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Dr.

Evangelino

KU : Luka Bakar listrik di kedua lengan dan tungkai AK: 2 hari SMRS saat pasien sedang bekerja sambil memegang besi didaerah Padalarang, tiba-tiba besi yang dipegangnya mengenai kabel listrik sehingga pasien mengalami luka di kedua lengan dan tungkainya. Riwayat pingsan (-) muntah (-). Pasien kemudian dibawa ke RS Cahya Kawaluyaan dirawat selama 2 hari namun belum pernah dilakukan pembersihan luka di ruang operasi. Pasien kemudian dirujuk ke RSHS.

Primary survey:

A: Clear + C-spine control B: RR :20 x/m, Bentuk & gerak simetris, VBS ki=ka C: N : 98x/m , T : 110/70 mmHg D: GCS E4M6V5=15 , Pupil bulat isokor ODS 3mm, RC +/+, parese -/-

Secondary survey: a/r palmar bilateral : a/r antebrachii dekstra : a/r antebrachii sinistra : a/r ekstremitas inferior sinistra : a/r ekstremitas inferior dextra : Total

luka luka luka luka luka

masuk (+) gr III 2% bakar gr III 3,5% bakar gr III 3,5% keluar (+) gr III 9 % bakar gr III 9%

: luka bakar III 27%

CRT (-), Pulsasi a. radialis dan a. ulnaris (-) pulsasi a. tibialis posterior dan a. dorsalis pedis (-)

Kedua lengan kontraktur (+)

PT INR APTT Hb Ht L Tr SGOT SGPT Ur Kr albumin Protein total Na K

: : : : : : : : : : : : : : :

15 2 24.8 14.5 42 23.300 159.000 737 241 77 2.28 2.4 4,8 125 5.3

AGD pH pCO2 pO2 HCO3 TCO2 BE Sat O2 Laktat

: : : : : : :

7.381 34.7 144.0 20.1 39.3 -8 99.0

: 0.8

Urinalisis : kuning keruh,kemerahan, protein urin 2+, Eritrosit banyak. EKG : sinus rhytm

DK/ : Luka bakar gr III 27% a/r palmaris bilateral, antebracii bilateral, ekstremitas inferior bilateral e.c listrik + Kompartemen syndrom + Sepsis berat.

Th/ : - EGDT - Antibiotik - Analgetik - ATS + TT - R/ Nekrotomi Debridement + fasciotomi

DO: (op. Dr. Ahmad H, Dr. Irzal)

a/r palmar bilateral

: luka masuk (+) : luka bakar gr III 3,5% : luka bakar gr III 3,5%

gr III 2%
a/r antebrachii dekstra a/r antebrachii sinistra

a/r ekstremitas inferior sinistra : luka keluar (+) gr III 9 %


a/r ekstremitas inferior dextra : luka keluar (+) gr III 9%

Total

: luka bakar III 27%

DK/ post op : Luka bakar listrik gr III 27% a/r palmaris bilateral, antebracii bilateral, ekstremitas inferior bilateral e.c listrik + kompartemen sindrom + Sepsis berat yang telah dilakukan EGDT + nekrotomi debridement +

Fasciotomi (79.63)

INA-DRG : 094103 ALOS : 18.6 days

IP MAJOR SKIN DISORDERS w/ MCC ISS : 75 RTS : 7.84

TRISS

: 31.8 %

Jam 13.00

T 110/70 98

R 24

S 37,4

UO 20cc

Keterangan Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/-, Abdomen : lembut, datar, BU(+), NT (-),NL (),DM (-) Hb/Ht/L/Tr : 14,5/42/23.300/159..000 SGOT/PT : 737/241 ; Ur/ Kr : 77/2,28 ; GDS : 155 Na/K : 125/5,3 Urinalisis : keruh, protein urin 2+, eritrosit banyak. AGD : pH=7,381/pCO2=34,7/pO2=144/HCO3=20, 1 TCO2=39,3/BE=-8/Sat O2=97,7%, Laktat : 2,8 Diputuskan dilakukan EGDT SIO (-) karena biaya Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/Abdomen : lembut, datar, BU(+), NT (-),NL (), DM (-), SIO (-) Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/Abdomen : lembut, datar, BU(+), NT (-),NL (), DM (-), SIO (-)

14.00

100/80

90

22

37,1

40cc

16.00

100/80

94

24

37,8

30cc

18.00

100/60

98

24

37,8

30cc

Jam 20.00

T 100/70 96

R 24

S 37,4

UO 30cc

Keterangan Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/Abdomen : lembut, datar, BU(+), NT (-),NL (), DM (-), SIO (+) dimulai EGDT Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/Abdomen : lembut, datar, BU(+), NT (-),NL (), DM (-) AGD Vena : pH=7,334/pCO2=43,50/pO2=51/HCO3=2 2,5, TCO2=44,8/BE=-3, SO2=73,4% Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/-, Abdomen : lembut, datar, BU(+), NT (-),NL (),DM (-) Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/-, Abdomen : lembut, datar, BU(+), NT (-),NL (),DM (-)

21.00

120/80

90

22

37,1

40cc

22.00

110/70

92

22

36,8

40cc

23.00

100/70

88

20

36,5

40cc

Jam 24.00

T 100/80 86

N 20

S 36,6

UO 50cc

Keterangan Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/-, Abdomen : lembut, datar, BU(+), NT (-),NL (),DM (-) Hb/Ht/L/Tr : 14,5/42/23.300/159..000 SGOT/PT : 737/241 ; Ur/ Kr : 77/2,28 ; GDS : 155 Na/K : 125/5,3 Urinalisis : keruh, protein urin 2+, eritrosit banyak. Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/-, Abdomen : lembut, datar, BU(+), NT (-),NL (),DM (-) Thorax : B/G simetris, VBS ka=ki, Ro -/-, wh -/-, Abdomen : lembut, datar, BU(+), NT (-),NL (),DM (-) PT/INR/APTT = 13,1/1,02/38,7 Hb/Ht/Leu/Tr = 10,7/33/17.000/109.000 AGD Vena: pH=7,339/pCO2=41,6/pO2=68,4/HCO3= 22,2, TCO2=52,9/BE=-3,4/SO2=73,6% AGD Arteri: pH=7,349/pCO2=39,3/pO2=104,8/HCO3= 21,5, TCO2=50,,9/BE=-3,8/SO2=97,9% Laktet : 1,2 Pasien naik OK.

01.00

110/70

88

20

36,5

60cc

02.00

110/70

80

20

36,6

60cc

Apakah

yang menjadi permasalahan utama pada pasien tersebut? Upaya apakah yang perlu dilakukan sebagai upaya damage
Kapan

/ source control?

perlu dilakukan amputasi sebagai definitive surgery?

Stop the Burning Process Neutralize the heat source Remove smoldering clothing

Airway Assess patency of airway consider the presence of smoke inhalation injury and carbon monoxide toxicity if smoke is present Breathing Assess adequacy of breathing efforts electrical current impair the ability to breathe Initiate respiratory assistance, if needed

Circulation Electrical burn acts like a crush injury to muscle Assess adequacy of circulation IV placement and fluid administration Cardiac monitoring is indicated with electrical injury Remove potentially constricting object, like jewelry compartment syndrome

Contact

time and exposure Voltage of electrical injury Voltage History of other traumatic injury

An

electrical current will produce an array of injuries if the current passes through the body. Most of the damage is beneath the skin surface and the actual injury can be underestimated. There are often several possible components to the injury.

the injury caused by the electrical current itself. The current generates intense heat often in excess of 2000F along its path through the body, can lead to severe muscle, nerve and blood vessel damage.

the injury from "arcing". = Ionization of air particles associated with a voltage drop is called arcing. The heat generated in the arc can be as high as 4,000C and can vaporize metal. This process frequently causes a patients clothing to ignite and cause flame burns.

is the skin burn caused by a flash.

A flash can result from the power source or from the ignition of clothing or surroundings. A flame burn can occur without underlying tissue injury.

is traumatic injury caused by the intense muscle spasm with the current or from a fall.

There is also a variety of cardiac, lung muscle, nerve and internal organ injuries which can occur, some being immediately life threatening.

= defined as exposure to a voltage of 1000 volts or greater (damage beneath the surface should be suspected). High-voltage injuries characteristically occur in an outdoor environment near power sources and lines. Electrical current can arc (jump) 1 inch from a power source or line for every 10,000 volts being carried, so that a person does not actually have to touch the source to sustain injury.

= defined as less than 500 volts (local heat damage is usually evident e.g. at the edge of the mouth in kids biting electric cords)

Low-voltage injuries occur characteristically in a home or residential environment. Electrocutions in bathtubs and by electric hair dryers are the most common causes of lowvoltage deaths.

Electrical burns more closely resemble a crush injury The immediate damage to muscle is caused by the heat, which is usually patchy in distribution along the course of the current, often most severe near the bones. injury the dead muscle releases myoglobin, into the blood stream. The muscle rapidly swells compressing local nerves and blood vessels. An incision through the overlying layers will be necessary to release the pressure (called a fasciotomy).

The dark nearly black urine on the left is caused by the muscle damage and pigment release. The urine gradually gets clearer over 24 to 48 hours with fluid resuscitation, however, kidney failure can result.

Immediate cardiac arrest is the most common cause of death after electrical injury. The process is due to both the direct alteration of rhythm by the current, fibrillation or to the depression of respiration and subsequent hypoxia. Hand to hand passage of a high voltage current has a reported immediate mortality of 60%. The initial heart problems are often reversible with CPR. High blood pressure is also quite common immediately after injury.

Impairment of the brain centers stimulation of breathing and severe central nervous system damage lack of breathing, Decreased muscle activity in the chest wall caused by a chest burn, muscle damage, or second-degree blunt traumatic injuries can markedly impair breathing.

Acute

central nervous system damage with coma, seizures, motor and, to a lesser extent, sensory deficits are well described. Many of these abnormalities are permanent.

Orthopedic injuries occur as a result of three processes: The most common orthopedic injury occurs as a result of severe immediate muscle spasm, long bone fractures and dislocation at major joints. Heat necrosis of local periosteum with subsequent production of non-viable bone and sequestrum formation vascular injury

Conjunctival

cataract ruptured ear drums

and corneal burns

FIRST DEGREE [I] Epidermal layer Pink, painful, and edematous Heals 3-5 days w/o scarring Causes: Flame Sun Flash from explosion

SUPERFICIAL SECOND DEGREE [IIA] Epidermis and papillary region of dermis Blisters, bullae, serous fluid Cherry red moist appearing Painful, sensation intact Edematous Heals in 7-28 days with minimal scarring Cause: flame,

DEEP SECOND DEGREE [IIB] Epidermis and reticular region of dermis Blisters, bullae, serous fluid Pale ivory moist appearing Painful, sensation intact Edematous Heals in 7-28 days with variable scarring Cause: flame, flash, scald, contact

THIRD DEGREE A full thickness burn destroys all three layers of skin Extends into subcutaneous tissue, loss of not only the skin but also the hair follicles, sweat glands, and the region where new skin cells are formed White, yellow, brown leathery appearance Thrombosed vessels, loss of elasticity, marked edema Possible escharotomy Painless to touch Requires grafting Causes: flame, electricity, chemicals, prolonged exposure May take 2-3 days to fully present true depth

FOURTH DEGREE Extends to muscle Loss of function Black, charred appearance May require amputation May require escharotomy and fasciotomy Causes: very prolonged exposure to flame, chemicals, and high voltage

If the extremity is ischemia without a pulse, anesthetic, and maintained in a flexed and contracted position amputation.

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