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SECOND PROBLEM

Catastrophic Blast
FORTUNE DE AMOR
405140230
GROUP 8
BURN INJURY Clinical indications of inhalation
injury include:
 Face and/or neck burns
establishing  Singeing of the eyebrows and
airway control nasal vibrissae
 Carbon deposits in the mouth
Immediate Lifesaving and/or nose and carbonaceous
Measures for Burn stopping the sputum
burning  Acute inflammatory changes in
Injuries
process the oropharynx, including erythema
 Hoarseness
 History of impaired mentation
gaining and/or confinement in a burning
intravenous environment
access  Explosion with burns to head and
torso
 Carboxyhemoglobin level greater
than 10% in a patient who was
involved in a fire
BURN INJURY
The Rule of Nines
 The adult body configuration is divided
into anatomic regions that represent 9%, or
multiples of 9%, of the total body surface
 Body-surface area (BSA) differs
considerably for children. The infant’s or
young child’s head represents a larger
proportion of the surface area, and the
lower extremities represent a smaller
proportion than an adult’s.
 The palmar surface (including the fingers)
of the patient’s hand represents
approximately 1% of the patient’s body
surface
BURN INJURY First-degree burns
 Erythema, pain, and the absence of
blisters
 They are not life-threatening and
generally do not require intravenous
fluid replacement because the
epidermis remains intact

Partial-thickness burns
 Red or mottled appearance with
associated swelling and blister
formation
 The surface can have a weeping, wet
appearance and is painfully
hypersensitive, even to air current
BURN INJURY

Full-thickness burns
 Usually appear dark and leathery
 The skin also may appear translucent or
waxy white
 The surface is painless and generally dry;
it may be red, but does not blanch with
pressure
BURN INJURY

Burn severity has also been classified as


mild, moderate, and severe based on a
combination of age, depth, and size
 Always assume carbon monoxide (CO) exposure in
BURN INJURY patients who were burned in enclosed areas
 Patients with CO levels of less than 20% usually have
Primary Survey and Resuscitation no physical symptoms
of Patients with Burns  Higher CO levels can result in:
AIRWAY - headache and nausea (20%–30%)
BREATHING - confusion (30%–40%)
CIRCULATION - coma (40%–60%)
- death (>60%)
Patients with burns require 2 to 4 mL of Ringer’s  Cherry-red skin color is rare
lactate solution per kilogram of body weight per  Because of the increased affinity of CO for
percentage BSA of deep partial-thickness and full- hemoglobin, it displaces oxygen from the hemoglobin
thickness burns during the first 24 hours to molecule and shifts the oxyhemoglobin dissociation
maintain an adequate circulating blood volume and curve to the left
provide adequate renal perfusion. The calculated  any patient in whom CO exposure could have occurred
fluid volume is initiated in the following manner: should receive high-flow oxygen via a non-rebreathing
one-half of the total fluid is provided in the first 8 mask
hours after the burn injury. The remaining one-half  baseline HbCO levels should be obtained, and 100%
of the total fluid is administered during the oxygen should be administered
subsequent 16 hours.
 Escharatomy
BURN INJURY
Secondary Survey and  Remove all jewelry on the patient’s extremities.
Related Adjuncts  Assess the status of distal circulation, checkIng for
cyanosis, impaired capillary refill, and progressive
Physical examination neurologic signs, such as paresthesia and deep-
Documentation tissue pain. Assessment of peripheral pulses in
Baseline determinations patients with burns is best performed with a
for patients with major Doppler ultrasonic flow meter.
burns  Relieve circulatory compromise in a
Peripheral circulation in circumferentially burned limb by escharotomy,
circumferential always with surgical consultation. Escharotomies
extremity burns usually are not needed within the first 6 hours after
Gastric tube insertion a burn injury.
Narcotics, analgesics,  Although fasciotomy is seldom required, it may be
sedatives necessary to restore circulation for patients with
Wound care associated skeletal trauma, crush injury, high-
Antibiotics voltage electrical injury, and burns involving tissue
beneath the investing fascia.
Tetanus
Chemical Burn
 exposure to acid, alkali, petroleum product
 Clinical: alkali burns > serious than acid burns (penetrate more deeply)
 Management: immediately flush away the chemical with water (20 to 30
minutes).

Electric burn
 a source of electrical power contact with a body
 Mechanism: The body can serve as a conductor of electrical energy  heat generated
results in thermal injury to tissue different rates of heat loss from superficial and deep
tissues  deepmuscle necrosis, spinal injuries, trombosis  rhabdomyolysis 
myoglobin release  acute renal failure.
BURN INJURY
CRITERIA FOR TRANSFER
1. Partial-thickness and full-thickness burns on greater than 10% of the BSA in any patient
2. Partial-thickness and full-thickness burns involving the face, eyes, ears, hands, feet, genitalia, and
perineum, as well as those that involve skin overlying major joints
3. Full-thickness burns of any size in any age group
4. Significant electrical burns, including lightning injury (significant volumes of tissue beneath the surface
can be injured and result in acute renal failure and other complications)
5. Significant chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting illness that could complicate treatment, prolong recovery, or
affect mortality
8. Any patient with a burn injury who has concomitant trauma poses an increased risk of morbidity or
mortality, and may be treated initially in a trauma center until stable before being transferred to a burn
center
9. Children with burn injuries who are seen in hospitals without qualified personnel or equipment to
manage their care should be transferred to a burn center with these capabilities
10. Burn injury in patients who will require special social and emotional or long-term rehabilitative
support, including cases involving suspected child maltreatment and neglect
 Significant cause mortality Chest injuries
 Hypoxia, Hypercarbia, Acidosis
 Initial assessments & treatments : Breathing :
 Primary Survey  Signs :
 Resuscitation of Vital Functions  ↑↑ RR
 Change in breathing pattern
 Detailed Secondary Survey  Shallows respirations
 Definitive care  Cyanosis ( late sign )
 Must be recognized :
Airway :  Tension Pneumothorax
 Open Pneumothorax
Look, Listen, Feel
 Fail Chest
Identification Injury :  Pulmonary Contusion
 Upper Airway Obstruction  Massive Hemothorax
 Change in voice quality
Chest injuries: TENSION PNEUMOTHORAX
Signs :
 Chest pain Management :
 Air hunger  Immediate decompression
 Respiratory distress  inserting a large-caliber needle
 Tachycardia in the 2nd ICS in the
 Hypotension midclavicular line of the
affected side
 Tracheal deviation away from the side of
injury  Repeated reassessment is
necessary
 Unilateral absence of breath sounds
 Definitive treatment : insertion
 Elevated hemithorax without respiratory
of a chest tube
movement
 Neck vein distention
 Cyanosis (late manifestation)
Chest injuries: TENSION PNEUMOTHORAX

Needle decompression
Chest injuries: OPEN PNEUMOTHORAX

Management :
Large defects of the chest wall that
 Closing the deffect
remain open results in an open
pneumothorax ( sucking chest wound )  Sterile oclusive dressing
Pathophysiology :  Large, overlap the wound
If wound is 2/3 of the tracheal  chest  Taped securely on 3 side
wall defect with each respiratory effort  Inspiration: prevented air entering
 effective ventilation is impaired  Expiration: air escape from pleural
Signs :  Definitive treatment: surgical closure
Hypoxia, Hypercabia
Chest injuries: OPEN PNEUMOTHORAX

Dressing for
treatment
Chest injuries: Flail Chest & Pulmonary Contusion
Pathopysiology :
 Multiple rib fractures ( 2/> ) Chest X-Ray  multiple rib
 Loss of continuity of chest wall fractures
 Deffect on thoracic cage ABG  hypoxia
 Severe disruption of normal chest wall Initial treatment :
movement  Ventilation
Can cause hypoxia  Oxygen
Diagnose :  Fluid Resuscitation
 Moves air poorly Definitive treatment :
 Thorax’s movement asymmetrically  Oxygenation
 Uncoordinated  Fluids administer
 Palpation : abnormal respiratory motion &  Analgesia
crepitation
Chest injuries: Flail Chest & Pulmonary Contusion
Chest injuries
Circulation :
 Quality, rate, and regularity of pulse
 Hypovolemia : radial and dorsalis pedis pulse is absent
 Skin color and temperature
 Neck vein
 Cardiac monitor and pulse oxymeter
 Must be recognized :
Massive Hemothorax
Cardiac Tamponade
Chest injuries: MASSIVE HEMOTHORAX
Accumulation >1500 mL blood in
chest cavity
Diagnose :
Shock + absence of breath
sound/dullness to percution on 1
side of chest
Initial treatment :
 simultaneous restoration of blood
volume and decompression of the
chest cavity
 IV access, crystalloid infusion
Accumulation of blood & fluid 
 Chest tube, collect the blood  compressing the lung 
autotransfusion compromise respiratory effort
Chest injuries: CARDIAC TAMPONADE

Pericardium filled by blood from


heart, great vessels, pericardial Initial treatment : fluid replacement  no
vessels response  cardiac tamponade  surgery
or pericardiocentesis ( no surgeon )
Diagnose  Beck’s Triad :
Subxyphoid pericardiocentesis :
 Venous pressure elevation
 Aspirate blood
 Decline in arterial pressure
 Ultrasound to facilitate accurate
 Muffled heart tones insertion
Diagnose method :  Not for blood in pericardial sac has
Echocardiogram, FAST, clotted
Pericardial window
Chest injuries: CARDIAC TAMPONADE
Chest injuries

 Secondary Survey  8 lethal injuries :


 Simple Pneumothorax
 Hemothorax  Other manifestations of chest injuries :
 Pulmonary contusion  Subcutaneous Emphysema
 Tracheobronchial tree injury  Crushing injury to the chest
 Blunt cardiac injury  Rib, Sternum, and Scapular
 Traumatic aortic disruption Fractures
 Traumatic diaphragmatic injury
 Blunt esophageal rupture
Abdominal injuries
Abdominal trauma :
 Blunt trauma
 Penetrating trauma
 Solid visceral injuries
 Gastrointestinal injuries
 Retroperitoneal injuries
 Diaphragmatic injuries
Abdominal injuries
Blunt trauma  diffuse injury  all abdominal organs at risk for injury
 a compression or crushing by direct energy transmission  if the
compressive, shearing, or stretching forces exceed tissue tolerance limits
 disrupted  injury to solid viscera ( eq. liver or spleen ) or rupture of
hollow viscera ( eq. the GI tract ).
Penetrating trauma  stab wounds or gunshot wounds injure in several
ways.
Solid visceral injuries  blood loss  hypotension, tachycardia,
skin changes, mental confusion  non specific signs.
Hollow visceral injuries  blood loss & peritoneal contamination.
Abdominal injuries
 Pancreas injuries :
 It generally occurs in a direct blow on epigastrium
 The first 8 hours post trauma  CT scan with double contrast may not show the
injury of the pancreas  repeat the examination if suspicion persists.
 Repeating CT scan  no difference with the previous result  surgery exploration
Pelvic injuries
 Pathophysiology :
 The bony pelvis consists of the ilium, ischium, and pubis, which form an anatomic
ring with the sacrum
 Disruption of this ring requires significant energy
 Because of the forces involved, pelvic fractures frequently involve injury to organs
contained within the bony pelvis; trauma to extra-pelvic organs is common
 Pelvic fractures : often associated with severe hemorrhage due to the extensive blood
supply to the region
Pelvic injuries
Classifications based on mechanism of injury :
 lateral compression
 anteroposterior compression
 vertical shear

Grade I Associated sacral compression on side of impact


Grade II Associated posterior iliac ("crescent") fracture on side of impact

Grade III Associated contralateral sacroiliac joint injury


Pelvic injuries

B2 type partially stable B1 type partially stable C1 type unstable


Pelvic injuries
Clinical presentations :
 Tenderness, or instability on palpation of the bony pelvis
 Hematuria
 A hematoma over the ipsilateral flank, inguinal ligament, proximal
thigh, or in the perineum
 Neurovascular deficits in the lower extremities
 Rectal bleeding
Pelvic injuries
Blunt injury to pelvis  complex fractures with major hemorrhage 
plain radiographs, CTs
Sharp spicules of bone can lacerate the bladder, rectum, or vagina.
CT cystography is performed if the urinalysis findings are positive for
RBCs.
Urethral injuries : the examination reveals blood at the meatus, scrotal, or
perineal hematomas.
Life-threatening hemorrhage can be associated with pelvic fractures and
may initially preclude definitive imaging.
Pelvic injuries
 Diagnosis :
 History : suspect in high energy injury
 Physical Examination :
Radiograph :
 Every patient should have lateral c-spine, chest, & anteroposterior pelvic
radiograph
 AP pelvic is done to detect major ( and potentially life-threatening ) pelvic injury
Pelvic injuries
CT scan :
 Good at assessing haemorrhage in peritoneum and retroperitoneum  can aid
planning of vascular or orthopaedic procedures
 Good at assessing pelvic fractures
 Requires stable patient (?assisted stability)
Pelvic injuries
The initial management of pelvic fractures are directed to control of
hemorrhage.
For unstable fractures and the “open-book” type  external fixation in
the acute setting.
Pelvic injuries
Complications :
 The incidence of deep venous thrombosis ↑
 Continued bleeding from fracture or injury to pelvic vasculature
 GU problems from bladder, urethral, prostate, or vaginal injuries : the
incidence of urethral injuries varies by the type of pelvic fracture
 Sexual dysfunction, infections from disruption of bowel or urinary
system, chronic pelvic pain ( more so if the sacroiliac joints are
involved )
Anatomy
 Columna vertebralis:
 7 os cervikal
 12 os toraks
 5 os lumbal
 Os sakrum dan koksigis
 Medula spinalis
 Cortikospinal tract motorik
 Spinotalamikus tract sensorik
 Columna vertebra posterior propioseptif
Medulla Spinalis Lesion
Principal:
 LMN  stage of lesion
 UMN  lower stage of lesion
Pemeriksaan Sensorik
• Daerah yg bisa menjadi patokan:
– C3  atas deltoid
– C6  Ibu jari
– C7  Jari tengah
– C8 Jari Kelingking
– T4 Papila mammae
– T8  Proc. Xiphoideus
– T10  umbilicus
– T12  simfisis pubis
– L 4  betis
– L5 antar ibu jari dam telunjuk kaki
– S1  lateral kaki
– S3  tuberositas isikum
– S4 dan 5  Perianal
Pemeriksaan Motorik
• Daerah Miotom yg bisa menjadi patokan:
– C4  deltoid
– C6 biseps, ekstensor karpi radialis longus
et brevis
– C7  trisep
– C8 Jfleksor mpe jari tengah
– T1 abductor digiti minimi
– L2 Illiopsoas
– L3,4  quadtriceps, refleks patella
– L4,5, S1 Hamstring
– L5 tibialis anterior dan ekstensor halusis
longus
– S1  gastroknemius, soleus
Spinal cord injury
Laboratory diagnosis
Arterial blood gas (ABG) measurements - May be useful to evaluate
adequacy of oxygenation and ventilation
Lactate levels - To monitor perfusion status; can be helpful in the
presence of shock
Hemoglobin and/or hematocrit levels - May be measured initially
and monitored serially to detect or monitor sources of blood loss
Urinalysis - Can be performed to detect any associated
genitourinary injury
Spinal Cord Injury
Imaging
Plain radiography - Radiographs are only as good as the first and
last vertebrae seen, therefore, radiographs must adequately depict
all vertebrae
Computed tomography (CT) scanning - Reserved for delineating
bony abnormalities or fracture; can be used when plain radiography
is inadequate or fails to visualize segments of the axial skeleton
Magnetic resonance imaging (MRI) - Used for suspected spinal
cord lesions, ligamentous injuries, and other soft-tissue injuries or
pathology
Treatment
 Airway management - The cervical spine must be maintained in neutral
alignment at all times; clearing of oral secretions and/or debris is essential
to maintaining airway patency and preventing aspiration
 Hypotension - Hypotension may be hemorrhagic and/or neurogenic in acute
spinal cord injury; a diligent search for occult sources of hemorrhage must
be made
 Neurogenic shock - Judicious fluid replacement with isotonic crystalloid
solution to a maximum of 2 L is the initial treatment of choice; maintain
adequate oxygenation and perfusion of the injured spinal cord;
supplemental oxygenation and/or mechanical ventilation may be required
Complications
Bladder control
Skin sensations
Depression
Bowel control
Pain
Circulatory control
Respiratory control

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