Initial Assessment and

Management of the Trauma

Patient

Hfastedge, Wikimedia Commons

Tujuan
Mekanisme cedera
Manajemen trauma dasar

Survei primer
Resusitasi
Survei sekunder
Format ABCDE
Imobilisasi c-spin

Manajemen luka dan fraktur

 5.8 million deaths/year

10% of worlds deaths
32% more deaths than HIV, TB
and
Malaria combined

Source: Global Burden of Disease, WHO, 2004

Injury: Scale of the Global

Problem

Epidemiology
Trimodal Distribution of Trauma Deaths
Golden Hour = 80% of trauma
deaths in first hour after injury
Rapid trauma care has greatest
level of impact in these patients

50%

30%
20%

Immediately

Hours

Days/Weeks
4

Mekanisme Cedera
Trauma Tumpul
Compression Forces
Cells in tissues are compressed and crushed
E.g. Spleen

Shear Forces
Acceleration/Deceleration Injury
E.g. Aorta
Shearing force = Spectrum from Full thickness tear
(Exsanguination) to Partial tear (Pseudoaneurysm)

Overpressure
Body cavity compressed at a rate faster than the
tissue around it, resulting in rupture of the closed
space
E.g. Plastic bag
E.g. in trauma = diaphragmatic rupture, bladder
injury
5

Dasar Penilaian Trauma

Persiapan
Pembentukan tim
Pengecekan alat
APD (kacamata, sarung tangan, apron, masker, topi, sepatu boot)
Triage
Urutkan pasien berdasarkan tingkat kegawatdaruratan
Survei Primer
Untuk mengidentifikasi cedera yang mengancam jiwa dan
menatalaksananya
Resusitasi
Prosedur cepat dan pengobatan untuk menangani cedera yang
ditemukan pada survey primer
Survei Sekunder
Riwayat cedera dan pemeriksaan fisik untuk mengevaluasi
cedera lain
Monitoring dan Evaluasi, Secondary adjuncts
Rujukan ke Trauma Center
6

Survei Primer

Airway and Protection of Spinal Cord

Breathing and Ventilation
Circulation and Control Hemorrage
Disability
Exposure and Control of the Environment
7

Survei Primer
Prinsip
Ketika menemukan masalah
selama survei primer, SEGERA
TANGANI!
Jika pasien memburuk, ulangi
survey primer dari awal

Airway dan Proteksi Medulla

Spinalis

Kenapa ini yang pertama?

Kehilangan jalan nafas dapat menyebabkan kematian

dalam <3 menit
Prolonged hypoxia = perfusi inadekuat, kerusakan organ

Penilaian Airway

Tanda vital = RR, O2 sat

Status mental = Agitasi, Somnolen, Koma
Patensi jalan nafas= Sekresi, Stridor, Obstruksi
Cedera di atas klaivikula
Status ventilasi = Otot bantu nafas, retraksi, wheezing

Tanda Klinis

Pasien yang mampu bicara normal tidak memiliki

gangguan jalan nafas
Suara serak mungkin mengindikasikan cedera trakea atau
laring
Pernapasan yang cepat mengindikasikan suatu obstruksi
pernapasan
9

Intervensi Jalan
Nafas
Menjaga patensi jalan nafas

Suction
Chin Lift/Jaw thrust
Nasopharyngeal Airway
Definitive Airway

Dept. of the Army, Wikimedia Commons

Airway Support

Oksigen
NRBM (100%)
Bag Valve Mask
Definitive Airway

Ignis, Wikimedia Commons

Definitive Airway

Intubasi endotrakeal
Krikotiroidektomi
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons

10

Proteksi Medulla Spinalis

Prinsip umum : melindungi seluruh tulang belakang
sampai dengan cedera tersingkirkan dengan
pemeriksaan radiografi atau tanda klinis
pemeriksaan fisik
Proteksi C-Spinal
Cervical collar
Penting:
Penatalaksanaan (Imobilisasi) sebelum diagnosis
Mengembalikan kepala ke posisi netral
Jangan lakukan traksi
Diagnosis trauma medulla spinalis seharusnya
tidak mendahului resusitasi
Kecelakaan motor dan jatuh paling memungkinkan
berhubungan dengan trauma medulla spinalis.
Fokus Utama = Pencegahan cedera lebih lanjut 11

Immobilisasi C-Spine
Mengembalikan kepala ke posisi netral
position
Pertahankan in-line stabilization
Aplikasikan cervical collar dengan ukuran
yang benar
Perekat

Paladinsf (flickr)
James Heilman, MD, Wikimedia Commons

12

Breathing dan
Ventilasi

Prinsip umum : pertukaran gas yang adekuat dibutuhkan

untuk memaksimalkan oksigenisasi
Penilaian Pernafasan dan ventilasi: LOOK, LISTEN, FEEL
Inspeksi
Deviasi trakea
Otot bantu nafas
Retraksi
Kehilangan nafas spontan
Pergerakan dinding dada yang tidak seimbang
Auskultasi
Equal Bilateral
Suara nafas menurun/menghilang
Palpasi
Deviasi trakea
Fraktur kosta
Cedera dinding dada
13

 Identifikasi Cedera yang

mengancam jiwa :
Tension Pneumothoraks
Pemeriksaan fisik
Suara nafas mengilang
Distensi vena leher
Deviasi trakea
Delldot (wikimedia)

Penatalaksanaan
Needle Decompression
2nd Intercostal space,
Midclavicular line
Tube Thoracostomy
5th Intercostal space, Anterior
axillary line

Author unknown,
www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.ht
m

14

 Hemothoraks
Sumber perdarahan = paruparu,
dinding dada, jantung, aorta,
diafragma
Pemeriksaan Fisik
Suara nafas menghilang/menurun
Perkusi pekak
Hemodinamik tidak stabil

Penatalaksanaan = Large Caliber Tube

Thoracostomy
Author unknown,
http://www.trauma.org/index.php/mai
n/images/C11/

15

 Flail Chest
Fraktur costae
Pemeriksaan fisik = pergerakan dinding
dada tidak simetris
Penatalaksanaan = improve
abnormalities in gas exchange

http://images1.clinicaltools.com/images/trauma
/flail_chest_wounded.gif

Early intubation for patients with

respiratory distress
Avoidance of overaggressive fluid
resuscitation

Author unknown,
http://www.surgical-tutor.org.uk/default-home.htm?
specialities/cardiothoracic/chest_trauma.htm~right

16

 Open Pneumothoraks

Author unknown,
http://www.trauma.org/index.php/main/image/
902/

Sucking Chest Wound

Defek dinding dada
Penatalaksanaan
Plester 3 posisi

Middle and bottom images:

Author unknown,
http://www.brooksidepress.org/Products/Op
erationalMedicine/DATA/operationalmed/Pro
cedures/TreataSuckingChestWound.htm

17

Needle Thoracostomy
Needle
Thoracostomy
Garis midclavicula
14 gauge angiocath
Sela iga kedua
Author unknown,
www.trauma.org/index.php/main/article
/199/index.php?main/image/95/

18

Tube Thoracostomy
Insertion site

5th intercostal space,

Anterior axillary line

Sterile prep, anesthesia with lidocaine

2-3 cm incision along rib margin with #10 blade
Dissect through subcutaneous tissues to rib
margin
Puncture the pleura over the rib
Advance chest tube with clamp and direct
posteriorly and apically
Observe for fogging of chest tube, blood output
Suture the tube in place
Complications of Chest Tube Placement

Author unknown,

http://www.trauma.org/images/image_libr
ary/chest0051a.jpg

Injury to intercostal nerve, artery, vein

Injury to lung
Injury to mediastinum
Infection
Allergic reaction to lidocaine
Inappropriate placement of chest tube

19

Circulation dan Kontrol

Perdarahan
Tanda Klinis Syok
Perubahan status mental
Takikardi (HR > 100)
Arterial Hypotension (SBP < 120)
Femoral Pulse SBP > 80
Radial Pulse SBP > 90
Carotid Pulse SBP > 60
Perfusi jaringan inadekuat
Pucat
Kulit dingin
CRT >2 detik
Urin output << (UOP < 0.5 mL/kg/hr)
20

 Tipe syok pada trauma:

Hemoragik
Obstruktif

Cardiac Tamponade
Tension Pneumothorax

Neurogenik

Spinal Cord injury

Sumber perdarahan

Thoraks
Abdomen
Pelvis
Fraktur Femur Bilateral

21

 Penatalaksaan Perawatan Emergensi

Pasang 2 IV Line
Monitor nadi dan TD
Prinsip Penatalaksanaan Umum
Hentikan Perdarahan
Tekan langsung
Tutup luka sementara
Close open-book pelvic fractures
Abdominal pelvic binder/bed sheet
Perbaiki volume sirkulasi
Kristaloid 2L
Immobilisasi fraktur (Bidai)
Responders vs. Nonresponders
Respon sementara = ongoing blood loss
Tidak respon = consider other source for shock
state or operating room for control of massive
hemorrhage

22

 Tamponade Jantung
Becks Triad
Pericardium
Blood

Distensi vena jugularis

Hipotensi
Suara jantung menjauh

t
ar
He

Penatalaksanaan
Pericardiocentesis
Open thoracotomy

Epicardium

Aceofhearts1968(Wikimedia)

23

Pericardiocentesis
Puncture the skin 1-2 cm inferior to xiphoid
process
45/45/45 degree angle
Advance needle to tip of left scapula
Withdraw on needle during advance of
needle
Preferable under ultrasound guidance or EKG
lead V attachment
Complications
Author unknown,
http://www.trauma.org/images/image_library/ch
est0054_thumb.jpg

Aspiration of ventricular blood

Laceration of coronary arteries, veins,
epicardium/myocardium
Cardiac arrhythmia
Pneumothorax
Puncture of esophagus
Puncture of peritoneum

Author unknown,
www.brooksidepress.org/ProductsTrauma_Surgery?M=A

24

Disability
Pemeriksaan neurologis
Pemeriksaan pupil
Dilatasi pupil -> herniasi otak
Skala AVPU
Alert
Responds to verbal stimulation
Responds to pain
Unresponsive
Glasgow Coma Scale: 3-15

25

 Glasgow Coma Scale

Eye
Spontaneously opens 4
To verbal command
3
To pain 2
No response 1
Best Motor Response
Obeys verbal commands 6
Localizes to pain 5
Withdraws from pain 4
Flexion to pain (Decorticate Posturing)
3
Extension to pain (Decerebrate Posturing)
No response 1
Verbal Response
Oriented/Conversant 5
Disoriented/Confused 4
Inappropriate words 3
Incomprehensible words 2
No response 1

GCS 8
Intubate

26

Disability
Prinsip
Pencegahan cedera lebih lanjut dan
identifikasi cedera neurologis
Penurunan kesadaran = Trauma kepala
sampai terbukti
Menjaga perfusi cerebral untuk mencegah
cedera kepala lebih lanjut
Adequate oxygenation
Avoid hypotension

27

Exposure
Lepas semua pakaian
Periksa tanda cedera lain

Logroll the pasien untuk memeriksa

bagian belakang pasien
Minimal 3 orang

Cegah hipotermi
Selimuti pasien
Hipotermia = Koagulopati
Meningkatkan risiko hemoragik

28

Exposure

Author unknown,
http://www.trauma.org/index.php/main/image/98/C11
29

Exposure

Author unknown,
http://www.trauma.org/images/image_library/chest004
4b.jpg

30

Trauma Logroll
One person
= Cervical
spine
Two people =
Roll main
body
One person
= Inspect
back and
palpate spine

Cdang, Wikimedia Commons

31

Secondary Survey
Secondary Survey is completed after
primary survey is completed and
patient has been adequately
resuscitated.
No patient with abnormal vital signs
should proceed through a secondary
survey
Secondary Survey includes a brief
history and complete physical exam
32

History
AMPLE History

Allergies
Medications
Past Medical History, Pregnancy
Last Meal
Events surrounding injury, Environment

History may need to be gathered from

family members or ambulance service
33

Physical Exam
Head/HEENT
Neck
Chest
Abdomen
Pelvis
Genitourinary
Extremities
Neurologic
34

Physical Exam
Difficult airway

Source unknown

35

Physical Exam
Seatbelt sign

http://www.itim.nsw.gov.au/images/seat_belt_mark_2.jpg
Accessed 9/20/09 Google Image Search

36

Physical Exam
Battle Sign
Raccoon's Eyes
Cullens Sign

http://sfghed.ucsf.edu/Educatio
n/ClinicImages/Battle's
%20sign.jpg
Accessed 9/20/09 Yahoo
Images

http://healthpictures.com/eye/PeriorbitalEcchymosis.htm
Accessed 9/20/09 Yahoo Images

Grey-Turners Sign
H. L. Fred and H.A. van
Dijk (Wikimedia)

H. L. Fred and H.A. van Dijk

(Wikimedia)

37