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FKG AN - 2

PENANGANAN AWAL PADA PASIEN TRAUMA MAXILLOFASIAL INJURY


Departemen Anestesiologi dan Terapi Intensif FKG USU 2011

Etiology and Incidence


Multisystem injury 20-50% Nasal and mandibular fractures most common in community EDs Midface and zygomatic injuries most common in Trauma centers 25% of women with facial trauma result of domestic violence Incidence of concomitant cervical spine injuries with facial fractures

Emergency Medicine
TRIAGE PRIMARY SURVEY SECONDARY SURVEY STABILISATION TRANSFER DEFINITIVE CARE TRIASE SURVEI PRIMER SURVEI SEKUNDER STABILISASI RUJUKAN TERAPI DEFINITIF

Survei Primer

Periksa cepat berurutan Selesai dalam 2 menit Terapi segera apa yang ditemukan ( treat as you find )

Tujuan Survei Primer


Secepat mungkin menemukan kelainan yang mengancam jiwa (cepat mematikan)
di sektor A - B - C - D

Memberikan pertolongan yang memadai untuk menyelamatkan jiwa Pertolongan meliputi : Resusitasi Stabilisasi

Korban ledakan tabung elpiji Muka hangus Pneumotoraks (blast injury) Luka bakar luas Fraktura betis kiri

Jangan terpukau kelainan yang jelas terlihat

Ikuti Sistematika A - B - C - D

AIRWAY yang sulit

AIRWAY yang sulit masker oksigen tetap bermanfaat

Derajat kegawatan korban berbeda-beda Survei primer Triage Survei sekunder

Terapi definitif / rujukan RS lain Kamar Operasi

RESUSITASI & STABILISASI

ICU
Emergency Medicine Hanya 50% pasien trauma perlu operasi

Triage
Sorting of patients according to : ABCDEs Available resources Multiple casualties Mass casualties

Preparation
Prehospital System

Transport guidelines /protocols On-line medical direction Mobilization of resources Periodic review of care Closest appropriate facility

Preparation
Inhospital

Preplanning essential Equipment, personnel, services Standard precautions Transfer agreement

Standard Precautions
Cap Gown Gloves Mask Shoe covers Goggles/face Shields

Resuscitation
Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia

Survei Primer
Airway Breathing Circulation Disability Exposure

Sumbatan jalan nafas pasien tak sadar paling sering disebabkan pangkal lidah

Airway
menilai jalan nafas

Kesadaran (bisa bicara?) Look, Listen and Feel Gerak dada Gerak otot nafas tambahan Warna kulit, mukosa, kuku

Airway
mengatasi obstruksi / sumbatan jalan nafas

Lakukan chin lift / jaw thrust Bersihkan rongga mulut (suction?) Pasang jalan nafas oro / nasopharynx Lindungi tulang leher Intubasi trachea

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JN NasopharynxJaw thrust

JN Oropharynx

Walaupun tanpa intubasi masih banyak pasien dapat ditolong

JN Nasopharynx

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Head tilt

Neck lift

Chin-lift

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Emergency Management and Resuscitation


Airway
Most urgent complication-Airway compromise Simple interventions first No mandible?

Intubation
Avoid nasotracheal intubation May not want RSI
Benzodiazepines Ketamine Etomidate

Be Prepared and Be Creative

Primary Survey
Establish Patent Airway C-spine injury Pitfalls
Caution

Equipment failure Inability to intubate Occult airway injury Progressive loss of airway

Primary Survey
Suspect C-Spine Injury Spinal protection C-spine X-ray when appropriate

Lindungi leher dari gerakan

Previously recommended hand positions for manual in-line stabilisation of the cervical spine.

Currently recommended hand positions for manual in-line stabilisation of the cervical spine.

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Survei Primer
Airway Breathing Circulation Disability Exposure

Breathing
menilai pernafasan

Adakah udara keluar masuk

Look, Listen, Feel

Frekwensi nafas Gerak cuping hidung Cekungan sela iga

Breathing
membantu pernafasan

1. Oksigen (jika ada) 2. Pernafasan buatan 2. 2.

1.

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Jejas di dada:

Breathing
waspada
- Pneumotoraks tension - Fr costa / Flail chest - Hemotoraks berat - Kontusio paru

- Pneumotoraks terbuka

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Dekompresi pneumotoraks (tension) harus dikerjakan dalam Primary Survey

Survei Primer
Airway Breathing Circulation Disability Exposure

Circulation
mengatasi perdarahan

Hentikan perdarahan Posisi shock Pasang infus besar x 2 Ambil sampel darah

u/ darah donor dan periksa Hb

Beri infus cairan, 1000 ml cepat

Circulation
mengatasi perdarahan

Beri infus cairan, 1000 ml cepat


RL (Ringer Laktat) NaCl 0.9% (Garam Fisiologis) RA (Ringer Asetat) Hypertonic Saline Dextran 250 ml

Shock ?
Perfusi :
pucat - dingin - basah cap. refill time lambat (kuku, telapak)

Nadi > 100 Tekanan darah < 100 (atau 90) mmHg
Nadi masih teraba di :
radialis > 80 mmHg femoralis > 70 mmHg carotis > 60 mmHg

Circulation
waspada & cari lokasi perdarahan

Cedera intra-abdominal Cedera dada Patah tulang panjang Patah tulang pinggul Luka tusuk / tembus Luka kulit kepala

Primary Survey
Circulatory Management Control hemorrhage Restore volume Reassess Pitfalls Elderly Caution Athletes

Children Medication

Survei Primer
Airway Breathing Circulation Disability Exposure

Disability
menilai kesadaran

Periksa Pupil (besar, simetri, refleks cahaya) Periksa kesadaran A = Awake (sadar penuh) V = responds to Verbal command
(ada reaksi terhadap perintah)

P = responds to Pain (ada reaksi terhadap nyeri) U = Unresponsive (tak ada reaksi)

A- V - P - U Pupil

Primary Survey
Disability Baseline neurologic evaluation GCS scoring Pupillary response Observe for neurologic deterioration

Caution

Survei Primer
Airway Breathing Circulation Disability Exposure

Exposure
pemaparan

Lepaskan semua pakaian untuk pemeriksaan teliti menyeluruh, ada jejas apa saja Periksa punggung!

miringkan pasien cara Log-roll

Cegah hipotermia (kedinginan)

Primary Survey
Exposure / Environment Completely undress the patient
Prevent hypothermia
Caution

Survei Primer
Foto Dada sinar-X / Chest X-Ray ( jika ada) Tulang leher / C - Spine(lateral) Panggul ( Pelvis ) Abdominal USG

Adjuncts to Primary Survey


Vital sign ECG Urinary Output Adjuncts ABGs Pulse oximeter and CO

Urinary/gastric catheters unless contraindicated

Adjuncts to Primary Survey


Diagnostic Tools Chest and pelvic x-ray DPL Ultrasound

ACS

Survei Sekunder

Lanjutan dari survei primer Hanya bila ABC sudah stabil Teliti kepala sampai jari kaki Kembali ulang survei primer jika pasien tidak stabil / kondisi memburuk

Sistematika Emergency Medicine


TRIASE SURVEI PRIMER SURVEI SEKUNDER STABILISASI RUJUKAN TERAPI DEFINITIF

Survei sekunder

Mencari cedera yang mengancam jiwa atau cacad ekstremitas (life or limb) Pemeriksaan teliti dari kepala sampai kaki Dikerjakan setelah survei primer selesai Dikerjakan jika ABC sudah stabil Segera kembali ke survei primer jika ABC memburuk lagi

Pemeriksaan kepala

Kulit kepala (robekan, memar, laserasi) Tengkorak (nyeri tekan, depresi tulang) Mata (pupil, fundus, lensa, conjunctiva) Cairan CSF / darah dari telinga, hidung, mulut

Ada darah mengalir, tetapi dari mana ?

Periksa kesadaran dan syaraf


Glasgow Coma Score Pupil

ukuran, simetri, refleks cahaya

Fungsi motorik Fungsi sensorik Refleks-refleks

Secondary Survey
Head Complete neurologic examination GCS score determination Comprehensive eye/ear exam Pitfalls Unconscious patient Periorbital edema Occluded auditory canal

Secondary Survey

The complete history and physical examination

Secondary Survey
Key Components History Physical examination : Head-to-toe Tubes and finger in every orifice Complete neuro exam Special diagnostic tests Reevaluation

Secondary Survey
History A Allergies M Medications P Past Illnesses L Last meal E Events/Environment

Secondary Survey
Mechanisms of Injury

ACS

Maxillofacial Trauma-Physical Exam


Penetrating Injuries
Occult globe penetration Eyelid lacerations

Nose
Septal hematoma CSF Rhinorrhea

Ears
Subperichondral hematoma Hemotympanum Battle sign

Maxillofacial Trauma-Physical Exam


Oral and Mandibular Exam
Mandible deviation Teeth malocclusion Paresthesia Tongue Blade Test
95% Sensitive 65% Specific

Maxillofacial Trauma-Imaging
Head, chest and abdominal trauma takes precedence PE detects up to 90% of fractures Plain Films CT
Orbital fractures 3D images available

Maxillofacial Trauma-Specific Fractures


Frontal Sinus/Bone Fractures
Direct blow Frequent intracranial injuries Mucopyoceles Consult with NS for treatment, disposition and antibiotics

Nasoethmoidal-Orbital Injuries
Lacrimal apparatus disruption Bimanual palpation if medial canthus pain CT face

Maxillofacial Trauma-Specific Fractures


Maxillary Fractures
High-energy injury 100x gravity Malocclusion Facial lengthening CSF rhinorrhea Periorbital ecchymosis

LeFort Fractures

Maxillofacial Trauma-Specific Facial Fractures


Mandibular Fractures
Second most common facial fracture Often multiple Malocclusion Intraoral lacerations Sublingual ecchymosis Nerve injury

Pemeriksaan leher (1)


Lihat / inspeksi Palpasi (nyeri tekan, deformitas) Anggap leher cedera Imobilisasi pada posisi netral

Secondary Survey
Cervical Spine Palpate for tenderness Complete motor/ sensory exams Reflexes C-spine imaging Pitfalls Altered LOC for any reason Other severe , painful injury

Pemeriksaan dada mencari ulang kerusakan


Lihat / inspeksi Palpasi Perkusi Auskultasi Foto sinar-X dada (jika ada) ECG ( jika ada)

Secondary Survey
Chest Inspect Palpate Percuss Auscultate X-ray

Pitfalls Elderly Children

Secondary Survey
Abdominal Evaluation

Blunt trauma

Penetrating trauma

Secondary Survey
Abdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies Pitfalls
Hollow viscus and retroperitoneal injuries Excessive pelvic manipulation

Secondary Survey
Perineum
Contusions, hematomas, lacerations, urethral blood Sphincter tone , high riding prostate pelvic fracture, rectal wall integrity, blood Blood lacerations

Rectum

Vagina Pitfalls
Urethral injury in women, pregnancy

Ekstremitas / anggota gerak

Inspeksi

deformitas, robekan, memar, laserasi

Palpasi Palpasi nadi arteria distal Ingat compartment syndrome Jangan lupa periksa punggung Log-roll

Log-roll
Cari luka, robekan, memar, nyeri tekan, deformitas tulang belakang 4 orang

Pemberi komando instruksi yang jelas

Digulingkan serentak pelan-pelan

Foto sinar-x

Dikerjakan waktu survei sekunder Dada Tulang leher - 7 segmen vertebra Pelvis / panggul Lokasi lain sesuai indikasi
(misal fr tulang paha dll)

Secondary Survey
Musculoskeletal : Extreminities Contusion , deformity Pain Perfusion Peripheral neurovascular status X- rays as needed

Definitive Care
Local Facility ?? Transfer agreements ?? Local resources ?? ??

Trauma Center

Specialty Facility

Reevaluate
Proceed to Secondary Survey After :

Primary survey completed ABCD Es are reassessed Vital functions are returning to normal

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