Skenario Dr Su'eb, dktr di puskesmas rwt inap yg trletak di pnggr jalan lintas sumatera sekitar 50km dari Palembang.

Puskesmas dilengkapi pelayanan UGD dengan fasilitas yang lengkap. Suatu kecelakaan lalu lintas terjadi di sekitar 100m dari puskesmas. Mobil kijang pick-up yang melaju dengan kecepatan tinggi menabrak tiang listrik. Tiang listrik terlihat bengkok dan bagian depan mobil hancur,kaca depan pecah. Sang sopir terlempar keluar melalui kaca depan. Dr Su'eb yag mendengar tabrakan langsung pergi ke tempat kejadian dengan membawa peralatan tatalaksana trauma seadanya. Di tempt kejadian terlihat sang sopir,laki-laki 28 tahun tergeletak sambil merintih minta tolong. Sang sopir mengeluh dadanya sesak, nyeri pd dada, perutda n paha kanan. Melalui px sekilas: -pasien sadar tapi terlihat bingung, cemas dan kesulitan bernapas -tanda vital : RR 50x/m, nadi 140x lemah, TD 90/50 -wjh n bibir kbiruan -klt pcat,dngng,brkrngt dngn -GCS 14(e:4 m:6 v:4) stlh mlakukn pnangnan seadany,dr su'eb lgsg mmbw sng spir k UGD.

Data tmbhan: kepala: -terdapat luka lecet di dahi dan pelipis kanan diameter 5-7 cm - yg lain dlm bts nrml torak: -inspeksi grakn dndg dada asimtris,knan trtnggal RR 50x tmpk memar d sktr dada knan bwah smpai k smping -auskultasi bny npas knan mlemah,bsing npas kiri trdngr jelas bny jntg trdngr jls,cpt, HR 140x -palpasi nyri tkan pd dada knan bwh smpai k smpng (lokasi memar) krepitasi pd kosta 9,10,11 knan dpn -perkusi:kanan hpersonor,kri sonor -trakea brgeser k kiri,vena jugularis distensi abdomen -inspeksi dndng perut datar memar pd perut knan ats -auskultasi bsng usus mnurun -palpasi nyri tkan pd kuadran knan ats ekstremts -paha knan tmpk dformitas n memar pd paha tngah knan bla dgerakkn,pasien mnjerit kesakitan 1. Interpretasi pemerikaan sekilas

Pasien sadar, tapi bingung, cemas : tidak ada gangguan kesadaran, hanya pasien mungkin cemas terhadap luka-luka yang ada. Kesulitan bernafas : ada gangguan breathing sehingga paru-paru sulit untuk mengembang, atau ada gangguan pengembangan dada, atau volume dada berkurang Mengenali gangguan breathing - Look : adakah sesak, sianosis, gerakan dinding dada asimetris? - Listen : bising nafas - Feel : palpasi dinding dada adakah nyeri, fraktur ; perkusi ; trakea ; JVP Dapat dikarenakan : - Gangguan gerak dinding dada : kontusio thorax, fraktur costae - Gangguan volume thorax : hemothorax - Gangguan tekanan intrapleura : pneumothorax
Kecelakaan Kontusio thorax, fraktur costae Gangguan gerak dinding dada pneumothorax

Gangguan tekanan intrapleura Kesulitan bernafas

Tanda vital HR 140 : takikardia, merupakan mekanisme kompensasi jantung untuk mencukupi kebutuhan darah di perifer sehingga oksigen yang terangkut cukup untuk perfusi. Dapat juga merupakan tanda-tanda syok. RR 50 : takipnea, merupakan mekanisme kompensasi karena terjadi gangguan pernafasan ( kesulitan bernafas ) BP 90/50 : merupakan kompensasi lanjut terhadap syok. Kompensasi awal dari syok adalah peningkatan HR dan RR namun TD juga masih normal karena semua CO masih tinggi. Wajah dan kulit sianosis : tanda-tanda syok Kulit pucat, dingin, berkeringat dingin : tanda-tanda syok

Syok hipovolemik :
Syok : aliran darah yang tidak adekuat sehingga penghantaran oksigen ke jaringan tidak sesuai kebutuhan Syok hipovolemik : Dapat disebabkan oleh pendarahan, luka bakar, diare/muntah yang berat. Tanda-tanda syok : - Kulit dingin dan lembab - Sianosis - Nadi cepat dan lemah - Respirasi yang dangkal - Oliguria - Menurunnya kesadaran Tanda klinis pendarahan akut Kelas % Blood Loss I II III IV Up to 750 ml (15%) 750-1500 ml (15-30%) 1500-2000 ml (30-40%) >2000 (>40%)
kecelakaan

Gejala klinis Slight increase in HR; no change in BP or respirations Increased HR and respirations; increased diastolic BP; anxiety, fright or hostility Increased HR and respirations; fall in systolic BP; significant AMS Severe tachycardia; severe lowering of BP; cold, pale skin; severe AMS
Trauma abdomen Ruptur organ abdomen

Perdarahan massif yang tidak diketahui Perdarahan masif Tubuh tidak mampu mengkompensasi kehilangan darah yang terus berlanjut

syok

GCS 14 ( 4,6,4) : merupakan skor untuk melihat adakah terjadi gangguan kesadaran pada pasien trauma. Tanda terjadi cedera otak ringan juga memberikan skor GCS 14. GCS : Eye - 4 : mata terbuka spontan - 3 : mata terbuka karena mendengar perbincangan - 2 : mata terbuka karena nyeri - 1 : tidak ada respon mata Movement - 6 : mengikuti perintah - 5 : dapat melokalisasi nyeri - 4 : menarik extrimitas jika nyeri - 3 : extrimitas fleksi - 2 : extrimitas ekstensi - 1 : tidak ada pergerakan Verbal - 5 : mampu bicara dan mengerti perbincangan - 4 : mampu berbicara namun tampak bingung - 3 : kata-kata tidak dapat dimengerti - 2 : suara yang tidak dimengerti - 1 : tidak mampu berbicara 2. Interpretasi pemeriksaan fisik Kepala: - Terdapat luka lecet di dahi dan pelipis kanan diameter 5-7 cm - Yang lain dalam batas normal Torak: - Inspeksi gerakan dinding dada asimetris, kanan tertinggal RR 50x tampak memar di sekitar dada kanan bawah sampai ke samping - auskultasi bunyi napas kanan melemah, bising napas kiri terdengar jelas bunyi jantung terdengar jelas, cepat, HR 140x - palpasi nyeri tekan pada dada kanan bawah sampai ke samping (lokasi memar) krepitasi pada kosta 9,10,11 kanan depan - perkusi : kanan hipersonor, kiri sonor - trakea bergeser ke kiri, vena jugularis distensi Interpretasi : terjadi tension pneumothorax
After blunt trauma, pneumothorax is caused by rib fractures penetrating the lung parenchyma or by lung injuries without chest wall involvement.

Abdomen

inspeksi dinding perut datar memar pada perut kanan atas - auskultasi bising usus menurun - palpasi nyeri tekan pada kuadran kanan atas Interpretasi : terjadi pendarahan fraktur iga bawah meningkatkan terjadinya cedera abdominal terutama cedera hepar dan lien dan perlu dilakukan evaluasi lebih lanjut dengan CT scan abdomen-pelvis Ekstremitas - paha kanan tampak deformitas dan memar pada paha tengah kanan Bila digerakkan, pasien menjerit kesakitan Interpretasi : terjadi fraktur femur
Gunakan traksi Hare untuk jenis fraktur ini karena memperbaiki angulasi dan memendekkan dan mencegah kerusakan jaringan lunak di sekitar fraktur.

3. Prognosis dubia 4. Komplikasi Kepala : hematoma epidural Toraks : atelektasis, kematian Abdomen : peritonitis fr 5.
Table 43-4 -- Differential Diagnosis of Abdominal Injury by Major Organs Injury Clinical Signs and Symptoms Possible Associated Injuries Diagnosis and Management Liver injury can range from minor parenchymal injury with confined subcapsular bleeding to massive organ injury with uncontrolled hemorrhage. Significant injury or hemorrhage may be determined in hemodynamically stable patients by peritoneal lavage or CT.

Pain or tenderness in right Lacerated bowel upper quadrant Signs of hypovolemic shock Referred pain to right shoulder from diaphragmatic irritation Right lower rib fractures

Liver injury

CT may delineate extent of injury, but the Hepatic vascular injury management of minor injuries with minimal bleeding remains controversial. Renal injury Significant injury or bleeding requires surgery; in children, conservative expectant management is favored whenever possible. Surgical consultation is indicated for all suspected liver injuries. Patients with subcapsular hematomas are protected from further trauma that might result in rupture of the capsule.

Tenderness and pain in left upper quadrant Splenic injury Kehrs sign: referred pain to left shoulder from diaphragmatic irritation Muscle spasm, guarding,

Stomach, bowel, and pancreatic injury

Splenic injury may range from relatively minor parenchymal injury with confined bleeding within a subcapsular hematoma to complete parenchymal or vascular disruption with uncontrolled hemorrhage. Splenic injuries are the most common cause of intraperitoneal bleeding from blunt abdominal trauma. Enlarged spleen may cause medial displacement of

Renal injury Diaphragmatic injury

Injury

Clinical Signs and Symptoms rigidity Signs of hypoperfusion

Possible Associated Injuries

Diagnosis and Management the gastric bubble on plain film.

CT can delineate the extent of injury and bleeding Left lower rib fractures and is a useful adjunct in hemodynamically stable patients. 20% of fractures of 9th to 10th ribs have A splenectomy is required for unstable patients or associated splenic those with massive injury. injury A splenorrhaphy may be attempted in less damaged spleens, and minor injuries (particularly in children) may be treated conservatively by close observation and expectant management.

Mild epigastric pain and tenderness that may Seat beltassociated decrease initially and then injuries worsen after several hours Guarding and muscle spasm (relatively rare) Pancreatic injury Signs of hypovolemic shock (may be delayed) Ileus Severe back pain Epigastric pain, tenderness, Mesenteric vascular gastrointestinal pain, or injury guarding; blood in nasogastric fluid or bowels Ileus and distention Duodenal injury

Lack of significant acute physical findings from this retroperitoneal structure often make initial diagnosis difficult. A high amylase level in lavage fluid or evidence on CT coupled with a high degree of suspicion may result in early diagnosis. Undiagnosed injury may result in necrosis with subsequent pancreatitis, delayed bleeding, peritonitis, or cyst formation. No definitive diagnostic test exists for early and accurate diagnoses of these injuries following injury. Requires surgical intervention when suspected. High mortality rate (15%20%) due to other injuries. Free intraperitoneal rupture or air on plain film is presumed to be a perforation of the gastrointestinal tract. These patients require exploratory laparotomy.

Immediate symptoms and physical findings may be Solid organ injury (liver unremarkable, but over 4872 hours gradually and spleen) increasing pain and tenderness may indicate peritonitis from occult injury. Significant injury from blunt trauma may be difficult to diagnose initially when the injury involves the retroperitoneal portion of the duodenum. Contrast duodenography, CT, or exploratory laparotomy may aid in the diagnosis. Perforation in blunt trauma occurs at the points of fixed attachment, particularly the duodenum. Patients with suspected bowel perforation are given antibiotics in anticipation of surgery and a nasogastric tube to remove gastrointestinal contents. Bile or urine in peritoneal lavage fluid suggests biliary perforation or genitourinary disruption; both require surgical consultation and management.

Ruptured or perforated gastrointestinal tract Free air in peritoneum (hollow viscus)

Most often due to penetrating injury

More often due to penetrating trauma Signs of hypoperfusion Inferior vena cava Signs of retroperitoneal hematoma Abdominal distention,

Bowel perforation

In suspected inferior vena cava injury, intravenous access for fluid resuscitation is placed above the diaphragm. Vascular injury may cause significant hemorrhage and needs both aggressive resuscitation and immediate surgery. This injury is frequently catastrophic; DPL and CT may show hemorrhage while angiography and exploratory laparotomy define the extent of injury. Aggressive fluid resuscitation with acute surgical repair is necessary.

Spinal cord injury

Retroperitoneal hematoma

Injury

Clinical Signs and Symptoms tenderness, and rigidity Abdominal distention, tenderness, and rigidity

Possible Associated Injuries

Diagnosis and Management

Bowel perforation Spinal fractures

Emergency department thoracotomy to access the aorta and control bleeding may be required in catastrophic bleeding. The use of PASG to minimize bleeding is controversial.

Perforation of aorta Bruits and lost or or vascular rupture decreased distal pulses Signs of hypoperfusion Signs of retroperitoneal hematoma Flank or abdominal pain and tenderness Flank swelling or ecchymosis Blood at urethral orifice Hematuria (95%)

Pelvic fracture (e.g., 90% of bladder injuries Gross hematuria, anuria, and intraperitoneal injury. are associated with a pelvic fracture) Vascular injuries Spinal fractures Liver and spleen injuries Suspected renal injury can be evaluated by IVP, angiography, and contrast CT. Suspected urethral injury should be evaluated by urethrogram before placement of an indwelling urinary catheter. Suspected bladder injury or disruption can be evaluated by cystogram, cystoscopy, and CT. In renal injury due to blunt trauma the bleeding is usually confined by Gerotas fascia and the capsule. Therefore, if bleeding is limited, patients may be managed conservatively with supportive care and observation. Penetrating renal injury with uncontrolled bleeding or renal vascular injury usually requires surgical management. Transected or damaged ureters require surgical repair or external drainage; intraperitoneal bladder disruption will require surgical repair; retroperitoneal rupture needs urinary diversion with suprapubic cystostomy. Urethral injury is frequently managed conservatively; however, urinary diversion must be provided by a carefully placed indwelling urinary catheter or suprapubic cystostomy. Urologic consultation is obtained before any procedure.

Genitourinary (kidneys, ureters, urethra, and bladder)

Suprapubic tenderness or ecchymosis

Displaced prostate

Retroperitoneal hemorrhage

Distended bladder

Suprapubic mass from blood or urine Pain and tenderness in pelvis Urethral, bladder, and rectal injury Patients with significant blunt abdominal injury and the possibility of a pelvic fracture require pelvic radiographs. The pelvis is a ring structure and usually fractures in more than one place. Pelvic fractures may result in uncontrolled lifethreatening retroperitoneal hemorrhage and may require aggressive fluid resuscitation and early consultation. Pelvic stabilization with PASG or external fixation may minimize pain and bleeding. Uncontrolled bleeding may require angiography and selective embolization. No single diagnostic test will identify all diaphragmatic injuries. Plain chest radiographs with stomach, bowel, or nasogastric tube in the thorax, or CT with thoracic windows, and enhanced upper gastrointestinal radiographs may help diagnose these injuries. Thoracic aspiration of bowel contents or drainage

Fractured pelvis

Vascular injury and Referred pain to abdomen retroperitoneal or back bleeding Palpable fractures, crepitus, or instability Signs of hypoperfusion or retroperitoneal bleeding Ventilation compromise from herniation of intraabdominal contents Spinal fractures Uterine and vaginal injury Liver and spleen injury

Diaphragmatic injury

Bowel sounds in thorax Hypovolemic shock

Renal injury Lung and thoracic

Injury

Clinical Signs and Symptoms

Possible Associated Injuries injury

Diagnosis and Management from a chest tube indicates diaphragmatic or esophageal rupture. Surgical exploration may be required to diagnose these injuries, and, when identified, these injuries need surgical repair. Stabilization focuses on maintaining adequate ventilation. Abdominal wall injury is often difficult to differentiate from underlying or concomitant intra-abdominal injury and, therefore, is regarded as a diagnosis of exclusion. Conservative management is appropriate. Significant hematomas of the abdominal wall and along the rectus sheath can complicate DPL or lead to false-positive results. CT can determine the presence of a significant soft tissue hematoma, which may result from direct injury or dissection from retroperitoneal bleeding.

Stomach, bowel, or Stomach and bowel nasogastric tube in thorax injury on chest radiograph Thoracic aspiration of bile, gastric contents, or feces or drainage from chest tube; 95% of lesions are on left side Pain or tenderness localized to traumatized area Hematoma or localized swelling Increased pain with stress of rectus muscles Any intra-abdominal injury Liver or spleen injury

Abdominal wall injury

Vaginal bleeding or lacerations Lower abdominal pain, tenderness, and guarding

Other intra-abdominal injury Pelvic fractures

Uterine disruption or injury may result in significant bleeding and may require hysterectomy. During pregnancy, blunt abdominal trauma may cause a placental abruption, and patients with abdominal pain or vaginal bleeding require obstetric consultation and fetal monitoring.

Uterine and ovarian Tender or enlarged uterus Vaginal lacerations are identified by direct injury or ovaries on bimanual Pelvic vascular injuries examination with a speculum. They frequently examination require surgical repair. Hypovolemic shock, particularly from uterine trauma when pregnant (abruptio placentae or uterine rupture) Bladder and urethral injury

CT, computed tomography; DPL, diagnostic peritoneal lavage; IVP, intravenous pyelography; PASG, pneumatic antishock garment.

is hypotension caused by shock or tension pneumothorax?? Because I read that tension pneumothorax also can shift mediastinal and cause decreased b=venous return so there is hypotension