3. Tensi, nadi, respirasi, temperatur 4. Balance cairan
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Perawatan
1. Keseimbangan cairan 2. Nutrisi dan cairan
3. Atasi anemia,hipertensi, kejang 4. Cegah ulkus peptikum, dekubitus
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Kuliah 7 - Trauma Torak dr. Wawan
Initial Assessment / Management Primary Survey
Identifies most life-threatening injuries Resuscitation
Airway control
Ensure oxygenation / ventilation Needle / tube thoracostomy Secondary Survey
Identifies most
potentially lethal injuries Physical exam / diagnostic tests Definitive Care
Airway control
Ensure oxygenation / ventilation Tube thoracostomy
Hemodynamic support
Operation
Life threatening Chest Trauma Primary Survey Airway obstruction Tension pneumothorax Open pneumothorax Flail chest Massive hemothorax Cardiac tamponade Airway Obstruction Laryngeal injury Rare occurrence Hoarseness Subcutaneous emphysema Treatment • Intubation (caution)
• Tracheostomy (by surgeon) Breathing
Tension pneumothorax : Etiology
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Air enters pleural space with no exit Positive pressure ventilation
• Collapse of affected lung • ↓ Venous return
• ↓ Ventilation of opposite lung Tension Pneumothorax : Signs / Symptoms
• Respiratory distress • Distended neck veins • Unilateral ↓in breath sounds • Hyperresonance
• Cyanosis, late
Tension Pneumothorax : Management Immediate decompression Clinical diagnosis, not by x-ray Open Pneumothorax
• Cover defect • Chest tube
• Definitive operation
Flail Chest / pulmonary Contusion Reexpand lung
Oxygen
Judicious fluid management Intubation as indicated Analgesia
Circulation
Massive Hemothorax ≥ 1500 ml blood loss
Systemic / pulmonary vessel disruption Flat vs distended neck veins
Shock with no breath sounds and /or percussion dullness Rapid volume restoration
Chest decompression and x-ray Autotransfusion
Operative intervention Cardiac Tamponade
• ↓Arterial pressure • Distended neck veins • Muffled heart sounds • Patent airway
• IV therapy
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• Pericardiotomy Resuscitative Thoracotomy
Qualified surgeon present on patient’s arrival Indications
• Penetrating thoracic injury • Pulseless with electrical activity Contraindications
• Blunt injury
• Pulseless, without electrical activity Potentially- Lethal Chest Trauma
Identified by :
In –depth examination
Upright chest x-ray, if possible ABGs Pulse oximetry ECG Simple pneumothorax Hemothorax Pulmonary contusion Tracheobronchial tree injury Blunt cardiac injury
Traumatic aortic disruption Traumatic diaphragmatic injury Mediastinal traversing wounds Secondary Survey
Pneumothorax
Penetrating / blunt trauma V / Q defect
Hyperresonance ↓ Breath sounds Tube thoracostomy Hemothorax
Chest – wall injury Lung / vessel laceration Tube thoracostomy Pulmonary Contusion Most common Oxygenate, ventilate Selective intubation Tracheobronchial injury
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Blunt / penetrating trauma Partial vs complete
Diagnostic aid : Endoscopy
Treatment: Airway ventilation; Operation Blunt Cardiac Injury
Injury spectrum
Abnormal ECG : Monitor changes Echocardiography
Treat : Dysrhythmias, Q, complications Traumatic Aortic Rupture
Rapid acceleration/deceleration Ligamentum arteriosum
Salvage : identify early Surgical consult
Diaphragmatic Rupture Most diagnosed on left Blunt → large tears
Penetrating → small perforations Misinterpreted x –ray
Contrast radiography Operation
Mediastinal Traversing wounds Hemodynamically Abnormal
Exsanguinating thoracic hemorrhage Tension pneumothorax
Pericardial tamponade
Esophageal / tracheobronchial injury Spinal cord injury
Treatment
Bilateral tube thoracostomies Emergent surgical consultation Hemodynamically Normal
Vascular : Angiography
Tracheobronchial : Bronchoscopy
Esophageal Esophagography, esophagoscopy Treatment
Mandatory surgical consultation Repair identified injuries
Fakultas Kedokteran Universitas Warmadewa 2009 | IB Suryadi Putra Dwipayana [0970121023] 36 Subcutaneous Emphysema Airway injury Pneumothorax Blast injury Traumatic Asphyxia Petechiae Swelling Plethora Cerebral edema
Sternal, Scapular, and Rib Fractures : Pathophysiology Pain Splinting Associated injuries Impaired ventilation Pulmonary contusion Hemopneumothorax Retained secretion Atelectasis pneumonia Fractures – Sign Ribs 1- 3 • Severe force
• Associated injuries → High mortality risk Ribs 4 – 9
• Pulmonary contusion • Pneumohemothorax
Ribs 10 – 12 : Suspect abdominal injury Management
Chest x – ray
Chest tube as necessary Selective ventilation Adequate pain relief Treat associated injuries No constrictive devices Esophageal Trauma
Blunt vs penetrating Severe epigastric blow Pain, shock > injury
Pneumohemothorax without fracture Chest tube : Particulate matter
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Contrast swallow, esophagoscopy Operation
Other indication for Tube Thoracostomy Suspected, severe lung injury
• Air or ground transfer • General anesthesia
• Positive pressure ventilation Pitfalls
Simple pneumothorax → tension pneumothorax Retained hemothorax
Diaphragmatic injury
Delayed diagnosis of aortic injury
Severity of rib fractures pulmonary contusion Elderly
Managing Life-Thereatening Thoracic Injuries
Injury Diagnosis Therapy
Ventilator Compromises
1. Tracheobronchial disruption Hypoxia + inability to move air
Chest does not move with ventilation
Hemoptysis, subcutaneous emphysema / keduanya
Intube over a flexible bronchoscope
Perform tracheostomy
2. Open pneumothorax (sucking chest wound)
Hypoxia + chest wound Sound of air passing in-out
though wound
Apply occlusive dressing (vaseline gauze + sponge) Insert chest tube at site remote
from wound* 3. Flail chest Hypoxia and impaired
ventilation
Paradoxical chest movement Multiple rib fractures
(confirmed on roentgenogram)
Is respiration compromises Yes: perform endotracheal intubation
No: Observe patient and control pain
Circulatory and Ventilatory Compromise
4. Tension pneumothorax Respiratory distress (cyanosis is a later finding)
Unilateral absence of breathing sounds Distended neck veins
common*
Tracheal deviation to opposite side
Hypotension ay be present
Insert 18-gauge needle into second interspace at
midclavicular line
Insert chest tube into fifth interspace if air escapes or if patient improves with needle insertion
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5. Massive hemothorax Respiratory distress and hypotension
Dec. breath sounds + dullness to percussion
Diagnosis confirmed on roentgenogram
Replace volume Insert chest tube*
Circulatory Compromise
6. Cardiac tamponade Shock + cyanosis Distended neck veins*
Bilateral breath sounds present
Perform percardiocentesis for temporary therapy
Perform thoracotomy for definitive therapy
7. Aortic disruption History of blunt trauma Suspicious chest
roentgenogram
Aortography is diagnostic (computed axial tomographic scan less sensitive)
Repair during operation
8. Myocardial contusion Hypotension, dysrhythmia, or both are most common Echocardiogram,
electrocardiograms, cardiac enzymes
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Kuliah 8 – Abdominal Trauma & Shock dr. Yoga Bharata
Objectives
Describe external and internal anatomy
Recognize blunt vs penetrating injury patterns Identify signs of different types of injuries Apply diagnostic and therapeutic procedures Demonstrate and discuss DPL (for surgeon student) Abdominal Trauma
Unrecognized injury : Cause of preventable death Exam compromised by
o Alcohol, illicit drugs o Injury to brain, spinal cord o Injury to ribs, spine, pelvis Mechanism of injury
Blunt
Spleen, liver, and hollow viscus Compression
Crushing Shearing
Deceleration (fixed organs) Penetrating
Liver , small bowel, and colon Laceration / low energy Kinetic energy / high energy Assessment : History Blunt Speed Point of impact Intrusion Safety devices Position Ejection Penetrating Weapon Distance
Assessment : Physical Exam Inspection
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Palpation Auscultation
Local wound exploration by surgeon Pain over bony pelvis
Genitourinary, perineal, rectal, vaginal and gluteal Adjuncts : Intubation
Gastric Tube
Relieves dilatation
Decompresses stomach before DPL Basilar skull / facial fractures May induce vomiting / aspiration Urinary Catheter
Monitors urinary output
Decompresses bladder before DPL Diagnostic
Perhatikan!! Urethral injury Adjuncts : x – ray Studies Routine
Blunt : AP chest, pelvis
Penetrating : AP chest, abdomen with markers (if hemodynamically normal) Contrast
Urethrogram Cystogram GI
IVP
Special Studies in Blunt Trauma
DPL USG* CT
Time Rapid Rapid Delayed
Transport No No Required
Sensitivity High High? High
Specificity Low Intermediate High
Eligibility All patients All patients Hemodynami-cally normal
Indications for Celiotomy Blunt
+ DPL or ultrasound
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Peritonitis Penetrating
+ DPL or ultrasound
Peritoneal /retroperitoneal injury Peritonitis Hypotension Evisceration Plain X – ray Free air Retroperitoneal air Ruptured diaphragm Special Studies
CT scan : Free air, visceral injury ? Fluid?
Cystogram : Bladder rupture, intraperitoneal injury Arteriogram: Renal pedicle occlusion
Upper GI : Duodenal rupture
Special Problems : Blunt Trauma Diaphragram : abnormal chest X-ray Duodenum : retroperitoneal air, contrast
Small bwel : seat belt sign, chance fracture, free air Pancreas : amylase? CT?
GU : extravasation of contrast nonfunctioning renal Pelvic Fractures
Significant force applied Associated injuries Pelvic bleeding o Ends of bones o Pelvic muscles o Veins / arteries Mechanism AP compression Lateral compression Vertical shear Classification Open Closed Assessment Inspection
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Palpate prostate Pelvic ring
o Leg-length discrepancy , external rotation o Pain on palpation of bony pelvic ring o AP x-ray
Pelvic Fractures : Management
Shock Objectives
Define Shock.
Recognize the shock state. Determine the cause. Apply treatment principles.
Apply principles of fluid management. Monitor patient‟s response.
Employ options for vascular access.
Recognize complications of vascular access. Key Questions
Is the patient in shock?
What is the cause of the shock state? What can I do about it?
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What is the patient‟s response? What are the pitfalls?
Shock
Inadequate organ perfusion
Inadequate substrate delivery Anaerobic metabolism Celular dysfunction Cell death
How do you recognize it?
Scene information/mechanism of injury Physical examination
o Tachycardia
o Alteration in Conciousness o Cold, diaphoretic skin o Urinary output o Hypotension o Tachypnea
Recognition of Shock State 1. Tachycardia
2. Vasoconstriction 2. Cardiac output Narrow pulse pressure 3. Map
3. Blood Flow
Caution : Compensatory mechanisms
Class I Hemorrhage 750 mL BVL (<15%) crystaloid