Morning Report

Saturday,,March 24th 2012

25-year-old male was transferred to the ER of AA Hospital on March 12th 2012 following an electrical injury

BASIC LIFE SUPPORT in Unit Care (Cendrawasih I)

AIRWAY
Patient can talk spontaneously Stridor (-),, Snoring (-),, Gurgling (-)

CLEAR

BREATHING
Breath spontaneously,, RR = 20 x/minutes, respiratory motion symmetrically,, respiratory sound was vesicular R=L, rhonki (-)

CLEAR
The reality: the patient hadnt given O2 administration. He supposed to be given O2 10-12 Lpm via NRM for keeping O2 saturation

CIRCULATION
Blood Pressure = 140/90 mmHg HR = 99 x/minutes, reguler (A. dorsum pedis), warm acral, CRT<2 seconds Administration of IVFD RL 20 dpm

The evaluation: Urine output= 80 ml/h (BW= 55 kg), with the color was yellow and clear

EXCELLENT

DISABILITY
GCS 15 (E4V5M6) Pupils was isochor 3 mm/3mm, pupils reflect of light (+/+) Contralateral hemiparyse (-/-)

EXPOSURE
prevent hipotermia. Exposure for other injuries that threaten patients life

Chief complain: electrical injury in a hour b/t to the hospital

The History A hour b/t to the hospital, the patient contacted with high-voltage current in occupational setting as builder. Patient hold iron cylinder for building by hands while the iron was contacted with high-voltage current, prolong contact was about 1-3 minutes. The ground was on patients right foot which shown as flash burn.

 Afterward, patient felt tetanic muscles for all of his body, but he was still alert. He was transferred to local health clinic and was given IVFD (the type wasnt be known) and urine catheter, and then transferred to the ER of AA Hospital. Arrived at ER, the tetanic muscle was stop.

 In ER ( 2-3 hours), the patient told the color of his urine was chocolate at the first and became clear yellow.
From medical record: administration of IVFD RL 1 line 100 cc/h till the color urine was clear yellow...AB???Ketorolac???

No other secondary injuries (ex: fall down, head injury, chest injury, abdominal injury, etc) were complained.

Other Medical Histories: Cardiovascular disorder/disease (heart disease,

hypercholestremia, hypertension, stroke): (-)

Respiratory disorder/disease (asthma, chronic

of pulmonal disease): (-) History of epilepsy (-) History of DM (-) History of Tetanus immunization : wasnt be known

Family illness history:

History of hypertention (-) History of asthma (-) History of epilepsy (-) History of DM (-)

General state: poor Conciousness : CM Vital sign:

BP: 140/90 mmHg HR: 99 x /minutes RR: 20 x/minutes Temp: 37,9 0C

 Head

Eyes: Sclera: jaundice (-)

Konjunctiva: anemis (-) No visual impairment and sign of catarac (-)

Ears: no hearing impairment Lesion (-), Burn wound (-)

Neck
Sign of cervical injury (-) Burn wound (-)

 Chest

Normal

Cor: synus rhythm, murmur (-) Lung: respiratory motion symmetrically,, respiratory

sound was vesicular R=L, rhonki (-) Burn wound (-)

Abdominal: Normal

Ins: flat, hematoma (-), Burn wound (-) Aus: bowel sound (+) N, 6x/minute Pal: muscular rigidity (-), tenderness (-) Per: timphany

 Extremitas

: Localized

Genitaurinary: Normal

Ins: hematoma (-), lesion (-). Burn wound (-) Pal: tenderness (-)

Right and left of Superior extremities

(Regio antebrachii 1/3 distal and regio manus) Ins: Inflammation (+), muscle tetani (-). Burn wounds at joint areas (cubiti, axilla) 3rd grade-Burn wounds on hands Entry wound Pal :
Tenderness (+), non-pitting oedem (+) Signs of fracture or deformity (-) Sensoric (was difficult to measure cause pain of inflammation) Motoric (+, was limited cause pain and inflammation) Distal vascular (difficult to measure cause inflammation)

Entry Wound

Right and left of Inferior extremities

Ins: Inflammation (+), muscle tetani (-). 3rd grade-burn wounds at: Regio femoris anterior sinistra 1/3 distal Regio cruris posterior dextra et sinistra Regio dorsum pedis dextra (ground wound) et sinistra Pal : tenderness (+), non-pitting udem (+) Signs of fracture or deformity (-) Sensoric (+). Motoric (+) Distal vascular: A. dorsum pedis (+)

Ground wound

Electrical burn injury of 15 % TBSA

CBC (Complete Blood Count): WBC : 23.200 /L Hb : 16,3 gr/dl Ht : 45,7 % PLT : 278.000 /L

Glucose: 206 mg/dl (N=70 125 )

Renal function BUN : 9 mg/dL CR-S : 0,57 mg/dL UREUM : 19,3 mg/dL
Hepar function TBIL : 2,4 mg/dL D-BIL : 0,3 mg/dL I-BIL : 2,1 mg/dL AST : 172 IU/L ALT : 40 IU/L ALB : 4,0 g/dL

(N=7 18) (N=0,6 1,3) (N=20 40)

(N 1,0) (N 0,25) (N 0,75) (N=14 50) (N=11 60) (N=3,5 5)

Electrolites Na+ = 136,4 mmol/L (N=135-145) K+ = 3,92 mmol/L (N= 3,5-5) Cl- = 106,3 mmol/L (N=98-106)

URINALYSIS Color: chocolate Turbidity : cloudy

Protein = (+1) Glucose = (-) Bilirubin = (-) Uroblinogen = N pH = 5 BJ = 1,03 Blood = (+3) Keton = (-) Nitrit = (-)

Urine (clear yellow) maintain a urine output of 0,5-1 ml/kg/h EKG monitoring Check for serum myoglobin, creatine kinase, and arterial blood gas ATS + prophylactic administration of high-dose penicilin Burn wounds care with moist dressing or using MEBO Follow up for other advanced complications (arrythmia, cataract, compartment syndrome, septic, etc) Co for plastic surgeon