LAPORAN JAGA

SABTU, 12 JulI 2015

COASS JAGA:

CATHELIN STELLA

PRATHITA AMANDA A

RAHMA RUFAIDA

R. ARNETTA NAOMI
 Patient's Resume

 Outpatient :0
 Hospitalized :5
 Operation :0
 Consultants in charge

 Pediatric surgery : dr. Irhamni Sp.B,SpBA

 Digestive surgery : dr. Arief Setiawan, Sp. B KBD
 Orthopedic surgery : dr. IGM Febri Siswanto, Sp.OT
 Plastic surgery : dr. Budiman Sp. BP
 Neuro surgery : dr. Lukman Ma’aruf, Sp. BS
 Oncology surgery : dr. Agus Sutarman SpB(K)Onk
 Thoraco surgery : dr. Arief Widya Taufik Sp. BTKV
 Urology surgery : dr. Haryono Sp. U
 Patient's Resume

Outpatient : 0
Hospitalized : 5
Operation : 0
 Mr IK, 22 years old
 Chief Complaint:
Patient was referred from RS Permata and RS Hermina
Grand Wisata to RSPAD due to a gas blast in an enclosed
factory PT mandom happened 1 day prior to admission

 History of Present Illness

1 day prior to admission, patient noticed a gas leak in the
spray division room then suddenly there was an explosion
without knowing the presence of ignition source.
The fire then spreaded all over the room. Patients who were
trapped in that room started to panick then tried to escape
through a door jostling
 All victioms then brought to hospital nearby then
treated. Patiets were given IV fluid, antibiotik,
analgetic, folley cath insertion
 Patients then referred to RSPAD due to not having
a burn unit.
 Burn Victim PT. Mandom

Se Grad TBSA Inhalation Hemodynam

Name Age x Ward e (%) trauma Intubated ic
1. Nuraeni 46 P ICU II-III 63 % (+) + Unstable

2. Heni 23 L Burn unit IIAB 17.5 % (-) - Stable

3. Ningrum 21 P Burn Unit IIAB 21.5 % (-) - Stable

4. Wiwik 22 P Burn Unit IIAB 20 % (-) - Stable

5. Legiono 29 P Burn Unit IIAB 19 % (-) - Stable

 Physical Exam
 Primary Survey
 A : sign of inhalation trauma (nasal hair
singed,no hoarseness,black sputum,
hyperemic oral mucosa, lips oedema (+) we
did intubation
 B : Spontaneously, RR 18-24x/minutes
 C : we resuscitate the unstable patient
 D : GCS E4M6V5
Secondary Survey
Head : no hematoma, no bruises, no open wound, no palpable
fracture
Eyes : anemic (-/-), icteric (-/-), pupil reflex (+/+), pupils diameter 2
mm, isochor.
ENT : no active bleeding
Thorax: no bruises, movement symmetrical both hemi thorax
Lungs: vesicular, no crackles and wheezing in both lungs
Heart: heart sound I-II, normal, no gallop nor murmur
Abdomen:

- Inspection: flat, no bruises

- Palpation: supple, muscular rigidity(-), tenderness(-), rebound
tenderness (-)
-Auscultation: normal bowel sound
-Extremity : warm, CRT< 2”, motoric 5/5/5/5, no deformity
 Fluid (1500xBSA) + %+25)x
Name % Grade BSAx24
Fluid requirement with CVC
target 8-10 mm Hg, urine 0.5-
1. Nuraeni/24 63 II-III 11/kgbb/hour

(1500x1.5)=(17.5+25)x1.5x24 +
2. Heni/45 17.5 IIAB 2780/24 hours +157cc/hours
II-III (III degree = posterior
trunk, right superior
extremity and left superior (1500x1.6)=(21.5+25)x1.6x24 =
3. Ningrum/20 21.5 extremity 4185.6/24 hours = 174.4cc/hour

II-III (III degree = right (1500x1.6)=(20+25)x1.6x24 =

4. Wiwik/20 20 superior extremity) 4128cc/24 hours = 175cc/hour

(1500x1.6)+(19x25)x1.6x24 =
5. Legiono/50 19 IIAB 4089.6/24 hours = 170cc/jam
Nuraeni, 2-
3rd degree,
63%
Heni, 2AB
degree
17.5%
Wiwik,2-3rd
degree
20%
Ningrum
2-3rd
degree 21.5%
Legiono,
2ab degree,
19%
 Working Diagnosis

 Burn
injury 2AB-3 degree 17-63% of
TBSA due to flame
 Management
 Vital sign monitoring ( blood pressure, heart rate,
respiratory rate, temperature, and pain scale)
 Urine target 0.5-1cc/kgbb/hour
 Oxygen with ventillator or nasal cannula 5lpm
 IVFD : maintenance as writen before
 Antibiotic
 Analgetic
 Vitamin C
 Wound treatment  wound toilet at decontamination
chamber  wound dressing with burnazin and tulle