Burn injury
SKDI: 4A By : Febrian Putra 0908113658
Anamnesis: Ms. N , 14 years old, Female, came to Arifin Achmad General Hospital on October 19th, 2013 Chief Complain : Her body blistered because of fire 2 hours before admitted to hospital.
PRIMARY SURVEY
ward
Airway
Objective airway obstruction(-) Assesment Clear airway
Breathing
Objective Breathing spontaneously RR : 20 x/mins chest wall move symetrically Assesment Clear breathing
Circulation
Objective IVFD attached (1 line) HR: 90x/ minutes, regularly TD: 110/70 mmHg CRT: < 2 second warm extremity Assesment stable hemodynamic , clear circulation
Disability
Objective GCS 15 isokhor pupil, d : 3 mm. light reflect (+/+) motoric power : + Assesment clear mini neurologic assesment.
Exposure
Objective T : 36,5 0C Visible burn injury on head-neck, both right and left hand, and left leg.
Head - Neck
Right Hand
Left Hand
Left Leg
SECONDARY SURVEY
ward
Trauma Mechanism
2 hours before admitted to hospital, patient got burn injury because of fire from the stove . Patient wanted to shut the fire off from the pan, but it attacked her head-neck, both of her hands, and left leg. Patient wore T-shirt and short pants when the incident happened. After that, patient flushed with water by his family and took to hospital in 30 minutes
Physical examination
General condition: seemed mild illness Conciousness: compos mentis Vital sign:
Blood pressure : 110/70 mmHg HR: 90x / minutes RR: 20x/ minutes Temp : 36,5 0C
Localized Status
Inspection:
Burn injury on head-neck, both hand, and left leg of the patient . The color of the wound is red and the edge is black. Bula (+)
Palpation:
Tenderness on the wound (+).
: 7% : 10% : 5% : 10% + 32 %
Working diagnosis
Burn injury grade II A 32% caused by fire
Further examination
- Blood electrolyte, and albumin
Laboratorium result
Wbc: 7200 /ul Hb : 13,4 g/dl Ht : 42,4 % Plt: 234000 /ul
Na: 141,1 mmol/l K: 3,56 mmol/l Cl: 109,9 mmol/l Alb : 3,5 g/dl
Definitive Diagnosis
Burn injury grade II A 32% caused by fire
Therapy Planning
Fluid therapy (Baxter): Body weight 45 kg 10 x 45 x 4 = 1800 ml IVFD RL Day 1 : 1800 ml in first 8 hours 1800 ml in next 16 hour Day 2 : 1800 ml for second day
Thank you