FAKULTAS KEDOTERAN Makassar, 16 Oktober, 2019

UNIVERSITAS MUSLIM INDONESIA

TRAUMATOLOGI DAN KEGAWATDARURATAN

LAPORAN PBL
GAGAL NAPAS

Disusun Oleh:
KELOMPOK 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

Tutor : dr. Dian Fahmi Utami

FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
 2019

FOREWORD

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.

Makassar, October, 16th 2019

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 the classification of respiratory failure?
2. Explain about the primary survey and secondary survey of the respiratory
failure?
3. How to maintenance or do stabilization the patient with the respiratory
failure that caused by trauma?
4. Explain about the respiratory failure pathomechanism?
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. the classification of respiratory failure
Respiratory failure is a failure of the respiratory system in the
exchange of O2 and CO2 gases and is still a problem in medical
management. Practically, respiratory failure is defined as PaO2 <60
mmHg or PaCO2> 50 mmHg. 1 2

1) Type I Respiratory Failure (oxygenation failure, arterial hypoxemia)

Type I respiratory failure is characterized by partial abnormally

low arterial O2 pressure. Perhaps this is caused by any abnormality that
causes low intrapulmonary perfusion ventilation from right to left
characterized by low partial pressure of arterial O2 (PaO2 <60 mmHg
when inhaling ambient air). 1 2

Signs and symptoms:

 Dyspnea, Cyanosis
 Confused, somnolen
 Tachycardia, arrhythmia
 The use of muscle aids breathing
 Recession of the use of intercostal muscles
 Polycythemia
Causes of type 1 respiratory failure (oxygenase failure):

 Adult Respiratory Distrees Syndrome (ARDS)

 Asthma
 Lung edema
 Chronic Obstructive Pulmonary Disease (COPD)
 Intertisisal fibrosis
 Pneumonia
 Lung embolism
 Pneumothorax

4
  Pulmonary hypertension

2) Type II Respiratory Failure (ventilation failure: arterial hypercapnea)

Type II respiratory failure is caused by any abnormality that

decreases Central Respiratory drive, affects the transmission of signals
from CNS, or impedes the ability of the respiratory muscles to develop
lung and chest. Type II respiratory failure is characterized by an
increase in the partial pressure of abnormal arterial CO2 (PaCO2> 46
mmHg), and is followed simultaneously by a decrease in PaO2 - PaO2
that remains unchanged.2

Signs and symptoms:

 Increased cerebral blood flow and cerebrospinal fluid pressure
 Headache
 Asterixis
 Papyledema
 Warm extremities, pulse decreases
 Acidosis (respiratory and metabolic)
 ↓ pH, ↑ lactic acid

Causes of type II respiratory failure:2

a) Abnormalities concerning the Central Ventilatory Drive, which is a

respiratory control or respiratory drive located in the medulla of the
brain stem.2

 Infarction or brain hemorrhage

 Supratentorial emphasis on the brain stem
 Drug overdoses, narcotics, Benzodiazepines, anesthetic agents.

b) Abnormalities concerning the transmission of signals to the muscles

of respiration

 Myastania Gravis

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  Amytropic lateral sclerosis
 Guillain Barre Syndrome
 Spinal Cord Injury
 Multiple Sclerosis
 Residual paralysis (muscle paralysis)

c) Abnormalities in the respiratory muscles and chest wall

 Muscual dystrophy
 Polymyositis
 Flail Chest

Respiratory failure can also be distinguished based on the cause of trauma

or non-trauma.2
 Failure of breath due to trauma, including:
Pneumothorax, Hemothorax, Hydropneumothorax, Foreign body
obstruction, Flail chest, brain infarction or bleeding, suppression of
the supratentorial period in the brain stem
 Respiratory failure due to non-trauma, among others:
Effusion, asthma, pneumonia, vascular disease, myastania gravis,
Guillain barre syndrome, muscular dystrophy, polymyositis, and
others.

2. 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:3
• 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

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 Response
Awareness checks can be done in two ways namely qualitatively and
quantitatively:3
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

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

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  Score ≤5: Comma

 Airway Maintenance with

RESTRICTION OF CERVICAL SPINE MOTION
Upon initial evaluation of a trauma patient, first assess the airway to
ascertain patency. This rapid assessment for signs of airway obstruction
includes inspecting for foreign bodies; identifying facial, mandibular,
and/or tracheal/laryngeal fractures and other injuries that can result in
airway obstruction; and suctioning to clear accumulated blood or
secretions that may lead to or be causing airway obstruction. Begin
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.3
 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

Various kinds of airway obstruction

Airway obstruction can be total and partial. A total airway obstruction if not
corrected within 5 to 10 minutes can result in asphyxia (a combination of
hypoxemia and hypercarbi), breathing and cardiac arrest. Partial blockage
must also be corrected because it can cause brain damage, brain swelling,
pulmonary stroke, exhaustion, stopping breathing and secondary cardiac
arrest.4
1. Total airway obstruction

8
At the total airway obstruction does not hear the sound of breathing or not
feel the air through the nose or mouth. There are also additional signs of
retraction in the supraclavicular area and between the ribs if the patient is
still able to breathe spontaneously and the chest does not expand at the time
of inspiration.
2. Partial blockage of the breath
In partial airway obstruction there is a noisy air flow and sometimes
accompanied by retraction. Lime sounds indicate laryngospasm and sounds
like gargling indicate a blockage by a foreign object.

Symptoms and signs of blockage that appear marked by additional breath

sounds, include:5
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.

Head tilt and chin lift

This technique is performed on victims who have not experienced trauma to
the head, neck or spine.3

Jaw-Thrust Maneuver

9
To perform a jaw thrust maneuver, grasp the angles of the mandibles with
a hand on each side and then displace the mandible forward.3

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. 3

Oropharyngeal Airway
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

10
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.3

Laryngeal Mask Airway and Intubating LMA

The laryngeal mask airway (LMA) and intubating laryngeal mask airway
(ILMA) have been shown to be effective in the treatment of patients with
difficult airways, particularly if attempts at endotracheal intubation or bag-
mask ventilation have failed. 3

Definitive airway
Endotracheal Intubation
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

11
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.3

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.3

Surgical Cricothyroidotomy
Surgical cricothyroidotomy is performed by making a skin incision that
extends through the cricothyroid membrane. 3

12
 Breathing and ventilation

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.3
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 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. 3

13
2. 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. 3

3. Mouth to a protective device

The helper alone in using ambubags must be able to maintain the opening
of the airway by lifting the lower jaw, pressing the lid on the victim's face
strongly and pumping air by squeezing bagging. The helper must be able
to see clearly the movements of the victim's chest in each respiration.
Ambu bag is used with one helper holding the bag while scraping the air
while the other hand holds and fixes the mask. On the hand that holds the
mask, the thumb and index finger hold the mask to form the letter C while

14
 the other fingers hold the patient's lower jaw while simultaneously opening
the patient's airway by forming the letter E. 3

Oxygenation5
Flow rate Delivery
O2
Nasal canula 1 - 6 liter/minute 24–44 %
Simple Mask 5 – 8 liter/minute 40–60 %
Mask with 6 -10 liter/ 60-90%
reservoir minute
Non 4-10 liter/ minute 60-100%
Rebreathing

 Circulation

Blood Volume and Cardiac Output

Hemorrhage is the predominant cause of preventable deaths after injury.
Identifying, quickly controlling hemorrhage, and initiating resuscitation
are therefore crucial steps in assessing and managing such patients. 3
 Level of Consciousness—When circulating blood volume is reduced,
cerebral perfusion may be critically impaired, resulting in an altered
level of consciousness.
• 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

15
 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. 3

Cardiac Pulmonary Resuscitation (CRP)

Pulmonary Resuscitation (CPR), commonly known as CPR or
Cardiopulmonary Resuscitation, is an attempt to restore respiratory and /
or circulatory function due to the cessation of function and / or heart rate.
It can also be interpreted as an attempt to restore respiratory and / or
circulatory function which then allows for normal life to return after
respiratory and / or circulatory function fails.7
Indications:
• Stop breathing
Stopping breathing is characterized by the absence of chest movements
and respiratory air flow from the victim or patient. Stopping breathing is a
case that must be done basic life support measures.
 Cardiac arrest
At the time of cardiac arrest, it will immediately stop the circulation. This
stopping circulation will quickly cause the brain and vital organs to lack
oxygen. Disturbed breathing is an early sign of cardiac arrest. Cardiac
arrest is characterized by large palpable pulses (carotid, femoral, radial)
accompanied by blueness or very pale, breathing stop or one at a time,
pupillary dilatation does not react to light stimuli and the patient is
unconscious. Basic life support is part of the management of the medical
emergency department which aims to:7
 Prevents the cessation of circulation or the cessation of respiration.

16
 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.

CRP 8

17
18
 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).5

Bleeding is divided into 4 classes, divided by clinical signs, which

are useful for estimating the percentage of blood loss5

Classification of bleeding is divided into 4 classes:3

CLASS I CLASS II CLASS III CLASS IV

Approximate Almost 750 7500-1500 1500-2000 >2000
blood loss (ml)
Approximate Almost 15% 15-30% 30-40% >40%
blood loss
(percents)
Pulse pressure ↔ ↓ ↓ ↓
Blood pressure ↔ ↔ ↔/↓ ↓
Respiratory ↔ ↔ ↔/↑ ↑
rate
Urine output ↔ ↔ ↓ ↓↓
CNS ↔ ↔ ↓ ↓
Fluid Crystalloid Crystalloid Crystalloid or Colloid and
replacement Colloid and blood
(3:1) blood

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.
Tourniquetting is not recommended because, besides its small benefits in large

19
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.5

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.5

In patients suspected of having internal bleeding, surgery must be performed

immediately to stop the bleeding because giving blood or other fluids cannot
improve circulation.5

Fluid resuscitation

Intravenous fluids are classified into crystalloids and colloids. Crystalloid is a

solution where small organic and inorganic molecules are dissolved in water.
There are solutions that are isotonic, hypotonic, or hypertonic. Crystalloid fluids
have the following advantages: safe, non-toxic, reaction-free, and inexpensive.
The disadvantage of hypotonic and isotonic crystalloid fluid is its limited ability
to remain in the intravascular space.9

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.9
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
metabolic alkalosis caused by an increase in bicarbonate production due to
lactate metabolism.9

20
 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.9

The following table lists several types of crystalloid liquids and their
respective contents:9

Name Na+ K+ Mg+ Cl- Lactate Dekstros Calori

ee (gr/L) (Kcal/L)
Ringer 130 4 - 109 28 - -
laktate
NaCl 154 - - 154 - - -
0,9%
Dextrose - - - - - 27 108
5%

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.9
• 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
half-life of albumin in plasma is about 16 hours, with around 90%
remaining intravascularly 2 hours after administration.9
• Dextran

21
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.9

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 volume
(Ringer acetate / expansion
ringer lactate) 3. Longer
3. Can be stored duration
at room 4. Better tissue
temperature oxygenation
4. Free from 5. The incidence
anaphylactic of pulmonary
reactions edema and / or
5.Minimal systemic edema is
complications lower
Disadvantage
1. Edema can 1. Anaphylaxis
reduce the 2. Coagulopathy
expansion of the 3. Albumin can
chest wall aggravate

22
 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 15.3

 Exposure and Environmental Control

During the primary survey, completely undress the patient, usually by
cutting off his or her garments to facilitate a thorough examination and
assessment. After completing the assessment, cover the patient with warm
blankets or an external warming device to prevent him or her from
developing hypothermia in the trauma receiving area. Warm intravenous
fluids before infusing them, and maintain a warm environment.3
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

23
 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:3
•• Allergies
•• Medications currently used
•• Past illnesses/Pregnancy
•• Last meal
•• Events/Environment related to the injury

3. Stabilization for patient with the respiratory failure that caused by trauma
Based on the scenario 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: 10
Airway

Reassessing free airway. Can the patient talk and breathe freely?

If there is an obstruction then do:

• Chin lift / jaw thrust (the tongue is attached to the lower jaw)

• Suction (if tools are available)

24
• Guedel airway / nasopharyngeal airway

• Tracheal intubation with the neck held (immobilized) in a neutral

position. 10

Breathing

Reassess breathing enough. Meanwhile re-value whether the airway is

free.

If breathing is inadequate then do:

• Decompression of the pleural cavity (pneumothorax)

• Cover if there is a tear in the chest wall

• Artificial respiration. 10

Circulation

Reassess circulation / blood circulation. Meanwhile re-value whether the

airway is free

and breathing enough. If circulation is inadequate then do:

• Stop external bleeding

• Immediately attach two infusion lines with large needles (14-16 G)

• Give a liquid infusion

Disability

Reassess consciousness quickly, whether the patient is conscious, only

response to pain or totally unconscious. It is not recommended to measure
the Glasgow Coma Scale

AWAKE = A

25
SPEAKING RESPONSE (verbal) = V

PAIN RESPONSE = P

NO RESPONSE = U

This method is quite clear and fast. 10

Exposure

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. 10

MANAGEMENT OF BREAD ROADS

The first priority is to free the airway and keep it steady free. 10

1. Talk to the patient

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. 10

2. Give oxygen with a face mask (mask) or breath bag (selfinvlating)

3. Assess the airway

Signs of airway obstruction include:

• Sound rinsing

• Abnormal breath sounds (stridor, etc.)

• The patient is restless due to hypoxia

26
• Breathing using paradoxical breathing of muscles / chest movements

• Cyanosis

Beware of foreign objects in the airway.

Don't give sedative drugs to patients like this.

4. Maintain stability of the cervical vertebrae

5. Consider installing an artificial airway

Indications of this action are:

• Airway obstruction that is difficult to overcome

• Penetrating neck injury with enlarged hematoma

• Apnea

• Hypoxia

• Severe head trauma

• Chest trauma

• Facial trauma / maxillo-facial. 10

VENTILATION

The second priority is to provide adequate ventilation. 10

• Inspection / see breath frequency (LOOK)

Are there any of the following:

. Cyanosis

. Penetrating chest wounds

. Flail chest

27
. Sucking wounds

. Additional breath muscle movements

• Palpation / touch (FEEL)

. The displacement of the trachea

. Broken ribs

. Skin emphysema

. With percussion look for hemothorax and or pneumothorax

• Auscultation / hearing (LISTEN)

. Breathing sounds, heartbeat, bowel sounds

. Breath sounds decrease in pneumothorax

. Extra / abnormal breathing sounds

• 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

• If possible, give oxygen until the patient becomes stable

• If tension pneumothorax is suspected, decompression should be done

immediately

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

28
up the position of the needle until the thoracic drain installation is
complete.

• If tracheal intubation is tried one or two times, then try

cricothyroidotomy.

Of course this also depends on the ability of existing medical personnel

and equipment. 10

CIRCULATION MANAGEMENT

The third priority is improving circulation to be adequate.

'Shock' is a state of reduced organ perfusion and tissue oxygenation. In

patients This trauma condition is most often caused by hypovolemia.

The diagnosis of shock is based on clinical signs: Hypotension,

tachycardia, tachipnea, hypothermia, pale, cold extremities, slowing
capillary refill and decreased urine production. 10

Types of shock: 10

 Hemorrhagic shock (hypovolemic)

caused by acute loss of blood or fluid

body. The amount of blood lost due to trauma is difficult to

measure accurately even on Blunt trauma is often estimated to be
too low. Remember that: 10

• Large amounts of blood can accumulate in the abdominal cavity

and pleura.

• Bleeding femur shafts can reach 2 (two) liters.

• Bleeding pelvic fractures (pelvis) can exceed 2 liters Cardiogenic

shock: caused by reduced heart function, among others due to:

29
 • Myocardial contusion

• Cardiac tamponade

• Tension pneumothorax

• Penetrating heart wounds

• Myocardial infarction

Jugular venous pressure assessment is very important and ECG

should be recorded.

 Neurogenic shock

caused by loss of sympathetic tone due to marrow injury spinal cord

(spinal cord). The classic picture is hypotension without being
accompanied tachycardia or vasoconstriction. 10

 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. 10

Circulation resuscitation steps

The ultimate goal is to normalize tissue oxygenation. Because the cause of
this disorder is blood loss, fluid resuscitation is priority: 10
1. A good and smooth intravenous line must be installed immediately. Use
a large cannula (14-16 G). Under special circumstances a vein may be
needed
2. Infusion fluid (NaCL 0.9%) must be warmed to body temperature due to
hypothermia can cause blood clotting disorders.
3. Avoid fluids containing glucose.
4. Take enough blood samples for blood type examination and cross test.

30
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. 10

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. 10
• 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. 10
• 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. 10
• Abdominal injury
Laparatomy damage control must be done as early as possible if
resuscitation the liquid cannot maintain a systolic pressure between 80-90

31
mmHg. At time DC laparatomy, a large screen is placed to compress and
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. 10

Second priority: Fluid replacement, warming, analgesia with ketamine: 10

• Replacement fluid infusions must be warmed because of the process of
blood clotting works best in 38.5 C. Hemostasis is difficult in both
temperatures below 35 C. Hypothermia in trauma patients often occurs if
pre evacuation the hospital lasts too long (even in tropical weather). Easy
patient it gets cold but it's hard to warm up, because it's prevention
hypothermia is very important. Oral or intravenous fluids must be heated
40-42 C. Fluid in room rates equals cooling.
• Hypotensive fluid resuscitation: In cases where the cessation of bleeding
is not definitive or unconvincing volume is given by maintaining systolic
pressure between 80 - 90 mmHg during evacuation.
• Colloid liquid comes out, electrolyte fluid comes in! Latest research
results with the control group found a slight negative effect from colloid
use compared to electrolytes for fluid resuscitation.
• Oral fluid resuscitation (by mouth) is quite safe and efficient if the
patient is still has a reflex gag and no stomach injury. The liquid you drink
should be low sugar and salt. The concentrated liquid will cause osmotic
withdrawal from intestinal mucosa so arises negative effects. Diluted
cereal porridges using local ingredients is highly recommended.
• Analgesia for trauma patients can use repeated doses of ketamine 0.2
mg / kg. This drug has a positive inotropic effect and does not reduce gag
reflexes, making it suitable for evacuation of patients with severe trauma

32
SECONDARY SURVEY

Secondary surveys are only done if the patient's ABC is stable If During
secondary survey the patient's condition worsens then we must return10

REPEAT PRIMARY SURVEY.

All procedures performed must be properly recorded. Head-to-toe

examination is done with main concern: 10

Head examination

• Scalp and eyeball abnormalities

• Outer ear and tympanic membrane

• Periorbital soft tissue injury

Neck check

• Penetrating neck injuries

• Subcutaneous emphysema

• Trachea deviation

• Inflated neck veins

Neurological examination

• Assessment of brain function with the Glasgow Coma Scale (GCS)

• Assessment of spinal cord function with motor activity

• Assessment of touch / sensation and reflexes

Chest examination

• Clavicle and all ribs

• Breath and heart sounds

33
• ECG monitoring (if available)

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.

Breath distress (shortness) can be caused by: 10

• Rib / fracture chest fractures

• Pneumothorax

• Pneumothorax "tension"

• Hemothorax

• Lung contusion

• Open retractors

• Aspiration

Shock due to bleeding can occur due to hemothorax or hemomediastinum10

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. 10

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. 10

34
 Tension pneumothorax

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 breath well.10

4. the respiratory failure pathomechanism

The main path physiologic mechanisms of respiratory failure are:11

Hypoventilation: in which PaCO2 and PaO2 and alveolar –arterial PO2

gradient is normal. Depression of CNS from drugs is an example of this
condition.

V/P mismatch: this is the most common cause of hypoxemia.

Administration. Of 100% O2 eliminate hypoxemia. 

Shunt: in which there is persistent hypoxemia despite 100% O2

inhalation. In cases of shunt the deoxygenated blood (mixed venous blood)
bypasses the alveoli without being oxygenated and mixes with oxygenated
blood that has flowed through the ventilated alveoli, and this leads to
hypoxemia as in cases of pulmonary edema (cardiogenic or
noncardiogenic), pneumonia and atelectasis

Respiratory failure can arise from an abnormality in any of the

components of the respiratory system, including the airways, alveoli,
central nervous system (CNS), peripheral nervous system, respiratory
muscles, and chest wall. Patients who have hypoperfusion secondary to
cardiogenic, hypovolemic, or septic shock often present with respiratory
failure. Ventilatory capacity is the maximal spontaneous ventilation that

35
can be maintained without development of respiratory muscle fatigue.
Ventilatory demand is the spontaneous minute ventilation that results in a
stable PaCO2. 11
Normally, ventilatory capacity greatly exceeds ventilatory demand.
Respiratory failure may result from either a reduction in ventilatory
capacity or an increase in ventilatory demand (or both). Ventilatory
capacity can be decreased by a disease process involving any of the
functional components of the respiratory system and its controller.
Ventilatory demand is augmented by an increase in minute ventilation
and/or an increase in the work of breathing. 11

Respiratory physiology

The act of respiration engages the following three processes: 11

 Transfer of oxygen across the alveolus
 Transport of oxygen to the tissues
 Removal of carbon dioxide from blood into the alveolus and then into
the environment
Respiratory failure may occur from malfunctioning of any of these
processes. In order to understand the pathophysiologic basis of acute
respiratory failure, an understanding of pulmonary gas exchange is
essential. 11

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. 11
The quantity of oxygen combined with hemoglobin depends on the
level of blood PaO2. This relationship, expressed as the oxygen

36
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. 11
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. 11
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
alveolar ventilation, some units are underperfused, while others are
overperfused. 11
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). 11

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. 11
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

37
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. 11
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. 11

Hypoxemic respiratory failure

The pathophysiologic mechanisms that account for the hypoxemia

observed in a wide variety of diseases are V/Q mismatch and shunt. These
2 mechanisms lead to widening of the alveolar-arterial PO 2 gradient, which
normally is less than 15 mm Hg. They can be differentiated by assessing
the response to oxygen supplementation or calculating the shunt fraction
after inhalation of 100% oxygen. In most patients with hypoxemic
respiratory failure, these 2 mechanisms coexist. 11

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. 11
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

38
units from regions of lungs that have blood flow obstruction secondary to
embolism. 11
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. 11
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
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 P AO2), CaO2 is
arterial oxygen content (derived from PaO 2 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). 11
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. 11
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. 11

39
 Hypercapnic respiratory failure

At a constant rate of carbon dioxide production, PaCO 2 is

determined by the level of alveolar ventilation according to the following
equation (a restatement of the equation given above for alveolar
ventilation):
PaCO2 = VCO2 × K/VA
where K is a constant (0.863). The relation between PaCO 2 and alveolar
ventilation is hyperbolic. As ventilation decreases below 4-6 L/min,
PaCO2 rises precipitously. A decrease in alveolar ventilation can result
from a reduction in overall (minute) ventilation or an increase in the
proportion of dead space ventilation. A reduction in minute ventilation is
observed primarily in the setting of neuromuscular disorders and CNS
depression. In pure hypercapnic respiratory failure, the hypoxemia is
easily corrected with oxygen therapy. 11
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. 11

5. complication that may happen in the early management and how to solve it
Subcutaneous emphysema

Air in subcutaneous fat tissue is called subcutaneous emphysema. Air can

be from the outside, from the lungs penetrate the visceral and parietal
pleura into the subcutis or air from the lungs to the mediastinum and to the
subcutis without pleural damage.12

40
Suppression of blood vessels due to air entering the pericardial cavity or in
the blood vessels in the neck so that it blocks blood returning to the heart.
12

 Signs and symptoms

Air bubbles in subcutaneous tissue, in the form of nodules that can be

easily moved. Signs and symptoms of subcutaneous emphysema vary
depending on the cause, but are sometimes accompanied by neck swelling,
chest pain, difficulty swallowing, wheezing and difficulty breathing. In
certain cases, subcutaneous emphysema can be detected by touching the
skin in the area. At the touch will feel like tissue paper. When touched the
bubble can move and sometimes make a sound. 12

Subcutaneous emphysema is usually accompanied by swelling of the

surrounding tissue. Similarly, the patient's face. Because of the pressure
caused by the swelling, the patient's voice can change. 12

 Etiology

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. 12

- therapy

Subcutaneous emphysema does not require special therapy. Action is taken

if the amount of air in the subcutaneous tissue is very large and affects the
patient's breathing. The first thing to do is to use a chest tube and make

41
sure the chest tube is functioning properly (if the cause is a
pneumothorax). Installing a catheter or a small incision in the skin can
help expel air from subcutaneous tissue. 12

Shock

Shock is an emergency caused by the failure of blood perfusion to the

tissues, resulting in impaired cell metabolism. Death due to shock occurs
when this condition causes interference with nutrition and cell metabolism.
13

Hypovolemic shock is shock caused by blood loss or hemorrhagic shock.

- External hemorrhagic: trauma, gastrointestinal bleeding
- Internal hemorrhage: hematoma, hematothorax
The most common causes of hypovolemic shock are gastrointestinal
mucosal bleeding and severe trauma. 13

In patients with trauma, bleeding is usually suspected as a cause of shock.

However, this must be distinguished from other causes of shock. These
include cardiac tamponade (weakened heart sounds, neck venous
distension), tension pneumothorax (tracheal deviation, unilateral weakened
breath sounds), and spinal cord trauma. 13

Hemothorax can occur in traumatic pneumothorax so that intravenous

access with a large cannula is required for fluid resuscitation if the patient
experiences worsening to shock. Apart from bleeding, obstructive shock
can result from mediastinal shifting to the contralateral side, compressing
the contralateral lung and decreasing venous return. 13

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. 3,13

42
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. 3,13

Circulation:
Circulatory failure with shock signs such as hypotension, tachycardia, cold
acral or cyanosis indicates the possibility of pneumothorax tension or
cardiac tamponade. 13

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
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. 13

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. 13

43
 Thoracostomy Hose or Intercostal Catheter
This procedure is recommended if simple aspiration is ineffective and
thoracoscopy is not available. Catheter / hose installation point is the same
as simple aspiration needle placement point. This procedure causes rapid
lung expansion so that the duration of treatment will be reduced. The risk
of pulmonary re-expansion is that pulmonary edema will be greater if re-
expansion occurs too quickly so that the installation of water-seal is
recommended in the first 24 hours. Currently the installation of catheters
more often replaced with plastic hoses (18-24 Fr) compared to metal trokar
because of the risk of injury. The exact location of the hose can be seen
from the presence of bubbles during expiration and when coughing and
increasing the level of water in the water seal at the time of inspiration. 13

6. The Way Of Using Emergency Drugs

ADRENALIN / EPINEFRIN

Anaphylactic shock is used to treat circulatory disorders and

eliminate bronchospasm. Adrenaline / Epinephrine increases brain and
coronary perfusion.14

Effects: on the heart lungs, adrenaline stimulates α (α1 and α2)

receptors to cause peripheral vasoconstriction and stimulates β1 receptors
in the heart so that coronary arteries dilate so that blood flow to the
myocardial becomes better. 14

Dosage : For cardiac resuscitation, 1: 10,000 adrenaline (1 mg of

adrenaline and 10 ml of NaCl) 1 mg iv is repeated every 2-3 minutes until
resuscitation is successful or stopped. In patients with mild shock, the dose
is given 0.3-0.5 mg subcutaneously in a 1: 1000 solution. Whereas in
patients with severe shock, the dose can be repeated or increased from 0.5

44
to 1 mg. In CPR, the recommended dose is 0.5-1 mg in a 1: 1000 solution,
which can be repeated every 5 minutes because of its short service life. 14

DOPAMIN

Used in post-resuscitation if hypotension harms the perfusion of

vital organs, especially the kidneys. Also used to maintain blood pressure
and perfusion in septic shock, cardiogenic shock, and post cardiac
resuscitation. Before given to people with shock, hypovolemia must be
corrected first. 14

Indications: Hypotension which is not caused due to hypovolemia

Effect: Increase diuresis, Increase myocardial contractility, Almost does

not affect peripheral resistance, Causes dilated renal arterioles so as to
maintain kidney function. 14

Dosage: Dopamine doses start from 2-5 µg / kg / minute. 5-10 mg /

kg / minute to increase cardiac output, systolic blood pressure, can also be
given> 10 µg / kg / minute. Effects on the kidneys. These doses have
different effects. Dilution with liquid D5%, D10%, NaCL 0.9%. Before
and after giving observations of vital signs. 14

CEDILANID

Pharmacodynamics: This drug is used for supracentricular

tachyarytmia patients  and congestive heart failure.

Dosage: Digitized dose total amount is 0.8-1.6 mg IV, divided by 4

times moderate administration for 6 hours, followed by a maintenance
dose of 0.2 mg IM every 12 hours. 14

LIDOKAIN

Pharmacodynamics: Lidocaine is the drug of choice for ventricular

arrhythmias, its effects are immediate and its service life is short.

45
 Dosage: Dose for intravenous injection 1-1.5 mg / kg body weight
can be repeated in 3-5 minutes until a total dose of 3 mg / kg body weight
in the first 1 hour then drip dose 2-4 mg / minute for 24 hours later,
followed by maintenance dose in infusion droplets 15-50 µg / kg / minute.
can be given intratracheal or transtracheal at a dose of 2–2.5 times the
intravenous dose. 14

EPHEDRINE

Pharmacodynamics: The effect is the same as adrenaline, but

effective in oral administration, its potential is weaker but its service life is
7-10 times longer. Ephedrine is a sympathomimetic drug that acts doubly,
directly on the adrenergic receptors and indirectly by stimulating the
release of ketocolamine.

Dosage: To overcome hypotension due to spinal block during

anesthesia or halothane depression given ephedrine at a dose of 10-50 mg

IM or 10-20 mg IV. 14

ATTROPIN

Pharmacodynamics: Ttropin inhibits the influence of N.Vagus on

the SA node. Can increase the pulse of patients with sinus bradycardia or
AV block (AtrioVentrikuler) degrees 1 or 2.

Indications: Asystole bradycardia (careful administration of

atropine to bradycardia with ischemic or myocardial infarction),
organopathic poisoning (atropinization).

Dosage: Atropine preparations are 0.25 and 0.5 mg tablets and

injections. For infants and children given 0.01 mg / kgbb because it is easy
to experience intoxication and overdose. Can also be given a dose of 1 mg
IV bolus that can be repeated in 3-5 minutes to a total dose of 0.03-0.04

46
 mg / kg BW, for bradycardia 0.5 mg IV bolus every 3-5 minutes a
maximum of 3 mg. 14

FUROSEMID

Pharmacodynamics: Used to reduce pulmonary edema and brain

edema.
Effects: Side effects that can occur due to excessive diuresis are
hypotension, dehydration and hypokalemia.

Dosage: 20-40 mg intravenous. 14

7. Transportation and patient’s referral with the respiratory failure

Terms of transportation
In choosing the method of transportation, the principle of "do no further
harm" must be the main consideration. Travel between hospitals can be
dangerous, except if the patient has been stabilized, the accompanying
personnel are adequately trained, and have taken into account the
possibilities that occur during transportation.
If there is no fixed procedure, the following procedure is recommended:3,15
1) The referring doctor

The doctor who will refer must talk to the recipient doctor, and provide
the information below: 15,16

• Patient identity

• A brief history taking, including important prehospital data

• Initial findings on patient examination

• Responters for therapy

2) Information for officers who will accompany15,16

The accompanying officer must be at least notified:

47
 • Management of the patient's airway

• Liquid that has / will be given

• Special procedures that may be needed

• Revised Trauma Score, resuscitation procedures and changes that may

occur during the trip

3) Documentation

Included with the patient is documentation of the patient's problem, the

therapy that has been given, the patient's current condition to be
referred.15,16

4) Treatment before referring

The patient must be resuscitated in an attempt to make the patient as

stable as possible, as recommended below. 15,16

a. Airway

• Install airways or intubation if necessary

• Suction where necessary

• Install NGT to prevent aspiration

b. Breathing

• Determine the rate of breathing, give oxygen

• Mechanical ventilation if needed

• Install a chest tube (chest tube) where necessary

c. Circulation

• Control external bleeding

48
 • Install 2 infusion lines, start giving crystalloids

• Repair blood loss with crystalloids or blood, and continue

administration during transportation

• Install a urethral catheter to monitor urine output

• Monitor heart rate and rhythm. 3

8. Islamic perspective based on the scenario

Because of that, We decreed upon the Children of Israel that whoever kills
a soul unless for a soul or for corruption [done] in the land – it is as if he
had slain mankind entirely. And whoever saves one – it is as if he had
saved mankind entirely. And our messengers had certainly come to them
with clear proofs. Then indeed many of them, [even] after that, throughout
the land, were transgressors. (al-maidah verse 32)

49
 DAFTAR PUSTAKA

1. Nemaa PK. Respiratory Failure. Indian Journal of Anaesthesia,47(5):360-6

2. Deliana, Anna dkk. 2013. Indikasi Perawatan Pasien dengan Masalah
Respirasi di Instalasi Perawatan Intensif. J Respir Indo Vol. 33, No. 4.
3. American College of Surgeon. 2018. Advanced Trauma Life Support. Ed 10.
America

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4. Habib, Hadiki. 2016.Triase Modern Rumah Sakit dan Aplikasinya
di Indonesia. Research Gate Article. Instalasi Gawat Darurat RSCM.
5. Latief SA, Suryadi KA, Dachlan MR. Petunjuk Praktis Anestesiologi. Edisi 2.
Jakarta: FKUI 2009
6. Sudoyo, Aru, W. Seiyohadi, bambang. 2014. Buku Ajar Ilmu Penyakit
Dalam. Jilid II. Edisi VI. Jakarta : pusat penerbitan dep. IPD FKUI
7. Jeremy Ward, Robert Clarke. Dalam: Amalia Safitri, Rina Astikawati,
editor.2009. At a Glance Fisiologi. Edisi 1. Jakarta: Erlangga Medical series
8. American heart association. Guideline. 2015. Focus utama pembaruan
pedoman American Heart Association 2015 untuk CPR dan EEC.
9. Syamsul hilal salam.2016. Dasar-dasar terapi cairan dan elektrolit.
Universitas Hasanuddin . http://med.unhas.ac.id
10. Advance Trauma Life Support For Doctors. 2018. Ed. 9. Jakarta
11. Ata Murat Kaynar, MD. 2018. Respiratory failure. Departments of Critical
Care Medicine and Anesthesiology, University of Pittsburgh School of
Medicine
12. Faculty of Medicine, University of Indonesia. 1999. Capita Selekta Medicine,
Jakarta: Media Aesculapius.
13. Faculty of Medicine, University of Indonesia. 1995. Collection of Surgery
Studies, Jakarta: Binarupa Aksara
14. the fiji emergency drugs guidelines, 2007 national drug and therapeutic
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