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PATIENT IDENTITYName: Mr. SWAge: 37 y. oOccupation: Truck driverAddress: Jl. Ir. SutamiHISTORYThe action that given in D Hospitala. IVFD RL 2000 ccb. Ketolorac inj 1 amp/ IVc. Tranexamate acid 2 amp/ IVd. Ranitidin 1 amp/ IVPRIMARY SURVEYSECONDARY SURVEYFAST US

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LABORATORIESFULL BLOOD COUNTWBC: 11.000Hb: 8.0HCT: 23.5PLT: 219.000Na: 138K: 3.6Cl : 113GDS: 261Ureum: 33.8Creatinin: 1.4HbsAg: -112: -BLOOD GAS ANALYSISpH: 7.408pCO2: 27.8 mmHgpO2: 172.1 mmHgHCO3-: 17.7 mmol/LDid something went wrong?The procedure of finding the cause of hypovolemic shock was not according to the guidelineThe patient was still unstable during the refering processThe management of hypovolemic shockABDOMINAL TRAUMA MANAGEMENTWhether the patient is haemodynamically

stable unstableFIRST PRIORITIES PROTOCOL : Brief clinical examination to evaluate ABC along with cardiovascular status with blood pressure and pulse measurement.Accordingly, resuscitation and management of shock by maintenance of ABC IV fluidsnasogastric tube insertion Catheterization INITIAL ASSESSMENTPRIMARY SURVEYAirway assessmentEnsure cervical spine immobilizationClear mouth and airway if obvious foreign bodiesJaw trust and chin lift, if requiredIf Glasgow Coma Score 8, consider a definitive airwayBreathing and ventilationGive 100 per cent oxygen at high flowInspect/percuss and auscultate chestCheck for tension pneumothorax and immediately decompress if suspected

CirculationCheck pulse and blood pressureSecure two large-bore cannulae, take bloods andCommence fluid resuscitationExamine for evidence of blood loss and treat accordinglyDisabilityThe neurological status of the patient should be rapidly assessed.The pupils are monitored for size and reactivity, and a GCS measured.ExposureThe patient must be fully exposed and examined front and back using a carefully controlled log roll.Adjuncts to the primary surveyBlood tests full blood count, urea and electrolytes, clotting screen, glucose, toxicology, cross-matchECG, pulse oximetry, arterial blood gas (ABG)Two wide-bore cannulae for intravenous fluidsUrinary and gastric cathetersImagingTABLEDiagnostic Modalities in Abdominal Trauma

PERITONEAL LAVAGE ULTRASOUND CT SCANUseRecords intra-abdominal haemorrhage in stable/unstable traumaReveals intra-abdominal haemorrhage in stable and unstable in patientsReveals organ of injury and extent of blunt/penetrating abdominal trauma in stable patientsContra-indications Urgent demand for laparotomy Prior abdominal surgery Pregnancy and obesity Urgent demand for laparotomy Obesity and subcutaneous emphysema Need for emergency laparotomy in an unstable patient Unco-operative patients Allergy to contrast material DrawbackUnreliable in retroperitoneal and diaphragmatic traumaFailes to show small amount of fluid Unreliable in detection of rupture of bowel and diaphragmatic injuriesTime consuming High costSecondary SurveyThe secondary survey does not begin until after the primary survey has been completedThe purpose of the secondary survey is to identify all other injuries and perform a more thorough head to toe examination.Re-evaluationThis cannot be stressed enough. It is an integral process in the initial assessment of major trauma and should not stop once the patient leaves the emergency room. Continuous monitoring is invaluable here, especially of the vital signs and urinary output.BLUNT ABDOMINAL TRAUMA GUIDELINE

All blunt trauma patients with unstable hemodynamic, must be consider there is an internal bleeding or GI tract contamination with DPL or FASTPatients with stable hemodynamic can be evaluated by CT scan. And the decision of operation based on affected organ and trauma severity.

SHOCKShock, at its most rudimentary definition and regardless of the etiology, is the failure to meet the metabolic needs of the cell and the consequences that ensue.

Classification of ShockHypovolemicCardiogenicSeptic (vasogenic)NeurogenicTraumaticObstructiveHypovolemic/Hemorrhagic ShockThe most common typeLoss of circulating blood volume. This may result from loss of whole blood (hemorrhagic shock) or non hemorrhagic shock.The clinical signs of shock may be evidenced by agitation, cool clammy extremities, tachycardia, weak or absent peripheral pulses, and hypotension.

Management of Hemorrhagic ShockThe appropriate priorities are airway and breathing, circulation, disability, exposure, decompression, catheterization.Two IV lines needed for infusing big amount of fluids fast.The amount of fluid needed can be measured by grade of the shock. FluidsClass IClass IIClass IIIClass IVCristaloidCristaloidCristaloid and bloodCristaloid and bloodRespond EvaluationIts important to examined the patients respond by the clinical examination, such as urine output , consciousness, and peripherial perfusions.Fast RespondTransient RespondNo RespondVital SignsBack to normalBack to normal temporaryPulse and tension decreasing Still abnormalLoss of bloodMinimal (10 % - 20 5)Mild ( 20 % - 40 %)Severe (> 40 %)Crystaloid neededMinimalLotLotBlood neededFewLotImmediatelyOperationMaybeHigh probabilityAlmost alwaysBlood TransfusionSpesific and crossmatchSpesific typeEmergencyDid something went wrong?The procedure of finding the cause of hypovolemic shock was not according to the guidelineIn this case, the patients BP < 90 mmHg and it means this patient is unstable patient, finding the cause of the shock in an unstable patient is using FAST procedure not CT scan. The patient was still unstable during the referring processThe hemodinamic of patient should be stable before being transferred to another hospitalThe management of hypovolemic shockWhen the patient arrives, there was no NRM on himThere was just one IV line instead of twoThere was no catheter to evaluate the urine outputThere was no NGT attachedThere was no effort to do blood transfussion, the patient just got crystaloid.Why this patient had to referred to AWS hospital from the D hospital ?

THANK YOUHAPPY BIRTHDAY dr. Syaiful Mukhtar, Sp.B KBD

May Allah always bless you with happiness : )