I Nengah Kuning Atmadjaya

ASSESSMENT AND
RESUSCITATION IN
TRAUMA
MANAGEMENT.
I. N . KUNING ATMADJAYA.
BAG/SMF ILMU BEDAH FK UNUD/RSUP SANGLAH DENPASAR.
Mengapa penanganan trauma penting ?
 SYSTEM PENANGGULANGAN GAWAT
DARURAT TERPADU ( SPGDT ) • Emergency Nurse
(BTLS, BCLS, )
• Emergency physician
(BLS)
(ATLS, ACLS)
Layman • HOPE
• DOKTER SPESIALIS
(MFR, CSSR) (Paramedic , (ATLS, ACLS,BSS, DSTC, Peri
CSSR)
Police OPE CC, HOPE)
Fire Brigade 118
DISASTER MANAGEMENT
Security Guard Emergency
Civil Defense Ambulance ED 
Scouts Service
Red Cross OK
Access
Emergency ICU
Telephone Number
112,113,118 WARD
AMBULAT
OIR
PRE-HOSPITAL HOSPITAL
 Sistim kardiovaskuler

Jantung
Vena
Arteri
Preload kontraktilitas Afterload

Vasokonstriksi untuk
Ditunjukkan dengan mempertahankan tekanan
jumlah volume perfusi organ/ jaringan
intravaskuler
Kontraktilitas untuk
mempertahankan curah
jantung ( cardiac
Output )
 Ancaman

Rasa Takut Cedera/Trauma

Patofisiologi Trauma pada Tubuh Manusia
Nyeri

Luka ringan Luka berat/syok (-) Luka berat/syok (+)

Perdarahan Klas III/IV

Lokal Sistemik

Pro
Vasokonstriksi
InflamasiPro Anti Anti/Pro
-Kulit
Inflamasi InflamasiInflamasi Hipoksia
-Otot
-Hati/usus

SIRS CARS MARS Iskemi/nekrosis Iskemia

-Kulit ATP pH
-Otot
-Hati/usus
Sembuh Rad O2 Anergi Sembuh Transport Na+/K+ “Cell deformability”
Mediator Translok bakt
Pergeseran crn stasis
 sepsis
GOM Sepsis
Paru Resusitasi: Sel bengkak hemokonsentrasi mikrotrombosis
Ginjal GOM -operasi
Hati -hipotermi Hiposantin
Usus/
Perfusi kapiler
Translok
Bakteri –
Sepsis Reperfusi
Rad O2 leukosit
SIRS CARS Mediator Permiabilitas
MARS
Mikrokapilar
GOM Oksigen Edema interst.
-Hati/usus radikal mediator Tek. Jaringan
-Paru
Sembuh
-Ginjal
Asam urat
Peroksidasi lipid Hipoksia

Pusponegoro AD, 2004;

Menger et al, 1993 Reperfusi
Kerusakan jaringan
Common Pathway to Death
 Selalu mulai dengan Survai Primer
(mencari keadaan yang mengancam nyawa)

Konsep COT ACS.

A Airway dengan proteksi servikal
B Breathing dengan oksigenasi dan ventilasi
C Circulation dengan kontrol perdarahan
D Disability , keadaan neurologis
E Exposure dan kontrol hipotermi
Persiapan
Bagaimana menilai penderita dalam 10 detik ?
Ajak penderita berbicara !

Repon baik menunjukkan

A Airway baik
B Breathing baik
C Circulation mungkin baik
D Disability mungkin baik

Bila tidak ada respon : Primary survey

A Airway

Proteksi servikal
Assess :
• Look
• Listen
• Feel
A Airway with C-spine protection

• Jalan nafas dijaga manual

* Suction (cairan - gurgling)
* Chin lift – Jaw Thrust (snoring)
BLS
• Jalan nafas sementara
* Oropharingeal
* Nasopharyngeal

Bila tidak berhasil : Airway definitif ALS

A Airway with C-spine protection
Jalan nafas definitif

Nasotracheal

Orotracheal
• tanpa muscle relaxant
• dengan muscle relaxant

Krikotiroidotomi
 Breathing
B (dengan oksigenasi dan ventilasi)

Bila breathing terganggu :

Selalu
Oksigen Ventilasi
(11 LPM) (bila nafas tidak adekuat)
B Breathing : cari penyebab
Cedera toraks yang dengan cepat dapat
mengakibatkan kematian :

Open Tension Flail Chest Massive

Pneumotoraks Pneumotoraks dengan Hematotoraks
Kontusio Paru
B Breathing : Open Pneumothorax

Sesak karena bernafas liwat lubang toraks

Tutup : Open  Closed , lalu “WSD”
B Breathing : Open Pneumothorax

Atau : kasa 3 sisi, lalu “WSD”

B Breathing : Flail chest dengan
Kontusio paru

Bila ventilasi tidak adekuat : Assist

B Breathing : Massive Hematothorax

“WSD”, bila masif  torakotomi

C Circulation
Kontrol perdarahan
Assess : Gangguan Perfusi

•Akral dingin
•Tachycardia
•Gangguan kesadaran
•Tachypneu
•Hipotensi
•Oliguria/anuria
C Circulation

Kenali Syok : • akral dingin

• takikardi

Kontrol Perdarahan

Perbaikan volume
C Circulation : kontrol perdarahan Internal

• Toraks : torakotomi ?
• Abdomen : laparotomi ?
• Pelvis : PASG, Gurita, C-clamp ?
• Ekstremitas : Bidai
Paradigma shock

Shock

Hypoxic Cellular Priming

Reperfusion Injury Inflammation

Cellular Damage

Multiple Organ Failure

Death
Trauma Hemorrhage Hypoxia

Prime insult
Cellular ischemia
Resuscitation
Reperfusion injury

Vasoconstriction
Microcirculatory thrombosis
Primary perpetuators
Leukocyte/platelet/RBC aggregation

Microcirculatory flow maldistribution

Leukocyte-mediated cell injury Secondary perpetuators

Cytokine and other mediator
effects, locally and systemically

Gut translocation Tertiary perpetuators

Sepsis
Ischemia
ATP
Ischemia/Reperfusion Injury

AMP

Adenosine
Xanthine dehydrogenase

Inosine
Xanthine oxidase
Hypoxanthine Xanthine
SOD Catalase
O2 O2- H2O2 H2O
Fe++
OH

Reperfusion Tissue
Damage
“two hit” model of postinjury multiple organ failure

First Second
Hit Hit
Late
Primed
MOF
Splanchnic Systemic
IschemiaInflammatory
& Responseprimed
Not

Reperfusion Recovery
Cannot Early
resuscitate MOF
A, B, C, D & M.I.S.T :
“Primary Survey” / “Initial Assessment” :
ATLS  A & “Cervical Control”.
B & “Ventilation”.
C  Volume & “Stop Bleeding”,
D.
DSTC  M.I.S.T  “Triad Of Death” 
Hipotermi, Koagulopati, Asidosis Tdk Terkontrol !!!
“Damage Control”
“Bogota Bag”.
“ICU”  OK.
Elektif  Musibah A, B, C, D 
“Primary Survey” 
“Damage Control”  ICU  OK.
Key Issues : Shock Management
 Recognize inadequate organ perfusion
 Identify the cause
• Hemorrhagic vs nonhemorrhagic
 Treatment
• Stop the bleeding!
• Restore volume

© ACS 46
Cardiac Physiology

CO = SV x HR

Preload Contractility Afterload

Venous Vascular
dp / dt
Capacitance © ACS
Tone 47
Cellular Alteration in shock

© ACS 48
Recognition of Shock State
1. Tachycardia
2. Vasoconstriction
2.  Cardiac output
Narrow pulse pressure
3.  Map
3.  Blood Flow

Caution : Compensatory mechanisms

© ACS 49
Classification of Hemorrhage

 Class I-IV
 Not absolute
 Only a clinical guide
 Subsequent treatment determined by
patient response

© ACS 50
Class I Hemorrhage
750 mL BVL

© ACS 51
Class II Hemorrhage
750 – 1500 mL BVL

© ACS 52
Class III Hemorrhage
1500 – 2000 mL BVL

© ACS 53
Class IV Hemorrhage
≥ 2000 mL BVL

© ACS 54
C Circulation : perbaikan volume

Infuus : Guyur, RL yang dihangatkan

(jangan lupa ambil sampel darah)
C Circulation : kontrol perdarahan

Haemorrhage Control bila eksternal : direct pressure

Etiology of Shock
Hemorrhagic Nonhemorrhagic
 Most common  Tension

 Clinical pneumothorax
• H&P  Cardiogenic

• Selected  Neurogenic

diagnostic tests  Septic

© ACS 57
Hemorrhagic Shock
 Loss of circulating blood volume
 Normal blood volume
• Adult 7% of ideal weight
• Child: 9 % of ideal weight

© ACS 58
Assessment and Management

 Recognize shock
 Stop the bleeding !
 Replenish intravascular volume
 Restore organ perfusion

© ACS 59
Assessment and Management

 Airway and Breathing

• Oxygenate and ventilate
• PaO2 > 80 mm Hg (10.6 kPa)
 Circulation
• Assess
• Control
• Treat

© ACS 60
Assessment and Management
 Disability – cerebral perfusion
 Exposure / Environment
• Associated injuries
• Prevent hypothermia
 Gastric and bladder decompression
 Urinary output

© ACS 61
Management : Vascular Access

 2 large – caliber, peripheral IVs

 Central access
• Femoral
• Jugular
• Subclavian
 Intraosseous
 Obtain blood for crossmatch

© ACS 62
Management : Fluid Therapy

 Warmed crystalloid solution

 Rapid fluid bolus Ringer’s lactate
• Adult : 2 liters Ringer’s lactate
• Child : 20 ml /kg Ringer’s lactate
 Monitor response to initial therapy

© ACS 63
Reevaluate Organ perfusion
Monitor
 Vital signs

 CNS status

 Skin perfusion

 Urinary output

 Pulse oximetry

© ACS 64
Resuscitation Evaluation
Hourly Urinary Output
Inadequate output suggests
inadequate resuscitation

© ACS 65
D Disability
D Disability : pemeriksaan
neurologis

• Cedera kepala bisa mati cepat !

• Eye
• Verbal
• Motorik

1. Pupil 2. GCS 3. Tanda lat. lainnya

D Disability : pemeriksaan
neurologis

Resusitasi A-B-C dengan

cepat dan baik akan
memperbaiki prognosis
dengan nyata !
E Exposure
 PASIEN
initial assassment

AIRWAY BREATHING CIRCULATION

reevaluasi A B C

MATI KLINIK
EVALUASI CARDIAC RJP
DC
MEDIKAMENTOSA

MATI BIOLOGI
E Exposure and Environment Control

Buka : • Buka pakaian basah (hipotermi !)

• Lihat cedera lain yang
mengancam nyawa

Tutup : • Jangan sampai hipotermi

Boleh log roll bila ada indikasi

 Tambahan
Pada
Primary Survey
 Adjuncts to Primary Survey

Vital signs
ECG ABGs

PRIMARY SURVEY
Pulse
Urinary
oximeter
output
and CO2
Urinary / gastric catheters
unless contraindicated
 Adjuncts to Primary Survey

Diagnostic Tools
 Adjuncts to Primary Survey

Diagnostic Tools

● FAST
● DPL
Tambahan pada Primary Survey

Foley Catheter Gastric Tube

Ada kontra-indikasi ?
Tambahan pada Primary Survey : Monitor

• EKG
• Pulse Oxymeter
• Capnograph
What is the secondary survey?

The complete
history and
physical
examination
TERIMAKASIH