REFLEKSI KASUS

ABDOMINAL BLUNT TRAUMA +

HYPOVOLEMIC SHOCK E.C
INTERNAL BLEEDING
Achmad Aidil Tazakka
Anindyta Audie Dhea A.
Nadila Lupita Puteri

Lecturer: dr. Syaiful Mukhtar Sp. B (K)BD

PATIENT IDENTITY
Name : Mr. SW
Age : 37 y. o
Occupation : Truck driver
Address : Jl. Ir. Sutami
HISTORY
Chief Complaint

Whole stomach ache

History of Present Illness

Patient admitted to AWS ER 1 hour after being crushed on his left

abdomen by a truck while he was laying down under that truck to fixing
the machine. At the moment, his friend accidentally drove the truck
without knowing the patient was still under the truck. After that, patient
felt so much pain in his whole stomach, but no sign of nausea,
vomiting and no external wound was seen. He was moaning and looks
so agitated. He was brought to ER at one of the private hospital by his
friends imidiately. There, the patient was given intravenous fluid and
other medications, and was refered to AWS Hospital to get CT scan.
 The action that given in D Hospital
a. IVFD RL 2000 cc
b. Ketolorac inj 1 amp/ IV
c. Tranexamate acid 2 amp/ IV
d. Ranitidin 1 amp/ IV
PRIMARY SURVEY
Airway Clear
RR: 40x/min NRM 11 lpm
Breathing
Symetrical breathing, deviation (-)
HR: 123x/min reguler, slightly weak pulse
Circulation BP: 70/50 mmHg
Sat: 95%
GCS: E4 V5 M6
Disability Pupil: isokor (3mm/3mm)
Pupillary reflex: (+/+)

Exposure External wound (-)

 SECONDARY SURVEY
Normochepalic, anemic (+/+), icteric (-/-),
Head
sianotic (-/-)
Neck Lymphadenopathy (-)

Heart:
Inspection = Apex beat (+)
Palpation = Apex beat (+) 1 fingerbreadth middle
to left midclavicluar line (ICS V)
Percussion = Within normal range
Auscultation = S1S2 regular, mumur (-), gallop (-)
Thorax Lung:
Inspection = Chest wall movement equal and
adequate
Palpation = Chest wall movement equal D=S
Percussion = Sonor
Auscultation = Ves (+/+), rho (-/-), Whe (-/-)
Abdomen Look for Local Status
Clammy (+), Deformity (-),
Extremity
Edema (-), CRT > 2
Inspection: Distended (+), bruises
Local (-)
Status: Auscultation: bowel sound (+)
Abdominal
Percussion: dullness (+)
Region
Palpation: mucular defans (+)
FAST US at AWS Hospital
X-RAY
LABORATORIES
FULL BLOOD COUNT BLOOD GAS ANALYSIS

WBC : 11.000
Hb : 8.0
HCT : 23.5
PLT : 219.000
pH : 7.408
Na : 138
K : 3.6 pCO2 : 27.8 mmHg
Cl : 113 pO2 : 172.1 mmHg
GDS : 261
HCO3- : 17.7 mmol/L
Ureum : 33.8
Creatinin : 1.4
HbsAg : -
112 : -
Working Diagnosis

Abdominal blunt trauma+ Hypovolemic shock gr. III

e. c. Internal bleeding

Planning

O2 NRM 11 lpm
PRC transfusion 5 packs
Urine catheterization
NGT
Ketorolac inj 1 amp
Emergency laparatomy exploration
Did something went wrong?
The management of hypovolemic shock
The procedure of finding the cause of hypovolemic shock
was not according to the guideline
The patient was still unstable during the refering process
ABDOMINAL TRAUMA
MANAGEMENT
 INITIAL ASSESSMENT
Whether the patient is haemodynamically

stable unstable
FIRST PRIORITIES PROTOCOL :
Brief clinical examination to evaluate ABC along with
cardiovascular status with blood pressure and pulse
measurement.
Accordingly, resuscitation and management of shock by
- maintenance of ABC
- IV fluids
- nasogastric tube insertion
- Catheterization
PRIMARY SURVEY
Airway assessment
Ensure cervical spine immobilization
Clear mouth and airway if obvious foreign bodies
Jaw trust and chin lift, if required
If Glasgow Coma Score 8, consider a definitive airway
 Breathing and ventilation
Give 100 per cent oxygen at high flow
Inspect/percuss and auscultate chest
Check for tension pneumothorax and immediately decompress if
suspected
 Circulation
Check pulse and blood pressure
Secure two large-bore cannulae, take bloods and
Commence fluid resuscitation
Examine for evidence of blood loss and treat accordingly
 Disability
The neurological status of the patient should be rapidly assessed.
The pupils are monitored for size and reactivity, and a GCS
measured.
Exposure
The patient must be fully exposed and examined front and back
using a carefully controlled log roll.
 Adjuncts to the primary survey
Blood tests full blood count, urea and electrolytes, clotting
screen, glucose, toxicology, cross-match
ECG, pulse oximetry, arterial blood gas (ABG)
Two wide-bore cannulae for intravenous fluids
Urinary and gastric catheters
Imaging
 TABLE
Diagnostic Modalities in Abdominal Trauma
PERITONEAL ULTRASOUND CT SCAN
LAVAGE
Use Records intra- Reveals intra- Reveals organ of injury
abdominal abdominal and extent of
haemorrhage in haemorrhage in blunt/penetrating
stable/unstable stable and unstable abdominal trauma in
trauma in patients stable patients
Contra- Urgent demand for Urgent demand for Need for emergency
indications laparotomy laparotomy laparotomy in an
Prior abdominal Obesity and unstable patient
surgery subcutaneous Unco-operative
Pregnancy and emphysema patients
obesity Allergy to contrast
material
Drawback Unreliable in Failes to show small Unreliable in detection
retroperitoneal and amount of fluid of rupture of bowel and
diaphragmatic diaphragmatic injuries
trauma Time consuming
High cost
 Secondary Survey
The secondary survey does not begin until after the
primary survey has been completed
The purpose of the secondary survey is to identify all other injuries
and perform a more thorough head to toe examination.
Re-evaluation
This cannot be stressed enough. It is an integral process in the initial
assessment of major trauma and should not stop once the patient
leaves the emergency room. Continuous monitoring is invaluable
here, especially of the vital signs and urinary output.
 BLUNT ABDOMINAL TRAUMA GUIDELINE
 All blunt trauma patients with unstable hemodynamic,
must be consider there is an internal bleeding or GI tract
contamination with DPL or FAST
Patients with stable hemodynamic can be evaluated by
CT scan. And the decision of operation based on affected
organ and trauma severity.
SHOCK
Shock, at its most rudimentary definition and regardless of
the etiology, is the failure to meet the metabolic needs of
the cell and the consequences that ensue.
 Classification of Shock
Hypovolemic
Cardiogenic
Septic (vasogenic)
Neurogenic
Traumatic
Obstructive
Hypovolemic/Hemorrhagic Shock
The most common type
Loss of circulating blood volume. This may result from
loss of whole blood (hemorrhagic shock) or non
hemorrhagic shock.
The clinical signs of shock may be evidenced by agitation,
cool clammy extremities, tachycardia, weak or absent
peripheral pulses, and hypotension.
Management of Hemorrhagic Shock
The appropriate priorities are airway and breathing,
circulation, disability, exposure, decompression,
catheterization.
Two IV lines needed for infusing big amount of fluids fast.
The amount of fluid needed can be measured by grade of
the shock.

Fluids Class I Class II Class III Class IV

Cristaloid Cristaloid Cristaloid Cristaloid
and blood and blood
Respond Evaluation
Its important to examined the patients respond by the
clinical examination, such as urine output ,
consciousness, and peripherial perfusions.
Fast Respond Transient No Respond
Respond
Vital Signs Back to normal Back to normal Still abnormal
temporary
Pulse and
tension
decreasing
Loss of blood Minimal (10 % - Mild ( 20 % - 40 Severe (> 40 %)
20 5) %)
Crystaloid Minimal Lot Lot
needed
Blood needed Few Lot Immediately
Operation Maybe High probability Almost always
Blood Spesific and Spesific type Emergency
Transfusion crossmatch
Did something went wrong?
The procedure of finding the cause of hypovolemic shock
was not according to the guideline
In this case, the patients BP < 90 mmHg and it means this patient
is unstable patient, finding the cause of the shock in an unstable
patient is using FAST procedure not CT scan.
The patient was still unstable during the referring process
The hemodinamic of patient should be stable before being
transferred to another hospital
 The management of hypovolemic shock
When the patient arrives, there was no NRM on him
There was just one IV line instead of two
There was no catheter to evaluate the urine output
There was no NGT attached
There was no effort to do blood transfussion, the patient just got
crystaloid.
Why this patient had to referred to AWS hospital from the D
hospital ?
THANK YOU
HAPPY BIRTHDAY
OUR BELOVED TEACHER
dr. Syaiful Mukhtar, Sp.B KBD

May Allah always bless you with happiness : )