manajemen trauma tumpul abdomen

8/13/2019 Manajemen Trauma Tumpul Abdomen

1/10

105

SECTION

4

SECTION 4

MANAGEMENT ALGORITHMS

Page

Blunt Abdomen 107

S. DAmours

Penetrating Abdomen 108

S. DAmours

Widened Mediastinum 109

S. DAmours

Penetrating Chest 110

S. DAmours

Moribund Penetrating Chest 112

M. Sugrue

Penetrating Extremity 113

S. DAmours

Penetrating Neck 114

M. Sugrue

Pelvic Fractures Haemodynamic Instability 115

M. Heetveld / I. Harris / G. Schlaphoff


2/10

106

SECTION

4

Page

Cervical Spine Clearance 116S. DAmours / M. Sheridan

Suspected Spinal Cord Injury 117S. DAmours

Head Injury Mild 118M. Sugrue

Head Injury Severe 119M. Sugrue

Suspected Urethral Injury 120M. Sugrue

Moribund Patient 121

M. Sugrue

MAST Suit Removal 122

A. Flabouris

SECTION 4

MANAGEMENT ALGORITHMS (continued)


3/10

107

SECTION

4

BLUNT ABDOMEN

Suspected Blunt Abdominal Injury

Haemodynamically Stable Haemodynamically Unstable

Complete 2o Survey*, and

CXR / PXR

Early FAST or DPL (15min)

-ve

FAST No FAST

+ve

Observe

CT Abdomen

with contrast

Significant

mechanismConcomitant head

injury or othersignificant injury

+ve -ve

Repeat

FAST or

DPL

Abdomen soft

and non tender

LAPAROTOMY

*If seat belt stripe (bruising) present,

have a low threshold for DPL as it is

most sensitive for hollow viscus injury.

Observation:

Serial clinicalexam by same

examiner

S.DAmours: 2002

Complete 2o Survey*, and

CXR / PXR


4/10

108

SECTION

4

PENETRATING ABDOMEN

PENETRATING ABDOMINAL

TRAUMA

Haemodynamically unstable?YES

NO

LAPAROTOMY

Anterior or Lateral Wound?

Gunshot Wound?

Frank Peritonitis?

Evisceration?

Positive Diagnostic Laparoscopy*

YES

NO

NO

NO

NO

Observation

YES

YES

YES

YES

NO Stable Flank and Back

Wounds

Triple Contrast CT scan,+/- DPL, +/- Diagnostic

Laparoscopy

+ve -ve

ObservationLAPAROTOMY* Preferred Investigation

DPL/Local wound exploration are

options but laparoscopy is better.2002: DAmours


5/10

109

SECTION

4

WIDENED MEDIASTINUM

Blunt thoracic injury with significant

deceleration mechanism and

abnormal mediastinum on CXR

Very high index of

suspicion

Pseudocoarctation

Paraplegia

Contact

Cardiothoracic

surgeon

To O.T.

? On table TOE

High index of suspicion

Mediastinum >12cms

or

3 radiological signs ?

Arch Aortogram

and Contact

Cardiothoracic surgeon

(simultaneously)

AbnormalAbnormal

Repair Observe

Low to moderate index of

suspicion

Mediastinum 8- 12cms

or


6/10

110

SECTION

4

PENETRATING CHEST

PENETRATING CHEST TRAUMA

Central Chest The B ox

Between nipple lines

Xiphisternum to clavicles

Loss of cardiacoutput in ED

Haemodynamicsunstable

patient is dying

Haemodynamicsstable

L Antero-lateralThoracotomy

CONSIDER: Incision of

pericardiumRepair hole in

heart

Clamp aorta

Clamp hilum

Internal cardiacmassage

Pack apicalvessels

See algorithmpage 112.

Echocardiographyor FAST and consider:

Aortogram

Oesophagram/

Oesophagoscopy

Thoracotomy

Upright CXR

Chest Tube ifsignificant haemo/

pneumothorax

FAST (optional):Pericardial effusion

Mediansternotomy withcardiothoracic

surgery

CX R

Cardiothoracic surgeryconsultation and

Thoracotomyormedian sternotomy

Chest tubeto side of injuryYES

Contd.

+ve


7/10

111

SECTION

4

Thoracoabdominal?

Also seePenetrating

Abdomen page10 8

Lateral ChestLateral to nipple lines

Observation

Chest Tube toside of injury

FAST (optional):

Pericardial effusion?

Upright CXR

Repeatupright CXRin 4 hours

Pneumothoraxlarger?

Pneumoorhaemothorax

Chest tubeplacement

(minimum 32Fr)

Bleeding:

>1500 mlsimmediately, or,>200mls/hour

Call Cardiothoracicsurgeon

Arrange thoracotomy

Call Cardiothoracicsurgeon

Arrange thoracotomy

CXR

Minimal or nopneumothorax

YES

PENETRATING CHEST TRAUMAContd.

Haemodynamicsstable

Haemodynamicsunstable

YES YES

YES

YES

YES

NO

2002: DAmours


8/10

112

SECTION

4

MORIBUND PENETRATING CHEST

MORIBUND PENETRATING CHEST TRAUMA

(No pulse but still has ECG rhythm)

CED Thoracotomy

(Left anterolateral thoracotomy)

BChest Drains

AET Tube (cold)

TIME 1-2 mins 2-3 mins 4 mins

(chest open


9/10

113

SECTION

4

PENETRATING EXTREMITY

X-rays of limb (2 views) with radio-opaquemarkers at entry / exit wounds

Hard signs of Vascular Injury?

Expanding haematoma

Arterial Bleeding

Audible bruit or palpable thrill

Distal ischaemia

Operative Exploration

YES

Measure ABI (ankle

brachial index)

NO

Consider angiography

first if multiple levels ofinjury possible (multipleGSWs) or consider

doing angio in OT

0.9

Consider angiography orduplex in consultation

with Vascular Surgeon

Low likelihood ofsignificant arterial

injury.

Observe patient.

2002: DAmours


10/10

114

SECTION

4

PENETRATING NECK INJURY

A B Cs

Unstable * Stable

EXPLORE

SURGICALLY

Zone I Zone II Zone III

Arteriography

Endoscopy

Gastrograffin

EXPLORE

SURGICALLY

Arteriography

EMBOLISEOBSERVE

+ve-ve

-ve+ve

2002: Sugrue/DAmours

* Includes rapidly expandinghaematomas and active

arterial bleeding.

Zones of the Neck:

I Inferior to cricoid cartilage

II Between cricoid cartilage andangles of mandible

IIIAbove angles of mandible.

PENETRATING NECK INJURY

manajemen trauma tumpul abdomen

Documents