HS/M/48yo

Chief Complaint: Electrical burn on

the chest,
and left leg
It had been suffered since 13 hours
before admitted to H. Adam Malik
Hospital. The patient get
electrocuted while he was working
and then pateint fall down(3m).
History of shortness of breath (-), the
patient was referred from district
hospital.

Primary Survey:
A : clear
B : breathing spontaneously, RR:
20x/m
C : HR: 88x/m, BP: 140/90, Temp :
37.2C
D: GCS:15
E: secondary survey

Secondary Survey
Head : Eye : pupil equal, conjunctiva anemis (-/-)
Neck : no abnormality
Thoraks : L : in localized state
L : Vesiculer
F : Sonor on both hemithoraks

Abdomen
: L : in localized state
L : peristaltic (+)
F : Soepel

Upper extremity : no abnormality

Lower extremity : in localized state

Localized State
Thorax : electrical burn 6% on the right and left
hemithorax
Abdomen : electrical burn 6% on the abdomen
Back : electrical burn 2% on the left lower back
Extremity inferior : (L) electrical burn 9% on the left
thigh
: (L) electrical burn 4% on the left leg
: (R) electrical burn 3% on the right
posterior leg

Laboratorium finding
Hb / Hct / WBC / PLT : 10,80 / 27,30 / 22,26 / 46
Na / K / Cl : 138 / 3,2 / 118
Ureum/Creatinin : 71,80 / 1,40 mg/dL
Blood Glucose : 74,4 mg/dL
Albumin : 2,0

Working Diagnosis : electrical burn 30 % on the

chest, back, and leg

 Treatment at the ER :
IVFD Crystaloid
Baxter Formula: 4x70kgx30

8400ml 4200ml in first 8hours, 4200ml in

next 16 hours
Insertion Urine catheter
Antibiotic
Analgesic
ATS injection
Patient was prepared for debridement