Managment

of Trauma Pa/ent in
ER
Dr.Achmad Yani Sp B Sp BA
IGD RSUPN Dr CiptoMangunkusumo
 Objectives
nEpidemiology of Trauma Care
nMechanisms of Injury
nBasics of Trauma Management
Primary Survey
Resuscitation
Secondary Survey

2
 TRAUMA ???

REAL
LIFE
AND
DEATH
Poten/al life lost
Accident Epidemiology
Jumlah Kecelakaan, Koban Mati, Luka Berat, Luka Ringan, dan Kerugian Materi yang Diderita Tahun 1992-2011

Kerugian Materi
Tahun Jumlah Kecelakaan Korban Mati Luka Berat Luka Ringan
(Juta Rp)
1992 19.920 9.819 13.363 14.846 15.077
1993 17.323 10.038 11.453 13.037 14.714
1994 17.469 11.004 11.055 12.215 16.544
1995 16.510 10.990 9.952 11.873 17.745
1996 15.291 10.869 8.968 10.374 18.411
1997 17.101 12.308 9.913 12.699 20.848
1998 14.858 11.694 8.878 10.609 26.941
1999*) 12.675 9.917 7.329 9.385 32.755
2000 12.649 9.536 7.100 9.518 36.281
2001 12.791 9.522 6.656 9.181 37.617
2002 12.267 8.762 6.012 8.929 41.030
2003 13.399 9.856 6.142 8.694 45.778
2004 17.732 11.204 8.983 12.084 53.044
2005 91.623 16.115 35.891 51.317 51.556
2006 87.020 15.762 33.282 52.310 81.848
2007 49.553 16.955 20.181 46.827 103.289
2008 59.164 20.188 23.440 55.731 131.207
2009 62.960 19.979 23.469 62.936 136.285
2010 66.488 19.873 26.196 63.809 158.259
2011 108.696 31.195 35.285 108.945 217.435

Sumber : Kantor Kepolisiian Republik Indonesia

 In ours
Grak TRISS
 Epidemiology
Trimodal Distribution of Trauma Deaths

n Golden Hour = 80% of trauma deaths

50% in rst hour after injury
n Rapid trauma care has greatest level
of impact in these patients

30%
20%

Immediately Hours Days/Weeks

7
 Mechanisms of Injury

Mechanism of Injury :
Frontal Impact Collisions
Lateral Impact Collisions
(T bone)
Rear Impact Collisions
Rollover Mechanism
Open Vehicle or
Motorcycle
Pedestrian Vs. Car
 Mechanism of Injury :

Penetrating Injury
(Guns vs. Knives)
Falls
 Basics of Trauma Assessment
nPreparation
nTriage
nPrimary Survey
nResuscitation
nSecondary Survey
nMonitoring and Evaluation, Secondary
adjuncts
nTransfer to Denitive Care

LIFE IS MATTER !!!
Pa/ent alive if they
come to big hospital or
trauma center

 Trauma Team
Doin it 24/7
ED Physicians
Anesthesiology
Surgeons
General and Trauma and Cri@cal Care
Neurosurgery
Orthopedics
Medical Students
Nurses
Radiology Techs
Radiologists
Lab techs

Preparation for Patient Arrival
Key to sucsessful for trauma team
As long as the ins/tu/on
and the sta is
commiVed to mee/ng
the challenges involved
in the care of the
trauma pa/ent, and
have a rigorous
performance
improvement process,
outcomes will be
successful.
What happens when this
pa@ent comes to the ER
where you are
moonligh@ng?
Dont panic!
 Air goes in & out!
Oxygen is good!
Blood goes round & round!
Stop bleeding!
Put things back where and
how they belong!
 Ini@al Assessment:
Prerequisites
Wide-angled view

PaRern recogni@on skills

Ability to triage and set priori@es

Organized structure
TRIAGE
 Primary Survey
nAirway and Protection of Spinal Cord
nBreathing and Ventilation
nCirculation
nDisability
nExposure and Control of the Environment

21
 Primary Survey
nKey Principles
When you nd a problem during the
primary survey, FIX IT.
If the patient gets worse, restart from the
beginning of the primary survey
Some critical patients in the Emergency
Room may not progress beyond the
primary survey

22
 Airway and Protection of Spinal Cord
nWhy rst in the algorithm?
Loss of airway can result in death in < 3 minutes
Prolonged hypoxia = Inadequate perfusion, End-organ damage
nAirway Assessment
Vital Signs = RR, O2 sat
Mental Status = Agitation, Somnolent, Coma
Airway Patency = Secretions, Stridor, Obstruction
Traumatic Injury above the clavicles
Ventilation Status = Accessory muscle use, Retractions, Wheezing
nClinical Pearls
Patients who are speaking normally generally do not have a need
for immediate airway management
Hoarse or weak voice may indicate a subtle tracheal or laryngeal
injury
Noisy respirations frequently indicates an obstructed respiratory
pattern
23
Airway Interventions
n Maintenance of Airway Patency
Suction of Secretions
Chin Lift/Jaw thrust Dept. of the Army, Wikimedia Commons

Nasopharyngeal Airway
Denitive Airway
n Airway Support
Oxygen
NRBM (100%) Ignis, Wikimedia Commons
Bag Valve Mask
Denitive Airway
n Denitive Airway
Endotracheal Intubation
nIn-line cervical stabilization
Surgical Crichothyroidotomy
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons 24
 C-spine Immobilization
nReturn head to neutral position
nMaintain in-line stabilization
nCorrect size collar application

26
 Breathing and Ventilation
n General Principle: Adequate gas exchange is required to
maximize patient oxygenation and carbon dioxide elimination
n Breathing/Ventilation Assessment:
Exposure of chest
General Inspection
n Tracheal Deviation
n Accessory Muscle Use
n Retractions
n Absence of spontaneous breathing
n Paradoxical chest wall movement
Auscultation to assess for gas exchange
n Equal Bilaterally
n Diminished or Absent breath sounds
Palpation
n Deviated Trachea
n Broken ribs
n Injuries to chest wall

27
 Breathing and Ventilation
n Identify Life Hemothorax
Threatening Injuries
Tension Pneumothorax

28
 Breathing and Ventilation
Flail Chest nOpen Pneumothorax
Sucking Chest Wound
Large defect of chest
wall

n Shock
Circulation
Impaired tissue perfusion
Tissue oxygenation is inadequate to meet metabolic demand
Prolonged shock state leads to multi-organ system failure and cell
death
n Clinical Signs of Shock
Altered mental status
Tachycardia (HR > 100) = Most common sign
Arterial Hypotension (SBP < 120)
n Femoral Pulse SBP > 80
n Radial Pulse SBP > 90
n Carotid Pulse SBP > 60
Inadequate Tissue Perfusion
n Pale skin color
n Cool clammy skin
n Delayed cap rell (> 3 seconds)
n Altered LOC
n Decreased Urine Output (UOP < 0.5 mL/kg/hr)

30
 Circulation
n Types of Shock in Trauma
Hemorrhagic
n Assume hemorrhagic shock in all trauma patients until proven
otherwise
n Results from Internal or External Bleeding
Obstructive
n Cardiac Tamponade
n Tension Pneumothorax
Neurogenic
n Spinal Cord injury
n Sources of Bleeding
Chest
Abdomen
Retroperitoneal
Pelvis
Bilateral Femur Fractures

31
 Circulation
n Emergency Nursing Treatment
Two Large IV Lines
Cardiac Monitor
Blood Pressure Monitoring
n General Treatment Principles
Stop the bleeding
n Apply direct pressure
n Temporarily close scalp lacerations
Close open-book pelvic fractures
n Abdominal pelvic binder/bed sheet
Restore circulating volume
n Crystalloid Resuscitation (2L)
n Administer Blood Products
Immobilize fractures
n Responders vs. Nonresponders
Transient response to volume resuscitation = sign of ongoing blood loss
Non-responders = consider other source for shock state or operating room
for control of massive hemorrhage

32
 Disability
n Baseline Neurologic Exam
Pupillary Exam
n Dilated pupil suggests transtentorial herniation on ipsilateral side
AVPU Scale
n Alert
n Responds to verbal stimulation
n Responds to pain
n Unresponsive
Gross Neurological Exam Extremity Movement
n Equal and symmetric
n Normal gross sensation
Glasgow Coma Scale: 3-15
Rectal Exam
n Normal Rectal Tone
n Note: If intubation prior to neuro assessment, consider quick
neuro assessment to determine degree of injury

33
 Disability
nKey Principles
Precise diagnosis is not necessary at this point in
evaluation
Prevention of further injury and identication of
neurologic injury is the goal
Decreased level of consciousness = Head injury until
proven otherwise
Maintenance of adequate cerebral perfusion is key
to prevention of further brain injury
nAdequate oxygenation
nAvoid hypotension
Involve neurosurgeon early for clear intracranial
lesions

34
 Exposure
nRemove all clothing
Examine for other signs of injury
Injuries cannot be diagnosed until seen by provider
nLogroll the patient to examine patients back
Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine
Minimum of 3 people, often more providers required
nAvoid hypothermia
Apply warm blankets after removing clothes
Hypothermia = Coagulopathy
nIncreases risk of hemorrhage

35
Exposure

36
 Trauma Logroll
nOne person =
Cervical spine
nTwo people =
Roll main
body
nOne person =
Inspect back
and palpate
spine

37
 Secondary Survey
nSecondary Survey is completed after primary
survey is completed and patient has been
adequately resuscitated.
nNo patient with abnormal vital signs should
proceed through a secondary survey
nSecondary Survey includes a brief history
and complete physical exam

38
 Secondary Survey
Pa@ent history
Head to toe physical exam
Radiography
Lateral C-spine, C-xray, pelvis
One cavity above/below entrance/exit wounds
FAST
Urinary bladder drainage
NGT
Blood sampling/monitoring
Does this patient
need to go to the
OR ?!
Penetra@ng Abdominal Trauma
Penetrating
Abdominal
Trauma

GSW KSW

HD Stable/No
OR HD Unstable
peritonitis

Peritoneal
OR
Penetration

Positive Negative

OR Observation
Blunt Abdominal Injuries
Blunt Trauma

Peritonitis Indeterminate

OR HD Stable HD Unstable

CT FAST/DPL

Positive Negative

OR Keep Looking
 SCORING SYSTEM
Revised Trauma Score
Injury Severity Score
Trauma Revised Injury Severity Score
Calculate the score than you can predict...

 Denitive Care
nSecondary Survey followed by radiographic
evaluation
CtScan
Consultation
nNeurosurgery
nOrthopedic Surgery
nVascular Surgery
nTransfer to Denitive Care
Operating Room
ICU
Higher level facility

45
Thank you