Oleh

dr.Yevri Zulfiqar ,SpB.SpU

Bagian bedah FK unand/

KSM Uologi RS M Djamil
Padang 2016
 PenatalaksanaanAwal Kegawatdaruratan
Bedah 1 ( multipel trauma, syok hemoragik,
dan sepsis )

 Penatalaksanaan Awal Kegawatdaruratan

Bedah 2 ( luka bakar, listrik dan petir )
 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
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
 Prehospital
 Inhospital

 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
 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
 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
 Circulation with hemorrhage control :
 Assess sumber perdarahan
 Resusitasi cairan
 Disability : status neurologis:
A : allert
 V: verbal respon
 P: pain respon
 U: unresponsif
Verbal Response Motor response
Oriented 5 Obeys 6
Confused 4 Localizes 5
Inappropriate words 3 Withdraws 4
Incomprehensible sounds 2 Decortication 3
None 1 Decerebration 2
None 1
Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1
 Remove all clothes
 Cover to prevent hypothermia
 Airway
 Oral
 Nasal- do not put in someone with facial
trauma
 Endotracheal
 Surgical
 Breathing
 Supply O2
 Ventilate alveoli
 Circulation
 Establish 2 large bore IVs
 Draw blood
 Vigorous IV therapy
 ECG monitoring
 Avoid hypothermia
 Evaluate PEA
 Other dysrhythmias
 Hemorrhage classification
Class % blood Heart rate Blood Pulse Resp rate Capillary Urine Other Mortality
loss pressure pressure refill output
I 10 – 19 Normal
(750 cc)
II 20 – 29 >100 Slightly Delayed
(1250)

III 30 – 39 >120 (>30) Very Oliguria Acidosis 25%

(2000) Delayed

IV >40 >140 Anuria 60%

 Catheters
 Urinary
 Rectal first
 Check for other signs of urethral injury
 Gastric
 Oral v.s. nasal placement
 Monitoring
 ABG’s
 Pulse oximetery
 Blood pressure
 ECG
 Should not delay resuscitation
 AP pelvis
 AP chest
 Lateral C-spine
 Odontoid, AP C-spine
 FAST scan
Focused Assessment Sonography in Trauma
 Ultrasound
1. Pericardial sac (epigastric area)
2. Hepatorenal fossa
3. Splenorenal fossa
4. Pelvis or Pouch of Douglas (bladder)
 Head-to toe evaluation
 Vital sign evaluation
 Detailed neuro exam if not done in primary
survey
 Special procedures
 “Tubes and fingers in every orifice”
A Allergies
M Medications
P Past illnesses
L Last meal
E Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment
 Scalp
 Eyes
 Nose
 Mouth
 Bite occlusion
PITFALLS
 C-spine injury
 Esophageal injury
 Tracheal or laryngeal injury
 Carotid injury (blunt or penetrating)
PITFALLS
 Tension pneumothorax
 Open chest wound
 Flail chest
 Cardiac tamponade
 Aortic rupture (widened mediastinum)
PITFALLS
 Liver or splenic flexure
 Deceleration injuries

Hollow viscus, Lumbar spine

 Pancreatic injury
 Major intraabdominal vascular injury
 Renal injury
 Pelvic fractures
PITFALLS
 Urethral injury
 Rectal injury
 Bladder injury
 Vaginal injury
PITFALLS
 SPINE FRACTURES
 Fractures with vascular compromise
 Pelvic fractures
 Digital fractures
PITFALLS
 Increased intracranial pressure
 Subdural hematoma
 Epidural hematoma
 Depressed skull fracture
 Spine injury
 Beware of unconscious patient
 Continuous reevaluation
 Definitive care
Hemorrhagic Shock
Definisi :

Inadequate Perfusion
and oxygenation
Vascular Solid Organ Bones
Aorta Spleen Pelvis
Vena Cava Liver Femur

Quickly Rule Out Blood Loss

Chest – CXR / FAST
Abdomen - FAST
Pelvis – Xray
Femur – exam / Xray
 Fracture Associated Blood Loss

• Humerus 750 ml
• Tibia 750 ml
• Femur 1500 ml
• Pelvis >3L

Associated Soft Tissue Trauma

Release of Cytokines
• Increased permeability
• Magnify fluid loss
 Hemorrhagic
Shock

Pathophysiology
 Heart Stroke Cardiac
Rate
(beats/min)
X Volume
(cc/beat)
= Output
(L/min)

Myocardial
Preload Afterload
Contractility

Cardiac Output
 Blood Inadequat
Acidosis
Loss e
Perfusion

Cellular
Cellular
Edema
Hypoxia

Lactic
Aerobic
Acid Anaerobic
Metabolism
Metabolism
 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 CLASS II CLASS III CLASS IV

BloodLoss (ml) <750 750-1500 1500-2000 >2000

% 15% 15%-30% 30-40% >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 mildly anxious confused
anxious anxious confused lethargic
 Traditional Emerging
Management Management
Fluid Blood Fluid Blood
Give 2 Liters PRBC 5-10 u Minimize 1:1 or 1:2
↓ → ↓ (Plasma: RBC)
Continue IV’s Wait for labs
wide open ↓ Protocolize
Plasma ↓
↓ Massive
Platelets Transfusion
Protocol
 Systemic Inflammatory Response Syndrome
(SIRS)
 Sepsis
 Severe Sepsis
 Septic Shock
2 or more of the following:
 Temp >38ºC or <36ºC
 HR >90 beats/min
 RR >20 breaths/min or PaCO2 <4.5kPa
 WBC >12,000 or <4000 cells/mm3, or >10%
immature (band) forms
 SIRSin the presence of proven or suspected
infection
 Sepsis
associated with hypotension,
hypoperfusion and/or organ-dysfunction
 Sepsis with hypotension despite adequate
fluid resuscitation
 May be ‘vasodilatory’ and/or ‘distributive’
shock
 Include all patients on vasopressors or
inotropic support
 CVS
 Renal
 Hepatic
 CNS
 Haematological
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)
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
Pemberian cairan sesuai kebutuhan pasien
What are they?
 Clinical signs
 Warm skin, conscious level, u/o
 Haemodynamic variables
 CVP
 Bloods
 Serum Lactate
Akses yang cepat ke vaskuler melalui vena
sentral
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.
 Early intervention saves lives
 Send cultures immediately
 Give antibiotics early (<1 hour on ICU)
 Aggressivetargeted fluid resuscitation on
the spot (early goal-directed therapy)
 CVC / ScvO2 if shocked / Lactate > 4
 Involve surgeons/radiologists early
(source control)
Terima Kasih