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    Primary Survey: Sign/ Symptom DX Treatment Result

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    Ade Sinaga
    The document provides a primary survey of a patient with flame burns to 57% of their body surface area, noting clear airway and breathing, stable circulation, normal disability assessment, and exposed burns to the face, neck, back, hands, and abdomen requiring moist dressing. Pain is assessed and labs, fluid needs, and degree of dehydration are determined to guide resuscitation in the emergency department and debridement surgery under general anesthesia.

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    Primary Survey: Sign/ Symptom DX Treatment Result

    Uploaded by

    Ade Sinaga
    27 views25 pages
    The document provides a primary survey of a patient with flame burns to 57% of their body surface area, noting clear airway and breathing, stable circulation, normal disability assessment, and exposed burns to the face, neck, back, hands, and abdomen requiring moist dressing. Pain is assessed and labs, fluid needs, and degree of dehydration are determined to guide resuscitation in the emergency department and debridement surgery under general anesthesia.

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    The document provides a primary survey of a patient with flame burns to 57% of their body surface area, noting clear airway and breathing, stable circulation, normal disability assessment, and exposed burns to the face, neck, back, hands, and abdomen requiring moist dressing. Pain is assessed and labs, fluid needs, and degree of dehydration are determined to guide resuscitation in the emergency department and debridement surgery under general anesthesia.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    27 views25 pages

    Primary Survey: Sign/ Symptom DX Treatment Result

    Uploaded by

    Ade Sinaga
    The document provides a primary survey of a patient with flame burns to 57% of their body surface area, noting clear airway and breathing, stable circulation, normal disability assessment, and exposed burns to the face, neck, back, hands, and abdomen requiring moist dressing. Pain is assessed and labs, fluid needs, and degree of dehydration are determined to guide resuscitation in the emergency department and debridement surgery under general anesthesia.

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    © All Rights Reserved
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    of 25

    PRIMARY SURVEY

    Sign/ Symptom Dx Treatment Result

    Airway: Clear, Airway Secure


    Flame burn (inhalasi)
    (-)
     Electrical Burn
    Breathing: 20 x/menit, Oxygenation, Breathing: 20 x/mnt,
    SP: vesikuler, ST: Sat O2 98%
    ronkhi -/- Flame Burn Mild to
    deep dermal 57% o/t
    Circulation: Face, neck, back, -IV line no: 18G Akral H/M/K
    Akral: H/M/K Hand, Abdomen -IVFD Rl 20 gtt/i TD: 110/70 mmHg
    TD: 110/60 mmHg -Inj. Ketorolac 30mg HR: 98 x/menit
    HR: 97 x/menit -Inj. Ceftriaxone 1gr
    UOP: Catheter (-)
    Sign/ Symptom Dx Treatment Result

    Disability: GCS 15;


    Pupil Isokor
    3mm/3mm; RC +/+

    Flame Burn Mild to


    deep dermal 57% o/t
    Exposure: Luka di Face, neck, back, Tutup dengan kasa Luka tertutup kasa
    wajah, leher, dada, Hand, Abdomen lembab
    punggung, tangan
    PENILAIAN NYERI

     Provocation : Ketika menggerakkan tangan dan kepala


     Quality : Nyeri seperti tertusuk
     Regio : Wajah, dada,punggung dan tangan
     Severity : Numeric scale 3-4 (10)
     Time : Terus menerus
    LABORATORIUM (28-12-2021)

     Hb/Ht/Leu/PLT : 10,1/31/10.320/260.000
     PT/APTT/INR : 15,5(13,5)/44,5(35,2)/1,16
     Na/K/Cl : 124 /4,0/ 95
     Albumin/GDS : 2,3 /87
     Bun/Ur/Cr : 12/26/0,47
    KEBUTUHAN CAIRAN

     Preloading : 10-20 cc/kg= 700-1400 cc


     Cairan rumatan (maintenance) = 4(10)+2(10)+50= 110 cc/jam
     Penguapan = 4-6 (BB)= 4-6 (70)= 280 cc- 420 cc / jam
     Estimate blood volume (EBV) = 65 x BB = 65 x 70 = 4550 cc
    Menentukan Derajat Dehidrasi
    Kriteria Pierce
    Ringan Sedang Berat
    Gejala
    (Def: 3-5 % BB) (Def: 6-8% BB) (Def: > 10 %BB)
    Turgor Kulit Berkurang Turun Sangat Turun
    Lidah N Kecil-Keriput Lunak Kecil-Keriput Lunak
    Mata N Cowong Sangat Cowong
    Ubun-ubun N Cekung Sangat Cekung
    Rasa Haus + + +
    Nadi N/↑ ↑↑ Tak Teraba
    Lemah Kecil
    Tensi N/↓ ↓↓ N/turun
    Urine out put ↓ ↓↓ Pekat ↓↓↓ (-)
     Resusitasi Cairan dengan Dehidrasi Ringan: (3-5)% x 70 = 2100-3500 cc
    Cairan maintenance = (4x10)+(2x10)+(1x50) = 110 cc
     Rehidrasi lambat :
     8 jam
     1500 + (110x8)= 2380 cc/8 jam = 297 cc/jam = 99 tts/mnt

     16 jam
     1500 + (110x16)= 2760 cc/16 jam = 172,5 cc/jam = 57 tts/mnt
     Koreksi Hiponatremia :

    513-124 = 12,54 meq


    (0,6x50) + 1
    10 x 1000 = 797,44 cc/24 jam
    12,54
    = 33,22 cc/jam
    = 11 tts/mnt
     Koreksi Albumin :

    Albumin : ∆ Albumin x BB x 0.8


    : (3,5-1.3) x 50 x 0.8 88 gr
    1 flash = albumin 20 %/ albumin 25 %
     Koreksi Anemia

    ∆ Hb x bb x 3  (12-10) x 70 x 3  420 cc
    1 bag PRC = 175 cc
    PENANGANAN DI IGD

     Bed rest + Head Up 30


     Oksigenasi 2 L/menit nasal canul
     IVFD Asering 20 tpm
     Inj. Ceftriaxone 2gr/24jam
     Inj. Omeprazole 40mg/12 Jam
     Inj. Ketorolac 30mg /8jam
     Inj. Parasetamol tab 1 gr/8 jam
    DIAGNOSA : FLAME BURN MILD TO DEEP DERMAL
    57% O/T FACE, NECK, BACK, HAND, ABDOMEN

     Tindakan : Debridement
     PS ASA : 3E (Imbobilisasi, Hipoalbumin,
    Hiponatremia, Anemia)
     Anestesi : GA ETT
     Posisi : Supine
    PROBLEM LIST AKTUAL

    Masalah Pemecahan
    • Pasien emergensi  Anggap • Puasakan sejak direncanakan
    lambung penuh operasi

    • Pasien dengan luka bakar  • Kurangi penguapan  tutup


    Peran kulit sebagai barrier luka dengan kasa lembab NaCl
    hilang

    • Pasien dengan leukositosis •Beri antibiotik yang adekuat

    • Pasien dengan hipoalbumin, • Hati-hati pemberian cairan ,


    albumin berfungsi menjaga koreksi albumin, dan pemberian
    tekanan onkotik nutrisi tinggi protein
    PROBLEM LIST AKTUAL

    Masalah Pemecahan
    • Pasien dengan anemia • Pastikan delivery oksigen
    • Berikan Supplementasi Oksigen
    • Siapkan darah
    • Hitung Kebutuhan PRC
    PROBLEM LIST POTENSIAL

    Masalah Pemecahan
    •Pasien dengan luka bakar  kerusakan • Penguapan & kehilangan panas tubuh
    jaringan kulit  penguapan dan kehilangan besar  Resiko terjadi dehidrasi &
    panas tubuh besar  Resiko terjadi hipotermi 
    dehidrasi dan hipotermi • Monitoring hemodinamik, UOP.
    • Hangatkan cairan infus
    • Hangatkan cairan irigasi,
    • Atur suhu ruangan

    • Resiko perdarahan  Hitung EBV • EBV = 65 x 70 = 4550 cc


    (Estimated Blood Volume) EBL = 10 % = 455 cc
    20 % = 910 cc
    30 % = 1365 cc
    Resusitasi cairan dengan target uop 0.5-1
    cc/kgbb/jam

    MABL = ( Ht Sekarang- 30)x EBV


    HT Sekarang+30
    PROBLEM LIST POTENSIAL

    Masalah Pemecahan

    Post operasi
    •Nyeri post operasi •Analgetik adekuat
    •Infeksi post operasi •Beri antibiotik adekuat
    •Penyembuhan luka • Nutrisi tinggi kalori dan tinggi protein
    TERIMA KASIH
    POSISI INTUBASI

    Adapted from
    Walls et al.
    Manual of
    Emergency
    Airway Management.
    2nd Ed. 2004.
     Anatomi

     Ukuran epiglotis yang relatif lebih panjang


     Ukuran trakea dan leher yang lebih pendek
     Tonsil dan adenoid yang lebih menonjol
     Otot diafragma dan interkosta yang lebih lemah
     Hambatan aliran udara yang lebih besar
     Farmakologi

     Immature hepatic transformation


     Penurunan protein darah yang berperan sebagai pengikat obat
     Peningkatan FA/FI yang lebih cepat dan waktu induksi dan pemulihan dari agen
    anestesi inhalasi lebih cepat
     Peningkatan konsentrasi alveolar minimum
     Volume distribusi dari obat larut air relatif lebih besar
     Immature neuromuscular junction

     FA/FI fractional alveolar concentration/fractiona inspired concentration


    4. Paralysis with induction:
    a. One of the following induction agents (or equivalent) given rapid IV push prior to
    paralysis:
    i. Etomidate 0.3 mg/kg IV
    ii. Midazolam 0.3 mg/kg IV
    iii. Ketamine hydrochloride 1.5 mg/kg IV
    iv. Propofol 1‐2mg/kg IV
    b. Paralytic agent by IV push immediately after induction agent:
    i. Succinylcholine 1.5 mg/kg IV
    ii. Rocuronium 1 mg/kg IV if succinylcholine contraindicated (see table below)
    5. Protection:
    a. Sellick maneuver (firm pressure on cricoid cartilage to prevent gastric regurgitation)
    should be applied as soon as consciousness lapses and be maintained throughout intubation
    until tube placement confirmed
    6. Placement:
    a. Insert endotracheal tube with direct visualization of the vocal cords
    b. Inflate cuff
    c. Confirm endotracheal tube is in the trachea using end tidal CO₂ capnography
    d. Auscultate lungs bilaterally to ensure right mainstem intubation has not occurred
    e. Secure endotracheal tube with tape
    f. Release Sellick maneuver
    7. Post‐intubation management:
    a. Chest x‐ray to assess placement of endotracheal tube (tip
    should be at mid trachea)
    b. Long‐acting sedatives and, if necessary, paralytics
    i. Lorazepam 0.05 mg/kg IV for sedation
    ii. Vecuronium 0.1 mg/kg IV for paralysis
    c. Initiate mechanical ventilation
    d. Sedative: Propofol bolus/drip
    PARKLAND FORMULA

     4ml/kgBB x % TBSA
     Terbagi 2 pemberian:
     8 jam pertama
     16 jam kedua

     Contoh  Lk/40thn/60kg/%TBSA: 40%


     4mlx60x40=9.600ml
     8 jam pertama: 4.800ml/ 8 jam: 600ml/ jam  200 gtt/i
     16 jam kedua: 4.800ml/ 16 jam: 300ml/ jam  100 gtt/I
     Target UOP: 0,5-1 ml/kgBB/jam

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