MODUL 1

Decreased of Consciousness
Emergency and Traumatology
GROUP 15
PROBLEM BASE LEARNING

Medical Faculty
Muslim University of Indonesia
Tutor : dr. Wawan Susilo, S.ked
110 212 0007 Rezky Andika Putry
110 212 0015 Rahmat Badaruddin
110 212 0031 Al Husna Pratiwi Aksan
110 212 0035 A. Sitti Rahmatullah
110 212 0053 Marwah Fadilat
110 212 0054 Ahmad Nur Fauzi
110 212 0082 Muhammad Awaluddin
110 212 0088 A. Amalya Permatasari A
110 212 0089 Dwi Nawaluddin Naprisal
110 212 0100 Muh. Alif Adhani
110 212 0118 Nurul Hikmah Pratiwi
Case 1
A female, 30 years old, entered the hospital emergency room with

decreased of consciousness. On laid on the bed and examined, the patient

responds to pain stimuli by open her eyes and keep snoring with breathing

rhythm of 40 beats/min. The face looked pale, nose and ears are bleed.

Found lesion on the left temple region and right lower limb deformities.
DIFFICULT WORD
- Deformity is abnormality and
trauma in musculoskeletal system
that give abnormality shape at
extremity or body.
KEYWORDS
A female, 30 years old

decreased of consciousness

the patient responds to pain stimuli by open her eyes

Snoring airway disturbance

breathing rhythm of 40 beats/min takipneu Shock sign

symptoms
the face looked pale

nose and ears are bleed

Suspect: trauma
Found lesion on the left temple region basis cranii

right lower limb deformities

Questions
1. Whats the initial assessment for the patient
based on case?

2. Pathomechanism of signs and symptoms

based on case?

3. How about islamic point of view?

PHASES

PreHospital Hospital
(Triage)
Phase Phase

MULTIPLE CASUALTIES
MASS CASUALITIES
Initial Assessment

First action

Primary Survey

Secondary Survey

Defenitif care
First Action
Ask for Help!!

Self-Protection
Standard Precautions

In-Line Position
 Primary Survey
Airway Assessment
1. Look: pale appereance , which means there is
interference in the airway

2. Listen: snoring sounds indicating a partial

blockage of the airway

3. Feel: gusts of breath sounds

Source:
American College of Surgeons Committee On Trauma. Editor. Advanced Trauma Life Support for Doctorss. United Stated of America : American College of
Surgeons Committee On Trauma; 2008.p.1-16
 LOOK LISTEN - FEEL
Management
Obstruction with tools
caused by the
SNORING base of tongue
Oropharyngeal
falls back
airway

Management without tools failed

Airway patent

Move to Endotraceal
intubation
Breathing

failed
in-line
immobilization
Airway Surgical
Cricotiroidotomy
American College of Surgeons Committee On Trauma. Editor. Advanced Trauma Life Support for Doctorss. United
Stated of America : American College of Surgeons Committee On Trauma; 2008.p.1-16
 Primary Survey
Breathing Assessment
BREATHING ASSESMENT

Look for symmetrical rise and fall of the chest and adequate chest wall
excursion. Asymmetry suggests splinting of the rib cage or a flail chest.

Listen for movement of air on both sides of the chest. Decreased or absent
breath sounds over one or both hemithorax should alert the examiner to
the presence of thoracic

Feel for abnormal breathing, intra cranial injury can cause abnormal breathing
patterns and compromise adequacy of ventilation. (diaphragmatic
breathing OR abdominal breathing)
Reference:
Advance Trauma Life Support for Doctor
The American Natiopnal Red Cross. Administering Emergency Oxygen [pdf]
 Primary Survey
Breathing Assessment
LOOK LISTEN - FEEL

breathing rhythm of
40 times/min

Reference:
Advance Trauma Life Support for Doctor
The American Natiopnal Red Cross. Administering Emergency Oxygen
[pdf]
 Breathing Device

Reference:
Advance Trauma Life Support for Doctor
The American Natiopnal Red Cross. Administering Emergency Oxygen [pdf]
 Cont Breathing

Breathing
Move to Circulation
voluntary

Check Carotid CPCR

Drugs intervention
Pulse Evaluation

Reference:
Advance Trauma Life Support for Doctor
The American Natiopnal Red Cross. Administering Emergency Oxygen [pdf]
Primary Survey
Circulation Assessment
External bleeding Direct/bandage pressure
(ear and nose bleeding, lesion Pledget
on left temple) debridement

Consultation to surgeon
Suspect internal bleeding Suspect abdominal trauma: USG or DPL

2 large-caliber IV catheter (2-3 L crystaloid fluid)

simultaneously take a blood sample for a routine examination,
Pale blood chemistry, pregnancy test (women of childbearing age), blood
type and cross-match and Blood Gas Analysis (BGA)

Deformity Splint

Prevent hypothermia Kortbeek JB1, Al Turki SA, dkk. 2013. Advance Trauma Life Support 8th Edition.
American College Surgeon Committee on Trauma
takipneu

Hipovolemic
shock grade
4

pale
How to manage the
patient in this situation?
 Hypovolemic Shock Management
If due to bleeding, stop it by direct press or suturing.

Put the patient in shock position (trendelenberg position)

Note the general condition and vital signs

Giving fluid: as much as possible in a short time

Before blood is available, or the shock that was not caused by bleeding, can be
given liquid plasma (plasmanate), plasma expander or other fluids (Ringer's
lactate, NaCl 0.9% should be combined with other fluids as quickly out into the
extravascular space.

Supportive medication: vasodilator, corticosteroid, diuretics, correction of

acidosis

Purwadianto, Agus. 2013. Kedaruratan Medik: Pedoman Penatalaksanaan Praktis. Jakarta: Karisma.
Cont
Colloid therapy failed

Blood Transfusion

Do not give RL or Blood continuously but do resucitation operative

 Primary Survey
How to Assess
Disability Assessment the patient?

Level of
consciousness Light Reflex

GCS Reaction of
Size of pupil
Pupil
Eye: 2 (respond with pain)
Verbal: 1 (non responsive) GCS 4 severe trauma
Motoric: 1 (non responsive) capitis (for GCS 3-8)
Primary Survey
Expossure Assessment

The patient should be completely undressed, usually by cutting

off garments to facilitate a thorough examination and

assessment

cover the patient with warm blankets or an external warming

device to prevent hypothermia in the ED

Secondary Survey
Anamnesis
AMPLE
Defenitive Care
Re-Check ABC

Secondary Physical examintaion

survey Head to Toe Examination Transfer to
Trauma Center
Vital Sign

Laboratory general blood

and blood chemistry
examination

Radiology skull xray,

thorax xray, USG
Transfer to Trauma Center
Patient already in stable condition

Vital sign monitoring

IV line, NGT, chateter (have been installed)

Installed Oxygen

Suitable transportation

Assist by doctor

Confirmed in the hospital that have trauma center

Pathomechanism
Head Fracture Ruptur of Intracranial
injury basis a.meningea pressure Urges of
cranii media increase space

Blood from a.meningea

media flow to the nose and suppress the
ear Descreas of cerebral
consciousness hemispheres and
Bleeding at ARAS
Decrease of
nose and ear
suply O2 at Disturbace of
brain prefusion at
brain

compensation
hiperventilation takipnea

1. Harris, S. 2004. Penatalaksanaan Pada Kesadaran Menurun dalam Updates in Neuroemergencies. FKUI. Jakarta. Hal.1-7
2. American College of Surgeon Committee on Trauma. Cedera Kepala. Dalam : Advanced Trauma Life Support for Doctors. Edisi Ke-Tujuh. Ikatan Ahli Bedah Indonesia. Komisi trauma IKABI, 2004.
Hal: 167-186
3. Nuty WN, Endang M. Perdarahan hidung dan gangguan penghidu, Epistaksis. Dalam: Buku ajar ilmu penyakit telinga hidung tenggorok. Edisi 3. Jakarta, Balai Penerbit FK UI, 1998: 127 31.
 The Face Looked Pale

Bleeding a lot Hypovolemic Shock Vasoconstriction of

pheripheral blood vessel

Less perfusion in the

Pale skin

Reference:
Kolecki P. Hypovolemic Shock. 2012. Available at: http://emedicine.medscape.com/article/760145-overview#a0104.
Accesed: 1 October 2015
Butler A. Shock. Recognition, Pathophysiology, and treatment. 2010.
accesed: http://www.dcavm.org/10oct.html. pada 1 Oktober 2015.
 Phatomechanism Of Deformity
Heavy
Trauma pressure and Fracture
constantly

DEFORMITY

UCSF. UNIVERSITY OF CALIFORNIA, SAN FRASINSCO. DEPARTEMENT OF ORTHOPEDY SURGERY. DEFORMITY

HTTP://ORTHOSURG.UCSF.EDU/OTI/PATIENT-CARE/DIVISIONS/CONDITIONS/DEFORMITY/
Islamic Perspective
a) The Medical:

"Therefore we set (a law) for the Children of Israel that whoever kills a human
being, not because it (kill) another person, or for spreading mischief in the
land, it is as if he has killed all mankind. And who saved a life, it is as if he
saved the life of all human beings. And there came to them Our Messengers
with (carrying) the particulars that clear, then many of them thereafter
seriously exceed the limits in mischief on earth. " (QS. Al-Maidah, verse 32)
Islamic Perspective
b) Patients:
"Appointed pen of three groups:
1. People who sleep until she was awake,
2. The child until he baligh,
3. Those crazy until he returned his wits "
(HR. Abu Daud No. 4403, Shaykh Al Bani)
Islamic Perspective
c) Family Patient:

"For indeed after difficulty there is relief, the real hardship comes
ease."
(QS. Al-Insyirah, verse 5-6)
Reference:
Harris, S. 2004. Penatalaksanaan Pada Kesadaran Menurun dalam Updates in Neuroemergencies. FKUI.
Jakarta. Hal.1-7
American College of Surgeon Committee on Trauma. Cedera Kepala. Dalam : Advanced Trauma Life Support
for Doctors. Edisi Ke-Tujuh. Ikatan Ahli Bedah Indonesia. Komisi trauma IKABI, 2004. Hal: 167-186
Nuty WN, Endang M. Perdarahan hidung dan gangguan penghidu, Epistaksis. Dalam: Buku ajar ilmu penyakit
telinga hidung tenggorok. Edisi 3. Jakarta, Balai Penerbit FK UI, 1998: 127 31.
Harsono (ed.) 2005. Buku Ajar Neurologis Klinis. Cetakan ketiga. Penerbit Gadjah Mada University Press.
http://motusswedish.com/hl/?/11546/Snoring Mountain Orthopaedic Trauma Surgeons
McDonald JP. A review of surgical treatment for obstructive sleep apnoea/hypopnoea syndrome. Surgeon.
2003;1:259-264. Review.
Snoring. Kids HealthNemours Foundation website. Available at:
http://kidshealth.org/kid/health%5Fproblems/teeth/snoring.html. Updated January 2014. Accessed June 3,
2015.
Snoring and sleep apnea. American Academy of OtolaryngologyHead and Neck Surgery website. Available
at: http://www.entnet.org/HealthInformation/snoring.cfm. Accessed June 3, 2015.
Obstructive sleep apnea. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed.
Updated January 19, 2015. Accessed June 3, 2015.
Sher AE. Upper airway surgery for obstructive sleep apnea. Sleep Med Rev. 2002;6:195-212. Review.
Reference:
Yaggi HK, Concato J, et al. Obstructive sleep apnea as a risk factor for stroke and death N Engl J Med.
2005;353:2034-2041.
http://emedicine.medscape.com/article/248108-overview#a7
Dahlan S. 2007. Ilmu Kedokteran Forensik Pedoman Bagi Dokter dan Penegak Hukum p.77-80. Semarang:
Badan Penerbit Universitas Diponegoro Buku Ilmu Kedokteran Forensik. FK UI
Haines, Cynthia. 2013. Bruising. From site: http://www.healthgrades.com/symptoms/bruising. Access date:
September 29th, 2015.
Ucsf. University of California, San Frasinsco. Departement of Orthopedy Surgery. Deformity
http://orthosurg.ucsf.edu/oti/patient-care/divisions/conditions/deformity/ Accessed October 2, 2015
Kolecki P. Hypovolemic Shock. 2012. Available at: http://emedicine.medscape.com/article/760145-
overview#a0104. Accesed: 1 October 2015
Butler A. Shock. Recognition, Pathophysiology, and treatment. 2010.
accesed: http://www.dcavm.org/10oct.html. pada 1 Oktober 2015.
American College of Surgeons Committee On Trauma. Editor. Advanced Trauma Life Support for Doctorss.
United Satated of America : American College of Surgeons Committee On Trauma; 2008.
Purwadianto, Agus. 2013. Kedaruratan Medik: Pedoman Penatalaksanaan Praktis. Jakarta: Karisma
Intial evaluation of the trauma patient. By emedicine medscape internet.October 3rd 2015.
THANKS FOR ATTENTION