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IDENTITAS
Nama
: Ida Bagus Putu Lila Buana
Umur
: 50 tahun
Alamat
: Br Penyembahan Petak Kaja Gianyar
Dx masuk : CF tibial plateau D Sch II
OF Humerus D 1/3 T gr. IIIC
OF Antebrachii D 1/3 D gr. II
OF Cruris D 1/3 T gr. II
Union Fr. Clavicula D 1/3 T
OF antebrachii S segmental gr. IIIA
Vascular injury susp. Ruptur a. Axillaris D
DD. Ruptur a. brachialis D
Rsu ganesa
TIME CHART
Rs sanglah
meninggal
Sanglah
25/3/12
23.30
Kejadian
25/3/12
21.00
26/3/12
06.30-09.00
Orto
Debridement+ext-fix
+backslab antebrachii D
Antebrachii S
+ cruris D
Sanglah
Masuk OK IRD
24.00
RSU Ganesa
25/3/12
26/3/12
26/3/12
26/3/12
26/3/12
01.30
Mulai incisi
Orto
Ext. fix
humerus D
02.30-06.30
BTKV
Repair a + v Axillaris D
Graft dari v.saphena
magna S
10.00-12.00
thrombectomy
12.00 12.30
Hacting situasi
faciotomy
28/3/12
23.15 meninggal
Pasien datang sadar mengeluh nyeri pada tangan kanan, tangan kiri dan kaki
kanan setelah mengalami kecelakaan lalu lintas 3 jam SMRS. Riwayat
pingsan (-), Mual/muntah (-),. Pasien rujukan dari RS Ganesha dengan
diagnosis OF humerus D+OF antebrachii S+ OF cruris D. Riwayat syok di RS
ganesha (+) dan telah dilakukan resusitasi
Primary Survey:
A : lapang
B : Spontan, RR : 24x/mnt,
C : Stabil TD : 100/60 mmHg, N : 100 x/mnt
D : alert
SS
GCS E4V5M6
kepala
: CH (-)
mata
: RP +/+ isokor 3 mm, konj pucat -/maxillofacial
: edema (-) , maloklusi (-),
floating maxila (-)
THT
: otorea-/- rhinorea -/Thorax
: simetris, jejas (-)
cor : S1S2 tunggal reguler murmur (-)
po : ves +/+, rh -/- wh -/sonor/sonor
Abd
: distensi(-) jejas (-), defans (-)
Ekstrimitas
: status lokalis
STATUS LOKALIS
R. Humerus D
L: edema (+), fat bubble (+), bone expose (+), bleeding
aktif (-)
F : kripitasi (+), NT (+), pulsasi a.brachialis (-),
M : ROM distal (-)
R. Antebrachii D
L: v.appertum (+), pucat
F : NT (+), krepitasi (+), pulsasi a. radialis (-), a. ulnaris
(-)
M: ROM distal (-)
R.Antebrachii S
L: v.appertum (+).
F : NT (+), krepitasi (+), pulsasi a radialis (+), a. ulnaris
(+)
M: ROM distal terbatas
STATUS LOKALIS
R. Cruris D
L: edema (+), fat bubble (+), bone expose
(+), bleeding aktif (-)
F : kripitasi (+), NT (+),, a. Dorsalis pedis (+)
M : ROM distal terbatas
Ass:
OF Humerus D gr IIIC
OF Antebrachii D gr II
OF Cruris D gr II
OF Antebrachii S gr IIIA
Vascular injury susp ruptur axillary D
DL
DD: arteri brachialis D
Penunjang
Humerus D AP/Lat
Antebrachii D et S AP/Lat
Cruris D AP/Lat
WBC
HGB
HCT
RBC
PLT
25,37
12,70
36,40
4,18
216,50
SGOT
SGPT
Alb
BUN
CRE
46,20
33,10
3,72
14,00
1,21
Dx :
OF Humerus D 1/3 tgh gr IIIC
OF antebrachii D 1/3 distal gr
II
OF Antebrachii S Segmental Gr IIIA
OF Cruris D 1/3 tgh gr II
Union fr clavicula D 1/3 tgh
Vascular injury susp ruptur a. axilary
Tx:
Debridement+external fixasi+repair vascular
humerus D
Debridement + back slab antebrachii S dan cruris
Debridement + fasciotomy +external fixasi
antebrachii D
HCU
Dx:
Ruptur total a. axilaris D
Of Humerus D 1/3 tengah Gr IIIc
Of Antebrachii S Segmental Gr IIIa
Cf Antebrachii D 1/3 distal gr II
OF Cruris D 1/3 T Gr II
TX:
BTKV: Repair vaskular - v. saphena magna graft trombektomi
ruptur m. biceps, m. brachialis, m. triceps, ruptur a-v.
axilaris D, ruptur n. Medianus, n. Ulnaris
Ortho: Debridement + fasciotomy+ eksternal fiksasi + backslab
S: DPO
O:
TD: 118/57 (inotropik +) CVP 7, N: 114/ Rr 12x/m On ventilatory
support, T: 37
PEEP: 5, FiO2: 100% Sa: O2 100%
mata
: RP +/+, isokor 2/2mm
THT
: OTT (+), NGT (+)
Thorax : simetris,
pulmo: Ves +/+ Rh -/- WH-/Cor : S1S2 tunggal, murmur (-)
Abdomen : dist.(-), BU (+) N
Extremitas
atas D: Luka post op terawat terpasang external fixasi dan back slab
CRT<2, Sat O2 98%
UG:
CM
CK
ASS
Jam
WBC
HGB
HCT
RBC
PLT
: Anemia
Asidosis metabolik
: lanjut perawatan intensif
koreksi anemia
06.05
10,09
6.06
18,70
2,13
103,50
10.05
9.56
7,20
21,20
2,35
93,10
18.24
9,60
6,80
19,90
2,36
77,00
Ph
PCO2
PO2
HCO3SO2 %
N2
BE
K
JAM
PT
kPT
APTT
kAPTT
INR
SGOT
SGPT
Alb
BUN
CRE
Bil. Total
Indirek
Direk
Alkali phosp
21.00
11,50
71,00
33,50
1,74
260,00
248,90
2,41
13,00
1,79
0,44
0,12
0,32
78,00
06.05
7,28
50,00
158.00
23,50
99.00
135.00
- 6.0
5.00
10,05
7.10
45.00
169.00
14.00
99.00
136.00
-6.80
5.30
18.24
7.01
53.00
123
13,40
96.00
141.00
-8.00
4.00
S: DPO
O:
TD: 100/50 (inotropik +) CVP 5 N: 120 T: 38 Rr 12x/m
Cvc 500
PEEP 5
FiO2 60% Sa O2 100%
mata : RP +/+, isokor 2/2mm
THT
Thorax : simetris,
pulmo
CM :
3150
CK :
725
cc/24 jam
cc/24 jam
LAB:
WBC 10.27, HGB 8.50, HCT 25.40, PLT 34.80, RBC 3.13,
SGOT 260/ SGPT 248/ Alb 2,41/ BUN 39 / CR 1,79/ GDS 194/
pH 7,21/PCO2 40/PO2 180/HCo3-16/TCO2 17/BE -11,9/ SO2
99/Na 137/K 5,3
S: DPO
O:
TD: 130/50 (inotropik +) CVP: 10 N: 120 T: 39,5
RR: 12
Cvc 500
PEEP 10
FiO2 60% 80% Sa O2 100%
mata : RP +/+, isokor 2/2mm
THT
Thorax : simetris,
pulmo
CM :
1725
CK :
200
cc/17 jam
cc/17 jam
Lab:
WBC
HGB
HCT
RBC
PLT
AGD :
Ph
PCO2
PO2
HCO3SO2 %
Na
K
BE
jam
05.55
15.13
7,22
54,00
78,00
22.10
92.00
134.00
5,30
-11.00
7,22
56.00
93.00
22,90
95,00
132.00
5.90
-12.05
DL
15,00
10,80
31.00
3,69
90,00
PT
kPT
APTT
kAPTT
INR
19,00
12.00
46,50
34.20
1,89
SGOT
SGPT
Alb
BUN
CRE
2.230,00
1.839,00
2,132
46,63
4,445
Jam
TERIMA KASIH
Damage Control :
Indikasi :
Kontrol Perdarahan.
Kontrol Kontaminasi.
Metabolic Failure
Triad Of Death :
1. Hipotermi.
2. Asidosis yg Persiten.
3. Koagulopati.
COAGULOPATHY
HYPOTERMI
A
Cold diuresis
Plasma shift
Viscosity
HCT
CO
Sludging
Acidosis
Thrombosis microcirculation
MODS
Tissue hypoxia
DIC
ASIDOSIS
Most
control
controlhemorrhage
hemorrhage
control
controlcontamination
contamination
intraabdominal
intraabdominalpacking
packing
temporary
temporaryclosure
closure
Transfer problems
PART
PARTIII
III--OR
OR
pack
packremoval
removal
definitive
definitiverepair
repair
Transfer problems
PART
PARTII
II--ICU
ICU
core
corerewarming
rewarming
correct
correctcoagulopathy
coagulopathy
maximize
maximize
hemodynamics
hemodynamics
ventilatory
ventilatorysupport
support
36
32
Therapeutic
window
30
0
30
60
90
Time (hours)
120
Ancaman
Rasa Takut
Cedera/Trauma
Nyeri
Luka ringan
Lokal
Pro
Inflamasi Pro
Inflamasi
SIRS
Sembuh
Sistemik
Vasokonstriksi
Anti
Anti/Pro
-Kulit
Inflamasi Inflamasi
-Otot
-Hati/usus
CARS
Rad O2
Anergi
Mediator
MARS
Sembuh
CARS
Iskemia
ATP
pH
Transport Na+/K+
Translok bakt
sepsis
GOM
Sepsis
Paru
GOM
Ginjal
Hati
Usus/
Translok
Bakteri
Sepsis
SIRS
Iskemi/nekrosis
-Kulit
-Otot
-Hati/usus
Hipoksia
Cell deformability
stasis
Pergeseran crn
Resusitasi:
Sel bengkak
-operasi
-hipotermi Hiposantin
hemokonsentrasi
mikrotrombosis
Perfusi kapiler
MARS
Sembuh
Reperfusi
Rad O2
Mediator
leukosit
Oksigen
radikal
GOM
-Hati/usus
-Paru
-Ginjal
mediator
Permiabilitas
Mikrokapilar
Edema interst.
Tek. Jaringan
Asam urat
Peroksidasi lipid
Reperfusi
Hipoksia
Kerusakan jaringan
DSTC-Indonesia
43
EXTREMITY TRAUMA
SKIN AND SUBCUTANEOUS TISSUE
MUSCLE AND TENDON
BONE
JOINT LIGAMENT AND CARTILAGE
ARTERI AND VEIN
PERIFERAL NERVE
DSTC-Indonesia
44
Priorities in surgical
management
SAVE
LIFE
SAVE LIMB
SAVE JOINT
RESTORE FUNCTION
DSTC-Indonesia
45
LIFE THREATENING
FEMORAL FRACTURE
330 1300 ml
BLOOD LOSS
CRUSH INJURY
INTRA VASCULAR DEBRIS
MEDIATOR IMFLAMMATION
EMBOLISM ARDS
MOF
ARF
DSTC-Indonesia
FAT
46
LIMB THREATENING
SALVAGE
AMPUTATION
DSTC-Indonesia
47
PROTOCOL MANAGEMENT OF
SEVERE EXTREMITY INJURIES
1.
2.
3.
4.
48
PROTOCOL ..
7.
8.
49
Mangled extremity
High
energy trauma
Vascular injury
Severe comminuted
Soft tissue damage
DSTC-Indonesia
50
DSTC-Indonesia
51
Delayed amputation
High
morbidity
Bad prognosis
Age
Disability
Cost
DSTC-Indonesia
52
DSTC-Indonesia
COMPLICATION
Nerve
Vascular
Joint movement
DSTC-Indonesia
54
COMPLICATION
Secondary Ototoxicity, nephrotoxicity,myonecrosis
from
antibiotic
Secundary spread of infection, sepsis/
MOF/death
Psychosocial
Depression, loss of self-worth
Economic hardship, questionable employment status, marital
problem
Functional Chronic pain
Disability-muscle strength/endurance,decrease in activities of daily
function
Loss of ability to return work, inability to participate
in recreational activities.
Cosmesis Scars, bulky flaps.
DSTC-Indonesia
55
Mangled-Extremity-Syndrome Index
Criteria
Score
Criteria
Score
Bone injury
< 25
Simple
25-50
Segmental
>51
Segmental comminuted
Integument injury
Guillotine
Articular
Crush/burn
Avulsion/degloving
DSTC-Indonesia
56
Nerve injury
Contusion
Age
Transection
< 40
Avulsion
40-50
50-60
2
3
Vascular injury
Vein transected
>60
Artery transected
Pre-existing disease 1
Artery thrombosed
Shock
Artery avulsed
57
Suprapopliteal
1
Popliteal
2
Infrapopliteal
3
DSTC-Indonesia
1
2
3
58
Mild
Moderate
Severe
1
2
3
<6
0
6-12
2
>12
4
Salvage < 7, amputation > 8
DSTC-Indonesia
59
Score
DSTC-Indonesia
60
Limb schema
Pulse reduce or absent but perfusion normal
1*
2*
3*
DSTC-Indonesia
61
Shock
Systolik blood pressure always > 90 mmHg
DSTC-Indonesia
62
Age
< 30
30 50
> 50
DSTC-Indonesia
63
sensate
loss of dorsal
partial plantar
complete plantar
DSTC-Indonesia
SCORE
0
1
2
3
64
ISCHEMA
None
Mild
Moderate
Severe
0
1*
2*
3*
SOFT-TISSUE INJURY/CONTAMINATION
Low
0
Medium
1
High
2
Severe
3
* Double value if duration of schema exceeds 6
hours
DSTC-Indonesia
65
SKELETAL INJURY
Low energy
Medium energy
High energy
0
1
2
3
Shock/blood pressure
Normotensive
Transien hypotension
Persistent hypotension
0
1
2
DSTC-Indonesia
66
Age (years)
<30
30-50
>50
0
1
2
DSTC-Indonesia
67
DSTC-Indonesia
68
DSTC-Indonesia
69
DSTC-Indonesia
70
DSTC-Indonesia
71
DSTC-Indonesia
72
DSTC-Indonesia
73
DSTC-Indonesia
74
DSTC-Indonesia
75
DSTC-Indonesia
76
?
DSTC-Indonesia
77
Summary
The
DSTC-Indonesia
78
Kronologis:
Kecelakaan jam 21.00 tgl 25/3/2012
BB = 90 kg, TB 175 cm
DL durante
26/3/2012
op :
03.13
08.47
WBC
10.09
9.56
RBC
HGB
HCT
PLT
2,13
6,6
8,7
103
2,35
7,2
21.2
93
Evaluasi
post op :
Tensi : 95/51
SaO2 100%
cairan masuk
kristaloid 5500 cc
koloid 1500 cc
PRC 2000 cc
FFP 500 cc
Perdarahan
Berdasarkan HCT = HCT x EBV = 3200 cc
HCT awal
Ket :
EBV = 6750 cc
ABC = 1350 cc
MRS : 25/3/12
MENINGGAL : 28/3/12 (23.50)
DIAGNOSA
Cf Antebrachii D 1/3
distal gr II
06.06
OF Cruris D 1/3 T Gr II
10,27 Gr IIIa
Of Antebrachii S Segmental
TH :
8,50
Cod
A MOF
B MULTI TRAUMA
C KLL
3,13
34,80