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Documenti di Professioni
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2019
MUSLIM INDONESIA UNIVERSITY
TRAUMATOLOGY
PBL REPORT
RESPIRATORY FAILURE
Arranged by :
GROUP 6
NURUL FITRIAH JUNAID 11020160046
RESKY ASFIANI RAHMAN 11020160051
RIDHA MARDHATILLAH 11020160048
MUHAMMAD SYARIFULLAH 11020160042
FIRMAWATI AR. 11020160171
DEFINA BUDI 11020160036
SITTI PUTRI SRIYANTI ASIS 11020160037
MUHAMMAD FARID JAMAL SAHIL 11020160049
RIYSKA AMALIA 11020160027
RESKY KARNITA DEWI 11020160072
Thank God we pray to Allah SWT thanks to His grace and guidance so
that report result of this tutorial can be finished well. And do not forget we send
greetings and shalawat to the Prophet Muhammad who has brought us from a
foolish realm into a realm full of cleverness. We would also like to thank those
who helped make this report and the tutors who have guided us during the tutorial
process. Hopefully this report on the results of this tutorial can be useful for any
part who has read this report and especially for the compilation team itself.
Hopefully after reading this report can broaden the reader's knowledge of
traumatology.
Group 6
2
I. SCENARIO
A 30 years old woman take to the puskesmas after having a crash accident an
hour ago. On physical examination, blood pressure 90/40 mmHg, pulse
100x/minute, respiration 26x/minute, temperature 37○c, visible bruise on the
left arm, bruises on the left chest and visible glass fragmnets in the left axilla.
During the observation in the emergency suddenly the pastient suffer from
severe shorthness of breath to cyanosis and decrease of consciousness.
II. KEYWORDS
A 30 years old woman take to the puskesmas after having a crash
accident an hour ago
blood pressure 90/40 mmHg hypotensiom
pulse 100x/minute normal
respiration 26x/minute hiperkapnia
temperature 37○c normal
visible bruise on the left arm
bruises on the left chest
visible glass fragmnets in the left axilla
suddenly the pastient suffer from severe shorthness of breath to
cyanosis and decrease of consciousness
III. QUESTIONS
1. Explain about the primary survey and secondary survey of the respiratory
failure?
2. Explain the classification of respiratory failure?
3. Explain about the respiratory failure pathomechanism?
4. How to maintenance or do stabilization the patient with the respiratory
failure that caused by trauma?
5. What is possibly complication that may happen in the early management
and how to solve it?
6. Explain about the way of using emergency drugs?
7. How to do transportation and patient’s referral with the respiratory failure?
3
8. Mention the perspective of Islam that fits the scenario?
IV. ANSWER
1. primary survey and secondary survey of the respiratory failure
The primary survey encompasses the ABCDEs of trauma care and
identifies life-threatening conditions by adhering to this sequence:
• Airway maintenance with restriction of cervical spine motion
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability(assessment of neurologic status)
• Exposure/Environmental control
Primary survey
Response
Awareness checks can be done in two ways namely qualitatively and
quantitatively:
Qualitative examination of degree of consciousness (AVPU):
A: Alert, if the patient is spontaneous and immediately responds
appropriately to paramedic questions.
V: Verbal, if the patient responds to commands, it may only be a groan.
P: Pain, if the patient only responds to pain stimuli.
U: Unrespond: if the patient does not respond
4
Quantitative examination of GCS awareness degrees
Description:
Score 14-15: Compos mentis
Score 12-13: Apathy
Score 10-11: Somnolent
Score 8-9: Stupor
Score 6-7: Semi-coma
Score ≤5: Comma
5
measures to establish a patent airway while restricting cervical spine
motion. If the patient is able to communicate verbally, the airway is not
likely to be in immediate jeopardy;however, repeated assessment of airway
patency is prudent. In addition, patients with severe head injuries who
have an altered level of consciousness or a Glasgow Coma Scale (GCS)
score of 8 or lower usually require the placement of a definitive airway.
The first thing that must be assessed is the smoothness of the airway. This
includes checking for airway obstruction that can be caused by foreign
matter
L = Look / see if there is interference with the airway
L = Listen / hear breathing air flow
F = Feel / feel the existence of respiratory air flow using a helper tube
Symptoms and signs of blockage that appear marked by additional breath sounds,
include:
6
1) Snoring = snoring, derived from the obstruction of the base of the tongue. how
to overcome: Chin lift, jaw thrust oropharyngeal / nasopharyngeal pipe
installation of endotracheal tube.
2) Gargling = gargling cause: there is fluid in the area. How to overcome: finger
sweep, suction.
3) Stridor = crowing, blockage in the vocalist plica. How to deal with:
cricotirotomy, tracheostomy.
(Sudoyo, Aru, W. Seiyohadi, bambang. 2014. Buku Ajar Ilmu Penyakit Dalam.
Jilid II. Edisi VI. Jakarta : pusat penerbitan dep. IPD FKUI)
Jaw-Thrust Maneuver
To perform a jaw thrust maneuver, grasp the angles of the mandibles with
a hand on each side and then displace the mandible forward.
7
Nasopharyngeal Airway
Nasopharyngeal airways are inserted in one nostril and passed gently into
the posterior oropharynx. They should be well lubricated and inserted into
the nostril that appears to be unobstructed.
Oropharyngeal Airway
8
Oral airways are inserted into the mouth behind the tongue. The preferred
technique is to insert the oral airway upside down, with its curved part
directed upward, until it touches the soft palate. At that point, rotate the
device 180 degrees, so the curve faces downward, and slip it into place
over the tongue.
Definitive airway
Endotracheal Intubation
9
Although it is important to establish the presence or absence of a c-spine fracture,
do not obtain radiological studies, such as CT scan or c-spine x-rays, until after
establishing a definitive airway when a patient clearly requires it. Patients with
GCS scores of 8 or less require prompt intubation. If there is no immediate need
for intubation, obtain radiological evaluation of the c-spine. However, a normal
lateral c-spine film does not exclude the possibility of a c-spine injury.
Needle Cricothyroidotomy
Needle cricothyroidotomy involves insertion of a needle through the cricothyroid
membrane into the trachea in an emergency situation to provide oxygen on a
short-term basis until a definitive airway can be placed. Needle cricothyroidotomy
can provide temporary, supplemental oxygenation so that intubation can be
accomplished urgently rather than emergently.
Surgical Cricothyroidotomy
Surgical cricothyroidotomy is performed by making a skin incision that extends
through the cricothyroid membrane
10
(American College of Surgeon. 2018. Advanced Trauma Life Support. Ed 10.
America)
The next step is to check whether the victim is breathing (Look, Listen.
Feel). Look at the thoracic state of the patient, whether or not there is
cyanosis, and if the patient is conscious then the patient is able to speak in
one long sentence. The patient's chest condition that is more or less
symmetrical may be caused by pneumothorak or pleurahemorage. To
distinguish percussion in the lung area. Hypersonic pulmonary sounds are
caused by pneumothorax while in pleurahemorage pulmonary sounds
become dim.
Based on the scenario the patient has tachypnea with breathing 26x /
minute. However other causes must be sought such as trauma and non-
trauma. According to the scenario the patient has a history of a traffic
accident, there is bruising on the left arm, injury to the left chest and
visible glass fragments embedded in the left axillary region which can
cause respiratory distress so that initial management can be given ie
measuring oxygen saturation and peripheral perfusion of the patient using
an oxymeter then giving oxygen as needed.
Things that can be done include lung resuscitation, can be done through
1. Mouth-to-mouth
To provide mouth-to-mouth breathing assistance, the victim's airway must be
open. Notice the two helper hands in the picture are still using the "Chin lift"
airway technique. The victim's nose must be covered either by hand or by pressing
the cheek on the victim's nose. The mouth of the helper covers the entire mouth of
the victim. The helper's eyes look towards the victim's chest to see the
development of the chest. Giving artificial respiration effectively can be known by
11
looking at the development of the victim's chest. Give 1 breath for 1 second, give
normal breathing. Then give a second breathing for 1 second. Give regular
breathing to prevent the helper from experiencing dizziness or dizzy
1. Mouth-to-mask
This method is done through breathing through a barrier mask to protect the
savior from being exposed to the victim's body fluids. Pocket masks are usually
made of plastic and contain a value of one that is designed to limit the exposure of
saviors to exhaled air, bodily fluids, and disease processes.
12
and index finger hold the mask to form the letter C while the other fingers hold
the patient's lower jaw while simultaneously opening the patient's airway by
forming the letter E.
Latief SA, Suryadi KA, Dachlan MR. Petunjuk Praktis Anestesiologi. Edisi 2.
Jakarta: FKUI 2009
Circulation
13
• Skin Perfusion—This sign can be helpful in evaluating injured
hypovolemic patients. A patient with pink skin, especially in the face and
extremities, rarely has critical hypovolemia after injury. Conversely, a
patient with hypovolemia may have ashen, gray facial skin and pale
extremities.
• Pulse—A rapid, thready pulse is typically a sign of hypovolemia. Assess
a central pulse (e.g., femoral or carotid artery) bilaterally for quality, rate,
and regularity. Absent central pulses that cannot be attributed to local
factors signify the need for immediate resuscitative action.
14
Providing external assistance to the circulation and ventilation of victims
who experience cardiac arrest or cardiac arrest through cardiac pulmonary
resuscitation (CPR).
Cardiac pulmonary resuscitation consists of two stages:
Primary survey: can be done by anyone.
Secondary surveys: can be carried out by trained medical and paramedical
personnel and is a continuation of the primary survey.
15
(American heart association. Guideline. 2015. Focus utama pembaruan
pedoman American Heart Association 2015 untuk CPR dan EEC.)
16
Bleeding
Bleeding is a loss of volume of blood circulation. Although it can be very
varied, an adult's normal blood volume is around 7% of body weight. For
example, male body weight around 70 kg, then the volume of blood
around 5 L. The volume of blood of obese adults is estimated based on
their ideal body weight, because calculations based on actual weight can
produce estimates that are too high. Blood volume for children is
calculated to be 8% to 9% of body weight (70-80mL / kg).
Solve bleeding
Bleeding can largely be stopped by pressing the wound directly with the hand or
finger followed by a pressure dressing or pressing the pulse pressure point.
17
Tourniquetting is not recommended because, besides its small benefits in large
arteries, it is also detrimental if the collateral vessels are depressed.
Tourniquettes are only used in amputated limb surgery. The most frequent
mistake in touring tourniquet is that the bond is not hard enough so that the veins
become blocked, but the arteries do not cause more blood loss. Such bleeding
will stop if the tourniquet is removed and the wound is elevated.
Losing more than 25% of blood volume requires a transfusion. While waiting for
blood, physiological saline solution, ringer lactate, or plasma replacement can be
used to treat circulatory insufficiency.
Fluid resuscitation
1. Crystalloid
The most widely used crystalloid fluids are normal saline and lactate.
Crystalloid fluids have a composition similar to extracellular fluid. Because
of the difference in properties between crystalloids and colloids, where
crystalloids will spread more to the interstitial space compared to colloids,
crystalloids should be chosen for resuscitation of fluid deficits in
theintersection space.
The use of large amounts of normal saline fluids can cause hyperchloremic
acidosis, whereas the use of large amounts of lactated ringer fluid can cause
18
metabolic alkalosis caused by an increase in bicarbonate production due to
lactate metabolism.
A 5% dextrose solution is often used if the patient has low blood sugar or has
high sodium levels. However, its use for resuscitation is avoided because of
complications resulting from, among others, hyperglycemic hyperomolality,
osmotic diuresis, and cerebral acidosis.
The following table lists several types of crystalloid liquids and their
respective contents:
2. Colloids
Colloid liquid is also referred to as plasma replacement fluid or commonly
called "plasma expander". In colloidal liquids there are substances /
substances which have high molecular weight with osmotic activity which
cause these fluids to tend to last for a long time in the intravascular space.
• Albumin
Albumin is a pure colloidal solution derived from human plasma. Albumin
is made by pasteurization at 600C in 10 hours to minimize the risk of
transmission of hepatitis B or C viruses or immunodeficiency viruses. The
19
half-life of albumin in plasma is about 16 hours, with around 90%
remaining intravascularly 2 hours after administration.
• Dextran
Dextran is a colloidal semisynthetic commercially made from sucrose by
leukonostok mesenteroides strain B 512 by using the enzyme sucrose
dextran. This results in a high BM dextran which is then adhered by acid
hydrolysis and separated by repeated ethanol fractionation to produce a
final product with a relatively narrow BM range. Dextran for clinical use is
available in Dextran 70 (BM 70,000) and Dextran 40 (BM 40,000) mixed
with physiological salts, dextrose or Ringer lactate.
Crystalloid Colloids
advantage
1. More easily 1. Expansion of
available and plasma volume
inexpensive without
2. The interstitial
composition is expansion
similar to plasma 2. Greater
(Ringer acetate / volume
ringer lactate) expansion
3. Can be stored 3. Longer
at room duration
temperature 4. Better tissue
4. Free from oxygenation
anaphylactic 5. The incidence
reactions of pulmonary
5.Minimal edema and / or
complications systemic edema
is lower
20
Disadvantage
1. Edema can 1. Anaphylaxis
reduce the 2. Coagulopathy
expansion of the 3. Albumin can
chest wall aggravate
2. Tissue myocardial
oxygenation is depression in
disrupted due to shock patients
increasing
capillary and cell
spacing
3. Requires 4
times more
volume
Disability
Towards the end of the primary survey an evaluation of the neurological
conditions was carried out quickly. What is assessed here is the level of
consciousness, pupil size and reaction, lateralization signs and the level
(level) of spinal injury. GCS (Glasgow Coma Scale) is a simple scoring
system and can predict patient outcomes. This GCS can be done as a
substitute for AVPU. This check has the lowest value 3 and the highest
value 15.
21
developing hypothermia in the trauma receiving area. Warm intravenous
fluids before infusing them, and maintain a warm environment
Secondary survey
The secondary survey does not begin until the primary survey (ABCDE) is
completed, resuscitative efforts are under way, and improvement of the
patient’s vital functions has been demonstrated. When additional personnel
are available, part of the secondary survey may be conducted while the
other personnel attend to the primary survey. This method must in no way
interfere with the performance of the primary survey, which is the highest
priority. The secondary survey is a head-to-toe evaluation of the trauma
patient—that is, a complete history and physical examination, including
reassessment of all vital signs. Each region of the body is completely
examined. The potential for missing an injury or failing to appreciate the
significance of an injury is great, especially in an unresponsive or unstable
patient. (Every complete medical assessment includes a history of the
mechanism of injury. Often, such a history cannot be obtained from a
patient who has sustained trauma; therefore, prehospital personnel and
family must furnish this information. The AMPLE history is
a useful mnemonic for this purpose:
•• Allergies
•• Medications currently used
•• Past illnesses/Pregnancy
•• Last meal
•• Events/Environment related to the injury
22
1) Type I Respiratory Failure (oxygenation failure, arterial hypoxemia)
23
Infarction or brain hemorrhage
Supratentorial emphasis on the brain stem
Drug overdoses, narcotics, Benzodiazepines, anesthetic agents, etc.
Myastania Gravis
Amytropic lateral sclerosis
Guillain Barre Syndrome
Spinal Cord Injury
Multiple Sclerosis
Residual paralysis (muscle paralysis)
Muscual dystrophy
Polymyositis
Flail Chest
24
Hypoventilation: in which PaCO2 and PaO2 and alveolar –arterial PO2
gradient is normal. Depression of CNS from drugs is an example of this
condition.
25
Respiratory physiology
Gas exchange
Respiration primarily occurs at the alveolar capillary units of the
lungs, where exchange of oxygen and carbon dioxide between alveolar gas
and blood takes place. After diffusing into the blood, the oxygen
molecules reversibly bind to the hemoglobin. Each molecule of
hemoglobin contains 4 sites for combination with molecular oxygen; 1 g
of hemoglobin combines with a maximum of 1.36 mL of oxygen.
The quantity of oxygen combined with hemoglobin depends on the
level of blood PaO2. This relationship, expressed as the oxygen
hemoglobin dissociation curve, is not linear but has a sigmoid-shaped
curve with a steep slope between a PaO2 of 10 and 50 mm Hg and a flat
portion above a PaO2 of 70 mm Hg.
The carbon dioxide is transported in 3 main forms: (1) in simple
solution, (2) as bicarbonate, and (3) combined with protein of hemoglobin
as a carbamino compound.
During ideal gas exchange, blood flow and ventilation would
perfectly match each other, resulting in no alveolar-arterial oxygen tension
(PO2) gradient. However, even in normal lungs, not all alveoli are
ventilated and perfused perfectly. For a given perfusion, some alveoli are
underventilated, while others are overventilated. Similarly, for known
26
alveolar ventilation, some units are underperfused, while others are
overperfused.
The optimally ventilated alveoli that are not perfused well have a
large ventilation-to-perfusion ratio (V/Q) and are called high-V/Q units
(which act like dead space). Alveoli that are optimally perfused but not
adequately ventilated are called low-V/Q units (which act like a shunt).
Alveolar ventilation
At steady state, the rate of carbon dioxide production by the tissues
is constant and equals the rate of carbon dioxide elimination by the lung.
This relation is expressed by the following equation:
VA = K × VCO2/ PaCO2
where K is a constant (0.863), VA is alveolar ventilation, and VCO2 is
carbon dioxide ventilation. This relation determines whether the alveolar
ventilation is adequate for metabolic needs of the body.
The efficiency of lungs at carrying out of respiration can be further
evaluated by measuring the alveolar-arterial PO2 gradient. This difference
is calculated by the following equation:
PAO2 = FiO2 × (PB – PH2 O) – PACO2/R
where PA O2 is alveolar PO2, FiO2 is fractional concentration of oxygen in
inspired gas, PB is barometric pressure, PH2O is water vapor pressure at
37°C, PACO2 is alveolar PCO2 (assumed to be equal to PaCO2), and R is
respiratory exchange ratio. R depends on oxygen consumption and carbon
dioxide production. At rest, the ratio of VCO 2 to oxygen ventilation (VO2)
is approximately 0.8.
Even normal lungs have some degree of V/Q mismatching and a
small quantity of right-to-left shunt, with PAO2 slightly higher than PaO2.
However, an increase in the alveolar-arterial PO 2 gradient above 15-20
mm Hg indicates pulmonary disease as the cause of hypoxemia.
27
Hypoxemic respiratory failure
V/Q mismatch
V/Q mismatch is the most common cause of hypoxemia. Alveolar
units may vary from low-V/Q to high-V/Q in the presence of a disease
process. The low-V/Q units contribute to hypoxemia and hypercapnia,
whereas the high-V/Q units waste ventilation but do not affect gas
exchange unless the abnormality is quite severe.
The low V/Q ratio may occur either from a decrease in ventilation
secondary to airway or interstitial lung disease or from overperfusion in
the presence of normal ventilation. The overperfusion may occur in case of
pulmonary embolism, where the blood is diverted to normally ventilated
units from regions of lungs that have blood flow obstruction secondary to
embolism.
Administration of 100% oxygen eliminates all of the low-V/Q
units, thus leading to correction of hypoxemia. Hypoxemia increases
minute ventilation by chemoreceptor stimulation, but the PaCO2 generally
is not affected.
Shunt
Shunt is defined as the persistence of hypoxemia despite 100%
oxygen inhalation. The deoxygenated blood (mixed venous blood)
bypasses the ventilated alveoli and mixes with oxygenated blood that has
28
flowed through the ventilated alveoli, consequently leading to a reduction
in arterial blood content. The shunt is calculated by the following equation:
QS/QT = (CCO2 – CaO2)/CCO2 – CvO2)
where QS/QT is the shunt fraction, CCO2 is capillary oxygen content
(calculated from ideal PAO2), CaO2 is arterial oxygen content (derived from
PaO2 by using the oxygen dissociation curve), and CvO2 is mixed venous
oxygen content (assumed or measured by drawing mixed venous blood
from a pulmonary arterial catheter).
Anatomic shunt exists in normal lungs because of the bronchial and
thebesian circulations, which account for 2-3% of shunt. A normal right-
to-left shunt may occur from atrial septal defect, ventricular septal defect,
patent ductus arteriosus, or arteriovenous malformation in the lung.
Shunt as a cause of hypoxemia is observed primarily in pneumonia,
atelectasis, and severe pulmonary edema of either cardiac or noncardiac
origin. Hypercapnia generally does not develop unless the shunt is
excessive (> 60%). Compared with V/Q mismatch, hypoxemia produced
by shunt is difficult to correct by means of oxygen administration.
29
depression. In pure hypercapnic respiratory failure, the hypoxemia is
easily corrected with oxygen therapy.
Hypoventilation is an uncommon cause of respiratory failure and
usually occurs from depression of the CNS from drugs or neuromuscular
diseases affecting respiratory muscles. Hypoventilation is characterized by
hypercapnia and hypoxemia. Hypoventilation can be differentiated from
other causes of hypoxemia by the presence of a normal alveolar-arterial
PO2 gradient.
4. stabilization the patient with the respiratory failure that caused by trauma
This ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
survey is called Primary survey that must be completed in 2 - 5 minutes.
Therapy is carried out simultaneously if the victim experiences a life threat
due to many systems the injured:
Airway
Assessing free airway. Can the patient talk and breathe freely?
• Chin lift / jaw thrust (the tongue is attached to the lower jaw)
Breathing
30
Assess breathing enough. Meanwhile re-value whether the airway is free.
• Artificial respiration
Circulation
Disability
AWAKE = A
PAIN RESPONSE = P
NO RESPONSE = U
Exposure
31
Take off the patient's clothes and body cover so that all possible injuries
can be searched there is. If there is a suspicion of neck or spinal cord
injury, then in-line immobilization should be done.
The first priority is to free the airway and keep it steady free
Patients who can answer clearly are a sign that the airway is free.
Unconscious patients may require artificial airway and respiratory
assistance. The cause of obstruction in an unconscious patient generally is
the fall of the base of the tongue to back. If there is a head, neck or chest
injury then during tracheal intubation cervical spine must be protected by
in-line immobilization.
• Sound rinsing
• Cyanosis
Beware of foreign objects in the airway. How to free the airway outlined
in Appendix 1
32
4. Maintain stability of the cervical vertebrae
• Apnea
• Hypoxia
• Chest trauma
VENTILATION
. Cyanosis
. Flail chest
. Sucking wounds
33
• Palpation / touch (FEEL)
. Broken ribs
. Skin emphysema
• Resuscitation Actions
If there is respiratory distress, the pleural space must be emptied from the
air and blood with installing thoracic drainage immediately without
waiting for an X-ray examination. If tracheal intubation is needed but it is
difficult, then do a cricothyroidotomy.
Special note
Large needles are inserted through the injured pleural space. Do it in the
second rib cage (ICS 2) in a line through the middle of the clavicle. Keep
up
the position of the needle until the thoracic drain installation is complete.
34
• If tracheal intubation is tried one or two times, then try
cricothyroidotomy.
equipment.
CIRCULATION MANAGEMENT
Types of shock:
35
• Myocardial contusion
• Cardiac tamponade
• Tension pneumothorax
• Myocardial infarction
Neurogenic shock
Septic shock
Rarely found in the initial phase of trauma, but often becomes causes
of death several weeks after trauma (through multiple organ failure).
Most
often found in victims of penetrating abdominal injuries and burns.
36
Urine
Urine production describes whether or not normal circulatory function
should be is> 0.5 ml / kg / hour. If the patient is unconscious with an old
shock it should be installed urine catheter.
Blood transfusion
Providing donor blood may be difficult, despite the large risk of mismatch
blood type, hepatitis B and C, HIV / AIDS. The risk of disease
transmission also exists even though the donor is his own family.
Transfusion must be considered if the patient's circulation is unstable even
though it has been get enough colloids / crystalloids. If the appropriate
donor blood group is not available, type O blood can be used (preferably
pack red cel and Rhesus negative. Transfusions should be given if the
hemoglobin is below 7g / dl if the patient continues to bleed. First priority:
stop bleeding
• Injury to the limbs
Torniket is useless. Besides that, tourniquets cause reperfusion syndrome
and add to the weight of the primary damage. The alternative is called
"pressure compress" often misunderstood. Severe bleeding due to stab
wounds and amputation wounds was stopped with subfascial solid gauze
plus manual pressure on arteries next to the proximal plus compressive
brakes (press evenly) throughout the section these limbs
• Chest injury
The source of bleeding from the chest wall is generally the arteries. Chest
tube installation / drain pipe must be as early as possible. This if added
with periodic suctioning, plus efficient analgesia, allows the lungs to
develop again at once clog the source of bleeding. For analgesia used
ketamine I.V. • Abdominal injury
Laparatomy damage control must be done as early as possible if
resuscitation the liquid cannot maintain a systolic pressure between 80-90
mmHg. At time DC laparatomy, a large screen is placed to compress and
37
clog source of bleeding from the abdominal organs (abdominal packing).
Incision in the midline it should be closed again within 30 minutes by
using towel clamps. This resuscitation action should be done with
ketamine anesthesia by a trained doctor (or maybe by a nurse for the home
smaller pain). It is clear that this technique must be learned first however if
done well enough it will save lives.
SECONDARY SURVEY
38
Secondary surveys are only done if the patient's ABC is stable If During
secondary survey the patient's condition worsens then we must return
Head examination
Neck check
• Subcutaneous emphysema
• Trachea deviation
Neurological examination
Chest examination
39
CHEST TRAUMA
A quarter of the total trauma deaths occur due to chest injuries. Death soon
occur if damage to the heart and large blood vessels. Death in phase the
next is due to airway obstruction, cardiac tamponade or aspiration. Most
chest trauma patients can be managed in simple ways without surgery.
• Pneumothorax
• Pneumothorax "tension"
• Hemothorax
• Lung contusion
• Open retractors
• Aspiration
Rib Fracture:
Can occur at the point of impact and cause lung tissue damage. In patients
Even minor trauma can cause rib trauma. Pieces of ribs can be stabilized
after 10-14 days. Perfect cure with callus is achieved after 6 weeks.
Flail chest:
The unstable part / segment moves on its own and is opposite to the chest
wall when breathing. This causes breath distress due to air flow in the
lungsbecome inefficient.
Tension pneumothorax
40
This dangerous situation occurs when air enters the pleural space but not
can come out again so that the pressure in the chest increases in height and
mediastinum displaced. The patient becomes congested and hypoxic.
Trachea is driven to a healthy side is a typical sign of pneumothorax that
has proceeded further. Thoracostomy needles must be done immediately
before installing the thoracic drain so the patient can breathe well
5. complication that may happen in the early management and how to solve it
Subcutaneous emphysema
Etiology
41
Subcutaneous emphysema is caused by blunt trauma or sharp trauma to the
thorax wall. When the pleural layer is hollow due to sharp trauma, air can
move from the lungs to the muscles and subcutaneous tissue in the chest
wall. When rupture of the alveoli occurs, for example in laceration of lung
tissue, air can move along the visceral pleura to the lung's hilum, then to
the trachea, neck and chest wall. The foregoing can also occur in rib
fractures that injure lung tissue. Because rib fractures can tear the parietal
pleura which can cause air to move from the lungs to the subcutaneous
tissue of the chest wall.
- therapy
Shock
42
distension), tension pneumothorax (tracheal deviation, unilateral weakened
breath sounds), and spinal cord trauma.
Airway:
When examining the airway, note whether there is an airway obstruction
such as the presence of additional breath sounds such as gargling that
indicates bleeding in the airways, or stridor that indicates upper airway
obstruction.
Breathing:
When assessing breathing efforts to consider are chest expansion,
respiratory rate, peripheral oxygen saturation. Asymmetrical chest
expansion with rapid respiratory rate can be found in pneumothorax. In
traumatic pneumothorax, also evaluate the signs of trauma to the chest,
such as bruises, wounds, or subcutaneous emphysema.
Circulation:
Circulatory failure with shock signs such as hypotension, tachycardia, cold
acral or cyanosis indicates the possibility of pneumothorax tension or
cardiac tamponade.
Oxygen Therapy
Give 100% oxygen immediately and maintain oxygen for the duration of
treatment. High-flow oxygen supplementation speeds up clinical pleural
air absorption. By inhaling 100% oxygen compared to free air, nitrogen
43
alveolar pressure will decrease and nitrogen will gradually be cleared of
tissue and oxygen will enter the vascular system. With high concentration
of oxygen supplementation, normally 1.2% of the volume will be absorbed
in 24 hours, 10% will be absorbed in 8 days and 20% in the next 16 days.
Nitrogen gradient differences that occur between capillary tissue and the
pneumothorax chamber will increase the absorption of the pleural cavity 4-
fold.
Simple Aspirations
The point for aspiration is between the ribs 2 in the midclavicular line. It
can also be done between the anterior axillary 5 ribs to prevent life-
threatening bleeding. needle aspiration or intravenous cannula insertion is
effective, comfortable, safe, and economical in some patients.
44
Anaphylactic shock is used to treat circulatory disorders and
eliminate bronchospasm. Adrenaline / Epinephrine increases brain and
coronary perfusion.
DOPAMIN
45
different effects. Dilution with liquid D5%, D10%, NaCL 0.9%. Before
and after giving observations of vital signs.
CEDILANID
LIDOKAIN
EPHEDRINE
IM or 10-20 mg IV.
46
ATTROPIN
FUROSEMID
Stabilization
Transportation
47
Is a business process to move from one place to another without using
tools. Depending on the situation and conditions in the field.
Stabilization Principle
- Rapid resuscitation
- Analgesia
- Look for and note the existence of injuries related to other disease
processes
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The patient to be referred must be examined and eligible to be referred.
The criteria for referred patients are if they meet one of:
Reference Preparation
1. Preparation of health workers, make sure the patient and family are
accompanied by a minimum of two competent health workers (doctors
and / or nurses).
2. Family preparation, inform the patient's family about the patient's latest
condition, and the reasons why need to be referred. Other family
members must take the patient to the place of referral.
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place of referral as soon as possible. Complete the ambulance, tools and
materials needed.
DAFTAR PUSTAKA
50
4. Syamsul hilal salam.2016. Dasar-dasar terapi cairan dan elektrolit.
Universitas Hasanuddin . http://med.unhas.ac.id
5. Nemaa PK. Respiratory Failure. Indian Journal of Anaesthesia,47(5):360-6
6. Deliana, Anna dkk. 2013. Indikasi Perawatan Pasien dengan Masalah
Respirasi di Instalasi Perawatan Intensif. J Respir Indo Vol. 33, No. 4.
7. Ata Murat Kaynar, MD. 2018. Respiratory failure. Departments of Critical
Care Medicine and Anesthesiology, University of Pittsburgh School of
Medicine
8. Faculty of Medicine, University of Indonesia. 1999. Capita Selekta Medicine,
Jakarta: Media Aesculapius.
9. Faculty of Medicine, University of Indonesia. 1995. Collection of Surgery
Studies, Jakarta: Binarupa Aksara
10. Soertidewi L. Penatalaksanaan Kedaruratan Cedera Kranio Serebral,
UpdatesIn Neuroemergencies, Tjokronegoro A, Balai Penerbit KUI, Jakarta,
2002, 80
11. Aziz H.Pranoko, Duta Dhanabhalan. Sistem Rujukan Puskesmas Batealit
Jepara [internet]. Semarang. 2012 [cited 2019 Sep 25] Tersedia di
:http://www.scribd.com/doc/115164565/protap-sistem-rujukan-puskesmas
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