Pemeriksaan fisik bedah

plastik

PEMBIMBING :
DR.HUNTAL NAPOLEON , SP.BP-RE

DISUSUN OLEH:
GERY ALDILATAMA
ETIOLOGI
KEBAKARAN API
JILATANA API TUBUH (FLASH
AIR PANAS (SCALD)
TERSENTUH BENDA PANAS (CONTACT BURN)
SENGATAN LISTRIK
BAHAN KIMIA
RADIASI
Derajat Luka Bakar
 KRITERIA BERAT RINGANNYA (AMERICAN BURN ASSOCIATION)
LUKA BAKAR RINGAN
- LUKA BAKAR DERAJAT II < 15%
- LUKA BAKAR DERAJAT II < 10%
PADA ANAK-ANAK
- LUKA BAKAR DERAJAT III < 1%
LUKA BAKAR SEDANG
- - LB. DERAJAT II 25% ATAU LEBIH PADA
-LUKA BAKAR DERAJAT II 15-25%
PADA ORANG DEWASA
- LUKA BAKAR DERAJAT II 10-20%
PADA ANAK-ANAK
- LUKA BAKAR DERAJAT III < 10%
LUKA BAKAR BERAT
ORANG DEWASA
- LB. DERAJAT II 20% ATAU LEBIH PADA
ANAK-ANAK
- LB. DERAJAT III 10% ATAU LEBIH
- LB. MENGENAI TANGAN, WAJAH, TELINGA,
MATA, KAKI DAN GENITALIA/PERINEUM.
- LB. DENGAN CEDERA INHALASI, LISTRIK,
DISERTAI TRAUMA LAIN
Burn wound assessment
Wallace Rule of Nines
In addition to calculating the area burnt, it is
useful to calculate the area not burnt, and to
check whether both calculation add up to
100%

Palmar Method
Palmar surface= 1% TBSA
For smaller, scattered burns

Pediactric Rules of Nines

For every year of life after 12 months 1% is
taken from the head and 0,5% is added to
each leg
9 years old  body is proportional to an adult
Lund and browder chart
Pemeriksaan Fisik (Status Lokalis) dan
Diagnosis
PF  berdasarkan regio:
Kepala-leher : derajat ? Luas %
Trunkus anterior : derajat ? Luas %
Trunkus posterior : derajat ? Luas %
Ekstremitas superior dextra : derajat ? Luas %
Ekstremitas superior sinistra : derajat ? Luas %
Ekstremitas inferior dextra : derajat ? Luas %
Ekstremitas inferior sinistra : derajat ? Luas %
Genitalia : derajat ? Luas %
-----------------------------------------------------------------------------------------------------------------
Total : derajat ? Luas %
DIAGNOSA:
Combustio ?%, Grade?, e.c?, trauma menyertai, hari ke?
 TRAUMA MENYERTAI (TRAUMA INHALASI)

• Ruang tertutup • Bau asap atau jelaga pada

• Luka pada wajah pernafasan

• Bulu rambut hidung terbakar • Sulit bernafas

• Butir arang karbon pada sputum • Udem laring

• Serak, batuk, sukar bicara

Pemeriksaan Penunjang
1. darah rutin
2. elektrolit
Electrical injury

MECHANISM OF INJURY:
1. Generation of heat
2. Flash burn
3. Arc burn
Chemical burns
ACID BURNS FIRST AID PRIORITIES:
• pH<7 Menghilangkan sisa bahan kimia
• Remove contaminated clothing and dry
• Coagulative necrosis
chemicals
• Protein denaturation forming coagulum limiting acid • Constant water flow  irigation for 30 min
penetration to deeper tissues
• Na, K, lithium  become reactive with
• Ex: accu, toilet bowl cleaners (sulphuric acid) water  mineral oil

ALKALI BURNS
• pH>7 SPECIFIC AGENTS
• Liquefactive necrosis • Hydrofluoric acid  calcium gluconate
• Bitumen  miscible with other petroleum
• Long term tissue destruction as they liquefy tissue and so
penetrate more deeply products (paraffin oil) and vegetable oil
• Tar  soluble only in highly aromatic
• Ex: Drain cleaners, paint removers
liquids  toluena
Tatalaksana
Resusitasi
Debridement
cairan

Rehabilitasi
STSG
medik
Resusitasi Cairan

DEWASA:
RL 4cc/KgBB/ % LUKA BAKAR/24 Jam
*(1/2 dosis dihabiskan dalam 8 jam pertama, ½ dosis selanjutnya dihabiskan 16 jam selanjutya)

ANAK
2cc x BB x luas luka bakar (%) + kebutuhan faali
(RL : Dextran = 17 : 3)
*Kebutuhan Faali
<1 th : BB x 100cc
1-3 th : BB x 75 cc
3-5 th : BB x 50cc
½  8 jam pertama
½  16 jam berikutnya
Burn wound care
• Film dressing
Superficial partial •
•
Foam dressing
Vaseline impregnated gauze
thickness • Mebo
• Hydrogel

• Antibiotic cream (SSD)

Deep partial • Silver based dressing
thickness • Early excision and skin grafting

Full thickness • Early excision and skin grafting

burns
 BURN WOUND MANAGEMENT
“EARLY EXCISION AND EARLY SKIN GRAFTING”

• ESCHARECTOMY = eschar removal

• Early = less than 72 hrs after injury onset
• Janzekovic (1970)  tangensial excision  excision performed layer by layer until bleeding spots appear, with
humby knife/dermatome
• Alternative for narrow and curvy areas of the body: Versajet hydrosurgery system

Indication:
• Deep burns are not expected to recover in 3 weeks
• The surface of the burn is white, red, brown, black
• There is no capillary refill nor sensibility
Advantages:
• Necrotizing skin excision  reducing source of infection
• Eliminate the important causes of SIRS
• Reduces the need for excess broad-spectrum antibiotics
• Reduce the need for massive blood transfusion  bleeding is less
than 1 ml/1 cm2 burns
• Healing is faster
Burns rehabilitation
ANTI-DEFORMITY POSITION
• Decrease the tendon, collateral augmentum, and joint capsule shortening
• Reduce edema of extremities

SPLINTING
• Prevents contracture
• Prevents deformities
• Pressure bandage  controlling burns scar

ROM EXERCISE
• Immediately after the trauma
• Passive  active
 FRAKTUR MAKSILOFASIAL

• Fraktur adalah hilang atau putusnya kontinuitas

jaringan keras tubuh.
• Fraktur maksilofasial adalah fraktur yang terjadi pada
tulang-tulang wajah yaitu tulang frontal, temporal,
orbitozigomatikus, nasal, maksila dan mandibula

1/3 atas : os.frontalis, regio supra orbita,rima orbita,sinus frontalis

1/3 tengah: os.nasal,os.zigomatikus,os

.lakrimal,os.maksilaris,os.palatinum. nasal konka inferior,os.vomer

1/3 bawah: mandibula

KLASIFIKASI
 INSPEKSI
Deformitas

Asimetri wajah

Hematoma/ekimosis periorbita

Edema pada wajah

Depresi malar eminensia  Hilangnya tonjolan prominen pada daerah zigomatikus

Laserasi

Ekskoriasi
PALPASI

Diskontinuitas tulang

Step-off deformity

Hipoestesia

Nyeri tekan

Mobilitas fragmen fraktur: misalnya

floating maxilla
lanjutan
PEMERIKSAAN MATA PEMERIKSAAN HIDUNG

Exophthalmus Epistaksis
Enophthalmus Deformitas nasal

Gangguan gerakan bola mata (eyeball entrapment) Blood clot pada cavum nasi

Diplopia Septal hematoma

Visus

Telecanthus

Subconjunctival bleeding
 Pemeriksaan Intraoral
Hematoma  palatum, sublingual, mukosa buccal
Laserasi mukosa ginggiva
Deformitas tulang
Maloklusi
Avulsi gigi, gigi goyang
Trismus/mouth opening
Tindakan lanjut
ORIF plate and screw
Rekonstruksi facial bone
IMF (Intermaxillary Fixation)
CHRONIC WOUNDS
Four Kinds of Chronic Wounds

Pressure Ulcer (PU)

Diabetic Ulcer (DU)
Venous Ulcer (VU)
Arterial Ulcer (AU)
Faktor Resiko
Usia = penuaan kulit, atropi, kulit menipis
Inkotinensia
Malnutrisi, hypoproteinemia
Anemia
Kondisi – kondisi yang dapat meningkatkan resiko seperti riwayat diabetes mellitus, penyakit
arteri perifer, gagal jantung, gagal ginjal, penyakit paru kronis, anemia, kelainan neurologis
merokok
 Penilaian luka
TEPI LUKA
Perlekatan ke dasar luka

BED LUKA
Jaringan nekrotik
KULIT SEKITAR LUKA
Jaringan granulasi
Warna
Fibrin
Kelembaban
Kolonisasi bakteri
Flexibilitas
Eksudat
Benda asing

UKURAN DAN DALAM LUKA

Tampak kulit, jaringan subkutan, fascia, otot atau
tulang
PALPASI
Neurovaskular distal (NVD)
◦ Pulsasi arteri distal (arteri dorsalis pedis, tibialis posterior)  Tidak teraba atau teraba lemah
◦ Capillary refill time

Pitting edema
Ankle branchial index (ABI) Normal (>1) <0,7 – 0,9 (iskemia ringan) <0,4 (iskemia berat)
Akral (hangat/dingin)
Ankle Brachial Index
Tatalaksana
Debridement
Preparasi bed luka
Rekonstruksi tutup defek: Flap, skin grafting
 Pressure Ulcers
Atau disebut juga ulkus dekubitus
Adanya gangguan dri peredaran darah ke jaringan
kulit karena tekanan tubuh ke benda diluar
70 % sering terjadi pada daerah pinggul (
trochanter ), bokong ( ischium), dan daerah
sekitar sakrum
 tatalaksana

Must relieve pressure or it won’t heal.

Must use moist dressing or it won’t heal.

 Dressings
Stage I: Thin film polymer
Stage II: Moist gauze (wet-to-wet) atau hydrocolloid
Stage III/ IV dead space/ exudate: hydrogel, wet-to-wet,
atau hydrocolloid dengan synthetic absorption dressing
below.
Stage III/ IV necrosis: debride,selanjutanya sama
dengan 3 dan 4
 Venous Stasis Ulcers
Akibat dari Valvular incompetence dan venous
obstruction.
Salah satu peyebab nya adalah hipertensi vena
◦ Dilatasi kapiler - fibrinogen leak, pembentukan jaringan
fibrin menghentikan aliran oxygen, nutrients, growth
factors.
◦ WBC terperangkap di kapiler - inflamasi - injury
Diagnosis of Venous Ulcers
Biasanya pada daerah betis
Bronzing (lipodermatosclerosis)
Tidak terdapat arterial insufficiency -ABI > 0.8
Tend to be slow-healing (~90% heal by one year), irregular, and associated
with edema and sloughing
 Diabetic Ulcers
Chronic ulcer in a diabetic patient, not primarily due to other causes
Extrinsic causes: smoking, friction, burn
Intrinsic causes: neuropathy, macrovascular and microvascular disease,
immune dysfunction, deformity, reopened previous ulcer
 Neuropathy in DU
monofilament selama 5 detik atau kurang
Pin prick test
 Treatment
Surgical debridement
Mengehindari tekanan pada kulit tubuh dengan benda diluar
Orthopedic shoes: drop recurrence rate from 83% to 17%
Total contact casting