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kuliah manajemen bencana dan p3k blok kegawatdaruraan fk uii
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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 penyakitAnamnesis
Survei Primer
Survei Sekunder +Pencitraan
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
Call For Help
AKTIFKAN SISTEM EMS
(Emergency Medical Service)
Atau bantuan tenaga medis lain
( Acute Care + Traumatology + Intensive Care)Three peaks of trauma related deaths
4 weeks4 weeks
2 weeks2 weeks
1 hour 3 hours1 hour 3 hours
First peakLaceration of brainbrainstemaorta spinal cordheart
Second peakExtraduralSubduralHemopneumothoraxPelvic fracturesLong bone fracturesAbdominal injuries
Third peakSepsisMulti organ failureSecondary Brain Injury
DEA
THS
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 TD : 80/50 mmHg
D: GCS : 15
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 ?
Arterial
- Pulse examination
- Hard signs
Pulsetile ext. bleeding
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 subclavian artery
Shoulder fx/dislocation axillary artery
Supracondylar humerus fx brachial artery
Elbow dislocation brachial artery
Pelvic fracture gluteal arteries
Femoral shaft fx femoral artery
Distal femur fracture popliteal artery
Knee dislocation popliteal artery
Tibial shaft fx 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 Combination is possibleis possible
The Organs ResponsesBlood loss
MicrovascularSystem Immune
& inflammatory organ response
responses
cellular Neuro-endocrine
metabolic Cardiovascular
response Pulmonary
Renal
Vicious Cycle of Hemorrhagic Shock
Endothelial ActivationMicrocirculatory damage
Cellular aggregation
Assessment of the class of shock (ATLS- a 70 kg
patient) Class
I II III IV
Blood loss (ml) up to 750 750-1500 1500-2000 >2000
% blood volume up to 15% 15%-30% 30%-40% > 40%
Pulse Rate < 100 >100 >120 > 140
Blood Pressure normal normal decreased decreased
Pulse Pressure n / decreased decreased decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine Output(cc/hr) >30 20-30 5-15 negligible
Mental status mild depr. depressed depr, conf. lethargic
Fluid resusc. Crystalloid Crystalloid Blood + Blood +
Crystalloid Crystalloid
Principles of Medical Care
• 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), 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. Control of Bleeding
2. Identification of Injury
3. Control of Contamination
4. 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 TriadSevere Trauma Prolonged
hypotension
Metabolic AcidosisMetabolic Acidosis
CoagulopathyCoagulopathy HypothermiaHypothermia
DEATHDEATH
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