Managemen bencana & P3Kpada kecelakaan kegawatdaruratan sehari2dr. Moch Junaidy Heriyanto, SpB, FINACS

EarthquakesWarExplosionsIndustrial accidents such as those occurring in miningRoad traffic accidents

TOTAL CARE Pencegahan TraumaPra- Rumah SakitSewaktu di UGDSewaktu di kamar bedahSewaktu perawatan

Pra-Rumah SakitResponse timePemilihan cairan resusitasiSelective hypotensive resuscitationMencegah hipothermi

Di Rumah SakitTriase & response timePenanganan segera koagulopati, hipotermia & asidosisTransfusi komponen darah berdasar indikasiDamage control surgeryDamage control resuscitation (Hematologic resuscitation)non-operative management cedera organ solid (NOM)perawatan ICU

MENGAPA TRAUMA PENTING DAN HARUS DITANGANI SEBAIK MUNGKIN

TRAUMA-1Penyebab kematian nomor satu di AS untuk golongan usia 1-44 tahun

Selama periode 1999 s/d 2003, tercatat sebagai penyebab utama kematian untuk usia < 65 tahun, melebihi kematian akibat kanker dan penyakit jantung-serebral

TRAUMA-2Pada trauma, penyebab kematian segera (early death) adalah syok hipovolemik atau cedera otak beratPada trauma berat, timbul iskemia di seluruh tubuh, dan kemudian setelah resusitasi dapat terjadi cedera reperfusi, berupa reaksi inflamasi berlebihan diluar kendali badan

KEMATIAN SETELAH DIRAWATUmumnya disebabkan infeksi nosokomial, sepsis dan MODS/MOFPenyebab kematian lain adalah cedera otak sekunder karena hipoksia serebri (hipotensi berlarut, sepsis intra abdominal)

TRIAD OF DEATHMoore EE Am J Surg, 1996, 172;405

Identifikasi Riwayat Perjalanan PenyakitPresentasi KlinisRiwayat penyakit dahuluPola presentasi penyakitAnamnesisSurvei PrimerSurvei Sekunder +Pencitraan

Survei PrimerA = AirwayB = BreathingC = CirculationD = DisabilityCepat Mengancam Jiwa

Survei SekunderSetelah Survei Primer selesaiKajian cepat : Tingkat kesadaran, fungsi saraf kranial, fungsi motorik, fungsi sensorik, refleks.

defisit neurologis fokal ???

Pengambilan KeputusanSurgery atau Konservatif ?Cito atau Elektif ?

Survei Primer + Sekunder + Pencitraan

Call For HelpAKTIFKAN SISTEM EMS(Emergency Medical Service)Atau bantuan tenaga medis lain

( Acute Care + Traumatology + Intensive Care)Three peaks of trauma related deaths4 weeks2 weeks1 hour 3 hoursFirst peakLaceration of brainbrainstemaorta spinal cordheartSecond peakExtraduralSubduralHemopneumothoraxPelvic fracturesLong bone fracturesAbdominal injuriesThird peakSepsisMulti organ failureSecondary Brain InjuryDEATHS

Laki laki, 25 thn, datang ke IRD keluhan nyeri perut akibat terkena benturan sepeda motor.4 jam SMRS saat penderita mengendarai motor mengalami tabrakan dengan pengendara motor lain, roda depan motor penabrak membentur perut penderita.

Survey Primer :A: baikB: RR : 24x/menitC: N : 120 x/mnt TD: 80/50 mmHgD: GCS : 15Penilaian kondisi pasien??

Initial management ??

pada pasien ini dilakukan : Infus RL 3000 cc NGT Catheter

pasca resusitasi : N : 92 x/mnt TD: 100/70 mmHg

apakah resusitasi yang dilakukan sudah tepat?

Survey sekunder : Regio abdomen :I : tampak jejas berupa hematom di epigastriumP: NT (+), NL (-), DM(-)P : TympaniA : BU (+)

RT : TSA baik, mukosa licin, Nyeri (-) sarung tangan; feses (+), darah (-)

General Principles of vascular trauma/injury Always start with ABCLarge IV pore lines External compression to control bleeding Look for hard signs of arterial injuries

Review Of CirculationCells need supply of nutrients and removal of by productsIn a unicellular organism this may occur via the cell membrane into say a pond or seaMulticellular organisms need a circulatory system

Prolonged & severe skeletal muscle ischemiarelease:Myoglobin (nephrotoxic)Potassium (arrhythmia)

Acute interruption of extremity blood flow can lead to organ failure and death if not recognized and treated aggressively

DELAY : increase the risk of irreversible ischemic injury, organ failure, and death

EARLY RECOGNITION AND TREATMENT

GOAL: reperfusion of the ischemic limb within 6 hour or less

Effects Of Acute IschemiaReduced blood flowPulseless, pallor, perishing coldNerve ischemiaPain, paralysis, ParesthesiaMuscle ischemiaRhabdomyolysisCompartment syndromeIschemia reperfusion syndrome

Hard signPulsatile bleedingExpanding hematomaPalpable thrillAudible bruitEvidence of regional ischemia:PallorParesthesiaParalysisPainPulselessnessPoikilothermia

Is this Arterial or Venous injury ?ArterialPulse examinationHard signs

Pulsetile ext. bleedingAbsent distal pulses.Expanding hematomaDistal ischemiaThrill or bruit

Is this Arterial or Venous injury ?Venous Low pressure dark blood external bleeding Non-expanding hematomaShock is rare unless associated with arterial injury

Vascular traumathe clock starts ticking

Blood loss Progressive ischemia Compartment syndrome Tissue necrosisIrreversible damage after 6 hours

Arterial injuries associated with fractures or dislocationsClavicle fracturesubclavian arteryShoulder fx/dislocationaxillary arterySupracondylar humerus fxbrachial arteryElbow dislocation brachial arteryPelvic fracturegluteal arteriesFemoral shaft fxfemoral arteryDistal femur fracturepopliteal arteryKnee dislocationpopliteal arteryTibial shaft fxtibial arteries

Physical examMajor hemorrhage/hypotensionArterial bleedingExpanding hematomaAltered distal pulsesPallorTemperature differential between extremitiesInjury to anatomically-related nerve

Asymmetric pulses warrant doppler examination (determine ABI)

Absent pulses warrant emergent vascular consultation/surgical exploration

Damage control Arteries that can be ligated with few consequences: The common and external carotid, subclavian, axillary , internal iliac arteries & Celiac axis.ICA ligation : 10-20% stroke rate.EIA,CFA & SFA: high risk of limb ischemia.SMA & IMA : gut necrosis

Damage control

Almost all veins including the IVC can be ligated when necessary

Shock :A state of inadequate tissue perfusion in which the delivery of oxygen to tissues and cells is insufficient to maintain normal aerobic metabolism. an imbalance between substrate delivery (supply) and substrate requirements (demand) at the cellular level.

Classification of shock based on etiology :HypovolemicCardiogenicNeurogenicInflammatory (Septic)ObstructiveTraumatic

Combination is possible

The Organs ResponsesBlood loss

MicrovascularSystem Immune& inflammatory organresponseresponses

cellularNeuro-endocrine metabolic Cardiovascularresponse PulmonaryRenal

Vicious Cycle of Hemorrhagic ShockEndothelial ActivationMicrocirculatory damageCellular aggregation

Assessment of the class of shock (ATLS- a 70 kg patient) ClassI II III IV

Blood loss (ml) up to 750750-15001500-2000 >2000 % blood volume up to 15%15%-30%30%-40% > 40%Pulse Rate < 100>100>120 > 140Blood Pressure normalnormaldecreased decreasedPulse Pressure n / decreaseddecreased decreasedRespiratory rate 14-2020-3030-40 >35Urine Output(cc/hr) >3020-305-15 negligibleMental status mild depr. depresseddepr, conf. lethargicFluid resusc. CrystalloidCrystalloidBlood + Blood +Crystalloid Crystalloid

Principles of Medical CareAims : to control the source of bleeding as soon as possible and to replace fluid lossPre hospital care :Evacuation time < 1 hour (usually urban trauma), immediate evacuation to a surgical facility (after airway and breathing (A, B) have been secured ("scoop and run"). Evacuation time > 1 hour, an intravenous line is introduced and fluid treatment is started before evacuation.

Fluid replacement strategyIn controlled hemorrhagic shock (CHS), where the source of bleeding has been occluded, fluid replacement is aimed toward normalization of hemodynamic parameters.In uncontrolled hemorrhagic shock (UCHS), in which the bleeding has temporarily stopped because of hypotension, vasoconstriction, and clot formation, fluid treatment is aimed at restoration of radial pulse or restoration of sensorium or obtaining a blood pressure of 80 mm Hg by aliquots of 250 mL of lactated Ringer's solution (hypotensive resuscitation).

How to prevent mortality from hemorrhagic shock ? Prevent early mortality with focus on resuscitation for hypovolaemia. Prevent secondary brain injury Prevent late mortality after trauma care with the emphasize on efforts to immuno-modulate inflammatory reactions.

Tissue hypoperfusion Algorithm in TraumaHarbrecht BG, Forsythe RM & Peitzman AB in TRAUMA Mattox. 2008

Tissue hypoperfusion Algorithm in TraumaHarbrecht BG, Forsythe RM & Peitzman AB in TRAUMA Mattox. 2008

Algorithm of Blood TransfusionTrauma, Edisi VI (Felociano DV, Mattox KL, Moore, EE., tahun 2008)

CONVENTIONAL TRAUMA LAPAROROTOMY FOR ESSENTIAL PARTSControl of BleedingIdentification of InjuryControl of ContaminationReconstruction

Indications forDamage Control SurgeryNeed to rapidly terminate the laparotomy (bail out) in exanguinating hypothermic, acidotic and coagulopathic patient who is about to die on operating tableInability to control bleedingInability to formally close the abdomen without tension needs temporary abdominal closureConsider the spillage control

WHO IS AN UNSTABLE PATIENT ?Hemodynamic LabilityAcidoticHypothermicCoagulopathicThe goal of damage control is to restore normal physiology rather than normal anatomy.

Sequence in Damage Control

Damage Control part IInitial Laparotomy

Damage Control part IISecondary Resuscitation

Damage Control part IIIDefinitive Surgery

The Lethal TriadSevere Trauma Prolonged hypotensionMetabolic AcidosisCoagulopathyHypothermiaDEATH

Terima kasih

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