Managemen bencana & P3K pada kecelakaan kegawatdaruratan sehari2

dr. Moch Junaidy Heriyanto, SpB, FINACS

 Earthquakes War

Explosions
Industrial accidents such as those occurring in

mining
Road traffic accidents

TOTAL CARE
Pencegahan Trauma
Pra- Rumah Sakit

Sewaktu di UGD
Sewaktu di kamar bedah Sewaktu perawatan

Pra-Rumah Sakit
Response time
Pemilihan cairan resusitasi Selective hypotensive resuscitation

Mencegah hipothermi

Di Rumah Sakit
Triase & response time Penanganan segera koagulopati, hipotermia & asidosis Transfusi komponen darah berdasar indikasi Damage control surgery Damage control resuscitation (Hematologic resuscitation) non-operative management cedera organ solid (NOM) perawatan ICU

MENGAPA TRAUMA PENTING DAN HARUS DITANGANI SEBAIK MUNGKIN

TRAUMA-1
Penyebab kematian nomor satu di AS untuk
golongan usia 1-44 tahun

Selama periode 1999 s/d 2003, tercatat

sebagai penyebab utama kematian untuk usia

< 65 tahun, melebihi kematian akibat kanker

dan penyakit jantung-serebral

TRAUMA-2
Pada trauma, penyebab kematian segera
(early death) adalah syok hipovolemik atau

cedera otak berat

Pada trauma berat, timbul iskemia di seluruh

tubuh, dan kemudian setelah resusitasi dapat

terjadi cedera reperfusi, berupa reaksi

inflamasi berlebihan diluar kendali badan

KEMATIAN SETELAH DIRAWAT

Umumnya disebabkan infeksi nosokomial,

sepsis dan MODS/MOF

Penyebab kematian lain adalah cedera otak

sekunder karena hipoksia serebri (hipotensi

berlarut, sepsis intra abdominal)

TRIAD
OF

DEATH

Moore EE Am J Surg, 1996, 172;405

Identifikasi
Riwayat Perjalanan Penyakit Presentasi Klinis Riwayat penyakit dahulu Pola presentasi penyakit
Survei Primer Survei Sekunder +Pencitraan

Anamnesis

Survei Primer
A = Airway B = Breathing C = Circulation D = Disability
Cepat Mengancam Jiwa

Survei Sekunder
Setelah Survei Primer selesai Kajian cepat : Tingkat kesadaran, fungsi saraf kranial, fungsi motorik, fungsi sensorik, refleks. defisit neurologis fokal ???

Pengambilan Keputusan
Surgery atau Konservatif ? Cito atau Elektif ?

Survei Primer + Sekunder + Pencitraan

AKTIFKAN SISTEM EMS

(Emergency Medical Service)

Atau bantuan tenaga medis lain

Call For Help

( Acute Care + Traumatology + Intensive Care) Three peaks of trauma related deaths
First peak Laceration of brain brainstem aorta spinal cord heart Third peak Sepsis Multi organ failure Secondary Brain Injury

DEATHS

Second peak Extradural Subdural Hemopneumothorax Pelvic fractures Long bone fractures Abdominal injuries

1 hour

3 hours

Laki laki, 25 thn, datang ke IRD keluhan nyeri perut akibat terkena benturan sepeda motor. 4 jam SMRS saat penderita mengendarai motor mengalami tabrakan dengan pengendara motor lain, roda depan motor penabrak membentur perut penderita.

Survey Primer :
A : baik B : RR : 24x/menit C : N : 120 x/mnt D : GCS : 15 TD : 80/50 mmHg

Penilaian kondisi pasien??

Initial management ??

pada pasien ini dilakukan : Infus RL 3000 cc NGT Catheter

pasca resusitasi : N : 92 x/mnt TD : 100/70 mmHg

apakah resusitasi yang dilakukan sudah tepat?

Survey sekunder :
Regio abdomen : I : tampak jejas berupa hematom di epigastrium

P: NT (+), NL (-), DM(-)

P : Tympani A : BU (+)

RT : TSA baik, mukosa licin, Nyeri (-) sarung tangan; feses (+), darah (-)

General Principles of vascular trauma/injury

Always start with ABC Large IV pore lines External compression to control bleeding Look for hard signs of arterial injuries

Review Of Circulation
Cells need supply of nutrients and removal of by products In a unicellular organism this may occur via the cell membrane into say a pond or sea Multicellular organisms need a circulatory system

Prolonged & severe skeletal muscle ischemia

release: Myoglobin (nephrotoxic) Potassium (arrhythmia)

Acute interruption of extremity blood flow can lead to organ failure and death

if not recognized and treated aggressively

DELAY : increase the risk of irreversible ischemic

injury, organ failure, and death

EARLY RECOGNITION AND TREATMENT

GOAL: reperfusion of the ischemic limb within 6 hour or less

Effects Of Acute Ischemia

Reduced blood flow Pulseless, pallor, perishing cold Nerve ischemia Pain, paralysis, Paresthesia Muscle ischemia Rhabdomyolysis Compartment syndrome Ischemia reperfusion syndrome

Hard sign
Pulsatile bleeding Expanding hematoma Palpable thrill Audible bruit Evidence of regional ischemia:
Pallor Paresthesia Paralysis Pain Pulselessness Poikilothermia

Is this Arterial or Venous injury ?

Pulsetile ext. bleeding Arterial - Pulse examination - Hard signs Absent distal pulses. Expanding hematoma Distal ischemia Thrill or bruit

Is this Arterial or Venous injury ?

Venous - Low pressure dark blood external bleeding - Non-expanding hematoma - Shock is rare unless associated with arterial injury

Vascular trauma
the clock starts ticking
Blood loss Progressive ischemia Compartment syndrome Tissue necrosis

Irreversible damage after 6 hours

Arterial injuries associated with fractures or dislocations

Clavicle fracture Shoulder fx/dislocation Supracondylar humerus fx Elbow dislocation Pelvic fracture Femoral shaft fx subclavian artery axillary artery brachial artery brachial artery gluteal arteries femoral artery

Distal femur fracture

Knee dislocation Tibial shaft fx

popliteal artery
popliteal artery tibial arteries

Physical exam
Major hemorrhage/hypotension Arterial bleeding

Expanding hematoma
Altered distal pulses Pallor Temperature differential between extremities Injury to anatomically-related nerve

 Asymmetric pulses warrant doppler examination (determine ABI)

Absent pulses warrant emergent vascular

consultation/surgical exploration

Damage control
Arteries that can be ligated with few

consequences:
The common and external carotid, subclavian, axillary , internal iliac arteries & Celiac axis. ICA ligation : 10-20% stroke rate. EIA,CFA & SFA: high risk of limb ischemia.

SMA & IMA : gut necrosis

Damage control

Almost all veins including the IVC can be

ligated when necessary

 Shock :
A state of inadequate tissue perfusion in which the delivery of oxygen to tissues and cells is insufficient to maintain normal aerobic

metabolism.
an imbalance between substrate delivery (supply)

and substrate requirements (demand) at the

cellular level.

Classification of shock based on etiology :

Hypovolemic

Cardiogenic
Neurogenic Inflammatory (Septic) Obstructive Traumatic
Combination is possible

Blood loss

The Organs Responses

Microvascular & inflammatory organ responses System Immune response

cellular
metabolic response

Neuro-endocrine
Cardiovascular Pulmonary Renal

Vicious Cycle of Hemorrhagic Shock

Endothelial Activation Microcirculatory damage

Cellular aggregation

Assessment of the Class class of I II 70 kg III patient) IV shock (ATLSa

Blood loss (ml) % blood volume Pulse Rate Blood Pressure Pulse Pressure Respiratory rate up to 750 up to 15% < 100 >100 normal n/ 14-20 normal decreased 20-30 20-30 750-1500 1500-2000 15%-30% 30%-40% >120 >2000 > 40% > 140 decreased decreased 30-40 5-15 depr, conf. lethargic decreased decreased >35 negligible

Urine Output(cc/hr) >30 Mental status

mild depr. depressed

Fluid resusc.

Crystalloid

Crystalloid

Blood +

Blood +

 Aims : to control the source of bleeding as soon as possible and to replace fluid loss Pre hospital care :
Evacuation time < 1 hour (usually urban trauma),

Principles of Medical Care

immediate evacuation to a surgical facility (after airway and breathing (A, B) have been secured ("scoop and run"). Evacuation time > 1 hour, an intravenous line is introduced

and fluid treatment is started before evacuation.

Fluid replacement strategy

In controlled hemorrhagic shock (CHS), where the source of
bleeding has been occluded, fluid replacement is aimed toward normalization of hemodynamic parameters. In uncontrolled hemorrhagic shock (UCHS), in which the bleeding has temporarily stopped because of hypotension,

vasoconstriction, and clot formation, fluid treatment is aimed

at restoration of radial pulse or restoration of sensorium or obtaining a blood pressure of 80 mm Hg by aliquots of 250 mL of lactated Ringer's solution (hypotensive resuscitation).

How to prevent mortality from hemorrhagic shock ?

1. Prevent early mortality with focus on resuscitation for hypovolaemia. 2. Prevent secondary brain injury 3. Prevent late mortality after trauma care with the emphasize on efforts to immuno-

modulate inflammatory reactions.

Tissue hypoperfusion Algorithm in Trauma

Harbrecht BG, Forsythe RM & Peitzman AB in TRAUMA Mattox. 2008

Tissue hypoperfusion Algorithm in Trauma

Harbrecht BG, Forsythe RM & Peitzman AB in TRAUMA Mattox. 2008

Algorithm of Blood Transfusion

Trauma, Edisi VI (Felociano DV, Mattox KL, Moore, EE., tahun 2008)

CONVENTIONAL TRAUMA LAPAROROTOMY FOR ESSENTIAL PARTS

1. 2. 3. 4. Control of Bleeding Identification of Injury Control of Contamination Reconstruction

Indications for

Damage Control Surgery

Need to rapidly terminate the laparotomy (bail out) in exanguinating hypothermic, acidotic and coagulopathic patient who is about to die on operating table Inability to control bleeding Inability to formally close the abdomen without tension needs temporary abdominal closure Consider the spillage control

WHO IS AN UNSTABLE PATIENT ?

Hemodynamic Lability
Acidotic

Hypothermic
Coagulopathic
The goal of damage control is to restore normal physiology rather than normal anatomy.

Sequence in Damage Control

Damage Control part I
Initial Laparotomy

Damage Control part II

Secondary Resuscitation

Damage Control part III

Definitive Surgery

The Lethal Triad

Severe Trauma Prolonged hypotension Metabolic Acidosis

DEATH

Coagulopathy

Hypothermia

Terima kasih