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Tim Kurikulum Pendidikan Preklinik Program Pendidikan Dokter Universitas Islam Malang 20092010
SKENARIO KEEMPAT
Add Hot Water
URAIAN SCENARIO
An. SDB, 3 tahun, BB 15kg, dibawa ke UGD setelah tersiram air panas saat akan mandi sore. Seluruh dada, perut, dan sebagian lengan atas kanan serta seluruh paha kanan dan sebagian atas paha kirinya terkena air panas. Pada pemeriksaan didapatkan bulla dengan dasar putih pada dada dan perut disertai nyeri hebat sedangkan pada lengan dan pahanya berwarna kemerahan dan nyeri. Saat kejadian, An. SDB masih menangis dan \ sadar. Namun dalam perjalanan ke rumah sakit, kesadaran An. SDB mulai menurun dan saat tiba di rumah sakit, An. SDB dalam kondisi koma Apa yang terjadi pada An. SDB?
3. BRAIN STORMING
Bacalah tentang: 1. Luka bakar 2. Mekanisme kulit terhadap luka bakar 3. Pengaruh luka bakar pada kadar Cairan, Elektrolit, dan Keseimbangan Asam Basa 4. Mekanisme terjadinya penurunan kesadaran pada luka bakar 5. Penanganan luka bakar (fase akut, sub akut, kronis, rehabilitatif)
4. CONCEPT MAPPING
Udara Panas (uap) Bahan Kimia (asam/basa kuat, korosif) Minimalisir Kontak
- Matikan Sumber - Jauhkan penderita - Siram air (solution to polution is dilution) - Singkirkan kontak/ bahan yang masih bisa menghantarkan panas - Cover patient with wet clothes - Cegah hipotermia - Waspada inhalasi asap - Dinginkan lesi untuk cegah destruksi lanjutan
SunLight Radiasi
Listrik
Ledakan Api Benda Panas (besi, kompor dll) Air way Patency Breathing O2 aplication Circulation IV Line Disability Exposure
Induksi Inflamasi
Kapiler Rusak
Inhalasi asap & keracunan CO-CO2 Kerusakan Mukosa Saluran Nafas & Pengikatan CO-CO2 dg Hb
Pg
Daya Tahan
Permeabilitas Vaskuler
Vasokonstriksi Arteri Kontraksi jantung Ritme Jantung Rangsang adrenal release glukortikoid, mineralokortikoid
Rangsang Simpatis
Tekanan Darah
Hipovolemi
Tidak Terkompensasi
Gagal Renal
Oliguria
Legenda
= Penyebab = Kompensasi = Permasalahan/Gagal kompenasai = Pencegahan & terapi
MAPPING KASUS
An.SDB /3Th Air panas
Dada & Perut = 13 % derajat II Lengan atas ka = 2 % derajat-I Paha atas ka. = 6,5% derajat I Paha atas ki. = 3,25% derajat I = 24,75%
LUKA BAKAR Derajat I Bulla (-) Derajat II tes jarum & tes vaskularisasi perifer + Derajat III tes jarum & tes vaskularisasi perifer Rangsangan Simpatis Reaksi inflamasi Ekstravasasi cairan u/ mendinginkan area yang terpapar
MINIMALKAN KONTAK (Lihat Atas) TANGANI KEGAWATAN (ABCDE) FAKTOR Yg DPT MEMPERBERAT LUKA BAKAR - Pasien Tua (> 50 th) atau anak <10 tahun - Fungsi organ Ginjal, hati, jantung belum sempurna - Kulit lebih tipis - Vol Cairan lebih sedikit
Balance - Cairan - Elektrolit - Asam basa - Nutrisi Antibiotik Analgetik Rawat Luka terbuka Multivitamin Pencegahan Parut & Kontraktur (proper positioning
Definitions A burn is the response of the skin and subcutaneous tissues to thermal injury. A partial thickness burn is a burn which either does not destroy the skin epithelium or destroys only part of it. They usually heal with conservative management. A full thickness burn destroys all sources of skin epithelial regrowth and may require excision and skin grafting if large. Common causes Thermal injury from dry (flame, hot metal) or moist (hot liquids or gases) heat sources. Electricity (deep burns at entry and exit sites, may cause cardiac arrest). Chemicals (usually industrial accidents with acid or alkali). Radiation (partial thickness initially, but may progress to chronic deeper injury). General Pain. Swelling and blistering. Specific Evidence of smoke inhalation (soot in nose or sputum, burns in the mouth, hoarseness). Eye or eyelid burns (early ophthalmological opinion). Circumferential burns (will need escharotomy). Investigations FBC. U+E. If inhalation suspected: chest X-ray, arterial blood gases, CO estimation. Blood group and crossmatch. ECG/cardiac enzymes with electrical burns.
Fluid Resuscitation Adults Children Initial 24 hours: Initial 24 hours: Lactated ringer's 2-4 ml/kg/%burn/24 hours LR at 5000 ml/m body surface area burn/24 hrs - given in the first 8 hours post-injury. plus 2000 ml/m body surface area burn/24 hrs Additional fluid required for inhalation given in the first 8 hours post-injury. Urine output injury. of 1 ml/kg/hr. Urine output of 30 ml/hr. Subsequent 24 hours: Subsequent 24 hours: 3750 ml/m body surface area burn/day plus 1500 1 ml/kg/% body surface area burn/day ml/m total body surfacearea/day RUMUS PENGHITUNGAN CAIRAN INFUS PADA LUKA BAKAR - Cara EVANS 1) Luas luka bakar dlm persen x BB dlm Kg = ml NaCL/24jam 2) Luas luka bakar dlm persen x BB dlm Kg = ml Plasma/24jam 3) Sebagai pengganti cairan akibat penguapa = 2000 ml D5% dalam 24 jam. NB diberikan dalam 8 jam pertama sisanya 16 jam berikutnya - Cara Muir Barclay = % luka bakar x BB /2 = 1 Aliquot cairan diberikan 6 aliquot cairan dalam 36 jam. 4 4 4 6 6, 12 jam dari waktu luka bakar - Cara Baxter = % luas luka bakar x BB x 4 ml = cairan dalam 24 jam, diberikan dalam 8 jam pertama sisanya 16 jam berikutnya, Hari ke dua = cairan hari pertama, ketiga = cairan hari ketiga - Parkland formula seperti dibawah
Complications
Immediate Compartment syndrome from circumferential burns (limb burns, limb ischaemia, thoracic burns hypoxia from restrictive respiratory failure) (prevent by urgent escharotomy). Early Hyperkalaemia (from cytolysis in large burns). Treat with insulin and dextrose. Acute renal failure (combination of hypovolaemia, sepsis, tissue toxins). Prevent by aggressive early resuscitation, ensuring high GFR with fluid loading and diuretics, treat sepsis.
Infection (beware of Streptococcus). Treat established infection (106 organisms present in wound biopsy) with systemic antibiotics. Stress ulceration (Curlings ulcer) (prevent with antacid, H2-blocker or proton pump inhibitor prophylaxis). Late Contractures.
BURN COMPLICATION
7. REPORTING
Tutor menggali kembali keberhasilan belajar mahasiswa melalui pertanyaan yang mengarah pada kemampuan mahasiswa menjelaskan LO yang ada sampai dengan batas minimum kompetensi (68%)
8. DAFTAR PUSTAKA
1. AY Sutedjo, 2007. Buku Saku mengenal penyakit melalui Pemeriksaan laboratorium, Amara Books, Yogyakarta 2. Chang R, 1998. Chemistry, 6th Edition, McGraw Hill, USA 3. Fauci et al., 2008. Harrison's Principles Of Internal Medicine, 17th Ed, McGraw-Hill Companies, Inc. USA 4. Ganong WF, 2003. Review of Medical Physiology, 21th edition, Mc Graw Hill, USA 5. Goldman L, Ausiello D (ed), 2007. Cecil Medicine, 23rd ed, Saunders Elsevier, USA 6. Guyton AC, Hall JE, 2000. Textbook of Medical Physiology, 10th Edition, WB Saunders, Philadelphia, USA 7. Horne MM, Swearingen PL, 2001. Keseimbangan cairan, elektrolit dan asam basa. Edisi terjemahan, Penerbit buku kedokteran EGC, Jakarta 8. Konsil Kedokteran Indonesia, 2006. Standar Kompetensi Dokter, KKI, Jakarta 9. Kumar V, Cotran RS, Robbins SL, 2003. Robins Basic Pathology, 7th edition, WB Saunders Co, Philadelphia, USA 10. la-Rocca JC, Otto SL, 1998. Terapi Intravena, Edisi 2, EGC, Jakarta 11. Murray RK, Granner DK, Mayes PA, Rodwell VW, 2000. Harpers Biochemistry, 25th Edition, McGraw Hill, USA 12. McPhee SJ, Lingappa VR, Ganong WF, Lange JD, 1997. Pathophysiology of Disease, an Introduction to Clinical Medicine, 2nd Edition, Appleton & Lange, USA 13. Park GR, Roe PG, 2000. Fluid Balance & Volume Resuscitation for beginners. Greenwich Medical media, London. 14. Rang HP, Dale MM, Ritter JM, Flower RJ, 2007. Rang And Dales Pharmacology, Churchill Livingstone, USA 15. Runge MS, Greganti MA, Netter FH, 2003. Netters Internal Medicine, Icon Learning System, USA 16. Rose BD, Post TW, 2001. Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th Edition, McGraw-Hill, USA. 17. Ferri FF, 2008. Ferri's Clinical Advisor Instant Diagnosis And Treatment, Mosby Elsevier, USA 18. McCann JAS, Holmes NH, Robinson JR, Putterman A, Houska A, Henry K, Bilotta K, Comerford KC, Weinstock D, Foulk L, 2007. Professional Guide to Signs and Symptoms, 5th Edition. Lippincott Williams & Wilkins. USA.