LBM 4

KUITKU MEEPUH DAN TERASA PANAS

STEP 1

STEP 2
1. Mengapa didapatkan bulla ?
2. Mengapa setelah diberi infus NaCL 30 tetes produksi urin hanya 5 cc dan
berwarna kemerahan ?
3. Mengapa pada vital sign didapatkan RR 24 dan TD 100/70 , nadi
100x/menit ?
4. Klasifikasi luka bakar ?
5. Penanganan pertama pada luka bakar ?
6. Kenapa didapatkan lengan kiri gosong dan paha kanan bengkak ,
hematom pada pelipis kanan?
7. Bagaimana terapi cairan pada pasien tersebut ?
8. Mengapa luka dibersihkan dengan povidon iodin ? benar atau tidak ?
9. Bagaimana patofisiologi luka bakar ?
10.Apa komplikasi luka bakar ?
STEP 7
1. Bagaimana patofisiologi luka bakar ?
Jawab:
Anatomi kulit

The bodys response to a burn

Burn injuries result in both local and systemic responses.
Local response
The three zones of a burn were described by Jackson in 1947.
Zone of coagulationThis occurs at the point of maximum
damage. In this zone there is irreversible tissue loss due to
coagulation of the constituent proteins.
Zone of stasisThe surrounding zone of stasis is
characterised by decreased tissue perfusion. The tissue in this
zone is potentially salvageable. The main aim of burns
resuscitation is to increase tissue perfusion here and prevent
any damage becoming irreversible. Additional insultssuch as
prolonged hypotension, infection, or oedemacan convert this
zone into an area of complete tissue loss.
Zone of hyperaemiaIn this outermost zone tissue perfusion is
increased. The tissue here will invariably recover unless there is

severe sepsis or prolonged hypoperfusion.

These three zones of a burn are three dimensional, and loss
of tissue in the zone of stasis will lead to the wound deepening
as well as widening.

Electrical injury
Specific causes of electrical injuries are classified
as:
a.

Low-voltage injuries- also called low-tension

injuries; low-voltage burns are caused by voltage

less than 1000 V. This group includes most
injuries caused by household current; the child
who bites into the cord producing lip, face and
tongue injuries as well as occupational injuries

resulting from the use of small power tools, or

those who become grounded while touching an
object that is energized.

Fig. 1: Low-voltage injury. Representative electric field

lines and isopotential lines established in the lower face
during oral contact with a home power cord.

B. High-voltage injuries- these burns are also

known as high-tension injuries, and they are a
result of exposure to 1000 V or more. These
injuries are often the result of occupational
exposure to outside power lines and the most
commonly occur when a conductive object
touches an overhead high voltage power line.
Rarely, patients get into electrical switching
equipment and directly touch energized component.

Fig. 2: High-voltage injury. Approximate electric field lines

when current path extends from hand to hand.

C. Lightning injuries- involve voltages higher than

those of the other injuries, and are usually
categorized separately. The typical lightning
injury involves energy with high voltage and high
amperage but extremely short duration. Lightning
is usually a unidirectional massive current
impulse and is best understood as a current
rather than a voltage phenomenon. The largest
flow of current tends to jump to the ground before
much of it passes through the body. Lightning injuries occur when the patient is part of or near
the lightning bolt, and generally, the patient was
the tallest object around or near a tall object,
such as a tree

Pathophysiology
Certain properties of electricity and tissue illustrate
the mechanisms of electrical injury and the ability
to predict patients outcomes. These properties include
voltage, current, resistance, and conductance.
Voltage is the electromotive force or the difference in
the electrical potential. The current is the flow of
electricity. The resistance of a material is its opposition
to the passage of an electric current through it, and
its conductance is its ability to transmit a current. In
addition, electricity can also form arcs and result in the
creation of plasma. The three major mechanisms (5, 6)
of electricity-induced injury are as follows:
1. Electrical energy causing direct tissue damage,
altering cell membrane resting potential,
and eliciting tetany.
2. Conversion of electrical energy into thermal
energy, causing massive tissue destruction
and coagulation necrosis.
3. Mechanical injury with direct trauma resulting
from falls or violent muscle contraction.
Factors that determine the degree of injury
include the magnitude of energy delivered, resistance
encountered current, current pathway, and duration of
contact. Systemic effects and tissue damage are
directly proportional magnitude of current delivered to
the victim. Current flow (amperage) is directly related
to voltage and inversed resistance, as dictated by Ohm
law (I=V/R; where I=current, V=voltage, R=resistance).
Electrical current is categorized as direct current (DC)

or alternating current (AC). Direct current, such as

current generated by batteries, flows in the same
direction constantly. Alternating current, such as current
available through household wall sockets, changes
direction periodically. Alternating current, which is
used in most households, is more dangerous than direct current. Direct current tends to cause a
single
muscle contraction often strong enough to force the
person away from the currents source. Alternating
current causes a continuing muscle contraction, often
preventing people from releasing their grip on the
currents source. As a result, exposure may be prolonged;
even a small amount of alternating currentbarely
enough to be felt as a mild shock- may cause
a persons grip to freeze. Slightly more alternating
current can cause the chest muscles to contract,
making breathing impossible. Still more current can
cause deadly heart rhythms (6, 7).
High voltage (>1000 V) current causes more
severe injuries than low voltage (<1000 V) and is more
likely to cause internal damage. The local electric field
is of sufficient magnitude to cause electrical breakdown
of cell membranes and cell lysis. In theory, large
cells such as muscle and nerve cells are more vulnerable
to electrical breakdown. The clinical evidence
which suggests that muscle and nerve cell membranes
may be ruptured by electrical trauma is:
The release of large quantities of myoglobin
from within the intracellular space;
The intense spasm and rigor commonly witnessed
which suggest that the muscle cell is

depolarized and perhaps that cytoplasmic ATP

levels are inadequate to dissociate the actinmyosin
complex;
The elevated levels of arachidonic acid derivatives
of membrane phospholipids;
The delayed paralysis and nerve cell death
years after electrical trauma in which no thermal
injury component exists; and
The particular vulnerability of large cells to
injury.
The passage of a given current generates more
heat in a more resistant conductor (tissue) than in a
less resistant conductor. Resistance is the ability to
impede the flow of electricity. The direct dissipation of
energy as heat is called joule heating, and this is the
major cause of thermal burns to tissue. This heat
generated will be proportional to the resistance of the
tissue through which the current is passing and duration
of contact as dictated by Joules law ( E= IVT =
I2RT; where E=energy, I= current, R= resistance and
T= duration of contact).Therefore, tissues that are less
conductive tend to heat up more as current passes
through them (7, 8). The order of tissues, from the most
conductive (i.e., least resistant) to the least conductive
(i.e., most resistant)

A current that travels from arm to arm or from

arm to leg may go through the heart and is much more
dangerous than a current that travels between a leg and
the ground. Electrical current through the head or
thorax is more likely to produce fatal injury. A current
that travels through the head may affect the brain.
Transthoracic currents can cause fatal arrhytmic cardiac
damage, or respiratory arrest. Tissues differ in
susceptibility to electrical damage as follows in Table
When an electrical current is transmitted by
means of direct contact with a conducting material or
an arc that reaches the tissue surface, the electrons
begin to flow, as ions flow in a solution. Flow can be
divided into direct type, indirect type and an arc. Direct
flow occurs when a person touches a conductor,
resulting in contact burns (Fig. 5).
Indirect flow occurs in flashovers, in which the
flow of current proceeds along the external surface of

the body and is enhanced by wet skin or clothing.

Flash (also called sideflash, flash discharge, splash
____________________________________________
Pattern of injury/Tussue damage
___________________________________________
Skin - flash burns, thermal burns, arc burns, linear
burns,contact electrical burns.
Muscle swell, pain, contractions, spasms, myonecrosis,
compartment syndrome.
Blood vessels blood cloths, microvascular deterioration,
myoglobinemia, vasoconstriction, thrombosis, ischemia
Heart arrhythmia, asystolia, ventricular fibrillation, sinus
tachycardia, myocardial necrosis/infarction, cardiac arrest.
Nerves weakness, paralysis, tingling, numbness, uncontrollable
loss of urine (incontinence), and chronic pain.
Brain seizures, hemorrhages, poor short-term memory,
unconsciousness, ischemia, personality changes, irritability,
difficulty sleeping.
Bones- joint dislocations, fractures, other blunt injuries.
Kidney- myoglobinuria, acute renal failure, acute tubular
necrosis.
Ears- perforation of the eardrum, hemorrhagia.
Eyes - cataracts.

_________________________________________________

2. Mengapa didapatkan bulla ?

Kerusakan jar permeabilitas jar meningkat ekstravasasi dr
intravaskuler ke ekstra bula
3. Mengapa setelah diberi infus NaCL 30 tetes produksi urin hanya 5 cc dan
berwarna kemerahan ? terapinya sesuai atau tidak ?
Jawab:

4. Kenapa didapatkan lengan kiri gosong , dada gosong seluruhnya dan paha
kanan bengkak , hematom pada pelipis kanan?
arus listrik tubuh (segitiga enthoven) arah impuls dr kanan ke kiri
Jawab:
Current
Electrical current is simply the rate of fl ow of
charge. If a circuit is passing 1 C/s, the current is
said to be 1 ampere (A). Since the charge carrier
in a copper wire is the electron, a current of 1 A
just means that 6.24 10

18

electrons are fl owing

thru the wire per second.

Figure 2.1 depicts a current of 1 A fl owing
through a human thorax. (This is about 10 times
that seen with transcutaneous pacing and about
1/20 that seen with external de fi brillation.) By
convention,
positive current is de fi ned as that fl owing
from the positive to the negative electrode (i.e., this
assumes positive charge carriers even if the carriers
are negative such as the electrons in a wire). What
the generator (with the wires) actually does is to

carry electrons to the opposite side of the thorax.

The body does not have free electrons to carry
charge internally so chlorine ions carry the charge
from the right to the left (of the subject) while
positively charged ions (primarily sodium but
also potassium, calcium, and magnesium, etc.)
carry current in the opposite direction.
Electrocardiographic (ECG) and de fi brillation
electrodes have a gel containing a metal and a salt
of that metal (typically silver or tin is the metal)
to facilitate the exchange of the electron for a
chlorine ion and vice versa. Without such a gel,
the resistance (to low voltages and low frequencies)
is extremely high on dry skin.

5. Mengapa pada vital sign didapatkan RR 24 dan TD 100/70 , nadi

100x/menit ?
Jawab:

Systemic response
The release of cytokines and other inflammatory mediators at
the site of injury has a systemic effect once the burn reaches
30% of total body surface area.
Cardiovascular changesCapillary permeability is increased,
leading to loss of intravascular proteins and fluids into the
interstitial compartment. Peripheral and splanchnic
vasoconstriction occurs. Myocardial contractility is decreased,
possibly due to release of tumour necrosis factor . These
changes, coupled with fluid loss from the burn wound, result in
systemic hypotension and end organ hypoperfusion.
Respiratory changesInflammatory mediators cause
bronchoconstriction, and in severe burns adult respiratory
distress syndrome can occur.

Metabolic changesThe basal metabolic rate increases up to

three times its original rate. This, coupled with splanchnic
hypoperfusion, necessitates early and aggressive enteral feeding
to decrease catabolism and maintain gut integrity.
Immunological changesNon-specific down regulation of the
immune response occurs, affecting both cell mediated and
humoral pathways.

6. Klasifikasi luka bakar ?

Penanganan , proses dan gambaran ?

7. Penanganan pertama pada luka bakar ?

- Ditempat kejadian : menjauhkan dari sumber kebakaran , dibungkus
kain basah .
Listrik : aliran dihentikan , kimia : dibersihkan
- Kulit yang terbakar disiram air yang mengalir
- Diselimuti mencegah hypotermi
- Saat dirumah sakit : selamatkan Airway ,Breathing : oksigen
,Circulating : cairan intravena
- Beri antibiotik agar tidak infeksi
-

Mencegah evaporasi berlebihan : siram pakai air , baju lepas . jika

kebakaran jangan diberi zat yg tidak larut dalam air (pasta gigi)
infeksi

8. Bagaimana terapi cairan pada pasien tersebut ?

Rumus Evan
a. Luas luka bakar % x BB (kg)= jumlah ml kristaloid /NaCl 0,9% per 24
jam
b. Luas luka bakar % x BB (kg)= jumlah (ml) koloid/ plasma per 24 jam
c. Dextrose 5% = 2000 ml per 24 jam
Hari pertama=separuh a+b+c diberikan dalam 8 jam pertama dan sisanya
diberikan 16 jam selanjutnya
Hari kedua , jumlah cairan a+bc yang diperlukan adalah separuh hari
pertama
Rumus baxter : diutamakan kristaloid
Luas luka % x BB x 4 ml = kebutuhan ml dalam 24 jam
Jenis : RL (hipertonis tek onkotik meningkat ) dan NaCL 0,9% (isotonis)
<8000 D (kristaloid)

9. Mengapa luka dibersihkan dengan povidone iodine ? benar atau tidak ?

Derajat 2 : ada bula rentan terjadi jar nekrotik jk tidak diberi
antiseptik akan lembab memperparah jar nekrotik
10.Apa komplikasi luka bakar ?
- Syok sepsis keluar cairan ke kapiler mempengaruhi sistem
kardiovaskuler kekurangan cairan.
Ada focal infeksi menurunkan humoral dan selular
- Anemi
- Gangguan koagulasi (DIC)
- Gangg GIT derajat >20% penurunan GIT respon hypovolemik
dan neurologis
- Gangg ginjal banyak cairan keluar elektrolit banyak keluar
produksi urin sedikit

STEP 4