Pemicu 3

Irwan Surya Angkasa

405150170
triage
Principle of Triage
• Process of prioritizing patient treatment during multiple and mass-
casualty events
• Do the most good for the most patients using available resources
• Make a decision
• Know and understand the rsources available
• Planning and rehearsal
• Determine triage category types
• Triage is continous (retriage)
 Primary Survey Secondary Survey
• A = airway (with cervical spinal protection) • should be done after complete
• B = breathing primary survey and stabilize patients
• Head to toe examination, include
• C = circulation (control hemorrhage)
history taking, physical examination ,
• D = disability laboratory studies and imaging
• E = exposure studies

History Taking Physical Examination

• M = mechanism of injury Mental status
• I = injuries found and suspected • Eyes
• S = signs and symptoms • Head
• T = treatment initiated • Maxillo-facial
• Cervical vertebrate & neck
• A = allegy • Thorax
• M = medication • Abdomen
• P = past illnesses • Pelvic
• L = last meal • Musculoskeletal
• E = events
LI 2 : Menjelaskan tentang luka
bakar
American Burn Association's Grading System for Burn
Severity and Disposition of Patients
TYPE OF BURN
MINOR MODERATE MAJOR
Criteria:  < 10 percent  10 to 20 percent TBSA  20 percent TBSA burn in
TBSA burn in burn in adult adult
adult  5 to 10 percent TBSA  > 10 percent TBSA burn
 < 5 percent burn in young or old in young or old
TBSA burn in  2 to 5 percent full-  > 5 percent full-
young or old thickness burn thickness burn
 < 2 percent  High-voltage injury  High-voltage burn
full-thickness  Suspected inhalation  Known inhalation injury
burn injury  Any significant burn to
 Circumferential burn face, eyes, ears,
 Concomitant medical genitalia or joints
problem predisposing  Significant associated
the patient to infection injuries (e.g., fracture,
(e.g., diabetes, sickle other major trauma)
cell disease)

Disposition: Outpatient Hospital admission Referral to burn center

management
Protocol for Fluid Resuscitation of the Burn Patient
Nutrition
• Patient’s energy and protein requirements will be extremely high due
to the catabolism of trauma, heat loss, infection and demands of
tissue regeneration.
• If necessary, feed the patient through a nasogastric tube to ensure an
adequate energy intake (up to 6000 kcal a day).
• Anaemia and malnutrition prevent burn wound healing and result in
failure of skin grafts. Eggs and peanut oil and locally available
supplements are good.
LI 3 : Menjelaskan tentang trauma
ABDOMINAL TRAUMA
Anterior abdomen :
• Costal margins superiorly
• Inguinal ligaments
• Symphysis pubis inferiorly
• Anterior axillary lines
laterally
Thoraco-abd :
• The area inferior to the
trans-nipple line anteriorly
• The infra-scapular line
posteriorly
• superior to the costal
margins
Flank :
• Area between the anterior
and posterior axillary lines
from the sixth intercostal
space to the iliac crest.
ABDOMINAL TRAUMA
Back :
• The back is the area located
posterior to the posterior
axillary lines from the tip of
the scapulae to the iliac
crests
Pelvic cavity :
• Surrounded by the pelvic
bones, is essentially the
lower part of the
retroperitoneal and
intraperitoneal spaces.
Blunt trauma
• Direct blow • Liver (35% to 45%)
• Cause compression and crushing • Small bowel (5% to 10%)
injuries to abdominal viscera and
pelvis  rupture, with secondary
hemmorrhage, contamination by
visceral contents, and associated
peritonitis
• Shearing injuries
• form of crushing injury that can
result when a restraint device is
worn improperly
• Deceleration injuries
• In which there is a differential
movement of fixed and nonfixed
parts of the body
• Bucket handle
• Organs most frequently injured
• The spleen (40% to 55%)
Penetrating trauma
• Stab wounds and low-velocity • Explosive devices cause injuries
gunshot wounds cause tissue  penetrating fragment wounds
damage by lacerating and cutting and blunt injuries from the
• High-velocity gunshot wounds patient being thrown or struck.
transfer more kinetic energy to
abdominal viscera
• Can cause increased damage
surrounding the track of the
missile due to temporary
cavitation
• Stab wounds  liver (40%), small
bowel (30%), diaphragm (20%),
and colon (15%)
• Gunshot wounds  small bowel
(50%), colon (40%), liver (30%),
and abdominal vascular structures
(25%)
Treatment
Thoracic Injury
• Thoracic injury is common in the poly-
trauma patient and can pose life-
threatening problems if not promptly
identified and treated during the primary
survey
• These patients can usually be treated or
their conditions temporarily relieved by
relatively simple measures, such as
intubation, ventilation, tube thoracostomy,
and fluid resuscitation
• The ability to recognize these important
injuries and the skill to perform the
necessary procedures can be lifesaving
• The primary survey includes management
of the following conditions:
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest and pulmonary contusion
• Massive hemothorax
• Cardiac tamponade
• The secondary survey includes
identification and initial treatment of the
following potentially life-threatening
injuries, utilizing adjunctive studies, such
as x-rays, laboratory tests, and ECG:
• Simple pneumothorax
• Hemothorax
• Pulmonary contusion
• Tracheobronchial tree injury
• Blunt cardiac injury
• Traumatic aortic disruption
• Traumatic diaphragmatic injury
• Blunt esophageal rupture
• Several manifestations of thoracic trauma
are indicative of a greater risk of associated
injuries:
• Subcutaneous emphysema
• Crush injuries of the chest
• Injuries to the upper ribs (1–3),
scapula, and sternum
Thoracic Injury
• Airway • Breathing
• Injury to the upper chest can • Respiratory movement and
create a palpable defect in the quality of respirations are
region of the sternoclavicular assessed by observing,
joint, with posterior palpating, and listening
dislocation of the clavicular • Cyanosis is a late sign of
head, which causes upper hypoxia in trauma patients
airway obstruction
• Management consists of a
closed reduction of the injury,
which can be performed by
extending the shoulders or
grasping the clavicle with a
pointed instrument, such as a
towel clamp, and manually
reducing the fracture
Tension Pneumothorax
• A tension pneumothorax develops when a attempt at subclavian or internal
“one-way valve” air leak occurs from the jugular venous catheter insertion
lung or through the chest wall • Traumatic defects in the chest wall
• Air is forced into the pleural space without • Thoracic spine fractures
any means of escape, eventually
• Signs and symptoms :
completely collapsing the affected lung
• Chest pain
• The mediastinum is displaced to the
• Air hunger
opposite side, decreasing venous return
and compressing the opposite lung • Respiratory distress
• Tachycardia
• Shock results from the marked decrease in
venous return causing a reduction in • Hypotension
cardiac output and is often classified as • Tracheal deviation away from the side
obstructive shock of injury
• Etiology : • Unilateral absence of breath sounds
• Mechanical ventilation with positive- • Elevated hemithorax without
pressure ventilation in patients with respiratory movement
visceral pleural injury • Neck vein distention
• Complicate a simple pneumothorax • Cyanosis (late manifestation)
following penetrating or blunt chest
trauma in which a parenchymal lung
injury fails to seal, or after a misguided
• Tension pneumothorax requires
immediate decompression and may
be managed initially by rapidly
inserting a large-caliber needle into
the second intercostal space in the
midclavicular line of the affected
hemithorax
Open pneumothorax (sucking chest wound)
Flail chest and pulmonary contusion
• A flail chest occurs when a segment • Therapy :
of the chest wall does not have bony
continuity with the rest of the
thoracic cage (multiple rib fractures)
• The major difficulty in flail chest
stems from the injury to the
underlying lung (pulmonary
contusion)  hypoxia
• Flail chest may not be apparent
initially if a patient’s chest wall has
been splinted, in which case he or
she will move air poorly, and
movement of the thorax will be
asymmetrical and uncoordinated
• Satisfactory chest x-ray may suggest
multiple rib fractures, but may not
show costochondral separation
• Initial treatment :
• Adequate ventilation
• Administration of humidified
oxygen
• Fluid resuscitation
• Definitive treatment :
• Adequate oxygenation
• Administer fluids judiciously
• Provide analgesia to improve
ventilation  intravenous
narcotics or local anesthetic
administration 
intermittent intercostal
nerve block(s) and
intrapleural, extrapleural, or
epidural anesthesia
Massive hemothorax
• Accumulation of blood and fluid in a
hemithorax can significantly compromise
respiratory efforts by compressing the lung
and preventing adequate ventilation 
hypotension and shock
• Massive hemothorax results from the rapid
accumulation of more than 1500 mL of
blood or one-third or more of the patient’s
blood volume in the chest cavity
• Causes :
• A penetrating wound that disrupts the
systemic or hilar vessels
• Can also result from blunt trauma
• Massive hemothorax is initially managed
by the simultaneous restoration of blood
volume and decompression of the chest
cavity
• Patients who have an initial output of less
than 1500 mL of fluid, but continue to
bleed, may also require thoracotomy
Cardiac tamponade
• Most commonly results from penetrating • Therapy :
injuries • The initial administration of
• Blunt injury also can cause the pericardium intravenous fluid will raise the venous
to fill with blood from the heart, great pressure and improve cardiac output
vessels, or pericardial vessels transiently while preparations are
made for surgery
• The classic diagnostic beck’s triad:
• Subxyphoid pericardiocentesis
• Venous pressure elevation
• Aspiration of pericardial blood alone
• Decline in arterial pressure may temporarily relieve symptoms
• Muffled heart tones
• Kussmaul’s sign
• PEA is suggestive of cardiac tamponade
• Diagnosis :
• Insertion of a central venous line with
measurement of central venous
pressure (CVP) may aid diagnosis
• Echocardiogram
• Focused assessment sonography in
trauma (FAST)
• Pericardial window
Simple pneumothorax
• Neither general anesthesia nor positive • A simple pneumothorax can readily
pressure ventilation should be convert to a life-threatening tension
administered in a patient who has pneumothorax, particularly if it is initially
sustained a traumatic pneumothorax or unrecognized and positive pressure
who is at risk for unexpected ventilation is applied
intraoperative tension pneumothorax
until a chest tube has been inserted
Hemothorax Pulmonary contusion
• Cause  lung laceration or • Pulmonary contusion can occur
laceration of an intercostal vessel without rib fractures or flail
or internal mammary artery due chest, particularly in young
to either penetrating or blunt patients without completely
trauma ossified ribs
• Thoracic spine fractures may also • Patients with significant hypoxia
be associated with a hemothorax (i.e., PaO2 <65 mm Hg [8.6 kPa]
• Bleeding is usually selflimited or SaO2 <90%) on room air may
and does not require operative require intubation and
intervention ventilation within the first hour
after injury
• As a guideline, if 1500 mL of
blood is obtained immediately
through the chest tube, if
drainage of more than 200 mL/hr
for 2 to 4 hours occurs, or if
blood transfusion is required,
operative exploration should be
considered
Tracheobronchial tree injury
• Such patients typically present with
hemoptysis, subcutaneous
emphysema, or tension
pneumothorax
• Incomplete expansion of the lung
after placement of a chest tube
suggests a tracheobronchial injury,
and placement of more than one
chest tube often is necessary to
overcome a significant air leak
• Bronchoscopy confirms the
diagnosis
• Temporary intubation of the
opposite mainstem bronchus may
be required to provide adequate
oxygenation
• Operative treatment of
tracheobronchial injuries may be
delayed until the acute
inflammation and edema resolve
Blunt cardiac injury
• Blunt cardiac injury can result in
• myocardial muscle contusion
• cardiac chamber rupture
• coronary artery dissection and/or
thrombosis
• valvular disruption
• Cardiac rupture typically presents
with cardiac tamponade and should
be recognized during the primary
survey
• Early use of FAST can facilitate
diagnosis
• Patients with blunt myocardial injury
may report chest discomfort, but this
symptom is often attributed to chest
wall contusion or fractures of the
sternum and/or ribs
• The presence of cardiac troponins can
be diagnostic of myocardial infarction
Traumatic aortic disruption
• Traumatic aortic rupture is a common (nasogastric tube) to the right
cause of sudden death after an • Widened paratracheal stripe
automobile collision or fall from a great • Widened paraspinal interfaces
height
• Presence of a pleural or apical cap
• Adjunctive radiologic signs on chest x-
• Left hemothorax
ray, which may or may not be present,
indicate the likelihood of major vascular • Fractures of the first or second rib or
injury in the chest and include : scapula
• Widened mediastinum
• Obliteration of the aortic knob
• Deviation of the trachea to the right
• Depression of the left mainstem
bronchus
• Elevation of the right mainstem
bronchus
• Obliteration of the space between
the pulmonary artery and the aorta
(obscuration of the aortopulmonary
window)
• Deviation of the esophagus
Traumatic diaphragmatic injury
• Perhaps because the liver obliterates the finding of a right-sided injury
defect or protects it on the right side of the
• If a laceration of the left diaphragm is
diaphragm, whereas the appearance of
suspected, a gastric tube should be inserted
displaced bowel, stomach, and nasogastric
(NG) tube is more easily detected in the left • The appearance of peritoneal lavage fluid in
chest the chest tube drainage also confirms the
diagnosis
• Blunt trauma  large radial tears that lead to
herniation • Minimally invasive endoscopic procedures
(e.g., laparoscopy or thoracoscopy) may be
• penetrating trauma  small perforations 
helpful in evaluating the diaphragm in
diaphragmatic hernias
indeterminate cases.
• The appearance of an elevated right
• Treatment is by direct repair
diaphragm on chest x-ray may be the only
Blunt esophageal rupture
• The forceful expulsion of gastric contents into the esophagus
from a severe blow to the upper abdomen  A linear tear in
the lower esophagus  Leakage into the mediastinum 
Mediastinitis  Immediate or delayed rupture into the pleural
space cause empyema
• Treatment :
• Wide drainage of the pleural space and mediastinum with
direct repair of the injury via thoracotomy, if feasible
• Repairs performed within a few hours of injury lead to a
much better prognosis
SPINE AND SPINAL CORD TRAUMA
• Spine injury, with or without • Complete spinal cord injury  when
neurologic deficits, must always be a patient has no demonstrable
considered in patients with multiple sensory or motor function below a
injuries certain level
• Epid: • Incomplete spinal cord injury  is
• 55%  cervical region one in which any degree of motor or
• 15%  thoracic region sensory function remains; the
prognosis for recovery is significantly
• 15%  thoracolumbar junction better
• 15%  lumbosacral area
 SPINE AND SPINAL CORD TRAUMA :
Sensory Examination

• DERMATOME
is the area of skin
innervated by the
sensory axons within a
particular segmental
nerve root.
SPINE AND SPINAL CORD TRAUMA :
Sensory Examination

• MYOTOMES
Each segmental nerve
(root) innervates more
than one muscle, and most
muscles are innervated by
more than one root
(usually two)
 certain muscles or
muscle groups are
identified as representing a
single spinal nerve
segment
Classifications of Spinal Cord Injuries
1. Level
• The neurologic level  the most
caudal segment of the spinal cord that
has normal sensory and motor
function on both sides of the body.
• Sensory level  the most caudal
segment of the spinal cord with
normal sensory function
• Motor level  similarly with
respect to motor func tion as the
lowest key muscle that has a
grade of at east 3/5 (Table 7.3)
2. Severity of neurologic deficit
• Incomplete paraplegia (incomplete
thoracic injury) 4.
• Complete paraplegia (complete
thoracic injury)
• Incomplete quadriplegia (incomplete
cervical injury)
• Complete quadriplegia (complete
cervical injury)
3. Spinal cord syndromes
• Central cord syndrome 
characterized by a disproportionately
greater loss of motor strength in the
upper extremities than in the lower
extremities, with varying degrees of
sensory loss
• Anterior cord syndrome 
characterized by paraplegia and a
dissociated sensory loss with a loss of
pain and temperature sensation
• Brown-Séquard syndrome  results
from hemisection of the cord, usually
as a result of a penetrating trauma
Morphology
• Fractures
• Fracture dislocations
• Spinal cord injury without
radiographic bnormalities (SCIWORA)
• Penetrating injuries
X-Ray Evaluation
1. Servical Spine
• Cervical spine radiography is indicated for all trauma
patients who have midline neck pain, tenderness on
palpation.
• CT scans may be used in lieu of plain images
• Under no circumstances should the patient’s neck be
forced into a position that elicits pain. All movements must
be voluntary.
2. Thoracic And Lumbar Spine
• The indications for screening radiography  same as those
for the cervical spine
LI 4 : Menjelaskan tentang fraktur
PELVIC TRAUMA
• Pelvic fracture is a disruption of the bony structures of the pelvis. In elderly
persons, the most common cause is a fall from a standing position
• Fractures associated with the great morbidity and mortality involve
significant forces such as from a motor vehicle collision (MVC) or fall from a
height
• The profound magnitude of force required to disrupt the pelvic ring
frequently causes severe injuries to other organ systems
• ATLS guidelines advocate the initial use of
crystalloid solutions to stabilize vital signs
in the trauma patient
• In contrast, arteriography is excellent at
both diagnosing and managing arterial
bleeding
• Embolization is highly effective for
controlling arterial bleeding.
• Angiography is indicated when
hypovolemia persists in ampatient with a
major pelvic fracture despite control of
hemorrhage from other sources.

C-clamp
American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) for
doctors: student course manual. 9th ed. Chicago: American College of Surgeons; 2012.
Cervical, Thoracic,
& Lumbar Spine
Fractures
References
• American College of Surgeons Committee on
Trauma. Advanced trauma life support (ATLS) for
doctors: student course manual. 9th ed. Chicago:
American College of Surgeons; 2012.
• John A. M, MD, dkk. Rosen’s Emergency Medicine
Concepts and Clinical Practice. 8th Edition. Volume
1. Philadelphia: Mosby Elsevier; 2012.
• https://chemm.nlm.nih.gov/StartAdultTriageAlgorit
hm.pdf