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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