Penatalaksanaan Awal

Kegawatdaruratan Bedah 1

Oleh
dr.Yevri Zulfiqar ,SpB.SpU
Bagian bedah FK unand/
KSM Uologi RS M Djamil
Padang 2016

Topik kuliah
Penatalaksanaan Awal Kegawatdaruratan
Bedah 1 ( multipel trauma, syok hemoragik,
dan sepsis )

Penatalaksanaan Awal Kegawatdaruratan

Bedah 2 ( luka bakar, listrik dan petir )

Multipel Trauma
Trauma/ cedera yang mengenai lebih dari satu
organ

Contoh diagnosis:
Multipel trauma :
Cedera kepala berat GCS 5
Fraktur humerus dextra 1/3 tengah terbuka
Peritonitis difuse ec. Trauma tumpul abdomen

Overview
1. Preparation
2. Triage
3. Primary Survey
4. Resuscitation
5. Secondary Survey
6. Continued postresuscitation monitoring and
re-evaluation
7. Definitive care

 Konsep inisial assesment dlm ATLS (Advance

Trauma Life Support
Primary survey
Secondary Survey
Re evaluasi (definitive care)

 Standar Awal : APD (alat perlindungan Diri);

tutup kepala
Masker
Sarung tangan
dll

Persiapan
Prehospital
Inhospital

Primary Survey

Airway
Breathing
Circulation
Disability: Neurologic Evaluation
Exposure/Environmental Control

 Primary Survey (ABCDE) dan Resusitasi

Selama dilakukannya Primary Survey, kondisi
yang mengancam jiwa harus diidentifikasi dan
ditangani secara simultan. Ingat bahwa
tindakan lanjutan yang logis harus disesuaikan
dengan prioritas yang didasari oleh
pemeriksaan pasien secara keseluruhan

Primary Survey

Airway

Patency
Foreign bodies
Facial Fractures
Protect C-spine

 Airway and C spine control : Pemeriksaan Jalan Nafas

dengan kontrol Cervical Spine
Pemeriksaan : Jalan nafas dan cari adanya :
Benda asing
Fraktur mandibula/facial
Fraktur trakeal/laryngeal
Pemeriksaan singkat Untuk mencari Obstruksi jalan nafas

Stridor
Retraksi
Sianosis

 Manajemen : Pertahankan jalan nafas yang paten

Lakukan manuver chin lift atau jaw thrust

bersihkan jalan nafas dari benda asing
Masukkan orofaringeal atau nasofaringeal airway
Pertahankan definitive airway
Intubasi orotracheal atau nasotrakeal
Needle cricothyrotomy dengan jet insufflation pada
jalan nafas
Krikotirotomi dengan pembedahan

Primary Survey

Breathing

Patency does not equal adequate ventilation

Expose chest
Auscultate
Conditions that may acutely impair ventilation
Tension pneumothorax

Massive hemothorax
Flail chest
Rib fractures
Open pneumo
Pulmonary contusion

Management:
Mini torakotomi
Wsd
torakotomi

Primary Survey
Circulation
Circulation with hemorrhage control :
Assess sumber perdarahan
Resusitasi cairan

Primary Survey

Disability

Disability : status neurologis:

A : allert
V: verbal respon
P: pain respon
U: unresponsif

Glasgow Coma
Verbal Response
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sounds 2
None
1

Eye Opening
Spontaneous 4
To speech 3
To pain
2
None
1

Motor response
Obeys
6
Localizes
5
Withdraws
4
Decortication 3
Decerebration 2
None
1

Primary Survey
Exposure
Remove all clothes
Cover to prevent hypothermia

Resuscitation
Airway

Oral
Nasal- do not put in someone with facial
trauma
Endotracheal
Surgical

Breathing
Supply O2
Ventilate alveoli

Resuscitation
Circulation

Establish 2 large bore IVs

Draw blood
Vigorous IV therapy
ECG monitoring
Avoid hypothermia
Evaluate PEA
Other dysrhythmias

Hemorrhage classification
Class

% blood
loss
10 19
(750 cc)

Heart rate

Blood
pressure

II

20 29
(1250)

>100

Slightly

III

30 39
(2000)

>120

IV

>40

>140

Pulse
pressure

Resp rate

Capillary
refill
Normal

Urine
output

Other

Mortality

Oliguria

Acidosis

25%

Delayed

(>30)

Very
Delayed

Anuria

60%

Resuscitation
Catheters
Urinary

Rectal first
Check for other signs of urethral injury

Gastric
Oral v.s. nasal placement

Resuscitation
Monitoring

ABGs
Pulse oximetery
Blood pressure
ECG

Roentgenograms

Should not delay resuscitation

AP pelvis
AP chest
Lateral C-spine
Odontoid, AP C-spine

NGT Intracranial

Other Imaging
FAST scan
Focused Assessment Sonography in Trauma

Ultrasound
1.
2.
3.
4.

Pericardial sac (epigastric area)

Hepatorenal fossa
Splenorenal fossa
Pelvis or Pouch of Douglas (bladder)

Secondary Survey
Head-to toe evaluation
Vital sign evaluation
Detailed neuro exam if not done in primary
survey
Special procedures

Tubes and fingers in every orifice

Secondary Survey
History

A Allergies
M Medications
P Past illnesses
L Last meal
E Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment

Secondary Survey (PE)

Head

Scalp
Eyes
Nose
Mouth
Bite occlusion

Secondary Survey (PE)

C-spine and neck
PITFALLS
C-spine injury
Esophageal injury
Tracheal or laryngeal injury
Carotid injury (blunt or penetrating)

Secondary Survey (PE)

Chest
PITFALLS
Tension pneumothorax
Open chest wound
Flail chest
Cardiac tamponade
Aortic rupture (widened mediastinum)

Pneumothorax

Tension Pneumothorax

Secondary Survey (PE)

Abdomen
PITFALLS
Liver or splenic flexure
Deceleration injuries
Hollow viscus, Lumbar spine

Pancreatic injury
Major intraabdominal vascular injury
Renal injury
Pelvic fractures

Secondary Survey (PE)

Perineum/Rectum/Vagina
PITFALLS
Urethral injury
Rectal injury
Bladder injury
Vaginal injury

Retrograde urethrogram

Secondary Survey (PE)

Musculoskeletal
PITFALLS
SPINE FRACTURES
Fractures with vascular compromise
Pelvic fractures
Digital fractures

Secondary Survey (PE)

Neurologic
PITFALLS
Increased intracranial pressure
Subdural hematoma
Epidural hematoma
Depressed skull fracture
Spine injury
Beware of unconscious patient

Subdural Hematoma

Epidural Hematoma

Aftercare
Continuous reevaluation
Definitive care

Hemorrhagic Shock
Hemorrhagic Shock

Definisi :

Inadequate Perfusion
and oxygenation

Injuries Prone to Hemorrhage

Vascular

Solid Organ

Bones

Aorta
Vena Cava

Spleen
Liver

Pelvis
Femur

Quickly Rule Out Blood Loss

Chest CXR / FAST

Abdomen - FAST
Pelvis Xray
Femur exam / Xray

Fracture Associated Blood Loss

Humerus
Tibia
Femur
Pelvis

750 ml
750 ml
1500 ml
>3L

Associated Soft Tissue Trauma

Release of Cytokines
Increased permeability
Magnify fluid loss

Hemorrhagic
Shock

Pathophysiology

Heart
Rate
(beats/min)

Preload

Stroke
Volume
(cc/beat)

Myocardial
Contractility

Cardiac Output

Cardiac
Output
(L/min)

Afterload

Cellular Response to Shock

Acidosis

Blood
Loss

Cellular
Edema

Lactic
Acid

Inadequat
e
Perfusion

Cellular
Hypoxia

Anaerobic
Metabolism

Aerobic
Metabolism

Classic Signs & Symptoms of Shock

Changing mentation
Tachycardia
Cool, clammy, skin
Prolonged capillary refill
Narrowed pulse pressure
Decreased urine output
Hypotension

Normal
Vitals do not
r/o Occult Hypo
Perfusion

ATLS Classification of
Hemorrhagic Shock
CLASS I
BloodLoss (ml)

CLASS II

CLASS III

CLASS IV

<750
15%

750-1500
15%-30%

1500-2000
30-40%

>2000
>40%

HR

<100

>100

>120

>140

BP

normal

normal

decrease

decrease

PP

normal

decrease

decrease

decrease

RR

14-20

20-30

30-40

>35

UOP

>30

20-30

5-15

negligible

CNS

slightly
anxious

mildly
anxious

anxious
confused

confused
lethargic

Blood Administration
Traditional
Management

Emerging
Management

Fluid

Blood

Fluid

Blood

Give 2 Liters

Continue IVs
wide open

PRBC 5-10 u

Minimize

1:1 or 1:2
(Plasma: RBC)

Wait for labs

Plasma

Platelets

Protocolize

Massive
Transfusion
Protocol

Sepsis

Definitions
Systemic Inflammatory Response Syndrome
(SIRS)
Sepsis
Severe Sepsis
Septic Shock

SIRS
2 or more of the following:
Temp >38C or <36C
HR >90 beats/min
RR >20 breaths/min or PaCO2 <4.5kPa
WBC >12,000 or <4000 cells/mm3, or >10%
immature (band) forms

Sepsis
SIRS in the presence of proven or suspected
infection

Severe Sepsis
Sepsis associated with hypotension,
hypoperfusion and/or organ-dysfunction

Septic Shock
Sepsis with hypotension despite adequate
fluid resuscitation
May be vasodilatory and/or distributive
shock
Include all patients on vasopressors or
inotropic support

Organ Failure

CVS
Renal
Hepatic
CNS
Haematological

How do we manage sepsis and septic

shock?
1) Investigate and treat sepsis

Try and find and treat source

Early blood cultures
Start antibiotics asap ideally within 1 hour and
after cultures taken

2) Assess extent of end organ hypoperfusion and

improve oxygen delivery (early goal directed
therapy)

Oxygen delivery
What does it mean?

Delivery (DO2) = O2 content x cardiac output

= ([Hb] x SpO2 x 1.34) x (HR x SV)
Oxygen content = [Hb] x SpO2 x 1.34
Cardiac output = HR x SV

Fluid Challenge
Pemberian cairan sesuai kebutuhan pasien

Markers of perfusion
What are they?

Clinical signs
Warm skin, conscious level, u/o

Haemodynamic variables
CVP

Bloods
Serum Lactate

CVP
Akses yang cepat ke vaskuler melalui vena
sentral

Further Management
What else can be done?

Low tidal volume ventilation

Steroids in septic shock
Activated Protein C
Glycaemic control
Stress ulcer prophylaxis
Thromboprophylaxis
Sedation scoring / holds etc.

Take Home Message(s)

Early intervention saves lives

Send cultures immediately

Give antibiotics early (<1 hour on ICU)
Aggressive targeted fluid resuscitation on the spot
(early goal-directed therapy)
CVC / ScvO2 if shocked / Lactate > 4
Involve surgeons/radiologists early (source control)