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 penyakit
Anamnesis
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
1 hour 3 hours
First peak
Laceration of brain
brainstem
aorta
spinal cord
heart
Second peak
Extradural
Subdural
Hemopneumothorax
Pelvic fractures
Long bone fractures
Abdominal injuries
Third peak
Sepsis
Multi organ failure
Secondary Brain Injury
D
E
A
T
H
S

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
is possible
The Organs Responses
Blood loss


Microvascular System Immune
& inflammatory organ response
responses

cellular Neuro-endocrine
metabolic Cardiovascular
response Pulmonary
Renal


Vicious Cycle of Hemorrhagic
Shock
Endothelial Activation
Microcirculatory 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 Triad
Severe Trauma Prolonged hypotension
Metabolic Acidosis
Coagulopathy Hypothermia
DEATH
Terima kasih