M.

Riyan Saputra

Pembimbing dr. Asep Hermana, Sp. B

Primary Survey The first step in patient management is performing the primary survey, the goal of which is to identify and treat conditions that constitute an immediate threat to life. The ATLS course refers to the primary survey as assessment of the "ABCs" (Airway with cervical spine protection, Breathing, and Circulation).

Ensuring a patent airway is the first priority in the primary survey. All patients with blunt trauma require cervical spine immobilization until injury is excluded Patients who have an abnormal breathing sounds, tachypnea, or altered mental status require further airway evaluation. Blood, vomit, the tongue, foreign objects, and soft tissue swelling can cause airway obstruction;

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the comatose patient, the tongue may fall backward and obstruct the hypopharynx; this may be relieved by either a chin lift or jaw thrust. Establishment of a definitive airway (i.e., endotracheal intubation) is indicated in 1. Patients with apnea 2. Impending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling, or aspiration

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a secure airway is obtained, adequate oxygenation and ventilation must be assured. All injured patients should receive supplemental oxygen. The following conditions constitute an immediate threat to life due to inadequate ventilation : 1. Tension pneumothorax, 2. Open pneumothorax, and 3. Flail chest with underlying pulmonary contusion.

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diagnosis of tension pneumothorax is implied by respiratory distress and hypotension in combination with any of the following physical signs in patients with chest trauma: a) Tracheal deviation away from the affected side, b) Lack of or decreased breath sounds on the affected side, and c) Subcutaneous emphysema on the affected side. d) Distended neck veins.

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immediate needle thoracostomy decompression in the second intercostal space in the midclavicular line may be indicated in the field, tube thoracostomy should be performed immediately in the ED before a chest radiograph is obtained.

A. Tube thoracostomy is performed in the midaxillary line at the fourth or fifth intercostal space B. Heavy scissors are used to cut through the intercostal muscle into the pleural space. C. The incision is digitally explored to confirm intrathoracic location and identify pleural adhesions. D. A 36F chest tube is directed superiorly and posteriorly with the aid of a large

 An

open pneumothorax or "sucking chest wound" occurs with full-thickness loss of the chest wall, permitting free communication between the pleural space and the atmosphere. Complete occlusion of the chest wall defect without a tube thoracostomy may convert an open pneumothorax to a tension pneumothorax.

 Temporary

management of this injury with an occlusive dressing that is taped on three sides. This acts as a flutter valve, permitting effective ventilation on inspiration while allowing accumulated air to escape from the pleural space on the untaped side, so that a tension pneumothorax is prevented.

A. Full-thickness loss of the chest wall results in an open pneumothorax. B. The defect is temporarily managed with an occlusive dressing that is taped on three sides,which allows accumulated air to escape from the pleural space and thus prevents a tension pneumothorax. Repair of the chest wall defect and tube thoracostomy remotefrom the wound is definitive treatment.

Temporary management of open pneumothorax ( Three sided dressing)

 Flail

chest is a clinical anatomic diagnosis noted in blunt trauma patients with paradoxical or reverse motion of a chest wall segment while spontaneously breathing. Flail chest is one of the worst subset of injury and is likely the most common serious injury to the thorax seen by clinician.
Flail Chest Treatment & Management in http://emedicine.medscape.com/article/433779-treatment

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a mid-1970s report, Trinkle et al, provided compelling evidence that many patients fared better with adequate pain control, this remains the standard today

Flail Chest Treatment & Management in http://emedicine.medscape.com/article/433779-treatment

Flail Chest (Paradoxical Movement)

Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result.

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initial approximation of the patient's cardiovascular status can be obtained by palpating peripheral pulses. Systolic blood pressure (SBP) must be 1. 60 mmHg for the carotid pulse to be palpable, 2. 70 mmHg for the femoral pulse, and 3. 80 mmHg for the radial pulse.

At this point in the patient's evaluation, any episode of hypotension (defined as a SBP <90 mmHg) is assumed to be caused by hemorrhage. IV access for fluid resuscitation is obtained with two peripheral catheters.

 Blood

should be drawn simultaneously and sent for measurement of hematocrit level, as well as for typing and cross-matching for possible blood transfusion in patients with evidence of hypovolemia.

Saphenous vein cutdowns are excellent sites for fluid resuscitation access

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the circulation section of the primary survey, life-threatening injuries that must be identified are 1. massive hemothorax 2. cardiac tamponade

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defined as >1500 mL of blood in the pleural space. After blunt trauma, a hemothorax usually is due to multiple rib fractures with severed intercostal arteries, but occasionally bleeding is from lacerated lung parenchyma. A massive hemothorax is an indication for operative intervention, but tube thoracostomy is critical to facilitate lung re-expansion.

More than 1500 mL of blood in the pleural space is a massive hemothorax. In the upright position, blood is visible dependently in the pleural space.

 <100

mL of pericardial blood may cause pericardial tamponade. The classic diagnostic Beck's triad 1. dilated neck veins, 2. muffled heart tones, and 3. a decline in arterial pressure

Cardiac Tamponade

Pericardiocentesis is indicated for patients with evidence of pericardial tamponade. A. Access to the pericardium is obtained through a subxiphoid approach, with the needleangled 45 degrees up from the chest wall and toward the left shoulder. B. Seldinger technique is used to place a pigtail catheter. Blood can be repeatedly aspirated with a syringe or the tubing may be attached to a gravity drain.

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Glasgow Coma Scale (GCS) score should be determined for all injured patients.

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the immediate threats to life have been addressed, a thorough history is obtained and the patient is examined in a systematic fashion. The patient and surrogates should be queried to obtain an AMPLE history (Allergies, Medications, Past illnesses or Pregnancy, Last meal, and Events related to the injury).