient Monitor ing

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


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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:


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Electric Shock:What Should You Do?

The victim:

Felt the currentpass throughhis/her body

The currentpassed through

the heart

Was held by thesource of the

electric current

Lostconsciousness

Yes

No No

No1 secondor more

Yes

No

Yes

Cardiac Monitoring24 hours

Touched a voltagesource of more

than 1 000 volts

Yes

No

Yes

Electric Shock:


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Electric Shock:What Should You Do?

Page 2.

Touched a voltagesource of morethan 1 000 volts

Cardiac Monitoring24 hours

Has burn markson his/her

skin

The currentpassed through

the heart

Yes

No

Yes

YesEvaluate and treat burns

(surgical evaluation,look for myogolbinuria, etc.)

No

Was thrown fromthe source

Evaluate trauma

No

Is pregnantEvaluate fetal

activity

No

Yes

Yes

No

BENIGN SHOCKReassure and discharge

Direction Services de SanteHydro Quebec, 1995


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Kriteria Rujukan Pasien LB

46

Grade 23 Luas LB>10% BSA pd semua umur.

Umur 50 thn Luas LB >20% BSA

Mengenai area :

Face

Eyes

Ears

Hand

Feet

Genitalia

Perineum

Sendi2 utama (Major

joints)


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Grd 3 dg Luas LB> 5% BSA

LB listrik, petir & Zat Kimia Trauma Inhalasi

Tdp Penyakit atau trauma penyerta

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Koordinasi dg dokter Pusat Rujukan.

Dirujuk dg:

Dokumentasi/ informasi yg

lengkap.

Hasil Laboratorium.

48

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