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2- Penanganan Awal Pada Pasien Trauma Maxillofasial Injury - Fkg an-2
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PENANGANAN AWAL PADA PASIEN TRAUMA
MAXILLOFASIAL INJURY
Departemen Anestesiologi dan Terapi Intensif FKG – USU
2011
FKG AN - 2
Etiology and Incidence
• Multisystem injury 20-50%• Nasal and mandibular fractures most common
in community ED’s• Midface and zygomatic injuries most common
in Trauma centers• 25% of women with facial trauma result of
domestic violence• Incidence of concomitant cervical spine
injuries with facial fractures
TRIAGEPRIMARY SURVEYSECONDARY SURVEYSTABILISATION TRANSFERDEFINITIVE CARE
TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF
Emergency Medicine
Survei Primer
• Periksa cepat berurutan• Selesai dalam 2 menit• Terapi segera apa yang ditemukan
( treat as you
find )
Tujuan Survei Primer
• Secepat mungkin menemukan kelainan yang mengancam jiwa (cepat mematikan)– di sektor A - B - C - D
• Memberikan pertolongan yang memadai untuk menyelamatkan jiwa
• Pertolongan meliputi :– Resusitasi– Stabilisasi
Jangan terpukaukelainan yang jelas terlihat
Ikuti Sistematika A - B - C - D
Korban ledakan tabung elpiji
Muka hangusPneumotoraks (blast injury)
Luka bakar luasFraktura betis kiri
AIRWAY yang sulit
AIRWAY yang sulitmasker oksigentetap bermanfaat
Triage
RESUSITASI & STABILISASI
Survei primerSurvei sekunder
KamarOperasi
ICU
Hanya 50%pasien traumaperlu operasi
Terapi definitif/ rujukan
Emergency Medicine
RS lain
Derajat kegawatankorban berbeda-beda
Triage
Sorting of patients according to :•ABCDEs•Available resources
Multiple casualties Mass casualties
Preparation
Prehospital System Transport guidelines /protocols On-line medical direction Mobilization of resources Periodic review of care Closest appropriate facility
Preparation
Inhospital Preplanning essential Equipment, personnel, services Standard precautions Transfer agreement
Standard Precautions
• Cap • Gown• Gloves• Mask• Shoe covers• Goggles/face • Shields
Resuscitation Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia
Survei Primer
AirwayBreathingCirculationDisabilityExposure
Sumbatan jalan nafas pasien tak sadar paling sering disebabkan pangkal lidah
Airwaymenilai jalan nafas
• Kesadaran (bisa bicara?) • Look, Listen and Feel• Gerak dada• Gerak otot nafas tambahan • Warna kulit, mukosa, kuku
Airwaymengatasi obstruksi / sumbatan jalan nafas
• Lakukan chin lift / jaw thrust • Bersihkan rongga mulut (suction?)• Pasang jalan nafas oro / nasopharynx • Lindungi tulang leher• Intubasi trachea
19
20
Walaupun tanpa intubasi masih banyakpasien dapat ditolong
JN OropharynxJN NasopharynxJaw thrust
JN Nasopharynx
21
X
Neck lift
Head tilt
Chin-lift
Emergency Management and Resuscitation
• Airway– Most urgent complication-Airway compromise– Simple interventions first– No mandible?
• Intubation– Avoid nasotracheal intubation– May not want RSI
• Benzodiazepines• Ketamine• Etomidate
– Be Prepared and Be Creative
Primary Survey
C-spine injury Pitfalls
• Equipment failure• Inability to intubate • Occult airway injury• Progressive loss of airway
Establish Patent Airway
Caution
Primary Survey
Suspect C-Spine InjurySpinal protection C-spine X-ray when appropriate
25
Previously recommended hand positions for manual in-line stabilisation of the cervical spine.
Currently recommended hand positions for manual in-line stabilisation of the cervical spine.
Lindungi leher dari gerakan
Survei Primer
AirwayBreathingCirculationDisabilityExposure
Breathingmenilai pernafasan
• Adakah udara keluar masuk– Look, Listen, Feel
• Frekwensi nafas• Gerak cuping hidung• Cekungan sela iga
28
Breathingmembantu pernafasan
• 1. Oksigen (jika ada)• 2. Pernafasan buatan 1.
2.2.
29
- Pneumotoraks tension- Fr costa / Flail chest - Hemotoraks berat- Kontusio paru
- Pneumotoraks terbuka
Jejas di dada:
Breathingwaspada
Dekompresi pneumotoraks (tension)harus dikerjakan dalam Primary Survey
Survei Primer
AirwayBreathingCirculationDisabilityExposure
Circulationmengatasi perdarahan
• Hentikan perdarahan• Posisi shock• Pasang infus besar x 2• Ambil sampel darah
– u/ darah donor dan periksa Hb• Beri infus cairan, 1000 ml cepat
Circulationmengatasi perdarahan
• Beri infus cairan, 1000 ml cepat – RL (Ringer Laktat)– NaCl 0.9% (Garam Fisiologis)– RA (Ringer Asetat)– Hypertonic Saline Dextran 250 ml
Shock ?• Perfusi :
– pucat - dingin - basah– cap. refill time lambat (kuku, telapak)
• Nadi > 100• Tekanan darah < 100 (atau 90) mmHg Nadi masih
teraba di :– radialis > 80 mmHg – femoralis > 70 mmHg– carotis > 60 mmHg
Circulationwaspada & cari lokasi perdarahan
• Cedera intra-abdominal• Cedera dada• Patah tulang panjang• Patah tulang pinggul• Luka tusuk / tembus • Luka kulit kepala
Primary Survey
Circulatory Management Control hemorrhage Restore volume Reassess Pitfalls Elderly Children
Athletes Medication
Caution
Survei Primer
AirwayBreathingCirculationDisabilityExposure
Disabilitymenilai kesadaran
• Periksa Pupil (besar, simetri, refleks cahaya)• Periksa kesadaran
– A = Awake (sadar penuh)– V = responds to Verbal command
(ada reaksi terhadap perintah)– P = responds to Pain
(ada reaksi terhadap nyeri)– U = Unresponsive (tak ada reaksi)
A- V - P - U
Pupil
Primary Survey
Disability Baseline neurologic evaluation
• GCS scoring • Pupillary response
Observe for neurologic
deterioration Caution
Survei Primer
AirwayBreathingCirculationDisabilityExposure
Exposurepemaparan
• Lepaskan semua pakaian untuk pemeriksaan teliti menyeluruh, ada jejas apa saja
• Periksa punggung!– miringkan pasien cara Log-roll
• Cegah hipotermia (kedinginan)
Primary SurveyExposure / Environment • Completely undress the patient
Prevent hypothermiaCaution
Survei Primer
Foto Dada sinar-X / Chest X-Ray ( jika ada)
Tulang leher / C - Spine(lateral)Panggul ( Pelvis )Abdominal USG
Adjuncts to Primary SurveyVital sign
ECG ABGs Urinary Adjuncts Pulse Output oximeter
and CO₂
Urinary/gastric catheters unless contraindicated
© ACS
Adjuncts to Primary Survey Diagnostic Tools• Chest and pelvic x-ray• DPL• Ultrasound
Survei Sekunder
• Lanjutan dari survei primer• Hanya bila ABC sudah stabil• Teliti kepala sampai jari kaki• Kembali ulang survei primer jika pasien
tidak stabil / kondisi memburuk
Sistematika Emergency Medicine
TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF
Survei sekunder
• Mencari cedera yang mengancam jiwa atau cacad ekstremitas (life or limb)
• Pemeriksaan teliti dari kepala sampai kaki
• Dikerjakan setelah survei primer selesai• Dikerjakan jika ABC sudah stabil• Segera kembali ke survei primer jika ABC
memburuk lagi
Pemeriksaan kepala
• Kulit kepala (robekan, memar, laserasi) • Tengkorak (nyeri tekan, depresi tulang)• Mata (pupil, fundus, lensa, conjunctiva)• Cairan CSF / darah dari telinga, hidung,
mulut
Ada darah mengalir, tetapi dari mana ?
• Glasgow Coma Score• Pupil
– ukuran, simetri, refleks cahaya• Fungsi motorik• Fungsi sensorik• Refleks-refleks
Periksa kesadaran dan syaraf
Secondary SurveyHead Complete neurologic examination GCS score determination Comprehensive eye/ear examPitfalls Unconscious patient Periorbital edema Occluded auditory canal
Secondary Survey
The complete history and physical
examination
Secondary SurveyKey Components History Physical examination : Head-to-toe “Tubes and finger in every orifice” Complete neuro exam Special diagnostic tests Reevaluation
Secondary Survey
HistoryA Allergies M MedicationsP Past IllnessesL Last meal E Events/Environment
© ACS
Secondary SurveyMechanisms of Injury
Maxillofacial Trauma-Physical Exam
• Penetrating Injuries– Occult globe penetration– Eyelid lacerations
• Nose– Septal hematoma– CSF Rhinorrhea
• Ears– Subperichondral hematoma– Hemotympanum– Battle sign
Maxillofacial Trauma-Physical Exam
• Oral and Mandibular Exam– Mandible deviation– Teeth malocclusion– Paresthesia– Tongue Blade Test
• 95% Sensitive
• 65% Specific
Maxillofacial Trauma-Imaging
• Head, chest and abdominal trauma takes precedence
• PE detects up to 90% of fractures
• Plain Films
• CT– Orbital fractures– 3D images available
Maxillofacial Trauma-Specific Fractures
• Frontal Sinus/Bone Fractures– Direct blow– Frequent intracranial injuries– Mucopyoceles– Consult with NS for treatment, disposition and
antibiotics
• Nasoethmoidal-Orbital Injuries– Lacrimal apparatus disruption– Bimanual palpation if medial canthus pain– CT face
Maxillofacial Trauma-Specific Fractures
• Maxillary Fractures– High-energy injury– 100x gravity– Malocclusion– Facial lengthening– CSF rhinorrhea– Periorbital ecchymosis
LeFort Fractures
Maxillofacial Trauma-Specific Facial Fractures
• Mandibular Fractures– Second most common facial fracture– Often multiple– Malocclusion– Intraoral lacerations– Sublingual ecchymosis– Nerve injury
Pemeriksaan leher (1)
• Lihat / inspeksi • Palpasi (nyeri tekan, deformitas)• Anggap leher cedera• Imobilisasi pada posisi netral
Secondary SurveyCervical Spine Palpate for
tenderness Complete motor/
sensory exams Reflexes C-spine imaging
Pitfalls • Altered LOC for any reason• Other severe , painful injury
Pemeriksaan dadamencari ulang kerusakan
• Lihat / inspeksi• Palpasi• Perkusi• Auskultasi• Foto sinar-X dada (jika ada)• ECG ( jika ada)
Secondary SurveyChest Inspect Palpate Percuss Auscultate X-ray
Pitfalls • Elderly • Children
Secondary Survey
Abdominal Evaluation
Blunt trauma Penetrating trauma
Secondary SurveyAbdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies Pitfalls
• Hollow viscus and retroperitoneal injuries• Excessive pelvic manipulation
Secondary SurveyPerineum
Rectum
Vagina
Pitfalls
Contusions, hematomas,lacerations, urethral blood
Sphincter tone , high –ridingprostate pelvic fracture,rectal wall integrity, blood
Blood lacerations
Urethral injury in women, pregnancy
Ekstremitas / anggota gerak
• Inspeksi – deformitas, robekan, memar, laserasi
• Palpasi• Palpasi nadi arteria distal• Ingat compartment syndrome• Jangan lupa periksa punggung
Log-roll
Cari luka, robekan, memar, nyeri tekan, deformitas tulang belakang
4 orang
Pemberi komandoinstruksiyang jelas
Log-roll
Digulingkan serentak pelan-pelan
Foto sinar-x
• Dikerjakan waktu survei sekunder• Dada• Tulang leher - 7 segmen vertebra• Pelvis / panggul• Lokasi lain sesuai indikasi
– (misal fr tulang paha dll)
Secondary Survey
Musculoskeletal : Extreminities Contusion , deformity Pain Perfusion Peripheral neurovascular status X- rays as needed
Definitive Care
Local Facility
??Transfer agreements?? Local resources ??
??
Trauma SpecialtyCenter Facility
Reevaluate
Proceed to Secondary Survey After : Primary survey completed ABCD Es are reassessed Vital functions are returning to
normal
END
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