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DEFINISI
KEPERAWATAN TRAUMA Trauma is defined by the American Heritage
Dictionary as a wound, especially one
produced by sudden physical injury. (Mifflin,
1991)
Injury is defined by the National Committee
for Injury Prevention and Control as
unintentional or intentional damage to the
body resulting from acute exposure to
thermal, mechanical, electrical, or chemical
energy or from the absence of such essentials
as heat or oxygen. (National Safety
RAMDHANY ISMAHMUDI Council,2000)
DEFINISI Trauma
Trauma is mechanical damage to the body
caused by an external force. The trauma
patient has been defined as an injured
person who requires timely diagnosis and
treatment of actual or potential injuries by a
multidisciplinary team of health care
professionals, supported by the appropriate
resources, to diminish or eliminate the risk of
death or permanent disability.(Hildreth,
2013)
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TRAUMA
One of three deaths occurred in
hospital as a result of injury could be
prevented
Often avoidable factors include simple
management errors in the early stages
(golden hour), rather than a failure of
complex definitive treatment (Royal
College of surgeons of England, 1988)
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PRINSIP MANAJEMEN KEGAWATDARURATAN PADA TRAUMA Prinsip Manajemen Kegawatdaruratan Pada Trauma Lanjut
F = Folley Catheter
A : Airway + Cervical Control
(kontra indikasi: Ruptur uretra)
B : Breathing + Ventilation Tanda:
C : Circulation + Hemorrhagic Control Keluar darah dr orifisium uretra eksterna
Hematoma di skrotum/supra simphisis
D : Disability Rectal touse: prostat melayang
E : Exposure + Hypothermia G = Gastric Tube
H = Heart Monitor and Pulse Oksimetri
Prevention
ICU/ICCU
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Critical Care
Lost life years
Situasi serius
Tiba-tiba, tidak dapat diduga
Mengancam/cenderung mengancam kehidupan 40
30
Tindakan cepat dan tepat
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Proses Keperawatan
Sama dengan sistem di ruangan lain 10
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Beda: 0
Trauma Cancer Cardio vascular
Waktu terbatas mengancam kehidupan
Informasi terbatas Pengkajian tidak harus lengkap Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
Mechanisms of Injury
Treatment price Blunt Trauma
Compression Forces
Cells in tissues are compressed and crushed
400
E.g. Spleen
Shear Forces
300
Acceleration/Deceleration Injury
E.g. Aorta
200
Shearing force = Spectrum from Full thickness tear
(Exsanguination) to Partial tear (Pseudoaneurysm)
334
Overpressure
100 Body cavity compressed at a rate faster than the tissue
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around it, resulting in rupture of the closed space
51 E.g. Plastic bag
0
Trauma Cancer Cardio vascular
E.g. in trauma = diaphragmatic rupture, bladder injury
Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003 16
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Primary Survey
Open Vehicle or Motorcycle/Moped Designed to identify injuries that are immediately life threatening and to treat
Pedestrian Vs. Car them as they are identified
Penetrating Injury (Guns vs. Knives) Resuscitation
Rapid procedures and treatment to treat injuries found in primary survey
before completing the secondary survey
Vincent J Brown (flickr) Secondary Survey
Full History and Physical Exam to evaluate for other traumatic injuries
Monitoring and Evaluation, Secondary adjuncts
Transfer to Definitive Care
ICU, Ward, Operating Theatre, Another facility
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Paladinsf
(flickr)
James Heilman, MD, Wikimedia Commons
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Author unknown,
www.trauma.org/index.php/main/article
/199/index.php?main/image/95/
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Circulation Circulation
Shock
Impaired tissue perfusion Types of Shock in Trauma
Tissue oxygenation is inadequate to meet metabolic demand Hemorrhagic
Prolonged shock state leads to multi-organ system failure and cell Assume hemorrhagic shock in all trauma patients until proven
death otherwise
Clinical Signs of Shock Results from Internal or External Bleeding
Altered mental status Obstructive
Tachycardia (HR > 100) = Most common sign
Cardiac Tamponade
Arterial Hypotension (SBP < 120) Tension Pneumothorax
Femoral Pulse SBP > 80
Radial Pulse SBP > 90 Neurogenic
Carotid Pulse SBP > 60 Spinal Cord injury
Inadequate Tissue Perfusion Sources of Bleeding
Pale skin color
Cool clammy skin Chest
Delayed cap refill (> 3 seconds)
Altered LOC Abdomen
Decreased Urine Output (UOP < 0.5 mL/kg/hr) Pelvis
Bilateral Femur Fractures
33 34
Circulation Circulation
Emergency Nursing Treatment
Two Large IV Lines Pericardial Tamponade
Cardiac Monitor
Blood Pressure Monitoring Pericardium or sac around heart fills with
General Treatment Principles blood due to penetrating or blunt injury to
Stop the bleeding Pericardium chest
Apply direct pressure
Temporarily close scalp lacerations Blood Becks Triad
Close open-book pelvic fractures
Abdominal pelvic binder/bed sheet Distended jugular veins
Restore circulating volume Hypotension
Crystalloid Resuscitation (2L)
Administer Blood Products Muffled heart sounds
Immobilize fractures Treatment
Responders vs. Nonresponders
Transient response to volume resuscitation = sign of ongoing blood loss Epicardium Rapid evacuation of pericardial space
Non-responders = consider other source for shock state or operating room Performed through a pericardiocentesis
for control of massive hemorrhage (temporizing measure)
Aceofhearts1968(Wikimedia)
Open thoracotomy
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Pericardiocentesis Circulation
Puncture the skin 1-2 cm inferior to xiphoid process
45/45/45 degree angle A word about cardiac arrest . . .
Advance needle to tip of left scapula Care of the trauma patient in
Withdraw on needle during advance of needle cardiac arrest
Preferable under ultrasound guidance or EKG lead V CPR
attachment Bilateral Tube Thoracostomy
Complications Pericardiocentesis
Aspiration of ventricular blood Volume Resuscitation
Laceration of coronary arteries, veins,
epicardium/myocardium
Traumatic cardiac arrest due to
Author unknown,
Cardiac arrhythmia
blunt injury has very low survival
http://www.trauma.org/images/image_library/ch
est0054_thumb.jpg Pneumothorax
rate (< 1%)
No point for emergency thoracotomy
Puncture of esophagus
Puncture of peritoneum Selected cases of cardiac arrest due
Author unknown,
to penetrating traumatic injury may
http://www.trauma.org/images/image_library/chest0 benefit from emergent
046.jpg thoracotomy
Pericardial tamponade
Cross clamp aorta
Author unknown,
37 38
www.brooksidepress.org/ProductsTrauma_Surgery?M=A
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Disability Disability
Key Principles
Precise diagnosis is not necessary at this point in Cervical Spinal Clearance
evaluation
Patients must be alert and oriented to person,
Prevention of further injury and identification of
neurologic injury is the goal place and time
Decreased level of consciousness = Head injury until No neurological deficits
proven otherwise
Maintenance of adequate cerebral perfusion is key Not clinically intoxicated with alcohol or drugs
to prevention of further brain injury Non-tender at all spinous processes
Adequate oxygenation
Avoid hypotension No distracting injuries
Involve neurosurgeon early for clear intracranial Painless range of motion of neck
lesions
41 42
Exposure Exposure
Remove all clothing
Examine for other signs of injury
Injuries cannot be diagnosed until seen by provider
Logroll the patient to examine patients back
Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine
Minimum of 3 people, often more providers required
Avoid hypothermia
Apply warm blankets after removing clothes
Hypothermia = Coagulopathy
Increases risk of hemorrhage
Author unknown,
http://www.trauma.org/index.php/main/image/98/C11
43 44
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Raccoon's Eyes
http://health-
pictures.com/eye/Periorbital-
http://sfghed.ucsf.edu/Education/Cli Ecchymosis.htm
Grey-Turners Sign
H. L. Fred and H.A. van H. L. Fred and H.A. van Dijk
Dijk (Wikimedia) (Wikimedia)
http://www.itim.nsw.gov.au/images/seat_belt_mark_2.jpg
Accessed 9/20/09 Google Image Search 51 52
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FAST FAST
Has largely replaced deep peritoneal lavage Sensitivity of 94.6%
(DPL) Specificity of 95.1%
Bedside ultrasound looking for blood Overall accuracy of 94.9% in identifying the
collection in an unstable patient.
presence of intra-abdominal injuries.
If the patient is unstable and a blood Yoshil: J Trauma 1998; 45
collection is found, proceed emergently to
the operating theater.
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Pregnancy
Supine Hypotensive Syndrome
After 20 weeks, enlarged uterus with fetus and amniotic
fluid compresses inferior vena cava
Decreases venous return and decrease cardiac output
Keep pregnant patients in left lateral decubitus position to
avoid excessive hypotension
Optimal maternal and fetal outcome is determined
by adequate resuscitation of mother
Fetal Monitoring
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfast.htm
65 66
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Author unknown,
www.trauma.org/index.php/main/image/45/print
Author unknown,
http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg 71 72
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Definitive Care
Secondary Survey followed by radiographic
evaluation
CatScan
Consultation
Neurosurgery
Orthopedic Surgery
Vascular Surgery
Transfer to Definitive Care
Operating Room
ICU
Higher level facility
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