1.

BECK’s Triad (3D)

a. Collection of 3 medical sign associated with acute cardiac tamponade (medical
emergency when excessive fluid accumulates in the pericardial sac around the heart
and impairs its ability to pump blood
b. Sign : low arterial BP(systolic<90,diastolic<60), distended neck vein(jugular venous
distention), muffled heart sound→ when fluid or tissue acts as barrier between the
heart and stethoscope, difficult to appreciate on auscultation(dampen sound)
c. Decrease BP, decrease heart sound, dan distended jugular vein
d. CO<4→ skin cool and clammy, SOB when lying supine, tachycardia >100, BP
continue to drop MAP<60, low systolic BP called pulsus paradoxus (systolic BP
change >10)
CVP>8→ disteneded jugular/neck vein

2. Pneumothorax vs Cardiac Tamponade

Pneumothorax
• Spontaneous pneumothorax: No clinical signs or symptoms in primary spontaneous
pneumothorax until a bleb ruptures and causes pneumothorax; typically, the result is acute
onset of chest pain and shortness of breath, particularly with secondary spontaneous
pneumothoraces
• Iatrogenic pneumothorax: Symptoms similar to those of spontaneous pneumothorax,
depending on patient’s age, presence of underlying lung disease, and extent of
pneumothorax
• Tension pneumothorax: Hypotension, hypoxia, chest pain, dyspnea
• Catamenial pneumothorax: Women aged 30-40 years with onset of symptoms within 48
hours of menstruation, right-sided pneumothorax, and recurrence
• Pneumomediastinum: Must be differentiated from spontaneous pneumothorax; patients
may or may not have symptoms of chest pain, persistent cough, sore throat, dysphagia,
shortness of breath, or nausea/vomiting

X-ray Pneumothorax
Procedure: Upright PA chest x-ray in inspiration is the modality of choice.
Supportive findings of pneumothorax
• Ipsilateral pleural line with reduced/absent lung markings
• Abrupt change in radiolucency
Deep sulcus sign
• Decreased radiodensity and deep costophrenic angle on the ipsilateral side.
• The sign is a result of interpleural air that collects basally and anteriorly in the supine
position.
Hemidiaphragm elevation on the ipsilateral side
If pulmonary disease is present: airway or parenchymal lesions

Supportive findings of tension pneumothorax

• Ipsilateral diaphragmatic flattening/inversion and widened intercostal spaces
• Mediastinal shift toward the contralateral side
• Tracheal deviation toward the contralateral side
Cardiac Tamponade (beck’s triad)
• Hypotension with a narrowed pulse pressure
o The fall in arterial blood pressure results from pericardial fluid accumulation inside
the pericardial sac, which decreases the maximum size of the ventricles. This limits
diastolic expansion (filling) which results in a lower EDV (End Diastolic Volume)
which reduces stroke volume, a major determinant of systolic blood pressure. This is
in accordance with the Frank-Starling law of the heart, which explains that as the
ventricles fill with larger volumes of blood, they stretch further, and their contractile
force increases, thus causing a related increase in systolic blood pressure.
• Jugular venous distention (JVD)
o The rising central venous pressure is evidenced by distended jugular veins while in a
non-supine position. It is caused by reduced diastolic filling of the right ventricle, due
to pressure from the adjacent expanding pericardial sac. This results in a backup of
fluid into the veins draining into the heart, most notably, the jugular veins. In severe
hypovolemia, the neck veins may not be distended.
• Muffled heart sounds
o The suppressed heart sounds occur due to the muffling effects of the fluid
surrounding the heart.
• Echocardiography is the main diagnostic method for detection of pericardial effusion and
tamponade.

X-ray Find :
3. ATLS
a. Airway maintenance with cervical spin eprotection
i. 1st cervical spine stabilization
ii. Assess the airway → clear if patient can talk
iii. Unconscious → may not able to maintain airway
iv. Open airway by using chin lift or jaw thrust
v. Airway block by blood/vomit, use suction instrument
vi. Obstruction → pass endotracheal tube
b. Breathing and ventilation
i. Chest → IPPA
ii. Asses for subcutaneous emphysema and tracheal deviation
iii. Aim is to identify and manage 6 life threatening condition: airway
obstruction, tension pneumothorax, massive hemothorax, open
pneumothorax, flail chest segment with pulmonary contusion, and cardiac
tamponade
iv. Inspection → flail chest, tracheal deviation, penetrating injuries and bruising
v. Palpation → subcutaneous emphysema
vi. Percussion & auscultation → tension pneumothorax and hemothorax
c. Circulation with bleeding control
i. Hypovolemic caused by significant blood loss
ii. 2 large bores IV lines and crystalloid solution may be given
iii. External bleeding controlled by direct pressure
iv. Use of rFVIIa not supported, may help control bleeding, risk of arterial
thrombosis
d. Disability/neurologic assessment
i. AVPU
Alert, Verbal stimuli response, Painful stimuli response, or unresponsive
ii. Establish consciousness, pupil size and reaction, spinal cord injury level
 iii. GCS = consciousness
iv. Altered consciousness → immediate reevaluation of patient oxygenation,
ventilation and perfusion status
v. Hypoglycemia, drugs and alcohol shoul be excluded to be considered as
traumatic brain injury
e. Exposure and environmental control
i. Undress the patient by cutting of the garments
ii. Cover the patient with warm blankets to prevent hypothermia
iii. Iv fluid should be warmed and warm environment maintained
iv. Patient privacy should be mmaintained

4. Complication Electrical Burn

Burns can be classified as high or low voltage. High voltages greater than 500-1000 Volts
cause deep burns and extensive deep tissue and organ damage. Low voltage exposures tend
to result in lesser injury. United States households are supplied with voltages in the 110 to
220 range which causes muscle tetany and can lead to prolonged exposure to the electrical
source, as the patient cannot let go.

Complications from electrical injuries are similar to those of other thermal burns, such as
• infection (which can progress to sepsis),
• compartment syndrome,
• and rhabdomyolysis (due to extensive muscle damage from internal burns).
• injuries from being thrown from the electrical source or from falling from a height (roof,
bucket truck, ladder) due to the electrical shock, and these injuries (long bone fractures,
spinal fractures, lacerations, pneumothorax, etc.).

Cardiac complications can occur. One can have

• an arrhythmia.
Anyone who experiences an arrhythmia or any chest pain or other typical cardiac-related
symptoms is also at risk of arrhythmia in the 24 to 48 hours following the injury. Thus these
patients should be kept on a cardiac monitor at all times. Any high voltage injury should
have continuous cardiac monitoring for a minimum of 8 hours.

A special consideration is pediatric electrical injuries that occur as the result of a child
putting a cord in the mouth and biting down, causing burn injury to the corners of the
mouth. These patients can be sent home if there are no other associated injuries, however,
the complication in this case to warn parents about is delayed bleeding from the labial
artery, which can occur about 7 days following the date of injury.

Due to the complicated nature of injury patterns with electrical injuries, anything more than
a minor electrical injury should have a qualified trauma and burn center as a final
disposition.

5. Treatment Tension Pneumothorax, Treatment PneumoHemothorax

Tension Pneumothorax
• Needle decompression followed by tube thoracostomy

Treatment of tension pneumothorax is immediate needle decompression by inserting a large-

bore (eg, 14- or 16-gauge) needle into the 2nd intercostal space in the midclavicular line. Air
will usually gush out. Because needle decompression causes a simple pneumothorax, tube
thoracostomy should be done immediately thereafter.

HemoPneumothorax :

6. Pneumothorax vs tensionpneumothorax
a. Pneumothorax → collection of air withnin the pleural space between lung ( visceral
pleura) and the chest wall (parietal pleura) that lead to partial or complete
pulmonary collapse
b. Classified as:
1. Spontaneous pneumothorax
a) primary spontenous pneumothorax → occur in patients without clinically
apparent underlying lung disease
b) Secondary spontaneous pneumothorax → occur as complication of underlying
lung disease
c) Recurrent pneumothorax → a 2nd epiosede of spontaneous pneumothorax, either
ipsi/contralateral
2. Traumatic pneumothorax → penuomthorax caused by trauma (penetrating injurt
and iatrogenic trauma)
3. Tension pneumothorax → life threatening variant of pneumothorax characterized
by progressively increase pressure within chest and cardiorespiratory compromise
c. Pneumothorax : increase intrapleural pressure → alveolar collapse → decreased
V/Q ratio and increase right to left shunting
Tension pneumothorax: (accumulate air compress the lung, shift the mediastinum,
elevate intrathoracic pressure, lower venous return, and lower cardiac output
causoing shick)
1.Disrupted viscerlal pleura, parietal pleura or tracheobronchial tree
2. One way valve mechanism, in which air enters the pleural space in inspiration but
can’t exit
3. Progressive accumulation of air in the pleural space and increasing positive
pressure within the chest
4. Collapse of ipsilateral lung, compression of contralateral lung, trachea, heart, and
SVC, angulation of inferior vena cava
5. Impaired respiratory function, reduced venous return to the heart
6. Reduced cardiac output
7. Hypoxia and hemodynamic instability
 7. Compartment Syndrome
compartment syndrome:
• pain,
• pallor (pale skin tone),
• paresthesia (numbness feeling),
• pulselessness (faint pulse)
• and paralysis (weakness with movements).

8. Celiotomy
a. Known as laparotomy
b. Surgical procedure involving small incisions through the abdominal wall to gain acess
into the abdominal cavity
c. Space accessed : digestive tract, liver, pancreas, gallbladder, spleen, bladder, male
prostate, female uterus & ovaries, retroperitoneum ( kidneys, aorta and abdominal
lymph node)
d. Typ eof incision
i. Midline (most common)
vertical incision on the middle of abdomen which follow linea alba
1)upper midline incision extend fromxiphoid process to the umbilicus
 2) lower midline incision limited by umbilicus superiorly and symphisis pubis
inferiorly
3)sometimes bisa gabungan keduanya dari xiphoid-symphisis pubis
4) midline incision technique:
- cut the skin in midline(linea alba)
-cut subcutaneous tissue
-divide the linea alba(white line of abdomen)
-pick up peritoneum, confirm that there is no bowel adhesion (intestinal
adhesion)
-nick peritoneum
-insert finger beneath the wound to make sure that there is no adhesion
-cut the peritoneum with scissors
ii. Kocher (right subcostal) incision → for liver, gallbladder and biliary tract
iii. Davis/rockey-davis → muscle splitting in RLQ incision doe appendectomy
iv. Pfannenstiel incision → transverse incision below umbilicus and above
symphisis pubis, skin and subkutan incised transversally, but linea alba
opened vertically. For cesarean section and abdominal hysterectomy.
v. Lumbotomy → lumbar incision which permit access to kidneys without
entering peritoneal cavity. Used for benign renal lesion and surgery of the
upper urological tract
9. EDH, SDH, SAH
 The uncus can squeeze the oculomotor nerve (a.k.a.
CN III), which may affect the parasympathetic input to the eye on the side of the affected nerve,
causing the pupil of the affected eye to dilate and fail to constrict in response to light as it should.
Pupillary dilation often precedes the somatic motor effects of CN III compression
called oculomotor nerve palsy or third nerve palsy. This palsy presents as deviation of the eye to
a "down and out" position due to loss of innervation to all ocular motility muscles except for
the lateral rectus (innervated by abducens nerve (a.k.a. CN VI) and the superior
oblique (innervated by trochlear nerve a.k.a. CN IV). The symptoms occur in this order because
the parasympathetic fibers surround the motor fibers of CN III and are hence compressed
first.[citation needed]
Compression of the ipsilateral posterior cerebral artery will result in ischemia of the ipsilateral
primary visual cortex and contralateral visual field deficits in both eyes
(contralateral homonymous hemianopsia).
Another important finding is a false localizing sign, the so-called Kernohan's notch, which results
from compression of the contralateral[9] cerebral crus containing descending corticospinal and
some corticobulbar tract fibers. This leads to Ipsilateral hemiparesis in reference to the herniation
and contralateral hemiparesis with reference to the cerebral crus.
With increasing pressure and progression of the hernia there will be distortion of the brainstem
leading to Duret hemorrhages (tearing of small vessels in the parenchyma) in the median and
paramedian zones of the mesencephalon and pons. The rupture of these vessels leads to linear
or flamed shaped hemorrhages. The disrupted brainstem can lead to decorticate posture,
respiratory center depression and death. Other possibilities resulting from brain stem distortion
include lethargy, slow heart rate, and pupil dilation.[8]
Uncal herniation may advance to central herniation.[6] The sliding uncus syndrome represents
uncal herniation without alteration in the level of consciousness and other sequelae mentioned
above.

a.

10. Fraktur Basis Cranii (anterior, mid, posterior)

• Basis Cranii fossa Anterior : rinnorhea dan racoon eyes
Darah keluar beserta dengan likor serebrospinal dari hidunng atau kedua mata dikelilingi
lingkaran “biru” ( Brill Hematoma tau Racoon’s eyes), rusaknya Nervus Olfactorius sehingga
terjadi hyposmia sampai anosmia.

• Basis Cranii fossa Media : ottorhea dan battle’s sign

Darah keluar beserta likor serebrospinal dari telinga. Fraktur memecahkan arteri carotis
interna yang berjalan di dalam sinus cavernous sehingga terjadi hubungan antara darah
arteri dan darah vena (A-V shunt).

• Basis Cranii fossa Posterior :

Tampak warna kebiru-biruann di atas mastoid. Getaran fraktur dapat melewati foramen
magnum dan merusak medulla oblongata, sehingga pennderita dapat mati seketika.
 KUIS
1. Tension pneumothorax pada sisi kiri sulit dibedakan dengan cardiac tamponade. Kedua
hal tersebut memiliki kondisi yang sama dimana terdapat elevasi dari venous pressure dan
penurunan dari arterial pressure. Cardiac tamponade memiliki ciri khas berupa beck’s
triad → distensi vena jugular, hipotensi, and muffled heart sound. Hipotensi akan sulit
untuk dikaji pada pasien yang mengalami hipovolemi. Tension pneumothorax dibedakan
dari cardiac tamponade dengan temuan absent breath sound, deviasi trakea, dan perkusi
lapang paru hipersonor.
2. Fraktur hiperfleksi pada region torakolumbal bersifat tifak stabil akibat dari disrupsi pada
ligamentum flavum, interspinous ligaments, dan supraspinous ligament.
3. Hemothorax & pneumothorax → terdapat absence breath sound
hemothorax & konsolidasi → perkusi dull
sehingga, hemothorax memiliki sifat absence breath sound & dull apabila dilakukan
perkusi
4. Pada pasien dengan hipovolemik shock, diperlukan tindakan intervensi
surgical(angioembolisasi) dan fluid resusitasi
5. Shock merupakan abnormalitas pada sistem sirkulasi disebabkan karena kurangnya
perfusi menuju jaringan/organ.
6. optimal immediate management → mempertahankan airway, observasi breathing dan
memperbaiki jalan napas, memulai resusitasi cairan, dan membara pasien menuju ke
ruang operasi (dilakukan secara bersamaan)
7. sengatan listrik dapat memicu kontraksi otot secara berlebihan yang dapat berakibat pada
rhabdomyolisis. Akibatnya ada pelepasan dari senyawa myoglobin dan menyebabkan
sumbatan sehingga berdampak pada gagal ginjal akut. Pemberian cairan secara agresif ini
dapat mencegah terjadinya sumbatan dari myoglobin pada ginjal.
8. Pada anak2 yang mengalami trauma → harus dianggap mengalami spine injury dan
dipertahankan dengan spine imobilisasi sampai hasil radiolog menunjukkan adanya
abnormalitas.
9. Immediate chest tube insertion merukan indikasi yang dilakukan pada massive
hemothorax dan tension pneumothorax → yang merupakan kondisis darurat karena dapat
menyebabkan deviasi trakea dan pergeseran dari upper dan lower respiratory apabila
tidak ditangani dengan segera. Pendarahan besar pada hemothorax diperlukan
peengeluaran cairan sesegera mungkin.
10. Dilakukan cricothyroidotomy → karena adanya loss anatomi landmark sehingga sulit
untuk dilakukan perbaikan pada airway. Lebih disarankan cricothyroidotomy dobanding
tracheostomy karena lebih gampang dilakukan, sedikit pendarahan, dan memerlukan
waktu yang lebih sedikit.
11. Adanya multiple system injuries, termasuk trauma kepala berat → harus segera ditransder
kedalam rumah sakit yang kusus dalam menangani hal tersebut. hal ini disebabkan karena
peralatan yang dimiliki lebih lengkap dan penanganan lebih cepat sehingga dapat
mencegah terjadinya komplikasi
12. Langsung dilakukan tindapakan laparotomy/celiotomy → diakibatkan pada pasien dengan
luka tembak bisa menyebabakn pendarahan massif dan berakibat pada hipovolemi shock.
Oleh karen aitu, lebih disarankan tindakan laparotomy langsung karena tes diagnostic
lainnya hanya akan memakan waktu yang sia-sia.
13. Tindakan pertama yang perlu dilakukan berupa assess airway. Terutama pada pasien
dengan GCS 6 sehingga airway perlu diperhatikan dengan benar-benar. Dan untuk
mempertahankan airway perlu dilakukan pemasangan endotracheal tube
14. Karena adanya laserasi spleen perlu dipersiapkan rumah sakit yang mampu melakukan
tindakan operasi dalam 24 jam untuk mencegah adanya komplikasi. Laserasi spleen yang
bergejala nyeri tidak perlu dilakukan surgery terlebih dahulu namun perlu diobservasi
untuk mencegah komplikasi yang timbul, sehingga dengan adanya rumah sakit yang siap
siaga bisa mencegah kompliakasi dari penyakit yang tidak diharapkan
15. Imobilisasi [ada spine injury memerlukan alat2 berupa long spine board, bolster(untuk
mecegah kepala berputar), semirigid cervical collar, dan scoop style stretcher. Sedangkan
air splint tidak diperlukan pada orang dengan spine injury dan diindikasikan pada orang
dengan injuty musculoskeletal.
16. Pada anak2 sering ditemukan adanya spinal cord injury tanpa adanya abonormalitas pada
hasil radiologi. Hal ini bisa disebabkan anak2 memiliki tulang yang lebih fleksibel dan
penyebuhan yang relative lebih cepat.
17. Laparotomy/celiotomy perlu dilakukan dengan segera pada orang yang sebelumnya
mengalami luka tembak. Sebelum itu, perlu diberikan resusitasi cairan terlbeih dahulu
untuk mencegah terjadinya hipovolemi shock
18. Perlu segera dilakukan needle dekompresi pada paru kiri → kecelakaan pada pasien
dengan adanya rib fracture bisa curiga pneumothorax. Sehingga penting untuk dilakukan
dekompresi pada paru yang affected
19. Pada pasien dengan injuri pada bagian wajah perlu diperhatikan airway. Hal ini
disebabkan → injuri pada wajah menyebakan fraktur tulang2 yang dapat mensupport
airway
20. Prinsip dasara pada triase → “Do the most good for the most patients using available
resources”.

21. Test Kleihauer-Betke yang positif mengindikasikann adanya fetomaternal hemorrhage.

Tapi test yang negative tidak meniadakan fetomatternal hemorage pada derajat minor, yang
masih saja dapat mendeteksi ibu yang memiliki Rh-negative.

22. Dalam kondisi ini kita harus selalu mengecek ABC, Airway dan Breathinng sudah
dilakukan. Tetapi untuk sirkulasi masih belum dilakukan. Pasien mengalami hypovolemic
shock.

Pada kasus ini HR=180, RR=48. →kelas 4 hypovolemik

Setelah didekompresi jadi HR=140, RR=36, BP=80/50.
Tetapi shock sudah diatasi, dengan begitu, sisanya harus dilakukan fiksasi pelvis, mencegah
perdarahan dalam yang tidak terlihat apabila ada.

23. Pada anak kecil , jumlah volume darah yang hilang untuk menjadi shock, lebih sedikit
dibandingkan pada dewasa. Tapi persentasinya volume blood losenya lebih tinggi disbanding
pada dewasa. Kira-kira 30% dari volume darah yang hilang untuk menyebabkan penurunan
dari tekanan darah sistolik pada anak-anak.

24. Karena ada pengurangan sensasi pada kaki medial dann jempol, ini merupakan masalah
neurovascular pada kaki kanan. Dengan dilakukannnya realignment pada fraktur, dapat
menngurangu kompresi dan dapat membebaskan beberapa pembuluh darah apabila ada yang
terjepit.
Lalu boleh dilakukan angiography atau ct, untuk menilai perfusi alirann darahnya.

25. Pada lateral c-spine, harus terlihat dasar dari tengkorak, semua ke-7 dari cervical spine,
dan bagian superior dari vertebra thorakik pertama harus terlihat.
C-spine film, harus dilakukan pada secondary survey.

26. Epidural hematoma, karena ada lucid interval diantara waktu kecelakaan dan penurunan
neurologis.

27. Treatment Frostbite :

-harus secepatnya mengurangi waktu durasi dari jaringann yang membeku.
-letakan pada suhu 40”C, sampai perfusi Kembali lagi.
-dengan jangka waktu 20-30 menit.
- Saat mencair, warnanya mungkin menjadi merah. mungkin juga merasakan sensasi
tersengat atau tertusuk yang menyakitkan, seperti "kesemutan."

28. Pakai torakostomi pada hemitoraks kiri dikarenakan → ada absent sound yang
menandakan adanya pneumothorax.

29. Pada kasus 24 tahun pasien massive hemothorax → harus dipasang central venous
pressure, untuk mendeteksi tekanan darah Karenna adanya desakann dari hemothorax,
mendesak jantung maupunn paru.

30. Fetal hypoxia dan distress → pada saat gestasi, vaskularisi berdilatasi maksima, karena
sangat sensitive terhadap stimulasi dari katekolamin. Pada wanita hamil yang kehilangann
banyak darah, dapat meningkatkann resisten dari pembuluh ke janin, mengurangi oksigenasi
ke fetal.

31. Precutaneuous peripheral veins in the upper extremities → karena lebih disarankan untuk,
rapid infusion dalam volume yang besar.
32. Karena tidak ada pendarahann dann fraktur, maka curiga trauma tumpul, mennyebabkann
pendarahan hemmorhage pada bagian dada dan abdomen.

33. Bilateral compartment syndrome → Paralysis pada otot kaki, merupakan tanda-tanda dari
compartment syndrome.

34.

Semua di atas benar, kecuali pada mediastinal emphysema Karenna → bukan merupakan
tannda dari rupture aorta, tapi merupakan tanda dari rupture esophageal.

35. Mencegah secondary brain injury → Pada Trauma Brain Injury, primer brain in jury,
terjadi karena hasil inisial, sedangkan pada secondary injury terjadi secara berkala. Memiliki
tujuan untuk mencegah develop menjadi secondary injury.

36. Kecelakaan maka yang dilihat → ABC, Airway yang pertama, maka harus dilakukan
endotracheal intubation.

37. Fracture of the cribiform plate → karena apabila dilakukann dalam konndisi fraktur
cribiform, ngt bisa masuk langsung ke otak.
38. Intercostal nerve blocks untuk relief pain. → pada pasienn terlihat adanya flail chest dan
pulmonary contusion. Ada hypoventilasi dan nyeri yang intens. Pertukaran udaranya
terganggu Karena adanya pulmonary contusion. Ventilasi bisa diimprove dengann analgesic.

39. Urinary output → untuk menmonitor resusitasi dan responn pasien. Sebagai indicator dari
perfusi rennalis dengan begitu, penanda perfusi secara general.

40. Bradycardia → karena curiga spinal shock, ada tanda bradycardia.