BARU KEGAWAT LB LISTRIK-PETIR

PENATALAKSANAAN AWAL KEGAWAT

DARURATAN BEDAH: LUKA

BAKAR,LISTRIK DAN PETIR

Dr. DEDDY SAPUTRA SpBP-RE FK Unand/RSUP dr M Djamil

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.



Initial Assessment

• Airway

• _Breathing • _Circulation • _Disability • _Exposure

Prinsip Penatalaksanaan LB:

 Menjamin: Restorasi ABCDE

Airway dan Breathing bebas.

Perfusi normal.

Keseimbangan cairan & elektrolit.

Suhu tubuh Normal.

A

irway &

B

reathing

• 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

C

irculation

• 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

C

alculate burn size (%)

• Burn depth

Superficial

Partial-thickness (PT)

Full-thickness (FT)

Indeterminate

• Only partial-thickness (2nd degree),

indeterminate, & full-thickness (≥3rd degree)

3 Zones of Thermal Injury

Coagulation

“Superficial”

• Formerly “1st-degree”

• Essentially a sunburn • _Pink

• _Painful

• _{NO blisters}

“Partial-thickness”

• Formerly

“2nd-degree”

• _Pink • _Moist

• Exquisitely painful • _Blistered

• _{Typically heals in <}

“Full-thickness”

• Formerly

“3rd-degree”

• _Dry

• _Leathery

• White to charred • _Insensate

“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}

C

alculate burn size

• _{Estimate %TBSA}

Palmar surface of pts hand = 1% TBSA

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

The Rule of Nines and Lund–Browder Charts

D

isability

(from other injuries)

• Primary & secondary surveys are

important!!!

• R/O non-thermal trauma … ~5% have

concomitant non-thermal injury

• Management of non-thermal trauma

E

verything else

• Vascular access: PIV is preferable

• Analgesia = IV opiates

• Conservative & judicious sedatives, prn only • Wood’s lamp eye exam for flash burns to face

• 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

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

24

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

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}

Electrical Injuries

Factors Determining Severity

Electrical Injuries

Factors Determining Severity

1. V = voltage

2. i = current

3. R = resistance

Electrical Injuries

Factors Determining Severity

Electrical Injuries

Factors Determining Severity

Mucous membranes Vascular areas

• _{volar arm, inner} Sole of foot

Heavily calloused palm

Resistance of Body Tissues

Least

• _Nerves • _Blood

•

_{Power lines range from:}

– _{Low: < 600 volts}

– _{Ultrahigh: > 1 million volts}

•

_{Most homes in US & Canada have a 120/240 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

•

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}

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

Cutaneous Injuries & Burns

•

Extensive flash and flame burns

•

Hemodynamic, autonomic,

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 µsec

•

Voltage >1,000,000 V

•

Currents of >200,000 A

•

_{Transformation of the electrical energy to}

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:}

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} 

Management of Electrical and

Lightning Injuries

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}

•

Preexisting heart disease: monitor such

patients for 24 hrs after the injury

•

_{Criteria for cardiac monitoring:}

– Exposure to high voltage – _{Loss of consciousness}

Electric Shock

:

What Should You Do?

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

Touched a voltage source of more than 1 000 volts

Yes

No

Electric Shock

:

What Should You Do?

Page 2.

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

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

Kriteria Rujukan Pasien LB

46

Grade 2–3

 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

Kriteria Rujukan Pasien LB

 Grd 3 dg Luas LB> 5% BSA

 LB listrik, petir & Zat Kimia

 Trauma Inhalasi

 Tdp Penyakit atau trauma penyerta

Kriteria Rujukan Pasien LB

 Koordinasi dg dokter Pusat Rujukan.

 Dirujuk dg:



_{Dokumentasi/ informasi yg}

lengkap.



_{Hasil Laboratorium.}