TUTORIAL 4

MULTIPLE TRAUMA

Tujuan pembelajaran :
1. Mahasiswa mampu memahami langkah-langkah primary survey dan secondary survey
2. Mahasiswa mampu memahami penurunan kesadaran karena trauma
3. Mahasiswa mampu belajar mengidentifikasi dengan cepat kegawatdaruratan yang
mengancam jiwa
4. Mahasiswa mampu menjelaskan secara komprehensif manajemen trauma, baik trauma
kepala maupun kemungkinan trauma lain yang menyertai kejadian
5. Mahasiswa mampu berfikir analitik terstruktur langkah-langkah resusitasi dan basic
trauma life support.
6. Mahasiswa memahami komplikasi perdarahan dan resusitasi berlebihan (agresif
volume resuscitation)
7. Mampu memahami prinsip transportasi prehospital

SKENARIO
Seorang laki-laki berusia 58 tahun datang ke IGD RSUD diantar temannya menggunakan
kendaraan angkutan barang karena penurunan kesadaran setelah terjatuh dari lantai 3 bangunan,
korban adalah pekerja bangunan di tempat kejadian. Ketika tiba di rumah sakit korban diterima
oleh triase kemudian diarahkan ke jalur biru menuju ruang resusitasi. Dokter jaga IGD
melakukan anamnesis dan pemeriksaan fisik head to toe. Dari hasil anamnesis didapatkan korban
tidak mengalami muntah maupun kejang sebelumnya di tempat kejadian.
Dari hasil pemeriksaan fisik didapatkan sebagai berikut:

daan Umum : Penurunan kesadaran A : snoring +, gurgling -

nafas spontan, frekuensi nafas 30 x/m dangkal, vesikuler +/+, rhonki -/- C : TD 180/110 mmHg, frekuensi nadi 134 x/m, SpO2 : 97-98
GCS E2V1M2
akral hangat, hematom regio fronto-temporal kanan, konjungtiva anemis +/+, deformitas di kaki kiri, tampak luka terbuka di paha kiri

Dokter jaga melakukan pertolongan sesuai ABCD yaitu memberikan ventilasi oksigen 100 %
dengan facemask, memasang collar neck, membersihkan jalan nafas, terapi cairan 2500 cc
Ringerasetat, 1000 cc gelofusin dan 500 cc NaCl 0,9 %. Selain itu dibantu perawat melakukan
balut bidai dan kontrol perdarahan di paha kiri korban, pemasangan kateter urin dan dilakukan
intubasi endotracheal.
------------------------------------------------------------ Stop disini dulu -----------------------------------
------------------------------------------------------------ Step selanjutnya ----------------------------------
Sejalan dengan proses tersebut dilakukan pemeriksaan penunjang laboratorium dan radiologis.
Darah rutin Hasil Nilai rujukan Satuan
Lekosit 25500 4000 - 11000 mm3
Neutrofil 90 50 - 70 %
Hemoglobin 6,6 12 - 18 d/dL
Trombosit 78 150 - 400 ribu/mm3
Hematokrit 24 37 - 54 %
Gol. Darah A - -

Kimia klinik Hasil Nilai rujukan Satuan

Gula Darah Sewaktu 93 70 - 140 mg/dL
Natrium 140 135 - 145 mmol/L
Kalium 3,2 3,6 – 5,5 mmol/L
Chlorida 98 98 - 108 mmol/L
 1 jam paska resusitasi, pasien tampak membuka mata bila dibangunkan, menggerakan jari tangan
saat distimulasi. Dokter memeriksa vital sign dengan hasil sebagai berikut
TT No.7,5
an on ventilator, frekuensi nafas 20 x/menit, vesikuler +/+, rhonki -/- C : TD 90/50 mmHg, frekuensi nadi 118 x/m, SpO2 : 98-100 %,
M3
t, ekstremitas bawah kiri terpasang bidai.
Urin kateter tampak produk + 50 cc dalam 1 jam, warna kuning pekat. Pasien dikonsulkan ke
spesialis Bedah dan Ortopedi untuk tindakan emergensi yaitu damage control surgery.
------------------------------------------------------------ Step selanjutnya ------------------------------------
Hasil konsultasi dengan dokter bedah dan ortopedi disarankan rujuk dan perawatan ICU untuk
perbaikan keadaan umum dan stabilisasi di bidang bedah saraf. Akan tetapi belum mendapatkan
rujukan yang tepat sehingga diputuskan untuk dirawat di ICU rumah sakit setempat terlebih
dahulu. Dokter anestesi menyarankan sedasi dan control nyeri untuk menurunkan tekanan
intracranial, bila MAP >80 berikan Mannitol 125 mg tiap 8 jam dan dilakukan pemeriksaan
AGD, D-dimer dengan hasil sebagai berikut:

Hematologi Hasil Nilai rujukan Satuan

Fibrinogen 90 210 - 358 mg/dL
Control Fib 237 206 - 310 mg/dL
D-Dimer 4,27 0 – 0,5 ng/mL
Kuantitatif

AGD Hasil Nilai rujukan Satuan

pH 7,09 7,35 – 7,45 -
PCO2 28 35 – 45 mmHg
PO2 175 71 – 104 mmHg
BE -18,1 (-2) – (+3) mmol/l
HCO3 10,3 21 – 31 mmol/l
SO2 99 95 – 98 %

Setelah 4 jam di IGD lalu pasien ditransfer ke ICU di rumah sakit setempat untuk monitoring dan
perbaikan keadaan critically ill nya.

Silahkan diskusikan kasus diatas dengan menggunakan metode CBL/Cased Based Scenario
berdasarkan informasi dan data yang ada.

---------------------Selamat Berdiskusi---------------------
Part 1 :

1. What is the triage that doctor do? And why the patient got blue line and
went to resuscitation room?
(Taufiquarahman)
The triage was develop by the American association which is called
“Emergency Severity Index”
 Darurat  (yellow and green) pure urgent, need immediate
treatment to prevent the “gawat” , haven’t severe
 Gawat  (blue and red)
(Rayhan)
 Blue : level 1  immediate resuscitation
 Red : level 2  treatment <30 minutes
 Yellow : level  treatment > 30 minutes
 Green : level 4  treatment 60 minutes
 White : level 5  treatment 120 minutes
(Jihan)
The patient in code blue because he got major trauma and deficit of GCS,
Level 1 need resuscitation  head injury and unconsciousness
(Farisan)
From GCS we can obtained information that the patient need to be transfer to Trauma
center/Hospital, because the prognosis might goes to bad condition, need immediate treatment
2. What is the meaning of ABCD-Primary Survey?
(definition of the treatment that have been done by the doctor)

(Laras)
Primary Survey consist of :
Airway  (+) Snoring  obstruction in the airway  The doctor
performed Indotracheal
Breathing Tachypnea
Circulation  Hypertension
Disabillity  GCS low (5)  sopor
Exposure  Injury of the patient had

We need to know is the patient has the possibility to shock, first coming we need to put on closer
for the injury,

(Farisan)
The doctor treatment is true, ABCD :
 Airway needs to be clear, Is there any obstruction either for body fluid or blood
 Breathing  ventilation, the doctor using facemask (need to be re asses : ET might be needed)
 Collar neck is a right option  the patient probably have head injury and its needed to
prevent excesive movement of the spine, Ensure the patient to not having much movement to
prevent fracture of eoshphageal and spine injury (Protective) Fluid therapy is also needed.
 Fluid therapy 2500 cc Ringerasetat, 1000 cc gelofusin dan 500 cc NaCl 0,9 %  Prevent shock
 Wound dressing  control excessive bleeding, to prevent shock,
 ET intubation  because of the patient on sopor  patient on the composition stage
(Taufiqurahman)
ABCD first thing to do  because if he has abnormal the circulation is also have the
similar/linear with GCS, Airway, Breathing, Circulation, the doctor needs to put this as primary
Priority. Meanwhile Disability, GCS becomes second Priority. Urine chatterer to determine fs
the patient has any hypovolemia if under <30 ml / hour, The urine chatterer to measure the
 patient urine output.

(Vicka)
Management of hypertension of the patient after traumatic Injury: cause by pressure
(Autoregulation effort)  cerebral blood flow, cerebral perfusion, elevation of Intercranial
pressure is dangerous condition, Treatment : Labitol  to normalize the hypertension

(Jihan) asking : The base theory of Fluid replacement therapy regarding to the scenario? (L.O.)
 2500 cc Ringerasetat
 1000 cc gelofusin
 500 cc NaCl 0,9 %
Volume for hypovolemic : 20 ml/Body weight
(Taufiqurahman)
Indication for the dose : to prevent the increasing of intercranial pressure due to trauma
(Farisan)
ITLS : when there’s active bleeding that might cause hypovolemic shock, re-asses the fluid
therapy, connect to laras explanation.  maintenance dose, to ensure that the plasma
volume is on normal stage.

Part 2 :

1. Interpretation of Patient Lab Data

Darah Hasil Nilai rujukan Satuan Interpretation
rutin
Lekosit 25500 4000 - 11000 mm3 High-due to
infection, head
Injury
Neutrofil 90 50 - 70 % High-due to
infection
Hemoglobin 6,6 12 - 18 d/dL Low-
Trombosit 78 150 - 400 ribu/mm3 Low-due to
Bleeding
Hematokrit 24 37 - 54 % Low-damage
to blood vessel
Gol. Darah A - -

Kimia klinik Hasil Nilai rujukan Satuan Interpretation

Gula Darah Sewaktu 93 70 - 140 mg/dL Normal
Natrium 140 135 - 145 mmol/L Normal
Kalium 3,2 3,6 – 5,5 mmol/L Low
Chlorida 98 98 - 108 mmol/L Normal

Rontgen Interpretation
(Odi)
 Head CT Scan: Lateral Appearance shows discontinuity of calvaria, follows by
inflammation cause by trauma, Upper appearance shows discontinuity, low sensi,
inflammation on skin relates to trauma. Posterior appearance shows discontinuity,
enlargement relates to trauma in regio tempo parietal.
 (Taufiqurahman)
Epidural hematom : the pattern of CT scan shows increasing opacity of the skull,
biconvex, known as lemon shape form.
Subdural hematom : the pattern of CT scan shows concave known as banana finding
Sub arachnoid hemoraghic : the pattern of CT scan shows uncoordinated shape

(Farisan)
We need to know that sensory to account the surgery treatment is needed or not

 X-ray Radiology:
(Navis)
Close Fracture of OS tibia Sinistra or on left side of the patient,
(Taufiqurahman)
Normal for the Hand/Limb, arcus aortha not in the normal size perhaps leads to hematom.
Part 3 :