2- Penanganan Awal Pada Pasien Trauma Maxillofasial Injury - Fkg an-2
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Transcript of 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
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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
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TRIAGEPRIMARY SURVEYSECONDARY SURVEYSTABILISATION TRANSFERDEFINITIVE CARE
TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF
Emergency Medicine
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Survei Primer
• Periksa cepat berurutan• Selesai dalam 2 menit• Terapi segera apa yang ditemukan
( treat as you
find )
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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
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Jangan terpukaukelainan yang jelas terlihat
Ikuti Sistematika A - B - C - D
Korban ledakan tabung elpiji
Muka hangusPneumotoraks (blast injury)
Luka bakar luasFraktura betis kiri
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AIRWAY yang sulit
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AIRWAY yang sulitmasker oksigentetap bermanfaat
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Triage
RESUSITASI & STABILISASI
Survei primerSurvei sekunder
KamarOperasi
ICU
Hanya 50%pasien traumaperlu operasi
Terapi definitif/ rujukan
Emergency Medicine
RS lain
Derajat kegawatankorban berbeda-beda
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Triage
Sorting of patients according to :•ABCDEs•Available resources
Multiple casualties Mass casualties
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Preparation
Prehospital System Transport guidelines /protocols On-line medical direction Mobilization of resources Periodic review of care Closest appropriate facility
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Preparation
Inhospital Preplanning essential Equipment, personnel, services Standard precautions Transfer agreement
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Standard Precautions
• Cap • Gown• Gloves• Mask• Shoe covers• Goggles/face • Shields
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Resuscitation Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia
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Survei Primer
AirwayBreathingCirculationDisabilityExposure
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Sumbatan jalan nafas pasien tak sadar paling sering disebabkan pangkal lidah
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Airwaymenilai jalan nafas
• Kesadaran (bisa bicara?) • Look, Listen and Feel• Gerak dada• Gerak otot nafas tambahan • Warna kulit, mukosa, kuku
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Airwaymengatasi obstruksi / sumbatan jalan nafas
• Lakukan chin lift / jaw thrust • Bersihkan rongga mulut (suction?)• Pasang jalan nafas oro / nasopharynx • Lindungi tulang leher• Intubasi trachea
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19
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Walaupun tanpa intubasi masih banyakpasien dapat ditolong
JN OropharynxJN NasopharynxJaw thrust
JN Nasopharynx
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X
Neck lift
Head tilt
Chin-lift
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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
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Primary Survey
C-spine injury Pitfalls
• Equipment failure• Inability to intubate • Occult airway injury• Progressive loss of airway
Establish Patent Airway
Caution
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Primary Survey
Suspect C-Spine InjurySpinal protection C-spine X-ray when appropriate
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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
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Survei Primer
AirwayBreathingCirculationDisabilityExposure
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Breathingmenilai pernafasan
• Adakah udara keluar masuk– Look, Listen, Feel
• Frekwensi nafas• Gerak cuping hidung• Cekungan sela iga
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Breathingmembantu pernafasan
• 1. Oksigen (jika ada)• 2. Pernafasan buatan 1.
2.2.
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- Pneumotoraks tension- Fr costa / Flail chest - Hemotoraks berat- Kontusio paru
- Pneumotoraks terbuka
Jejas di dada:
Breathingwaspada
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Dekompresi pneumotoraks (tension)harus dikerjakan dalam Primary Survey
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Survei Primer
AirwayBreathingCirculationDisabilityExposure
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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
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Circulationmengatasi perdarahan
• Beri infus cairan, 1000 ml cepat – RL (Ringer Laktat)– NaCl 0.9% (Garam Fisiologis)– RA (Ringer Asetat)– Hypertonic Saline Dextran 250 ml
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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
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Circulationwaspada & cari lokasi perdarahan
• Cedera intra-abdominal• Cedera dada• Patah tulang panjang• Patah tulang pinggul• Luka tusuk / tembus • Luka kulit kepala
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Primary Survey
Circulatory Management Control hemorrhage Restore volume Reassess Pitfalls Elderly Children
Athletes Medication
Caution
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Survei Primer
AirwayBreathingCirculationDisabilityExposure
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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)
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A- V - P - U
Pupil
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Primary Survey
Disability Baseline neurologic evaluation
• GCS scoring • Pupillary response
Observe for neurologic
deterioration Caution
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Survei Primer
AirwayBreathingCirculationDisabilityExposure
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Exposurepemaparan
• Lepaskan semua pakaian untuk pemeriksaan teliti menyeluruh, ada jejas apa saja
• Periksa punggung!– miringkan pasien cara Log-roll
• Cegah hipotermia (kedinginan)
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Primary SurveyExposure / Environment • Completely undress the patient
Prevent hypothermiaCaution
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Survei Primer
Foto Dada sinar-X / Chest X-Ray ( jika ada)
Tulang leher / C - Spine(lateral)Panggul ( Pelvis )Abdominal USG
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Adjuncts to Primary SurveyVital sign
ECG ABGs Urinary Adjuncts Pulse Output oximeter
and CO₂
Urinary/gastric catheters unless contraindicated
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© ACS
Adjuncts to Primary Survey Diagnostic Tools• Chest and pelvic x-ray• DPL• Ultrasound
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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
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Sistematika Emergency Medicine
TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF
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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
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Pemeriksaan kepala
• Kulit kepala (robekan, memar, laserasi) • Tengkorak (nyeri tekan, depresi tulang)• Mata (pupil, fundus, lensa, conjunctiva)• Cairan CSF / darah dari telinga, hidung,
mulut
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Ada darah mengalir, tetapi dari mana ?
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• Glasgow Coma Score• Pupil
– ukuran, simetri, refleks cahaya• Fungsi motorik• Fungsi sensorik• Refleks-refleks
Periksa kesadaran dan syaraf
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Secondary SurveyHead Complete neurologic examination GCS score determination Comprehensive eye/ear examPitfalls Unconscious patient Periorbital edema Occluded auditory canal
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Secondary Survey
The complete history and physical
examination
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Secondary SurveyKey Components History Physical examination : Head-to-toe “Tubes and finger in every orifice” Complete neuro exam Special diagnostic tests Reevaluation
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Secondary Survey
HistoryA Allergies M MedicationsP Past IllnessesL Last meal E Events/Environment
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© ACS
Secondary SurveyMechanisms of Injury
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Maxillofacial Trauma-Physical Exam
• Penetrating Injuries– Occult globe penetration– Eyelid lacerations
• Nose– Septal hematoma– CSF Rhinorrhea
• Ears– Subperichondral hematoma– Hemotympanum– Battle sign
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Maxillofacial Trauma-Physical Exam
• Oral and Mandibular Exam– Mandible deviation– Teeth malocclusion– Paresthesia– Tongue Blade Test
• 95% Sensitive
• 65% Specific
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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
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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
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Maxillofacial Trauma-Specific Fractures
• Maxillary Fractures– High-energy injury– 100x gravity– Malocclusion– Facial lengthening– CSF rhinorrhea– Periorbital ecchymosis
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LeFort Fractures
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Maxillofacial Trauma-Specific Facial Fractures
• Mandibular Fractures– Second most common facial fracture– Often multiple– Malocclusion– Intraoral lacerations– Sublingual ecchymosis– Nerve injury
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Pemeriksaan leher (1)
• Lihat / inspeksi • Palpasi (nyeri tekan, deformitas)• Anggap leher cedera• Imobilisasi pada posisi netral
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Secondary SurveyCervical Spine Palpate for
tenderness Complete motor/
sensory exams Reflexes C-spine imaging
Pitfalls • Altered LOC for any reason• Other severe , painful injury
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Pemeriksaan dadamencari ulang kerusakan
• Lihat / inspeksi• Palpasi• Perkusi• Auskultasi• Foto sinar-X dada (jika ada)• ECG ( jika ada)
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Secondary SurveyChest Inspect Palpate Percuss Auscultate X-ray
Pitfalls • Elderly • Children
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Secondary Survey
Abdominal Evaluation
Blunt trauma Penetrating trauma
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Secondary SurveyAbdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies Pitfalls
• Hollow viscus and retroperitoneal injuries• Excessive pelvic manipulation
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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
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Ekstremitas / anggota gerak
• Inspeksi – deformitas, robekan, memar, laserasi
• Palpasi• Palpasi nadi arteria distal• Ingat compartment syndrome• Jangan lupa periksa punggung
Log-roll
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Cari luka, robekan, memar, nyeri tekan, deformitas tulang belakang
4 orang
Pemberi komandoinstruksiyang jelas
Log-roll
Digulingkan serentak pelan-pelan
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Foto sinar-x
• Dikerjakan waktu survei sekunder• Dada• Tulang leher - 7 segmen vertebra• Pelvis / panggul• Lokasi lain sesuai indikasi
– (misal fr tulang paha dll)
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Secondary Survey
Musculoskeletal : Extreminities Contusion , deformity Pain Perfusion Peripheral neurovascular status X- rays as needed
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Definitive Care
Local Facility
??Transfer agreements?? Local resources ??
??
Trauma SpecialtyCenter Facility
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Reevaluate
Proceed to Secondary Survey After : Primary survey completed ABCD Es are reassessed Vital functions are returning to
normal
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