manajemen luka bakar(1)
TRANSCRIPT
Manajemen luka bakar
Arie Kusumaningrum
Kesulitan
• Diagnosis Estimasi – ukuran dan kedalaman – Fluid resucitation n maintenance– Airway management – Vascular acces – Thermal maintenance
• Children: keterbatasan fisiologi psikologis dalam berespon
Mekanisme injury
• Luka bakar lokal– Nekrosis sel yang dihasilkan oleh panas – Koagulasi nekrosis pada jaringan – Pada permukaan tubuh – Derajat kedalaman
– Kerusakan sel lebih lanjut ditentukan:• Intensitas panas• Durasi pajanan • Jaringan terlibat
Thermal injury
• Direct heat • Exposure to caustic chemicals• Contact with electrical current
– Radiation ----- rare
• Flame, flash burn, scald, contact burn
Electrical injury
• Kontak listrik voltase tinggi – Area kontak kering, … . tertekan– Kerusakan jaringan yang dalam : edema
sufascial dan nekrosis jaringan– Fasciotomy dapat direkomendasikan
• menurunakan tekanan dalam compartment otot • mempertahankan aliran aliran darah
• Komplikasi – Neurologi– Renal – Cardiac– Skeletal – Terpajan aliran listrik di luar tubuh/lingkungan:
baju dan objek lain : flash –flame type
Chemical injury
Assessment and management
• Initial phase– Manajemen kegawatdaruratan
• FASE AKUT: – PENGKAJIAN DAN MANAJEMEN
Manajemen kegawatdaruratan
Initial assessment and management
Care at the scene of accident
First aid
Rapid primary and secondary assessment
Care in the emergency department
Primary assessment
Secondary assessment
Stabilization and transport
ABA criteria, Stabil prime dan sekunder
, Dokumentasi, Komunikasi dan
kolaborasi
Systemic response
Asessment and care
First aid
1. • Mengurangi kedalaman
luka• Mengurangi perluasan
luka• Mengeluarkan sumber
luka• Mengentikan proses
2• Tutup luka – kain kering,
bersih• Mengukur suhu tubuh• Kompres basah pada luka
kecil• Hindari air pada luka besar
dan anak kecil• Hindari air es/es pada luka
→
Rapid primary and secondary assessment
Prioritas •Siapkan Transportasi ke RS
Terkait dengan multipel organ•Kaji lebih lanjut cedera/trauma lain•Atasi trauma/cedera
→
Primary assessment
Airway breathing
•Basic life support measure•Pengkajian dan manajemen oksigenasi: 100% FiO2, face mask,
•Spesial consideration: upper airway, lower airway = ET, MV
circulation•10% /> TBSA•IV resusitasi, 2 line, maintain, monitor•Skin color, sesnsation, CRT, elevasi ekstremitas area luka pada edema.•HR/jam 24 – 48 jam I pada deep burn/cir burn/elect burn.•Kateter urin
neurologic
•GCS/chlid •Level kesadaran
Expose and examin
•Lepas semua baju•Lepas perhiasan
→
Secondary assessment
Pengakjian • Riwayat
luka bakar sekarang• Me
kanisme
• Durasi
• Keparahan
• Waktu
• Kaji “intentional injury”
Riwayat medis • AMPLE
• Allergy
• Medications
• Prevuous illnes
• Last meal/fluid
• Events related to the injury
Pemeriksaan fisik • Head to
toe• Severyt
y, type of burn• LU
AS• T
BSA• R
ULE OF ONES OR HAND RULE
• RULE OF NINE
• BERKOW
• HEIGHT AND WEIGHT NOMOGRAM
• Kedalaman• D
EPTH AND DEGREE of BURN
Diagnostic studi• ABGs• Carbox
yhemoglobin
• Hmt, Hb, elektrolit, albumin, urynalisis, BUN
• Chest radiographic
• ECG
Wound care• Emerge
ncy care: chemical burn
• Manual debridement
• Topical antimicroba
NPO• NGT
pada > 20% BSA
• intubasi
Victims and mechanisms of intentional and unitentional burns
• Perpetrator– Parent, guardian, partner of parent, sibling– Partner, carer (relative or professional)– Partner, carer (relative or professional) – Self (accomplice)– Government/civil authorities, kidnappers
VictimWho gets burnedChildrenElderlyInfirmSelfCaptives
Mechanism of burnScaldsContact (hot and cold)ChemicalElectricalFrictionSpill .splashImmersionFlame
→
Rule of nine
→
The berkow
→
→
Kedalaman lukaDegree Depth History Etiology Sensation Appearance Healing
1st Degree SuperficialEpidermis only
Momentary Exposure
Sunburn Sharp, uniform pain
Blanches red, pink. Edematous, soft, flaking, peeling
± 7 days
2nd Degree Partial Thickness Epidermal and part of Dermal layer
Exposure of Limited Duration to Lower Temperature (40-55°C)
Scalds, flash burn without contact, weak chemical
Dull or hyperactive pain, sensitive to air/temperature changes
Mottled, red blanches red/pink, blisters, edema, serous exudate, moist
14-21 days
3rd Degree Full Thickness Entire epidermis, dermis and subcutaneous tissue
Long duration of exposure to high temperature
Immersion, Flame, Electrical, Chemical
Painless to touch and pinprick, May hurt at deep pressure
No blanching, pale white, tan charred, hard, dry, leathery, Hair absent
Granulates, Requires Grafting
4th Degree Underlying structures of muscle or bone
Prolonged duration of exposure to extreme heat
Electrical,Flame,Chemical
Usually painless
Charred, Skeletonized
Requires Fasciectomy, Possible amputation
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ABA criteria
→
Systematic response
kardiovaskuler
Pulmonary
Hematology
Gastrointestinal
Renal response
Metabolic
Imune and inflamatory response
hypotermia
→
Luka bakar terkait perawatan• Cedera inhalasi (drief & endorf, 2013)
Pulmonary trauma
• caused by inhalation of thermal or chemical irritants.
classes:
1) heat injury 2) local chemical irritation
3) systemic toxicity inhalation of
carbon monoxide or cyanide
Assessment and care
Resusitasi cairan
10%/> TBSA infant,/15% pada yang lebih tua. Jika perlu akses femoral
Formula baxter: • 4 ml RLx %TBSAX BB kg = 24 jam volume
cairan• Dhitung pada saat terjadi burn
Hitung kebutuhan cairan harian pertahankan 15% dextrosa dlm ½ NS
Kristaloid, eletrolit, koloid, sodium, volume expander, dextrose
Pengkajian luka dan perawatan
Tujuan:• Mencegah infeksi• Memfasilitasi
penyembuhan luka• Meningkatkan
kenyamanan• Mempertahankan fungsi
optimal• Meminimalkan
deformitas
Wound assessment and care
Wound debridementTopical
preparation
Special care areas
ExsisiTemporary wound
coverage
Autograft
Donor site
Preventing graft loss
Wound debridement
• Mechanical debridement • Chemical debridement • Surgical debridement
– Tangential excision– Fulll thickness excision
Topical preparation
• 1% silver sufodiazene silvadene SSD thermazene
• Mafenide acetat cream• Bacitracin • 0.5% silvernitrat solution
Temporary wound coverage
• Hommograft – allograft • Heterograft or xenograft• Synthetehic dressing
autograft
• Split thickness autograft • Full thickness autograft• Sheet graft • Meshed autograft• Cultured epithelial autograft (CEA)
Perlindungan pada child abuse
•Semua•Pengkajian awal – karakteristi lukapengkajian
•Injury – further harm •Inform petugas : abuse / neglectedlaporan
•Advokat pasien dan keluarga: jujur/tdk menghindar•Komunikasi pada anak – anak jujur
Intervensi terapeutik
FASE AKUT: PENGKAJIAN DAN MANAJEMEN
• 3 day – minggu dimulai denga onset diuresis, edema intertisial pada luka bakar– Pulmonary care – Metabolic and nutritional support– Burn wound sepsis– Septic shock– Pain and anxiety assessment and management– Presure sore prevention strategies– Physical and occupational theraphy– Social and cultural assessment and care– Patient and family education
• trims