Pemicu 2: Florence Stella

Pemicu 2 Florence stella

TRIAGE • Triage the central element of the hospital disaster response with implications far beyond the ED door. • The triage decision must therefore rely on a global impression of the patient’s clinical condition. • The major goal  facilitate better use of limited trauma resources.

Assessment • First patient expectant resuscitation team • Second patient immediate assessment, examinations (CT scan), stabilization • Third patient immediate • Fourth patient immediate (1st priority) • IV line • O2

LO 2. THERMAL TRAUMA • Burns  relatively common injuries caused by direct or indirect contact with heat, electrical current, radiation, or chemical agents. • The common denominator in all burns is protein denaturation and cell death. • Temperatures <44°C  generally tolerated for prolonged periods without causing burns • Temperatures >60°C  most tissue proteins are denatured. • Cell death occurs by one of two mechanisms: • Necrosis • Apoptosis

• Burn injury has been divided into three concentric zones: 1. 2. 3.

At the center of the burn Surrounding this central core (zone of ischaemia) Outermost zone of injury (zone of hyperemia)

• Regeneration of the damaged epidermis occurs from two primary sources: • Basal layer of cells • Dermal skin appendages (hair follicles and sebaceous glands)

CLASSIFICATION

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1st degree  epidermis 2nd degree superficial  papilary dermis 2nd degree deep  reticular dermis 3rd degree  full thickness 4rd degree  subcutaneous or deeper Rosen’s Emergency Medicine 7th Ed

First degree burn

CLASSIFICATION • Percentage of TBSA involved • Rules of nine : 18% front trunk, 18% back trunk, 18% each LE, 9% each UE, 9% head & neck, 1% perineal

Rosen’s Emergency Medicine 7th Ed

Management Airway • After exposure to superheated steam and toxic fumes, rapid and progressive upper airway  if not, edema may develop  compromised airway • If patient has compromised airway  orotracheal intubation is performed • If there is doubt  fiberoptic laryngoscopy should be performed

Management Breathing • D: history of exposure (ps burned in enclosed areas) and direct measurement of carboxyhemoglobin (HbCO) • Patients with CO levels < 20%  no physical symptoms • Higher CO levels result in: • Headache and nausea(20%-30%), confusion (30%-40%), coma (40-60%), death (>60%)

• Increased affinity of CO for hemoglobin, 240 times that of oxygen displaces oxygen from the hemoglobin molecule and shifts the oxyhemoglobin dissociation curve to the left • Patients should receive high-flow oxygen via non-rebreathing mask

Management Circulation • Patients may have accompanying hypovolemic shock  treat according to resuscitation principles in shock • Monitoring hourly urinary output can reliably assess circulating blood volume in the absence of osmotic diuresis  indwelling urinary catheter • Patients require 2 – 4 mL Ringer’s lactate solution/ kgBB/ percentage BSA of deep partialthickness and full-thickness during the first 24hrs • One-half of the volume required should be provided in the first 8 hrs, remaining one-half of the total fluid administer during the subsequent 16hrs • Formulas only provide starting target rate • After that, the fluid amount should be adjusted based on urine output target of 0.5mL/kg/hr for adults

Management • Always assume carbon monoxide (CO) exposure in patients who were burned in enclosed areas. • Higher CO levels can result in: • • • •

Headache and nausea Confusion Coma Death

• Early management of inhalation injury may require endotracheal intubation and mechanical ventilation. • Baseline HbCO levels should be obtained, and 100% oxygen should be administered. American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) for doctors: student course manual. 9th ed. Chicago: American College of Surgeons; 2012.

Electrical Injury • Primary electrical injury is the burn from radiated thermal injury when an electrical explosion occurs • Secondary blunt trauma from falls or being thrown from the electrical source by an intense muscle contraction or the explosive force • Clinical Features • Head and neck – head is common point of high-voltage injuries, and patient may exhibit burns and neurologic damage • Cardiovascular – cardiac arrest from asystole or ventricular fibrillation • Skin – burns • Extremities – muscle necrosis and compartment syndromes as a result of vascular ischemia and muscle edema. Damage to vessel wall may result in delayed thrombosis and hemorrhage, esp in small arteries to muscle. • Nervous system – transient loss of consciousness, unless there is concomitant head injury.

• Primary survey : • Airway and breathing • Intravenous fluid

• Management : • Standard crystalloid resuscitation in anticipation of myoglobinuria • Cardiac monitoring • ECG in high-voltage and low-voltage injury

Assessment Fourth patient’s • Second degree injury • • • •

Face 4,5% Chest & abdomen 18% Arms 9% Back 8 - 13%

• Third degree injury • Back 5 - 10%

• Total 44,5% - 54,5% • Prognosis malam

• Management • O2  high content, high flow • NaCl  2 IV line • Second degree cooling of the burn, burn dressings • Third degree excision, skin graft • Broad spectrum antibiotic Gram (+) • Bioplacenton • Indwelling urinary catheter • Analgetic tramadol • PPI

• First patient’s cardiac arrest • Management CPR

LO 3. HEAD TRAUMA

Clinical features and diagnostic strategies • History Details regarding the mechanism of injury to determine whether patient is at high risk for intracranial injury Past medical history, medications, recent drug or alcohol use, and complaints immediately before traumatic event

• Acute Neurologic Exam • Goals: detection of life-threatening injuries and identification of neurologic changes • Pupillary examination pupillary asymmetry, loss of light reflex, or dilated pupil suggest herniation syndrome

Clinical features and diagnostic strategies • Acute Neurologic Exam • Motor examination: posturing  assess strength and symmetry  look for hemiparesis contralateral

• Brainstem function  assessed patient’s respiratory pattern, pupillary size, and eye movements

• Deep tendon reflexes and Pathologic Reflexes tendon reflexes should be tested for symmetry babinski sign is nonspecific and can be caused by injury anywhere along the corticospinal tract

Assessment Second patient’s • Focal head injury CT scan

LO 4. SPINAL CORD TRAUMA • LMN  stage of lesion • UMN  lower stage of lesion

Spinal Cord Injury Classification • Quadriplegia injury in cervical region all 4 extremities affected • Paraplegia injury in thoracic, lumbar or sacral segments 2 extremities affected Injury either: • Complete • Loss of voluntary movement of parts innervated by segment, this is irreversible • Loss of sensation • Spinal shock

• Incomplete • Some function is present below site of injury • More favourable prognosis overall • Are recognisable patterns of injury, although they are rarely pure and variations occur

Injury defined by ASIA Impairment Scale A – Complete: no sensory or motor function preserved in sacral segments S4 – S5 B – Incomplete: sensory, but no motor function in sacral segments C – Incomplete: motor function preserved below level and power graded < 3 D – Incomplete: motor function preserved below level and power graded 3 or more E – Normal: sensory and motor function norma

Muscle Strength Grading • 5 – Normal strength • 4 – Full range of motion, but less than normal strength against resistance • 3 – Full range of motion against gravity • 2 – Movement with gravity eliminated • 1 – Flicker of movement • 0 – Total paralysis

Management • Immobilization: neck with semirigid cervical collar, long spine board, log roll technique to remove patient form board after arrival at ED • Fluid Resuscitation • Monitor CVP • Urinary catheter • Stomach catheter (for paraplegia and quadriplegia  stomach distension and aspiration)

• Steroid • •

Metilprednisolon 30mg/kg IV in 15 minutes Maintance: 5,4 mg/kg/hour in 24 hour, 3 hours after trauma or for 48 hour

LO 5. THORACIC TRAUMA • The most common  motor vehicle collisions (MVCs)  rupture of the myocardial wall or the thoracic aorta. • Causes of these include tension pneumothorax, cardiac tamponade, airway obstruction, and uncontrolled hemorrhage. • Hypoxia, Hypercarbia, Acidosis • Initial assessments & treatments : • • • •

Primary Survey Resuscitation of Vital Functions Detailed Secondary Survey Definitive care

Chest Wall Injury Pathophysiology

Clinical Features

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Outward expansion of the thorax by the respiratory muscles with descent of the diaphragm  negative intrathoracic pressure  passive air entry into the lungs during inspiration. blunt trauma.

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Elderly patients / preexisting pulmonary disease  unable to compensate for even minor chest wall trauma palpation  deformity, tenderness, or crepitus.

Subcutaneous Emphysema Pathophysiology

Clinical Features

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the presence of air in the tissues is a benign condition (chest trauma it usually represents serious injury). Air enters the tissues either extrapleurally or intrapleurally. Extrapleural tears in the tracheobronchial tree  allow air to leak into the mediastinum and soft tissues of the anterior neck, producing a pneumomediastinum. have Hamman’s crunch, which is a crackling sound with each heartbeat, heard on cardiac auscultation. Intrapleural lesions pneumothorax by allowing air to escape the lung through the visceral pleura into the pleural space  parietal pleura into the thoracic wall.

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Pericardiocentesis with aspiration of air from the pericardial space The underlying cause, such as pneumothorax, ruptured bronchus, or ruptured esophagus Benign pneumomediastinum secondary to a Valsalva maneuver  observation high-flow oxygen to facilitate the reabsorption of nitrogen from tissues

Rib Fracture Pathophysiology

Clinical features

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break at the point of impact/ posterior angle/ posterolateral area the weakest area. 4-6 ribs  most common potential for penetrating injury to the pleura, lung, liver, or spleen. Patients with right-sided  three times more likely to have a hepatic injury Leftsided  four times more likely to have a splenic injury. ribs 1 to 3  severe intrathoracic injury

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Diagnostic Strategies

tenderness, bony • crepitus, ecchymosis, and • muscle spasm over the • rib barrel compression test pain at the site of fracture.

Chest x-ray films CT scans simple rib fractures are strongly suspected  no need to routinely obtain a CT scan (unless other intrathoracic pathology needs to be studied)

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Oral pain Bupivacaine (Intercostal nerve blocks with a longacting anesthetic) with epinephrine  relieve symptoms up to 12 hours 1 or 2% lidocaine or 0.25% bupivacaine (along the inferior rib margin several centimeters posterior to the site of the fracture). Continuing daily activities and deep breathing  ensure ventilation and prevent atelectasis.

Sternal Fracture Pathophysiology

Clinical Features

Diagnostic Strategies

Management

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anterior chest pain, point tenderness over the sternum, ecchymosis, soft tissue swelling, or palpable deformity.

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Sternal fracture usually results from the diagonal strap of a seat belt restraining the upper part of the sternum. rapid deceleration from a frontal impact  the forward thrust of the body against the fixed seat belt across the sternum  fracture at that location. Mediastinal hematomas  related to aortic injuries acute blood loss and sudden alterations in cardiopulmonary physiology  hemodynamic deterioration. mediastinal hematomas can cause death from compression of adjacent structures

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Most fractures are transverse lateral radiographic view is often diagnostic (plain films are sometimes inconclusive). The advent of helical CT, especially with threedimensional images of the skeletal system  improved diagnosis of sternal fractures. lead electrocardiogram (ECG) should also be obtained during the initial evaluation.

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adequate analgesia. respiratory compromise, or physical deformity  Mechanically operative fixation

Flail Chest Pathophysiology

Clinical Features

Diagnostic Strategies

Management

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Flail chest results when three or more adjacent ribs are fractured at two points freely moving segment of the chest wall to move in paradoxical motion (hallmark) with the flail segment  inward with inspiration and outward with expiration. Underlying pulmonary contusion major cause of respiratory insufficiency with flail chest. the pain of the injury  muscular splinting with resultant atelectasis, hypoxemia, and decreased cardiac output

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paradoxical motion (sometimes be visualized) Pain, tenderness, and crepitus Endotracheal intubation and positive-pressure ventilation will internally splint the chest wall  the flail segment difficult to detect on physical examination. observed for signs of an associated injury such as tension pneumothorax.

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Multiple rib fractures  on chest x-ray films. CT scan is much more accurate detecting the presence and extent of underlying injury and contusion to the lung parenchyma. ECG and cardiac enzymes (dysrhythmias, high-grade blocks, or hemodynamic instability unexplained by other causes such as hemorrhage)

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Oxygen endotracheal intubation & mechanical ventilation CPAP effective analgesia cardiac and oximetry monitors applied operative internal fixation aggressive pulmonary physiotherapy

Pulmonary Contusion Pathophysiology

Clinical Features

Diagnostic Strategies

Management

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direct bruise of the lung parenchyma followed by alveolar edema and hemorrhage but without an accompanying pulmonary laceration Great force is required to produce pulmonary contusion, such as from a fall from height, an MVC, and other forms of significant trauma.

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dyspnea, tachypnea, cyanosis, tachycardia, hypotension, and chest wall bruising. hemoptysis and moist rales or absent breath sounds may be heard on auscultation. Palpation  fractured ribs

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x-ray studies (begin to appear within minutes of injury and range from patchy, irregular, alveolar infiltrate to frank consolidation ) CT- Scan Arterial blood gases

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primarily supportive Hypoxemia  intubating and ventilating each lung separately with a duallumen endotracheal tube and two ventilators. noninvasive positive pressure ventilation with BPAP or CPAP to avoid intubation and mechanical ventilation. restriction of intravenous fluids to maintain intravascular volume within strict limits vigorous tracheobronchial toilet, suctioning pain relief

Pneumothorax Pathophysiology •

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Pneumothorax can be divided into three types depending on whether air has direct access to the pleural cavity: simple, communicating, and tension. simple  there is no communication with the atmosphere or any shift of the mediastinum or hemidiaphragm resulting from the accumulation of air. It can be graded according to the degree of collapse as visualized on the chest radiograph. A small pneumothorax occupies 15% or less of the pleural cavity, a moderate one 15 to 60%, and a large pneumothorax more than 60%. Traumatic pneumothorax  fractured rib that is driven inward, lacerating the pleura. Communicating Pneumothorax  defect in the chest wall and most commonly occurs in combat injuries (shotgun wounds) Air can sometimes be heard flowing sonorously in and out of the defect, prompting the term “sucking chest wound.”

Tension Pneumothorax Pathophysiology

Clinical Features

Diagnostic Strategies

Management

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The progressive accumulation of air under pressure within the pleural cavity  shift of the mediastinum to the opposite hemithorax and compression of the contralateral lung and great vessels, It occurs when the injury acts like a one-way valve prevents free bilateral communication with the atmosphere  progressive increase of intrapleural pressure.

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Shortness of breath and chest pain acutely ill with cyanosis and tachypnea to misleadingly healthy. decreased or absent breath sounds and hyper-resonance over the involved side as well as subcutaneous emphysema dyspneic, agitated, restless, cyanotic, tachycardic, and hypotensive and display decreasing mental activity. The cardinal signs of tension pneumothorax are tachycardia, jugular venous distention (JVD), and absent breath sounds on the ipsilateral side.

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An upright film  small pleural effusions that are not visible on supine films, and it also allows better visualization of the mediastinum. chest radiograph  diagnosing a simple pneumothorax CT is very sensitive in finding small pneumothoraces even in supine patients

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Immediate decompression 14-gauge angiocatheter in the 2nd ICS in the midclavicular line of the affected side Repeated reassessment is necessary Definitive treatment : insertion of a chest tube

Open Pneumothorax • Large defects of the chest wall that remain open results in an open pneumothorax (sucking chest wound) • Pathophysiology : • If wound is 2/3 of the tracheal  chest wall defect with each respiratory effort  effective ventilation is impaired

• Signs: Hypoxia, Hypercabia • Management : • • • • • • •

Closing the deffect Sterile oclusive dressing Large, overlap the wound Taped securely on 3 side Inspiration: prevented air entering Expiration: air escape from pleural Definitive treatment: surgical closure

Hemothorax Pathophysiology

Diagnostic Strategies

Management

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Hemorrhage from injured lung parenchyma is the most common cause of hemothorax intercostal and internal mammary arteries causing hemothorax more often than hilar or great vessels. Bleeding from the intercostal arteries may be brisk (branch directly from the aorta). Tactile fremitus is decreased, and breath sounds are diminished or absent.

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The upright chest radiograph  meniscus of fluid blunting the costophrenic angle and tracking up the pleural margins of the chest wall when viewed on the upright chest x-ray film. With a massive hemothorax tension hemothorax signs and symptoms of both obstructive and hemorrhagic shock CT scanning has the highest sensitivity, Furthermore, one drawback of ultrasonography for the identification

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Close monitoring of the initial and ongoing rate of blood loss is performed. Immediate drainage of more than 1500 mL of blood from the pleural cavity  indication for urgent thoracotomy. Perhaps even more predictive of the need for thoracotomy is a continued output of at least 200 mL/hr for 3 hours. restoring the circulating blood volume controlling the airway as necessary serial chest radiographs lung reexpansion A large-bore tube should be inserted in the fifth interspace at the anterior axillary line and connected to underwater seal drainage and suction (20-30 mL H2O).

Hemothorax • Severe or persistent hemorrhage  thoracostomy or open thoracotomy. • operative intervention (complications from penetration of the lung parenchyma from tube thoracostomies) • Video-assisted thoracic surgery (VATS)  evaluation and evacuation of retained hemothorax, control of bleeding from intercostal vessels, and diagnosis and repair of diaphragmatic injuries.

Cardiac Tamponade • Cardiac tamponade compression of the heart due to fluid accumulation within the pericardium • Triad Beck’s • Hypotension • Distended neck vein • Muffled heart sound

• Kussmaul’s sign • PEA

Cardiac Tamponade • Initial treatment: fluid replacement  no response  cardiac tamponade  surgery or pericardiocentesis (no surgeon) • Subxyphoid pericardiocentesis: • Aspirate blood • US to facilitate accurate insertion • Not for blood in pericardial sac has clotted

• Resuscitative Thoracotomy: • Evacuate pericardial blood causing tamponade • Direct control of exsanguinating intra-thoracic hemorrhage • Open cardiac massage • Cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart

Assessment • Second patient’s close pneumothoraks, Subcutaneous Emphysema left chest • Management Water Seal Drainage

LO 6. ABDOMINAL TRAUMA BLUNT TRAUMA • 2 Intra-abdominal injuries may occur by four mechanisms: • • • • • • • •

Crushing of an organ against the spine, pelvis or the abdominal wall. Deceleration forces. Sudden increase of the intraluminal pressure and bursting of a hollow viscus. Injury by broken lower ribs. Results in two types of hemorrhage: intra-abdominal and retroperitoneal Spleen (40-55%); liver (35-45%); Small bowel (5-10%) History Mechanism of injury • Direct blow: eg: contact with lower rim of steering wheel. Compression & crushing injuries  deform solid and hollow organs  can rupture with secondary hemorrhage  contamination associated with peritonitis • Shearing injuries: crushing injury due to restraint worn improperly; deceleration injuries. Example of injury: laceration of spleen and liver, bucket handle injuries to small bowel

Clinical Examination • Inspection • Fully undressed • Anterior & posterior abdomen  abrasions, contusions, lacerations, penetrating wounds, etc • After rapid physical examination, patient should be covered with warmed blankets to help prevent hypothermia

• Auscultation • Presence or absence of bowel sounds • Free intraperitoneal blood/GI contents  ileus  loss of bowel sounds

• Percussion & Palpation • Rigidity and severe or increasing tenderness are signs of peritonitis. • Pain referred to the left shoulder (Kehr’s sign) is suggestive of splenic injury. Similarly, pain referred to the right shoulder is suggestive of hepatic injury.

• Assessment of: • • • •

Pelvic stability Urethral, perineal, rectal exam Vaginal exam Gluteal exam

Investigations If the patient clearly needs a laparotomy, undue delay for unnecessary investigations is unwarranted. • Evaluate all trauma patients admitted through the resuscitation room by means of ultrasound • Plain x-rays: • Chest x-ray thoracic trauma is a commonly associated problem • X-rays of the spine, pelvis, and ribs are obtained as indicated. • Abdominal CT scan

• Microscopic analysis for hematuria • Serum amylase • To exclude pancreatic trauma • Diagnostic peritoneal aspirate (DPA): • used in multi-trauma patients who are hemodynamically unstable and have a negative or questionable FAST exam and the source of hypotension is not obvious

• Imaging must be done if: • equivocal abdominal examination, altered sensorium, or distracting injuries (e.g. head trauma, spinal cord injury resulting in abdominal anesthesia) • unexplained shock/hypotension • multiple trauma patients who must undergo general anesthesia for orthopedic, neurosurgical, or other injuries • fractures of lower ribs, pelvis, spine • positive FAST

Management • Urology consult • Renal • minor injuries: conservative management • bedrest, hydration, analgesia, antibiotics

• major injuries: admit • conservative management with frequent reassessments, serial U/A ± re-imaging • Surgical repair (exploration, nephrectomy): hemodynamically unstable or continuing to bleed >48 h, major urine extravasation, renal pedicle injury, all penetrating wounds and major lacerations, infections, renal artery thrombosis

• Ureter – Ureterouretostomy

• Bladder – Extraperitoneal • minor rupture: Foley drainage x 10-14 d • major rupture: surgical repair

– Intraperitoneal • drain abdomen and surgical repair

• Urethra – anterior: conservative, if cannot void  Foley or suprapubic cystostomy and – posterior: suprapubic cystostomy (avoid catheterization) ± surgical repair

Penetrating Abdominal Injuries A distinction should be made between high-velocity and low-velocity injuries. This is necessary because the severity of the injury, the treatment, and the prognosis are different High-Velocity Injuries • High-velocity missiles cause extensive tissue damage. These patients almost always require a laparotomy. • Low-Velocity Injuries • These are usually due to “civilian” violence (stab wounds, most handguns). Management • general: ABCs, fluid resuscitation, and stabilization • gunshot wounds always require laparotomy

Investigations should be performed only on fairly stable patients where the abdominal physical examination is equivocal.

• Plain chest and abdominal x-rays (for gunshot wounds) • Look for associated hemopneumothorax, diaphragm abnormalities, fractures, missiles.

• Urinalysis for hematuria. • Diagnostic laparoscopy • Routine investigation for all asymptomatic left or anterior right thoracoabdominal injuries.

• CT scan with intravenous contrast for patients selected for nonoperative management. • Sigmoidoscopy should be done for pelvic gunshot wounds with suspected rectal injuries, especially if blood is found on rectal examination

Assessment Second patient’s • Abdomen is distended with disminished bowel sounds blunt abdominal trauma • Distended air/fluid in the abdomen ancillary tests

LO 7. PELVIC TRAUMA • Pelvic fracture is a disruption of the bony structures of the pelvis. In elderly persons, the most common cause is a fall from a standing position. • Fractures associated with the great morbidity and mortality involve significant forces such as from a motor vehicle collision (MVC) or fall from a height. • The profound magnitude of force required to disrupt the pelvic ring frequently causes severe injuries to other organ systems.

B2 type partially stable

B1 type partially stable

C1 type unstable

Diagnostic • Physical Examination • Perineal or genital ecchymosis or hematoma may be observed ecchymosis in the periumbilical area (Cullen’s sign) or flanks (Grey Turner’s sign) from retroperitoneal hemorrhage may be present. • Careful palpation of the pelvic ring to seek the presence of point tenderness is imperative • palpation starts at the symphysis anteriorly proceeds to both pubic rami, the iliac spines and crests and finally to the sacrum and SI joints posteriorly

• “Springboarding” of the pelvis to assess the rotational stability of the pelvic ring should be strictly avoided.

• Radiology • AP plain radiography of the pelvis (PXR) • Computed Tomography (CT)

• ATLS guidelines advocate the initial use of crystalloid solutions to stabilize vital signs in the trauma patient • In contrast, arteriography is excellent at both diagnosing and managing arterial bleeding • Embolization is highly effective for controlling arterial bleeding. • Angiography is indicated when hypovolemia persists in ampatient with a major pelvic fracture despite control of hemorrhage from other sources.

C-clamp

American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) for doctors: student course manual. 9th ed. Chicago: American College of Surgeons; 2012.

Assessment • Unstable on palpation Type C pelvic fracture • Multiple fractures compression lumbal and pelvic fractures • Management CT scan, resuscitation, immobilization

References • Rosen’s Emergency Medicine 7th Ed • American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) for doctors: student course manual. 9th ed. Chicago: American College of Surgeons; 2012.