KEGAWATDARURATAN

KLINIK

dr. Ratih. N. Sumirat, MKK

1906451224
PPDS KEDOKTERAN OKUPASI
 Airway Breathing Circulation Disability Exposure

No specific modifications on this chapter

Ratih Nurdiany Sumirat - 1906451224 2

• In this edition of ATLS, drug-assisted intubation has replaced
rapid sequence intubation (RSI) as a broad term that describes
RSI
• the use of medications to assist with intubation of a patient with
intact gag reflexes.

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• The initial resuscitation with crystalloid fluid still begins with a 1 liter bolus of warmed isotonic
fluid
• Large volume fluid resuscitation is not a substitute for prompt control of hemorrhage. Infusion of
more than 1.5 liters of crystalloid fluid has been associated with increased mortality
• Early control of external hemorrhage is pivotal to the management of the injured patient
• Massive transfusion is defined as the transfusion of more than 10 units of blood in 24 hours or
more than four units in one hour.
• Early resuscitation with blood and blood products in low ratios is recommended in patients with
evidence of Class III and IV hemorrhage
• A large prospective study demonstrated decreased mortality when tranexamic acid is given within
three hours of injury

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• Tension Pneumothorax
• use longer angio catheters to ensure successful access to the thoracic cavity.
• the fourth or fifth intercostal space mid-axillary line is used instead of the second intercostal
space mid-clavicular line in adult patients
• Hemothorax
• Chest tube size : 28–32 F to effectively drain hemothorax without resulting in increased retained
hemothorax
• FAST can be done to evaluate pneumothorax
• Blunt aortic injury can be diagnosed and treated using thoracic CTA.
• Hemodynamically normal patients with partial injury are now managed with endovascular
techniques. The injury is medically managed by decreasing the heart rate (<80bpm) and mean
arterial pressure (60–70 mm Hg) through the use of beta blockers.
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• Signs of bladder injury :
• blood at the urethral meatus,
• perineal ecchymosis,
• a high-riding prostate on physical examination. → NOT RELIABLE
ANYMORE

• preperitoneal pelvic packing is used to control pelvic hemorrhage from

pelvic fractures

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• Anti coagulation in elderly patient need to be consulted to neurosurgeon
• The new Glasgow Coma Scale (GCS) is introduced in the 10th edition. This version of the GCS
stresses reporting the numerical components of the score and adds a new designation, NT (not
testable), to be used when a component of the score cannot be assessed
• Early management of brain injured person;
• avoiding prolonged hyperventilation with PC02 <25 mm Hg;
• maintaining systolic blood pressure >100 mm Hg for patients 50–69 years and >110 mm Hg or higher for
patients ages 15–49 or older than 70 years old to decrease mortality and improve outcomes;
• Propofo is recommended for the control of increased intracranial pressure but not for improvement of six-
month outcomes;
• barbiturates are not recommended to induce burst suppression measured by electroencephalogram to
prevent the development of intracranial hypertension;
• prophylactic use of phenytoin or valproate is not recommended for preventing late post traumatic seizures.
Phenytoin is recommended to decrease the incidence of early post traumatic seizures (within seven days
of injury).
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• Spinal Immobilization → Spinal Motion Restriction

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• Bilateral femur fractures are markers of significant energy mechanism and are risk factors for
complications and death in blunt trauma.
• Antibiotics used to treat open fractures should be dosed based on the patient’s weight to
ensure adequate tissue levels are achieved.

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• Adult patients with deep-partial and full-thickness burns involving more than 20 percent of the
total body surface area(TBSA) should receive initial fluid resuscitation of 2 ml of lactated
ringers/%TBSA.
• Target fluid resuscitation is calculated based on 3 ml/kg/%TBSA in pediatric trauma patients and
4 ml/kg/%TBSA for electrical burns.
• Half of the fluid is given over the course of eight hours and the remaining half is provided over a
span of 16 hours.
• The rate of fluid administration should be titrated to effect using a target urine output of 0.5
ml/kg/hr in adults or 1 ml/kg/hr in children who are hemodynamically normal.
• Boluses are reserved for unstable patients.

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• the site for needle decompression of the chest is in the second intercostal
space mid-clavicular line
• Damage control resuscitation for pediatric trauma patients is defined as an
attempt to limit the use of crystalloid resuscitation, as in adults
• An initial bolus of 20 ml/kg bolus of fluid is followed by 10–20 ml/kg of
packed red blood cells and 10–20ml/kg of fresh frozen plasma and
platelets as part of a massive transfusion protocol

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• The following five preexisting conditions affect morbidity and mortality:
• Cirrhosis
• Coagulopathy
• Chronic obstructive pulmonary disease
• Ischemic heart disease
• Diabetes mellitus
• Elderly patients with one or more of these preexisting conditions are twice as likely to die as those
without.
• Pelvic fractures in older patients result in a greater need for transfusion even with stable
patterns of injury. The mortality is four times higher with these injuries, hospital stays are longer, and
these patients may not return to independent lifestyles.

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• Indication of amniotic fluid leakage is vaginal fluid ph of >4.5.

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• Performing unnecessary diagnostic tests, particularly
computed tomography (CT) scans, may produce such
delays.

• Clear communication between transferring and receiving

institutions is important. SBAR (also known as situation,
background, assessment, and recommendations) is a useful
guide to ensure all important information is relayed.
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THANK YOU 16