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11/21/2016

DEFINISI
KEPERAWATAN TRAUMA Trauma is defined by the American Heritage
Dictionary as a wound, especially one
produced by sudden physical injury. (Mifflin,
1991)
Injury is defined by the National Committee
for Injury Prevention and Control as
unintentional or intentional damage to the
body resulting from acute exposure to
thermal, mechanical, electrical, or chemical
energy or from the absence of such essentials
as heat or oxygen. (National Safety
RAMDHANY ISMAHMUDI Council,2000)

DEFINISI Trauma
Trauma is mechanical damage to the body
caused by an external force. The trauma
patient has been defined as an injured
person who requires timely diagnosis and
treatment of actual or potential injuries by a
multidisciplinary team of health care
professionals, supported by the appropriate
resources, to diminish or eliminate the risk of
death or permanent disability.(Hildreth,
2013)

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Injury: Scale of the Global Problem Trauma


Leading cause of death < 44 years of
5.8 million deaths/year age

Source: Global Burden of Disease, WHO, 2004


10% of worlds deaths
32% more deaths than HIV, TB and
Third cause of death in all age
Malaria combined groups (in 2020 may be second
cause of death)
3.2 million deaths and 312 million
patients seek medical attention
worldwide (1990)
Lost life years, disability
Major socio-economic problem
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TRAUMA
One of three deaths occurred in
hospital as a result of injury could be
prevented
Often avoidable factors include simple
management errors in the early stages
(golden hour), rather than a failure of
complex definitive treatment (Royal
College of surgeons of England, 1988)

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PRINSIP MANAJEMEN KEGAWATDARURATAN PADA TRAUMA Prinsip Manajemen Kegawatdaruratan Pada Trauma Lanjut

F = Folley Catheter
A : Airway + Cervical Control
(kontra indikasi: Ruptur uretra)
B : Breathing + Ventilation Tanda:
C : Circulation + Hemorrhagic Control Keluar darah dr orifisium uretra eksterna
Hematoma di skrotum/supra simphisis
D : Disability Rectal touse: prostat melayang
E : Exposure + Hypothermia G = Gastric Tube
H = Heart Monitor and Pulse Oksimetri
Prevention

Intensive Care (Perawatan Intensif)


Proses Keperawatan memerelukan pemantauan terus
menerus

Critical Care ( Perawatan Kritis/ Gawat)


Proses Keperawatan keadaan klien gawat

Ruangan Khusus untuk pelayanan dan asuhan


keperawatan yang efektif

Dilengkapi dengan alat-alat,


fasilitas khusus dan tenaga terlatih

ICU/ICCU

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Critical Care
Lost life years
Situasi serius
Tiba-tiba, tidak dapat diduga
Mengancam/cenderung mengancam kehidupan 40

30
Tindakan cepat dan tepat
20
36
Proses Keperawatan
Sama dengan sistem di ruangan lain 10
16
12

Beda: 0
Trauma Cancer Cardio vascular
Waktu terbatas mengancam kehidupan
Informasi terbatas Pengkajian tidak harus lengkap Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003

Mechanisms of Injury
Treatment price Blunt Trauma
Compression Forces
Cells in tissues are compressed and crushed
400
E.g. Spleen
Shear Forces
300
Acceleration/Deceleration Injury
E.g. Aorta
200
Shearing force = Spectrum from Full thickness tear
(Exsanguination) to Partial tear (Pseudoaneurysm)
334
Overpressure
100 Body cavity compressed at a rate faster than the tissue
88
around it, resulting in rupture of the closed space
51 E.g. Plastic bag
0
Trauma Cancer Cardio vascular
E.g. in trauma = diaphragmatic rupture, bladder injury

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003 16

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Mechanisms of Injury Basics of Trauma Assessment


Preparation
Frontal Impact Collisions Team Assembly
Lateral Impact Collisions (T bone) Equipment Check
Rear Impact Collisions Triage
Sort patients by level of acuity (SATS)
Rollover Mechanism Nico.se (flickr)

Primary Survey
Open Vehicle or Motorcycle/Moped Designed to identify injuries that are immediately life threatening and to treat
Pedestrian Vs. Car them as they are identified
Penetrating Injury (Guns vs. Knives) Resuscitation
Rapid procedures and treatment to treat injuries found in primary survey
before completing the secondary survey
Vincent J Brown (flickr) Secondary Survey
Full History and Physical Exam to evaluate for other traumatic injuries
Monitoring and Evaluation, Secondary adjuncts
Transfer to Definitive Care
ICU, Ward, Operating Theatre, Another facility

Juicyrai (flickr) Knockhill (flickr)


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Nxtiak (flickr)

Preparation for Patient Arrival Primary Survey


Airway and Protection of Spinal Cord
Breathing and Ventilation
Circulation
Organize Trauma
Response Team Disability
Exposure and Control of the Environment

Top and bottom images:


http://www.trauma.org/archive/resus/traumateam.html
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Primary Survey Airway and Protection of Spinal Cord


Why first in the algorithm?
Key Principles Loss of airway can result in death in < 3 minutes
Prolonged hypoxia = Inadequate perfusion, End-organ damage
When you find a problem during the
Airway Assessment
primary survey, FIX IT. Vital Signs = RR, O2 sat
Mental Status = Agitation, Somnolent, Coma
If the patient gets worse, restart from the Airway Patency = Secretions, Stridor, Obstruction
beginning of the primary survey Traumatic Injury above the clavicles
Ventilation Status = Accessory muscle use, Retractions, Wheezing
Some critical patients in the Emergency Clinical Pearls
Department may not progress beyond Patients who are speaking normally generally do not have a need
for immediate airway management
the primary survey Hoarse or weak voice may indicate a subtle tracheal or laryngeal
injury
Noisy respirations frequently indicates an obstructed respiratory
pattern
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Airway Interventions Protection of Spinal Cord


General Principle: Protect the entire spinal cord until injury has been
excluded by radiography or clinical physical exam in patients with
Maintenance of Airway Patency potential spinal cord injury.
Suction of Secretions Dept. of the Army, Wikimedia Commons
Spinal Protection
Chin Lift/Jaw thrust Rigid Cervical Spinal Collar = Cervical Spine
Nasopharyngeal Airway Long rigid spinal board or immobilization on flat surface such as
stretcher = T/L Spine
Definitive Airway Etiology of Spinal Cord Injury (U.S.)
Airway Support Road Traffic Accidents (47%)
Oxygen High energy falls (23%)
NRBM (100%) Ignis, Wikimedia Commons
Clinical Pearls
Bag Valve Mask Treatment (Immobilization) before diagnosis
Return head to neutral position
Definitive Airway Do not apply traction
Definitive Airway Diagnosis of spinal cord injury should not precede resuscitation
Endotracheal Intubation Motor vehicle crashes and falls are most commonly associated with
In-line cervical stabilization spinal cord injuries
Surgical Crichothyroidotomy Main focus = Prevention of further injury

U.S. Navy photo by Photographer's


Mate 2nd Class Timothy Smith,
Wikimedia Commons 23 24

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C-spine Immobilization Breathing and Ventilation


General Principle: Adequate gas exchange is required to
Return head to neutral position maximize patient oxygenation and carbon dioxide elimination
Breathing/Ventilation Assessment:
Maintain in-line stabilization Exposure of chest
General Inspection
Correct size collar application Tracheal Deviation
Accessory Muscle Use
Retractions
Blocks/tape Absence of spontaneous breathing
Paradoxical chest wall movement
Sandbags Auscultation to assess for gas exchange
Equal Bilaterally
Diminished or Absent breath sounds
Palpation
Deviated Trachea
Broken ribs
Injuries to chest wall

Paladinsf
(flickr)
James Heilman, MD, Wikimedia Commons
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Breathing and Ventilation Breathing and Ventilation


Identify Life Threatening Injuries Hemothorax
Tension Pneumothorax Blood collecting in the pleural space and is
Air trapping in the pleural space common after penetrating and blunt chest
between the lung and chest wall trauma
Sufficient pressure builds up and
pressure to compress the lungs and Source of bleeding = Lung, Chest wall
shift the mediastinum (intercostal arteries), heart, great vessels
Delldot (wikimedia)
Physical exam (Aorta), Diaphragm
Absent breath sounds Physical Exam
Air hunger
Absent or diminished breath sounds
Distended neck veins
Tracheal shift Dullness to percussion over chest
Author unknown, Hemodynamic instability
Treatment http://www.trauma.org/index.php/mai
Needle Decompression n/images/C11/
Treatment = Large Caliber Tube Thoracostomy
2nd Intercostal space, Midclavicular line 10-20% of cases will require Thoracostomy for control of bleeding
Tube Thoracostomy
5th Intercostal space, Anterior axillary
Author unknown,
www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.ht
line
m 27 28

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Breathing and Ventilation Breathing and Ventilation


Flail Chest Open Pneumothorax
Direct injury to the chest resulting in an Sucking Chest Wound
unstable segment of the chest wall that moves
separately from remainder of thoracic cage Large defect of chest wall
Typically results from two or more fractures on Leads to rapid equilibration of
2 or more ribs Author unknown, atmospheric and intrathoracic pressure
Typically accompanied by a pulmonary http://www.trauma.org/index.php/main/image/
Impairs oxygenation and ventilation
contusion 902/

Physical exam = paradoxical movement of chest Initial Treatment


segment Three sided occlusive dressing
http://images1.clinicaltools.com/images/trauma
/flail_chest_wounded.gif Treatment = improve abnormalities in gas Provides a flutter valve effect
exchange
Early intubation for patients with respiratory Chest tube placement remote to site of
distress wound
Avoidance of overaggressive fluid resuscitation Avoid complete dressing, will create a
tension pneumothorax
Middle and bottom images:
Author unknown,
Author unknown, http://www.surgical- http://www.brooksidepress.org/Products/Ope
tutor.org.uk/default- 29 rationalMedicine/DATA/operationalmed/Pro 30
home.htm?specialities/cardiothoracic/chest_trauma cedures/TreataSuckingChestWound.htm
.htm~right

Needle Thoracostomy Tube Thoracostomy


Insertion site
5th intercostal space,
Anterior axillary line
Sterile prep, anesthesia with lidocaine
2-3 cm incision along rib margin with #10 blade
Dissect through subcutaneous tissues to rib margin
Needle Thoracostomy Puncture the pleura over the rib
Advance chest tube with clamp and direct posteriorly and
Midclavicular line apically
Observe for fogging of chest tube, blood output
Suture the tube in place
14 gauge angiocath Complications of Chest Tube Placement
Injury to intercostal nerve, artery, vein
Over the 2nd rib Author unknown,
http://www.trauma.org/images/image_lib
Injury to lung
Injury to mediastinum
Infection
Rush of air is heard rary/chest0051a.jpg


Allergic reaction to lidocaine
Inappropriate placement of chest tube

Author unknown,
www.trauma.org/index.php/main/article
/199/index.php?main/image/95/

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Circulation Circulation
Shock
Impaired tissue perfusion Types of Shock in Trauma
Tissue oxygenation is inadequate to meet metabolic demand Hemorrhagic
Prolonged shock state leads to multi-organ system failure and cell Assume hemorrhagic shock in all trauma patients until proven
death otherwise
Clinical Signs of Shock Results from Internal or External Bleeding
Altered mental status Obstructive
Tachycardia (HR > 100) = Most common sign
Cardiac Tamponade
Arterial Hypotension (SBP < 120) Tension Pneumothorax
Femoral Pulse SBP > 80
Radial Pulse SBP > 90 Neurogenic
Carotid Pulse SBP > 60 Spinal Cord injury
Inadequate Tissue Perfusion Sources of Bleeding
Pale skin color
Cool clammy skin Chest
Delayed cap refill (> 3 seconds)
Altered LOC Abdomen
Decreased Urine Output (UOP < 0.5 mL/kg/hr) Pelvis
Bilateral Femur Fractures
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Circulation Circulation
Emergency Nursing Treatment
Two Large IV Lines Pericardial Tamponade
Cardiac Monitor
Blood Pressure Monitoring Pericardium or sac around heart fills with
General Treatment Principles blood due to penetrating or blunt injury to
Stop the bleeding Pericardium chest
Apply direct pressure
Temporarily close scalp lacerations Blood Becks Triad
Close open-book pelvic fractures
Abdominal pelvic binder/bed sheet Distended jugular veins
Restore circulating volume Hypotension
Crystalloid Resuscitation (2L)
Administer Blood Products Muffled heart sounds
Immobilize fractures Treatment
Responders vs. Nonresponders
Transient response to volume resuscitation = sign of ongoing blood loss Epicardium Rapid evacuation of pericardial space
Non-responders = consider other source for shock state or operating room Performed through a pericardiocentesis
for control of massive hemorrhage (temporizing measure)
Aceofhearts1968(Wikimedia)
Open thoracotomy

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Pericardiocentesis Circulation
Puncture the skin 1-2 cm inferior to xiphoid process
45/45/45 degree angle A word about cardiac arrest . . .
Advance needle to tip of left scapula Care of the trauma patient in
Withdraw on needle during advance of needle cardiac arrest
Preferable under ultrasound guidance or EKG lead V CPR
attachment Bilateral Tube Thoracostomy
Complications Pericardiocentesis
Aspiration of ventricular blood Volume Resuscitation
Laceration of coronary arteries, veins,
epicardium/myocardium
Traumatic cardiac arrest due to
Author unknown,
Cardiac arrhythmia
blunt injury has very low survival
http://www.trauma.org/images/image_library/ch
est0054_thumb.jpg Pneumothorax
rate (< 1%)
No point for emergency thoracotomy
Puncture of esophagus
Puncture of peritoneum Selected cases of cardiac arrest due
Author unknown,
to penetrating traumatic injury may
http://www.trauma.org/images/image_library/chest0 benefit from emergent
046.jpg thoracotomy
Pericardial tamponade
Cross clamp aorta
Author unknown,
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www.brooksidepress.org/ProductsTrauma_Surgery?M=A

Disability Glasgow Coma Scale


Disability GCS 8
Intubate
Baseline Neurologic Exam Eye
Spontaneously opens 4
Pupillary Exam To verbal command 3
Dilated pupil suggests transtentorial herniation on ipsilateral side To pain 2
AVPU Scale No response 1

Alert Best Motor Response


Responds to verbal stimulation Obeys verbal commands 6
Localizes to pain 5
Responds to pain
Withdraws from pain 4
Unresponsive Flexion to pain (Decorticate Posturing) 3
Gross Neurological Exam Extremity Movement Extension to pain (Decerebrate Posturing) 2
Equal and symmetric No response 1
Normal gross sensation Verbal Response
Glasgow Coma Scale: 3-15 Oriented/Conversant 5
Disoriented/Confused 4
Rectal Exam Inappropriate words 3
Normal Rectal Tone Incomprehensible words 2
Note: If intubation prior to neuro assessment, consider quick No response 1

neuro assessment to determine degree of injury

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Disability Disability
Key Principles
Precise diagnosis is not necessary at this point in Cervical Spinal Clearance
evaluation
Patients must be alert and oriented to person,
Prevention of further injury and identification of
neurologic injury is the goal place and time
Decreased level of consciousness = Head injury until No neurological deficits
proven otherwise
Maintenance of adequate cerebral perfusion is key Not clinically intoxicated with alcohol or drugs
to prevention of further brain injury Non-tender at all spinous processes
Adequate oxygenation
Avoid hypotension No distracting injuries
Involve neurosurgeon early for clear intracranial Painless range of motion of neck
lesions

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Exposure Exposure
Remove all clothing
Examine for other signs of injury
Injuries cannot be diagnosed until seen by provider
Logroll the patient to examine patients back
Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine
Minimum of 3 people, often more providers required
Avoid hypothermia
Apply warm blankets after removing clothes
Hypothermia = Coagulopathy
Increases risk of hemorrhage
Author unknown,
http://www.trauma.org/index.php/main/image/98/C11
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Exposure Trauma Logroll


One person =
Cervical spine
Two people =
Roll main
body
One person =
Inspect back
and palpate
spine

Author unknown, Cdang, Wikimedia Commons


http://www.trauma.org/images/image_library/chest0044b.jpg
45 46

Secondary Survey History


AMPLE History
Secondary Survey is completed after primary
survey is completed and patient has been
Allergies
adequately resuscitated. Medications
No patient with abnormal vital signs should Past Medical History, Pregnancy
proceed through a secondary survey Last Meal
Secondary Survey includes a brief history Events surrounding injury, Environment
and complete physical exam History may need to be gathered from family
members or ambulance service

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Physical Exam Physical Exam


Head/HEENT Difficult airway
Neck
Chest
Abdomen
Pelvis
Genitourinary
Extremities
Neurologic
Source unknown

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Physical Exam Physical Exam


Seatbelt sign
Battle Sign

Raccoon's Eyes
http://health-
pictures.com/eye/Periorbital-
http://sfghed.ucsf.edu/Education/Cli Ecchymosis.htm

Cullens Sign nicImages/Battle's%20sign.jpg Accessed 9/20/09 Yahoo Images


Accessed 9/20/09 Yahoo Images

Grey-Turners Sign
H. L. Fred and H.A. van H. L. Fred and H.A. van Dijk
Dijk (Wikimedia) (Wikimedia)
http://www.itim.nsw.gov.au/images/seat_belt_mark_2.jpg
Accessed 9/20/09 Google Image Search 51 52

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Adjuncts to Secondary Survey FAST Exam


Radiology
Standard emergent films Focused Abdominal Sonography in Trauma
C-spine, CXR, Pelvis
Focused Abdominal Sonography in Trauma
(FAST)
4 views of the abdomen to look for fluid.
Additional films
Cat scan imaging RUQ/Morrisons pouch
Angiography
Foley Catheter Sub-xiphoid view of heart
Blood at urethral meatus = No Foley catheter LUQ view of spleno-renal junction
Pain Control
Tetanus Status Bladder view of pelvis
Antibiotics for open fractures

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FAST FAST
Has largely replaced deep peritoneal lavage Sensitivity of 94.6%
(DPL) Specificity of 95.1%
Bedside ultrasound looking for blood Overall accuracy of 94.9% in identifying the
collection in an unstable patient.
presence of intra-abdominal injuries.
If the patient is unstable and a blood Yoshil: J Trauma 1998; 45
collection is found, proceed emergently to
the operating theater.

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FAST FAST Exam - RUQ


Right Upper Quadrant - Morrisons Pouch

Between the liver and kidney in RUQ.


First place that fluid collects in supine
patient.

University of Louisville ED,


University of Louisville ED,
www.louisville.edu/medschool/emergmed/ult
www.louisville.edu/medschool/emergmed/ult
rasoundfast.htm
rasoundfast.htm

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FAST Sub-xiphoid FAST Sub-xiphoid


Evaluate for pericardial fluid
View through liver
Transhepatic or Parasternal
Searches for fluid between heart and
pericardium

University of Louisville ED, University of Louisville ED.


www.louisville.edu/medschool/emergmed/ultrasoundfa www.louisville.edu/medschool/emergmed/ultrasoundfa
st.htm st.htm

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FAST Left Upper Quadrant FAST - LUQ

View between the spleen and kidney


Another dependent place that fluid collects
Also see diaphragm in this view

University of Louisville ED,


University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultraso
www.louisville.edu/medschool/emergmed/ultraso
undfast.htm
undfast.htm

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FAST Bladder View FAST Bladder View


Evaluates for fluid in the pouch of Douglas
Posterior to bladder
Dependent potential space

University of Louisville ED, University of Louisville ED,


www.louisville.edu/medschool/emergmed/ultrasoundfast.h www.louisville.edu/medschool/emergmed/ultrasoundfast.h
tm tm

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Interpret this FAST Image: Trauma in Special Populations

Pregnancy
Supine Hypotensive Syndrome
After 20 weeks, enlarged uterus with fetus and amniotic
fluid compresses inferior vena cava
Decreases venous return and decrease cardiac output
Keep pregnant patients in left lateral decubitus position to
avoid excessive hypotension
Optimal maternal and fetal outcome is determined
by adequate resuscitation of mother
Fetal Monitoring
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

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Trauma in Special Populations Classic Radiographical Findings


Pediatric Trauma Resuscitation
Differences in head to body ratio Pelvic Fracture
and relative size and location of
anatomic features make children
more susceptible to head injury,
abdominal injury
Underdeveloped anatomy leads to
chest pliability and less protection of
thoracic cage
Cardiac Arrest
Typically result from respiratory
arrest degrading into cardiac
arrest
Resuscitation
Broselow Tape
ABCDE
Author unknown,
Author unknown,
http://dukehealth1.org/images/deps_tape4_sm.gif
http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jpg
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Classic Radiographic Findings Classic Radiographic Findings


Epidural Hematoma Subdural Hematoma
Femur Fracture Middle Meningeal Artery Bridging Veins

Author unknown, Author unknown,


Author unknown, http://rad.usuhs.mil/medpix/tachy_p http://rad.usuhs.edu/medpix/tac
www.flickr.com/photos/40939239@N08/3771820 ics/thumb/synpic4098.jpg hy_pics/thumb/synpic519.jpg
024/
69 70

Classic Radiographic Findings Classic Radiographic Findings


Diaphragmatic rupture w/ spleen herniation Widened Mediastinum Aortic Injury

Author unknown,
www.trauma.org/index.php/main/image/45/print
Author unknown,
http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg 71 72

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Definitive Care
Secondary Survey followed by radiographic
evaluation
CatScan
Consultation
Neurosurgery
Orthopedic Surgery
Vascular Surgery
Transfer to Definitive Care
Operating Room
ICU
Higher level facility

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