ALGORITMA DALAM PENANGANAN

TRAUMA

MENGAPA PENTING ?

APAKAH ALGORITMA ITU ? Algoritma adalah suatu bagan

memuat serangkaian keputusan medik sesuai kondisi spesifik pasien

Agar mencapai hasil pengobatan terbaik

“The goals” dari algoritma:Memilih alternatif diagnosisApa pengobatannyaHasil yang ingin dicapai dengan mempertimbangkan untung dan ruginya serta biaya.

ALGORITMA Algoritma dapat diterapkan

untuk “decision making” sesuai skenario yang ditemukan dalam klinik

“The primary advantage of an algorithm is that it can summarize an evidence-based guideline into an easily and quickly available practice protocol for use in the clinical care setting”.

• Peitzman AB, et al : j Trauma, 2000, 49; 187-189• Rajani RR et al : Surgery 2006; 140: 625-632• Nix JA et al : J Trauma, 2001, 50: 835-842• Mc Intyre et al : Surgical Decision ,aking, 5th ed, 2004

WESTERN TRAUMA ASSOCIATION CRITICAL DECISION IN TRAUMA -1

The WTA has played significant role in guiding the practice of trauma surgery based on sound scientific evidence through publications of its multicenter trials

Rozycki GS et al : BOAST, a pilat study from WTA multicenter group, J Trauma 2005, 59:: 1356-1364

Biffe W et al : A POS on anterior abdominal stab wounds, J Trauma, Inpress

Ad hoc committee of the WTA to oversee the development of these algoritms

The algorithms were presented to the WTA memberships at the 38th Annual Meeting (Feb 24- March 1. 2008)

Membership discussion resulted in further refinement before final submission to the journal

Each algorithm will be reviewed on a cycle of every 3 years by the steering committee, (the expert panel)

WESTERN TRAUMA ASSOCIATION CRITICAL DECISION IN TRAUMA -2

WESTERN TRAUMA ASSOCIATION

CRITICAL DECISION IN TRAUMA

“ MANAGEMENT OF PELVIC FRACTURE WITH

HEMODYNAMIC INSTABILITY”

J Trauma, 2008. 65; 1012-1015 November 2008

INTRODUCTION-1 Mortality 18% to 40% in reported series of

pelvic fracture pts with hemodynamic instable

Death within the first 24 hours of injury was most often of a result of acute blood loss

Smith W et al, J Ortho trauma, 2007. 21; 31-37

Significant decrease in mortality rates have been shown with adoption of algorithms for management of these injuries

Balogh 2 et al, J Trauma 2005. 58; 778-782 Biffe WL et al, Ann Surg 2001, 233: 843-850 Pahleman T et al: Clin Orthop Relat RS, 1994 : 69-80

Management should be by a multidisciplinary team

INTRODUCTION-2 The key issues : are identifying the site(s)

of hemorrhage and controlling the bleeding Three major sources of bleeding arterial,

venous and cancellous bone:23 of 27 autopsy cases: hypogastric

artery (1973 study)63% : bilateral61% : more than one bleeding site70% : arterial bleeding

Miller PR et al : J. Trauma, 2003, 54: 437-443

16% to 55% : concomitant intra-abdominal injuries

Ben-Menachem J et al : AJR Am J Rontgenal 1991, 157: 1005-1014 Cryer Hal et al: J Trauma, 1988, 28: 973-980 Murr Pe et al : J Trauma, 1988, 20: 919-923

ALGORITHM FOR MANAGEMENT OF PELVIC FRACTURE

WTA, J Trauma, 2008, 65 ; 1012-1015

INFORMATION FAST : Focussed Abdomen Sonogram for

Trauma DPA : Diagnostic Peritoneal Aspirate Hemodynamic Instability :

Hypotension, BP < 90 mmHg PRBC 4-6 units Base deficit < - 6 Or both

Stable pts: Fast on DPA : negative, or Stabilized with minimal resuscitation

BP > 100 mgHg Normalizing base deficit Decreased fluid requirementDavis JW et al : J trauma, 1998

“ BASE DEFICIT IS SUPERIOR TO PH IN EVALUATING

CLEARANCE OF ACIDOSIS AFTER TRAUMATIC SHOCK”

Davis JW, Kamps KL, Parks SN: J Trauma, 1998; 44: 114-118

WESTERN TRAUMA ASSOCIATION (WTA)

CRITICAL DECISIONS IN TRAUMA:

“ MANAGEMENT OF ADULT BLUNT SPLENIC TRAUMA”

J Trauma, 2008,65 : 1007-1011

FOREWORD This is a position article from

members of WTA Because there are not PRTs, the

algorithm is based on the expert opinion of WTA members and published observational studies

Management algorithm will encourage institutions to develop local protocols based on the resources that are available and local expert consensus opinion

HISTORIC PERSPECTIVE-1

Management of blunt splenic trauma has changed drastically during the past 30 years

In the mid-1970s, recognition of the spleen’s immunologic importance and the lifelong risk of overwhelming post splenectomy sepsis

The pediatric surgeons provided continuing evidence that the best way to salvage the spleen was not to operate

Wesson DE et al, J Paediatric Surg, 1981; 16: 324-326Haller JA et al : ann Surg 1994, 219: 625-631Coburn MC et al: Arch Surg, 1995; 130: 332-338

HISTORIC PERSPECTIVE-2 Adult trauma surgeons were slow to

adopt non operative management (NOM) Early reports of its use in adults

documented a 30% to 70% failure rate, of which two-thrids underwent total splenectomy

With increasing experience with NOM, recognition that negative laparotomies caused significant morbidity and the availability of higher quality CT scanning

NOM has become the standard of care for adults by the mid-1990s

Cogbill TH et al. J Trauma, 1989, 29: 1312-1317Archer LP et al : Arch Surg, 1996: 131: 309-315Patcher HL et al; Ann Surg, 1998, 227: 708-719

ADULT BLUNT SPLENIC TRAUMA

WTA, J Trauma 2008, 65:1007-1011

INFORMATION Hemodynamic instability:

No validated scoring systemBP < 90 cm HgHR > 130 beat per minute = serious tachycardia

How the response to initial to ATLS recommended volume loading and the need for ongoing for resuscitation

UPDATED U.S. ADULT SPLENIC TRAUMA CASE

SERIES SINCE 2000

HEMODYNAMIC INSTABILITY SCORE

National Institute of Health, Sponsored Glue Grant Consortium 2006

SPLENIC INJURY SCALE

IMPORTANCE POINTS The decision of whether to perform a

splenectomy is dependent on the patient’s condition

Splenic salvage should be pursued in the hemodynamically stable patient

Packing of the spleen in damage control surgery should be discouraged because splenectomy is fairly simple and definitive

Splenic reimplantation without significant bacterial contamination is a safe but unproved method of preserving function

TECHNIQUES OF SPLENIC SALVAGE

Topical hemostatic agents Argon bean coagulation Direct suture repair Partial resection Wrapping the spleen with

absorbable mesh Splenic reimplantation

THANK YOU

GUIDELINES FOR ANTIBIOTIC ADMINISTRATION IN SEVERELY INJURED PATIENTS

Warko Karnadihardja01-2009

CONTRIBUTORS

1. Michael A. West : Depart of Surgery, Univ of California, San Fransisco, California

2. Michael B.Saphiro : Depart of Surgery, North western University, Feinberg School of Medicine, Chicago, Ilinois

3. Ernest E. Moore : Depart of Surgery, University of Colorado, Denver, Colorado

4. Jeffrey L.Johnson : Depart of Surgery, University of Colorado, Denver, Colorado

5. Avery B.Nathens : Depart of Surgery, University of Toronto, Toronto, Ontario

6. Joseph Cusheri : Depart of Surgery, University of Washington, Seatle, Washington

7. Ronald V.Maier : Depart of Surgery, University of Washington, Seatle, Washington

8. Brian G. Harbrecht : Depart of Surgery, University of Louisville, Louisville, Kentucky

9. Joseph P Minei : Depart of Surgery, University of Texas at South Western, Dallas, Texas

10. Paul E. Bankey : Depart.of Surgery, University of Rochester, Rochester, New York

CONTRIBUTORS

Supported by Large-Scale Collaborative Project Award (U 54-GM 62119)

The Natural Institute of General Medical Sciences, National Institute of Health

THE PRINCIPLES When the clinical decision to

treat a critically ill with antibiotics has been made

One must to identify the site of infection based on clinical signs and symptoms, laboratory or diagnostic radiology studies

Duration of hospitalization and local “antibiogram”

HOW TO IDENTIFY TO SOURCE?

Examination of patient Inspection of all wounds Chest radiograph Calculation of clinical pulmonary

infection score if ventilated Obtaining blood cultures Urinalysis CVC

IF IT IS IMPOSSIBLE TO IDENTIFY THE SITE?

Obtain cultures from all accessible suspected sites and

Initiate empiric, broad spectrum antibiotics

Culture information will permit appropriate “de-escalation” the initial broad empiric therapy

IF LIKELY SITE CAN BE IDENTIFIED?

ANSWER THESE QUESTIONS Is intra abdominal site

suspected? Is pulmonary source of infection

suspected? Is skin, skin structure or soft

tissue site suspected? Is a CVC infection suspected?

DECISION TO CONTINUE OR DISCONTINUE AND/OR ALTER AM / AB

TREATMENT

Based on the clinical response to treatment

Diagnostic or interventional findings

Culture and sensitivity data

HOW RELIABLE IS CULTURE?

Not all pts with infections will have positive cultures because ofLimitations of specimen handling

Microbiology laboratory variations

Time between specimen acquisition and culture

Precence of effective antibiotics at the time that specimens were obtained

NOT ALL PATIENT WITH INCREASED TEMPERATURE OR WBC HAVE AN INFECTION

!

DISCONTINUATION OF ANTIBIOTICS IS APPROPRIATE IF CULTURES AND OTHER DIAGNOSTIC STUDIES ARE NEGATIVE

!

SOP (STANDARD OPERATING PROCEDURE)

The Goal: To provide practical guidance with

respect to appropriate choice of ABs in severely injured critical ill pts

To assist clinicians making empiric AB choice in critically ill pts after the initial resuscitation phase

This guidelines should minimized the risk of both inadequate AM coverage and excessive broad spectrum AB administration

PROTOCOL RATIONALE

There is a moderate amount of level I evidence of that pertains to AM choices for critically ill pts in general, and tesser amount of information relates to trauma pts

Primary classes of infectionIAIPneumonia (VAP,HAP,HCAP, CAP)Skin and skin structure infection (SSSI)

CVCI

SOP FOR ANTIMICROBIAL

CHOICE

SOP SUMMARY Identify the critically ill patient need

AB Identify the likely site of infection If it is impossible to identify site,

obtain cultures from all accessible suspected sites

Initiale empiric, broad spectrum ABs Not all pts with a fever and

leucocytosis harbor an infection Discontinuation of ABs is appropriate

if cultures, diagnostic & studies are negative

THANK YOU

NUTRITIONAL SUPPORT OF THE TRAUMA

PATIENT

Warko Karnadihardja

02-09

J Trauma, Dec 2008.65. 1520-152

SUPPORTED

In part, by Large scale collaborative project

award (U54-GM 62119) from the National Institute of General Medical Sciences. National Institute of Health

CONTRIBUTIONS

1. George E. O’Koeje : Depart of Surgery, University of Washington Seattle, Washington

2. Joseph Cusheri : Depart of Surgery, University of Washington Seattle, Washington

3. Ronald V.Maier : Depart of Surgery, University of Washington Seattle, Washington

4. Marilyn Shelton : Depart of Hospitality and Nutrition, Harbor view Medical Center, Seattle, Washington

5. Ernest E. Moore : Depart of Surgery, Univ of Colorado, Denver, Colorado

6. Stephen F.Lowry, VMDNJ-RWJ Medical School, New Brunswich, New Jersey

7. Brain G Harbredit, Depart of Surgery, Univ of Kentucky, Louisville, Kentucky

CONTRIBUTIONS

INTRODUCTION Severely injured pts have marked

metabolic derangements, generally characterized by increased substrate utilization and protein catabolism

Specialized nutritional support is beneficial and improves important clinical outcomes in the critically illHeyland DK et al : JPEN, 2003; 27, 74-

83

PROTOCOL GOALSSTANDARS OPERATING PROCEDURE

(SOP)1. To optimize patient outcome

through enhancing tolerance of EN support and minimizing the complications

2. To generate guidelines that is based upon the best available evidence

SOPFOR NUTRITIONAL SUPPORT OF

THE TRAUMA PATIENTS

1. Selection of the pts for nutritional support

2. Approach to initiation3. Route of administration4. Nutrient formulation5. Nutritional support monitoringThis set of guidelines is evidence-based where possible and devised for pts with severe multisystem injury, who have

been resuscitated from marked physiologic derangements

FORMULATION Protein needs are initially : 1,5 to 2,0 g

protein/kg/d Caloric needs : 25 to 30 kcal/kg/d Monitor :

“Occult” and potentially excessive caloriesHyperglycemiaExcess CO2 productionFluid/electrolytesBlood stream infection

PN lipids : limited to 1 g/kg/d ( ≈ EN lipids) = less than 30% of total kcal

May AK et al : Ann Surg 1999; 65:560-574,

Dissonaike S et al. Crit Care 2007; 11; R114

SUPPLEMENTATION Recommendation:

Standard high protein 1 kcal/ml formula

When limiting volumes following large volume resuscitation, open abdomens and ongoing diuresis

Higher caloric density 1,5-2.0 kcal/m Specific Nutrients (additional)

GlutamineArginineRibonucleic acidsOmega-3 /fatty acids

“IMMUNE ENHANCED” SUPPLEMENTATION

The beneficial effect in severely injured humans are uncertainMendez C et al: J Trauma 1997, 42: 933-940Kudsk KA et al : Ann Surg 1996; 224: 531-540Combined supplementation of EN formula with arginine, omega-3 fatty acids and glutamine does not reduce mortality, infections, or organ failure in critically ill pts

This constrasts with demonstrated reduction in infections complications when are used in elective surgical pts

Heyland DK et al: JAMA, 2001; 286: 944-953

“IMMUNE ENHANCED” SUPPLEMENTATION

Arginine increases nitric oxide (NO) production, while beneficially influencing innate immune function and infections outcomes in elective surgery pts

Is detrimental in critically ill pts with sepsis

Sucher U, Heyland DK, Peter K: Br J Nutr 2002: 87 (S1), S121-

S132

RECENT ISSUES The gut is one of the first organs

exposed to shock and the last to be resuscitated in circulatory failure

Impairment of the gut plays a central roles in the pathogenesis of infection, sepsis and even MODS

Heyland, Dhaliwal & Suchner. 2005

THE ROLE OF GUT IN DYSFUNCTION INFLAMMATION TO MOF

GUT: THE STARTER FOR MOFLIVER: THE MOTOR FOR MOF

Delayed Enteral Feeding

Shock

BacteriaEndotoxin

Kupffer Cell

Gut

Liver

ARDS

ATN

Stress

Immune

Injured Tissue

PGE2 =

IL1 =

TNFC3a,C5a

O2

Enteral NutritionEvans & Park. Blackwell 1997.

KEY THERAPEUTIC STRATEGY

METABOLIC RESUSCITATION OF G.I.T

By providing adequate nutrition in general

Immunomodulatory substrates specifically to maintain gut barrier integrity

THE VICIOUS CYCLE OF OXYGEN FREE RADICAL PRODUCTION IN CRITICALLY ILL PATIENT

Surgery, trauma

Ischemia/ reperfusion

OFR

Tissue injury

Hypoperfusion

Inflammation

Cytokines

Infection

Endotoxin, bacteria

Sepsis

SIRS

Macrophage activation

(liver)

Monocytes/ leucocytes activation

OFR

OFROFR

OFR

Cytokines

Heyland, Dhaliwal & Suchners, 2005

POTENTIAL ROLES AND SITES OF ACTION OF IMMUNO NUTRIENTS IN SEPSIS

Sepsis

Glutamine release

Free fatty acid

Immune response

Adipose tissue

Cytokines and stress hormones

MuscleGut Liver

Macrophages

OKG GlutamineGlutamine

SCFAs

Arginine

n-3 PUFAs

n-3 PUFAs

n-3 PUFAs

EARLY ENTERAL VS PARENTERAL NUTRITION IN MAJOR TRAUMA (ATI 15-40)

( 11 PRCT, 2 META ANALYSIS, 1 MODEL)

Reduced septic morbidity Increase lymphocytic count Increase anastomotic strength in

peritonitis model Support wound healing

Moore EE, Jones TN : J Trauma 1986

Moore FA, Moore EE, Jones TN: J Trauma. 1989

Kudsk KA, Croce MA, Fabian TC et al : Ann Surg 1992

Moore FA, Feliciano DV, Andrassy RJ et al : Ann Surg. 1992

Khalili TM, Navarro RA, Meddleton J et al : An J Surg. 2001

GUT-SPECIFIC RESUSCITATION

THE GOALS : Early optimizing gut perfusion Prevent reperfusion injuryTHE PROTOCOL Earlier use of PRBC, instead of

aggressive use of crystaloids to avoid problematic bowel edema

Or to use new blood substitutes and / or hypertonic saline or colloids

Moore FA & Weisbroodt NW, 2003

MONITORING NUTRITIONAL SUPPORT

INCLUDES Bedside assessment of the patient

tolerance Daily evaluation by the dietician to

ensure nutritional targets Biochemical monitoring The effect of massive resuscitation

and marked fluid shifts during initial post injury week generally preclude the use of serum marker and body weight as indications

MONITORING NUTRITIONAL SUPPORT

“Once the patient enters an anabolic state, sufficient substrate is needed to rebuild proteins, heal wound, and restore muscle mass”

MONITORING GI TOLERANCE

High gastric residual volumes have often been considered a marker for gastric in tolerance of EN, reflux and broncho pulmonary aspiration of GI contents

Other manifestations:Poor gastric emptyingAbdominal distentionAbdominal tendernessDiarrhea Gastric ileus, infections colitis, intestinal ischemia and necrosis ( < 1%)

MONITORING GI TOLERANCE

Gastric aspirates are obtained every 4 to 6 hours

Residual volume of > 300 ml, mandates cessation of feeding with reassessment of residual volume 2 hours later

THANK YOU