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DISKUSI MULTI TRAUMA

Selasa, 3 April 2012

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

Tgl 26- 28/ 3 / 12


Rawat ICU

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

Lila Buana IB PT/L/50 th


RtS = 7.89, Tarr: 00.00 Tacc :21.00

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

MOI: pasien sedang mengendarai motor, terjatuh saat hendak menyalip


truk, kemudian lengan atas dan bawah tangan kanan, betis kanan serta
lengan bawah tangan kiri terlindas ban truk.

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

IB putu Lila Buana L/50th


MRS: 25/3/12 MHCU 26/3/12

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:

DK (+), urin jernih

CM

3400 cc/24 jam

CK

1500 cc/24 jam

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

IB Putu Lila Buana L/50th


MRS: 25/3/12
MHCU 27/3/12
Dx:
Rupture total a. axilaris D
OF Humerus D 1/3 tengah Gr IIIc
CF Antebrachii D 1/3 distal gr II
OF Cruris D 1/3 T Gr II
OF Antebrachii S Segmental Gr IIIa
TX:
BTKV: interpositional graft, thrombektomi
ruptur m. biceps, m. brachialis, m. triceps, ruptur a-v. axilaris D,
ruptur n. Medianus, n. Ulnaris
Ortho: Debridement + eksternal fiksasi + backslab

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

: 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 96%
UG

: DK (+), urin jernih

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

ASS: anemia + trombositopenia

P: lanjut perawatan intensif


Transfusi PRC dan TC

IB Putu Lila Buana L/50th


MRS: 25/3/12
28/3/2012
Dx:
Rupture total a. axilaris D
OF Humerus D 1/3 tengah Gr IIIc
CF Antebrachii D 1/3 distal gr II
OF Cruris D 1/3 T Gr II
OF Antebrachii S Segmental Gr IIIa
TX:
BTKV: interpositional graft, thrombektomi
ruptur m. biceps, m. brachialis, m. triceps, ruptur a-v. axilaris D,
ruptur n. Medianus, n. Ulnaris
Ortho: Debridement + eksternal fiksasi + backslab

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

: 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 95%
UG

: DK (+), urin keruh

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

19.00 : pasien bradikardia RJP membaik


Jam 22.45 : asistole, tensi tidak teraba resusitasi
Jam 23.15 : pasien meninggal
Cod
A MOF
B MULTI TRAUMA
C KLL

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

Hipotermi vasokonstriksi koagulopati


Perdarahan meningkat hipotensi syok
Perfusi dan oksigenasi jaringan tidak adekuat
Metabolisme anaerob laktat serum
Asidosis metabolik
Kadar laktat serum dan base deficit
Derajat syok
Prediksi survival/mortalitas
Kontraktilitas miokard dan CO menurun
Respon terhadap katekolamin menurun
Koagulopati, mortalitas meningkat

PIKIRKAN DAMAGE CONTROL

Core temperature : < 35 o C


PH : < 7,2
Base defisit
:
< -15 mmol/L (<55 years)
< -6 mmol/L ( >55 years)
Serum lactate: > 5 mmol/L
Coagulopathy : PPT PTT > 50% N

Most

extremity vascular injuries manifest one or


more of the obvious physical findings or hard
signs of hemorrhage: large, expanding or pulsatile
hematoma, absent distal pulses, a palpable thrill or
audible bruit over the wound, and distal ischemia
(the 6 Ps mentioned earlier).
These hard signs reflect a high probability of major
vascular injury requiring surgical repair in the
setting of injured extremities15

Feliciano, David V.; Mattox, Kenneth L.; Moore, Ernest E.


Title: Trauma, 6th Edition
Copyright 2008 McGraw-Hill
> Table of Contents > Section III - Management of Specific Injuries > Chapter 44 - Peripheral Vascular Injury

Although combined injuries are uncommon, the duration of


ischemia is critical to the outcome. Therefore, the arterial
repair should be performed first to restore circulation to the
limb before the orthopedic stabilization is addressed.
Sometimes, however, massive musculoskeletal trauma
renders a limb so unstable that external fixation must be
placed before the vascular procedure.
Selective use of intraluminal shunts and rapid installation of
an external fixator minimize limb ischemia in this setting,
thus allowing an unhurried orthopedic and vascular repair

Rutherford: Vascular Surgery, 6th ed., Copyright 2005 Elsevier

DSTC / KT- IKABI

Damage Control Sequence


PART
PARTII--OR
OR

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

WINDOW OF OPPORTUNITY 90 MINUTES


Simulation of heat loss during damage control
Operative Profiles
1 hour laparotomy at 21C
90 minutes at 21 C
90 minutes at 24 C

Core Temperature (C)

36

32

Therapeutic
window

30
0

30

60

90
Time (hours)

120

Ancaman
Rasa Takut

Cedera/Trauma

Patofisiologi Trauma pada Tubuh Manusia

Nyeri
Luka ringan

Luka berat/syok (-)

Luka berat/syok (+)


Perdarahan Klas III/IV

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

Pusponegoro AD, 2004;


Menger et al, 1993

Reperfusi

Hipoksia

Kerusakan jaringan

EXTREMITY TRAUMA LIMB


SALVAGE VS AMPUTATION

DSTC-Indonesia

KOLEGIUM ILMU BEDAH


INDONESIA
KOMISI TRAUMA IKABI

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.

Asses and diagnose injuries completely.


Restore impaired blood circulation rapidly.
Debride dead and/or contaminated tissue.
Restore skeletal stability with internal or
external fixation.
5. Repair articular fracture anatomically,
follow by early motion.
6. Repair disrupted muscle-tendon unit.
DSTC-Indonesia

48

PROTOCOL ..
7.
8.

Repair nerve lacerations.


Close wound as soon as adequate
debridement is assured.
9. Replace loss bone.
10. Repair or reconstruct unstable ligament.
11. Progressively resume use of limb, while not
exceeding strength of healing tissue.
12. Recognize and treat any complication.
DSTC-Indonesia

49

Mangled extremity
High

energy trauma
Vascular injury
Severe comminuted
Soft tissue damage

DSTC-Indonesia

50

Mangling extremity injury


Severe

injury to three of four


organ system ( skin, bone,
arteries, nerve)

DSTC-Indonesia

51

Delayed amputation
High

morbidity
Bad prognosis
Age
Disability
Cost
DSTC-Indonesia

52

COMPLICATION OF SEVERE OPEN


FRACTURE
Skin and soft tissue

Bone and fracture site

DSTC-Indonesia

Skin and tissue loss, wound slough,


coverage failure.
Compartment syndrome with necrosis of
muscle/nerve injury
Deep infection-acut / chronic
Bone loss, Delayed union, Malunion/loss
of alignment,
Non union
Fixation problem-failure of hardware
Bone refracture
53

COMPLICATION
Nerve

Direct injury or ischaemic damage


Reflex sympathetic dystrophy

Vascular

Arterial occlusion, venous insufficiency


Deep vein thrombosis
Compartment syndrome

Joint movement

DSTC-Indonesia

Associated joint surface fracture


Contracture, late arthritis

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

Injury severity score

Criteria

Score

Bone injury

< 25

Simple

25-50

Segmental

>51

Segmental comminuted

Bone loss <6 cm

Integument injury
Guillotine

Articular

Crush/burn

Articular with bone loss >6cm

Avulsion/degloving

Delay in time to operation


point per hour> 6h

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

< 20: functional limb salvage can be expected,> 20 which limb


DSTC-Indonesia
salvage is improbable

57

Predictive Salvage Index System


Criterion
Score
Level of arterial injury

Suprapopliteal
1

Popliteal
2

Infrapopliteal
3

DSTC-Indonesia

Degree of bone injury


Mild
Moderate
Severe

1
2
3
58

Degree of muscle injury

Mild

Moderate

Severe

1
2
3

Interval from injury to operating room (hours)

<6
0

6-12
2

>12
4
Salvage < 7, amputation > 8
DSTC-Indonesia

59

MANGLED EXTREMITY SEVERITY SCORE


Factor

Score

Skeletal / soft tissue injury


Low energy (stab, fracture, civilian gunshot wound)

Medium energy (open or multiple fracture)

High energy (shotgun or military gunshot wound)

Very high energy (above plus gross contaminated)

DSTC-Indonesia

60

Limb schema
Pulse reduce or absent but perfusion normal

1*

Pulseless, diminished capillary refill

2*

Patient is cool, paralysed, insensate, numb

3*

*double value if duration of ischaemia > 6 hours

DSTC-Indonesia

61

Shock
Systolik blood pressure always > 90 mmHg

Systolik blood pressure transienly < 90 mmHg

Systolik blood pressure persistenly < 90 mmHg

DSTC-Indonesia

62

Age

< 30

30 50

> 50

A MESS value > 7 predicted amputation

DSTC-Indonesia

63

NISSSA Scoring System


FACTOR
NERVE INJURY

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

Very 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

A NISSSA score >11 predicted amputation.

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

primary objective of polytrauma is


survival of the patient
The Mangled Extremity Severity Score can
assist in decision making, saving or
amputated

DSTC-Indonesia

78

Kronologis:
Kecelakaan jam 21.00 tgl 25/3/2012

BB = 90 kg, TB 175 cm

RS ganesha riwayat syok (+)


RSUP sanglah 23.30 tgl 25/3/2012
Didorong masuk ke OK jam 24.00 tgl 25/3/2012
Mulai incisi jam 01.35 oleh orthopedi utk eksternal fixation humerus dextra
Jam 02.45 06.30 : repair vaskuler oleh BTKV pulsasi a. Radialis Dekstra (+)
06.30 10.00 : fasciotomy + debridement + eksternal fixation pd antebrachii
dekstra
10.00-11.00 : thrombectomy pd a.axilaris oleh BTKV
11.00 -13.45 : debridement back slab pada cruris dekstra + antebrachii sinistra
15.00 : HCU

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

Fluktuasi hemodinamik durante op 76-130/56-62


HR 62-110, SaO2 99-100

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

IB putu Lila Buana


th
L/50

MRS : 25/3/12
MENINGGAL : 28/3/12 (23.50)
DIAGNOSA

Rupture total a. axilaris D

Of Humerus D 1/3 tengah Gr IIIc

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

BTKV: Repair vaskular


25,40
Ortho: Debridement
+ eksternal fiksasi , backslab

Cod
A MOF
B MULTI TRAUMA
C KLL

3,13
34,80