PRIMARY SURVEY ABC: CLEAR

DISABILITY: GCS 15 (E4, M6, V5)

EXPOSURE :
• Head: face: Burnt. (see: burn status)
• Abdomen : bowel movement (+), tenderness (-)
• Eyes: pupil: isocor, D: 3 mm, RC+/+, CA -/- , SI -/-
• Genital: ♂ , inserted DC (+), urin output: 350/6 hour
• Nose: hair nose: Burn
• Extrimity: warm acral, CRT <2 sec, burn injury in both
• Mouth: mucosal edema (-)
hand (see: burn status)
• Neck Burnt (+). hyperemic pharynx (-). Tracheal
deviation(-)

Pulmonary: Cardiac:
I: : S/M: symmetric, retraction (-), Ictus cordis : Tidak teraba
laceration (-), hematoma (-) Palpasi : ictus cordis teraba di ICS V MCS
P : frakture (-), ICS: normal Perkusi: Cardiomegaly (-)
P: sonor right=lef Auskultasi: S1,S2 Murni, Reguler, Murmur (-)
A: VBS right=lef, stridor -/-,
wheezing -/-, rhonki -/-
 Localized status
Degree of Burn Injury
Wallace
Lund Rules ofChart
and Browder Nine
Luas Luka
Region Base Blister
Bakar

Face Black, some are pale pink,

3,5% -
(anterior) especially in the cheek area

Neck 1% Black -
(anterior)
Right Hand
and 3% Pink +
forearm
burn injury on:
Lef hand
1,5% + 4,5% on both
Pink hand 2 -3 degree.
nd rd
4,5 %andon the face +
forearm
Conclusion : 9% burn injury 2 -3 nd rd
Total
degree 9% degree : 2-3
 Laboratory examination
Tanggal : 21 Juli 2017 Pemeriksaan Hasil Nilai Normal
Jam : 16.06 WIB
Hematologi
(+/- 2 jam setelah kejadian)
Hb 12,6 g/dL 12,0-14,0 g/dl
Leukosit 9.410 /µL 5.000-10.000 /µL
Hematokrit
Trombosit Diagnosis
37,4 %
305.000/µL
37,0 -43,0 %
150.000-400.000

9%Kimia
burnKlinik injury with 2 nd-3rd degree

Elektrolit
Natrium (Na) 142 mEq/L 135-153 mEq/L
Kalium (K) 3,5 mEq/L 3,5-5,3 mEq/L
Klorida (Cl) 102 mEq/L 98-109 mEq/L

Ureum 20 mg/dL 17-43 mg/dL

Creatinin 1,0 mg/dL 0,6-1,1 mg/dL

Gula Darah Sewaktu 191 mg/dL 70-200 mg/dL

 Therapy in P Hospital
• oksigen 3 liter/m,
• IVFD RL 1500cc, Insert DC no.
16,
• ceftriaxone 1 gram
• ketorolac 1 amp , ranitidine 1
amp
• Injection TT,
• Smear the wound with Burnazin
Therapy in RSIJ (instruction: SpBP)
• IVFD RL 20 cc/jam
• Ceftriaxone 1x2 g, Novalgin
2x1000 mg, Extrace 2x400 mg
• Aff kateter
• Wash the wound with
chlorhexidine 2% + dress with
paraffin gauze, everyday
• deep wound→ STSG
• debridement + STSG (Day 4)
Day Day Day
3 5 20

THANK YOU