PENANGANAN AWAL TRAUMA

PENANGANAN AWAL

TRAUMA MULTIPEL

Dr.SUWARDI.SpB.SpBATUJUANMenerapkan konsep / prinsip-prinsip penilaian awal pada penderita cederaMenentukan prioritas penanganannyaMenangani penderita cedera secara benar

PENDAHULUANTrauma menyebabkan kematian pada dekade 4 terbanyak di negara berkembang3,8 juta kematian / tahun di seluruh dunia312 juta mengalami trauma 300 ribu penderita mengalami cacat yang permanenTrimodal Kematian Karena CederaPuncak kematian pertamaMeninggal dalam beberapa detik sampai menit - laserasi otak- cedera batang otak- cedera leher level tinggi- cedera jantung- cedera pembuluh darah besar

2. Puncak kematian keduaMeninggal dalam beberapa menit sampai beberapa jam- subdural/epidural hematom- hemo/pnemo thorax- ruptur lien dan atau ruptur lever- fraktur pelvis- multipel trauma dengan perdarahan3. Puncak kematian ketigaterjadi beberapa hari atau minggu setelah trauma- karena infeksi- kegagalan multi organ

seconds to minutes minutes to hours GOLDEN HOUR

several days or weeks

Trauma - the leading cause of death in the first four decades of life

Death from trauma has a trimodal distribution:withinKonsep Dasar TraumaPenilaian dan penanganan masalah yang timbul dari A B C D EPrioritas penanganan yang sifatnya mengancam nyawaPenegakan diagnosis tidak diutamakanWaktu adalah pentingHindari penanganan yang memperparah pasienKONSEPA: Jalan napas dengan proteksi tulang leherB: Perfusi dan OxygenasiC: Circulasi dan Stop perdarahanD: Status NeurologisE: Expose atau pertahankan suhu tubuh

Airway ManagementChin-lift ManeuverBasic Techniques132-11Airway Management: Basic Techniques Chin-lift ManeuverDescribe maneuver.

Airway ManagementJaw-thrust ManeuverBasic Techniques142-12Airway Management: Basic Techniques Jaw-thrust ManeuverDescribe maneuver.

Airway Management

Surgical airway Cricothyroidotomy NeedleDefinitive AirwaySurgical

152-20Airway Management: Definitive AirwayDescribe pictures.A. Airway / Jalan NapasCara menilai dengan ditanya :1. Bicara jelas : jalan napas baik2. Suara serak : - terjadi cedera laryng atau trauma inhalasi trachea - perlu intubasi atau kalau perlu cricothyroidostomy

3. Tidak ada respon / koma - Terjadi sumbatan* lidah : suara ngorok* aspirasi/cairan : suara spt kumur2* benda asing * cedera wajahPenanganan * Suction : kanul yang rigid* Chin lift / dagu diangkat* Jaw thruss / Rahang bawah dimajukan Evakuasi benda asing

Definitif airway : intubasi atau cricothyroidostomy

PERHATIAN :Proteksi tulang leher selama melakukan penanganan jalan napas / inline immobilitation18Proteksi leher diperlukan pada kasus . Multipel trauma . Cedera di atas klavikula . Pasien dengan gangguan kesadaran . Riwayat jatuh dari ketinggianB. Breathing / PernapasanCara menilai :Inspeksi Rata-rata pernapasan tiap menitSesak napas / retraksiGerak napas yang tidak simetrisJejas / lukaAuskultasi Suara napas menghilang: isi udara atau cairanSuara napas tidak sama / menurunPerkusi Suara sonor : normalSuara hipersonor : isi udaraSuara redup : isi cairanKemungkinan bisa disebabkanTension pneumothoraxPneumothorax simpleHaematothoraxCedera thorax secara langsung/kontusio paru

Penanganan :Bebaskan jalan napasOxygenasi 11 -12 l/m dengan maskerDecompresi dadaVentilasi mekanik bila perlu

Tension PneumothoraxDisstres napasShockDistensi vena jugulerSuara nafas tidak terdengarHiper sonorCyanosis (stadiumlanjut)234-9Tension PneumothoraxHow do I identify a tension pneumothorax? How do I differentiate a tension pneumothorax from cardiac tamponade and hemorrhagic shock?During the discussion of differentiating a tension pneumothorax from cardiac tamponade and hemorrhagic shock, relate that blunt injury is a more likely cause of tension pneumothorax. Cardiac tamponade occurs more often with penetrating trauma. If hypovolemia exists, the patients neck veins will not be distended.

Tension PneumothoraxDiagnosis secara klinis, bukan dengan rongentSegera lakukan dekompresi Needle Chest tube

244-10Tension PneumothoraxHow do I treat tension pneumothorax?The students should relate that the tension pneumothorax must be immediately decompressed by inserting a needle, followed by insertion of a chest tube. Students should understand that tension pneumothorax is a clinical diagnosis, not confirmed by x-ray. Avoid going into too much detail about the procedures for needle and tube decompression of the chest, but explain that the students have the opportunity to perform these procedures later in the day.

Photograph courtesy of Francisco De Salles Collet E. Silva, MD, FACS, Brazil.Open Pneumothorax

254-11Open PneumothoraxDescribe the pathophysiology of an open pneumothorax using the illustration on the slide to explain ineffective ventilation and the rationale and technique for partially occlusive dressing. Use the second slide in the series to emphasize definitive management. Open PneumothoraxTutup luka dg plester 3 sisiChest tubeOperasi

264-12Open Pneumothorax

Photograph courtesy of Francisco De Salles Collet E. Silva, MD, FACS, Brazil

Flail Chest and Kontusio Paru

274-13 Flail Chest and Pulmonary ContusionHow do I recognize if this patient has a flail chest and pulmonary contusion?This is the only slide addressing the clinical sequelae of flail chest and pulmonary contusion. Emphasize that the problem with the flail chest is related to the patients pain and is similar to rib fractures, although it is more severe because of the number of fractures. Further explain that the flail segment serves as a marker for pulmonary contusion, which is the real cause of the patients hypoxemia.

Photograph used with permission from Trauma.org; Fernando Rodriguez, chest 0021a; Mexico; http://www.trauma.org/imagebank/imagebank.html. Flail Chest and Kontusio Paru

OksigenasiKembangkan paruIntubasi bila perluHati-hati pemberian cairanAnalgesia284-14Flail Chest and Pulmonary ContusionHow do I treat the patient with a flail chest and/or pulmonary contusion?Emphasize that the treatment goal is to reexpand the lung, eg, with CPAP (positive pressure) or physiotherapy, and to avoid progressive atelectasis. Analgesia is an important adjunct, but oversedation will promote hypoventilation and atelectasis.

Hemothorax MasiveKerusakan pemb darah sistemik/paru> 1500 ccShock dengan suara nafas menghilang dan redup pada perkusi

294-15Massive HemothoraxWhat is the cause and how do I identify if the patient has a massive hemothorax?Note that this type of injury results in a B and C problem.

X-ray courtesy of Ray McGlone, Royal Lancaster Infirmary; UK

Hemothorax MasiveResusitasi cairanDekompresi dada dg pasang chest tube Operasi atas indikasi304-16Massive HemothoraxHow do I manage the patient with a massive hemothorax?During the discussion of treatment for a massive hemothorax, emphasize that resuscitation continues in accordance with the shock guidelines. Placement of a thoracostomy tube is essential to expand the lung, and the use of an autotransfusion device is helpful. Medical personnel need to be familiar with the use of the autotransfusion device before it is needed. Most of these devices do not require anticoagulation when the blood is collected. When blood loss continues despite thoracostomy tube drainage and resuscitative efforts are employed, operative intervention is needed.C. CirculasiPenilaian : Nadi : rata-rata, isi, keteraturanKulit pucat , dingin dan lembabNapas cepat dan dangkalKesadaran menurun dan gelisahHipotensiProduksi urine sedikitPenyebab syokPerdarahan/hipovolemiaNon perdarahan* tension pnemothorax* tamponade jantung* cardiogenik* neurogenik* septikPrinsip Penanganan Menghentikan perdarahan dengan - bebat tekan : luka terbuka- pasang pelvic sling : fraktur pelvis- pasang bidai : fraktur ekstremitas- operasi : ruptur lien/hepar, cedera pembuluh darah besar2. Mengembalikan Volume cairan :- Pasang infus 2 jalur (jarum kaliber besar)- Cairan RL yang dihangatkan- Digrojog- Periksa golongan darah dan crossmath- Cegah hipotermiCara Evaluasi Hasil / ResponTerjadi perbaikan fungsi organOtak: kesadaran meningkatGinjal : urine keluar meningkatKulit: hangatPernapasan : menurunNadi : menurunFungsi vital kembali normal

D. Disability : status neurologiPenilaian : 1. GCS - respon membuka mata - respon verbal - respon motorik 2. Pupil - reflek cahaya - diameter pupilE. Eksposure/enviromentPakaian dibuka : cari adanya perlukaan yang mengancam nyawaDiselimuti : cegah hipotermiTambahan survei primerPasang pipa lambungPasang kateterPasang EKGFoto : servikal lateral thoraks AP pelvisReevaluasi . selaluMATUR NUWUN