10 th Edition

Dave Kennedy / Vincent Gunawan

INTRODUKSI
 9 prinsip dasar ATLS
1. Persiapan
• Pre hospital (MIST)
• Mechanism of injury
• Injury and illness
• Sign and symptoms
• Treatment
• Intra hospital
• APD (6 → Cap, Googles, Glove , Mask, Gown,
Boots)
2. Triase
• Multiple Causalities → Pasien < Nakes → Merah
duluan
• Mass Casualities → Pasien> Nakes → Hijau
duluan
TRIAGE
 9 prinsip dasar ATLS
3. Primary survey (LIFE THREATENING) → 10 second Assesment
• Airway + C- Spine
• Breathing + Ventilation
• Circulation + Hemorrage control
• Disability → GCS
• Exposure → prevent hypothermia

* Minimal 4 orang untuk logroll

 9 prinsip dasar ATLS

4. Tambahan primary survey

• Pulse oximetry
• BGA
• Kateter urin dan gaster (konfirmasi masing-masing apakah ada ruptur uretra
dan fraktur basis cranii)
5. Consideration of the need for patient transfer (konsul/rujuk)
 9 prinsip dasar ATLS
6. Secondary survey
• AMPLE (Allergies, Medication , past illness , Last meal, Enviromental)
7.Tambahan secondary survey (PF Head to toe ;pemeriksaan
penunjang) →DON’T INTERFERE THE UNSTABLE PART
8. Monitoring post resusitasi dan re-evaluasi
9. Tatalaksana definitive
• Treat greatest threat to life first
• Recognise the definitive diagnosis is not immediately important
• Detailed history is not essential to begin the evaluation of patient with acute injuries
AIRWAY
 AIRWAY
• The talking patient → Clear
• Identifikasi sumbatan dan lokasinya ( lidah/darah) → diliat dari suara gargling/
snoring
• C-Spine injury = Multiple trauma , Battle sign , Racoon eyes, Cedera di atas
klavikula , nyeri pada area leher, seatbelt mark (injury to carotid arteries)
• Pasien tidak sadar → Selalu curiga ada cedera servikal !!!!
• Tanpa refelks muntah → Oropharingeal airway
• GCS <8 → pemasangan definitive aiway (Intubasi /Surgical)
Supplemental oxygen must
be administered to all
severely injured trauma
patients.
RECOGNISE
• Maxillofacial trauma
• Midface fracture
• Mandible fracture
• Neck trauma
• Carotid artery injury → Airway blocking
• Laryngeal trauma
• Hoarsness
• Subcutaneous emphysema
• Palpable fracture
• Burn trauma
• Facial burn → Potential inhalation injury
 RECOGNISE
• LOOK
• Tachypnea → early sign
• Universal sign of choking (hands around
neck)
• Altered level of consciousness
• Agitated (O2↓)
• Obtunded (CO2 𝗍 )
• Retraction of muscle
• Sianosis
RECOGNISE
•LISTEN
• Nasal Voice, hot potato voice
(Nasopharynx)
• Snoring , gargling (Oropharinx)
• Hoarsness , Insipartory
stridor(laryng)
• Expiratory Stridor (trachea)
• Wheezing (Bronchus)
AIRWAY MANAGEMENT

PATIENT
WITH
HELMET
AIRWAY MANAGEMENT

PENILAIAN
AIRWAY
LEMON
AIRWAY MAINTAIN TECHNIQUE
Chin-Lift Maneuver Jaw-Thrust Maneuver
AIRWAY MAINTAIN TECHNIQUE

OROPHARYNGEAL
AIRWAY
AIRWAY MAINTAIN TECHNIQUE

Extraglottic and supraglottic devices

Laryngeal Mask Airway and Intubating Laryngeal Tube Airway and Intubating LTA
(LMA )
AIRWAY MAINTAIN TECHNIQUE

Extraglottic and supraglottic devices

The i-gel® supraglottic airway Multilumen esophageal airway
DEFINITIVE AIRWAY
• Criteria for establishing airway
• A → Airway Compromise
• B → Oxygenation inadequate
• C → Cerebral hypoperfusion
• D → GCS ≤ 8
ENDOTRACHEAL INTUBATION

Notes :
- Nasotracheal preferable for Spontaneous
breathing
- Facial trauma contraindicatied for
nasotreacheal intubation
- You can use BURP Manuver to help the
visualization of laryngx
(Backward, upward, and rightward pressure)
PEDIATRIC INTUBATION
ETT SIZE

Kedalaman : (Usia/2)+12
LARYNGOSCOPE SET
POSITION

ANAK → 2 tahun ke atas

AIRWAY DECISION SCHEME
No Definitive airway /
PERSIAPAN: Oksigenasi ?
surgical airway
Suction, 02, OPA,NPA,
Bag-mask, laryngoscope, Yes
gum elastic bougie, Difficult
Extraglottic device, LEMON CALL FOR HELP
surgical / needle
cricothroideotomy kit, Easy
ETT, Pulse oximetrey,
CO2, Capnography, drug Intubation

AWAKE
GEB/LMA/LTA INTUBATION
Unsuccesful

Definitive airway / surgical airway

 RAPID SEQUENCE INTUBATION

*Etomidate, 0.3 mg/kg

*1 to 2 mg/kg succinylcholine IV
MEDICATION
USED FOR
INTUBATION
 SURGICAL AIRWAY
Indication:
• Edema of the glottis
• Fracture of the larynx
• Severe oropharyngeal hemorrhage that obstructs the airway
• Inability to place an endotracheal tube through the
vocal cords
 SURGICAL AIRWAY • Needle Cricothyroidotomy

• Penggunaan jarum no 12/14

pada dewasa dan 16/18 pada
anak
• Durasi penggunaan hanya sampai
30-45 menit
• Oksigne 15 L dengan connector Y
• Metode penggunaan 1:4
• Hindari pada pasien trauma
kepala
 SURGICAL AIRWAY • Surgical Cricothyroidotomy

• Penggunaan ETT ukuran 5-7 mm

• Hindari pada anak <12 tahun
SURGICAL CRICOTHYROIDOTOMY
BREATHING
OVERVIEW
• Setiap pasien trauma → BERIKAN OKSIGEN
• Gunakan pulse oxymeter untuk pemantauan oksigenasi
• Cek trauma pada dada (Tension pneumothorax , Fractured ribs . Flail
chest, pulmonary contusion)
RECOGNITION
• LOOK
• Type of breathing : Seesaw breathing, Abdominal breathing → Below C3 spine
injury
• Symmetrical rise and fall of the chest
• Tachypnea
• Listen
• Breath sound, wheezing, rales
• Pulse Oxymetry
PEMBERIAN OKSIGEN ADEKUAT
ALAT KECEPATAN ALIRAN %OKSIGEN
NASAL KANUL 1 L/menit 21-24%
2 L/ menit 25-28%
3 L/ menit 29-32%
4 L/menit 33-36%
5 L/menit 37-40%
SUNGKUP MUKA SEDERHANA 6-10 L/menit 35-60%
SUNGKUP MUKA DENGAN 6 L/menit 60%
RESERVOIR 02 7 L/ menit 70%
8 L/ menit 80%
9 L/menit 90%
10-15 L/menit 95-100%
SUNGKUP MUKA DENGAN 4-8 L/menit 24-35%
VENTURI 10-15 L/menit 40-50%
SATURASI-OKSIGEN
ALAT KECEPATAN ALIRAN %OKSIGEN
95 -100% Normal O2 max 4L/menit
90-94% Hipoksia ringan-sedang Sungkup muka sederhana O2 6-
10L/menit
85-89% Hipoksia berat Sungkup muka dengan reservoir O2
10-15 L /menit
<85% Hipoksia mengancam nyawa VTP O2 100%
CIRCULATION
 No single vital sign and no
laboratory test, on its own,
can definitively diagnose
shock
OVERVIEW
• Hemorrhage is the most common cause of shock in trauma patients.
CIRCULATION
PARAMETER OF CIRCULATION
• Pulse → Central pulse: femoral
dan carotid artery → Deskripsikan
: Cepat /lambat, teratur, kuat
angkat , terisi penuh
• Level of consciousness (GCS) →
due to brain perfusion
• Skin Perfusion →Cold, pink skin
a/r wajah dan eskstrimitas dan
CRT< 2s
HEMORRAGHE CONTROL
• Direct pressure → jika tidak bisa ganti
Torniquet (lepas pasang tiap jam)
• Jangan klem vaskular (HARAM!)
• Identify the source of bleeding (FAST,
DPL)
• IV 2 line / tranfusi set + kateter urin
• Pasien anak <40 kg → 20 ml/kgbb
• Bolus 1-1.5 L +/- Asam tranexamat bolus
3 jam → diikuti 8 jam
• Pasien Obes→ Pake BB ideal
RECOGNISE
Several consideration for treatment
1. Patient age
• Old age → less tamponade
mechanism
• Obse patient → Blood loss de to
soft tissue injury
1. Severity of injury, particularly the type
and anatomic location of injury
2. Time lapse between injury and
initiation of treatment
4. Prehospital fluid therapy
5. Medications used for chronic condition
ESTIMATED BLOOD LOSS DUE TO FRACTURE
MANAGEMENT

The basic management principle is to stop

the bleeding → replace the volume loss
 MANAGEMENT
• Vascular acces→ two largecaliber (minimum of 18-gauge in an adult) in
peripheral and central vein
• Alternative: intraosseus access
• As intravenous lines are started, draw blood samples → type and crossmatch
• Chateterization → Monitoring urine output
• Urethral injury is contraindicate for insertion of a transurethral catheter before
radiographic confirmation of an intact urethra
• UO →0.5 mL/kg/hr in adults; 1 mL/kg/hr in pediatric; 2 mL/kg/hr in children under <1
y.o
• Prevent hypothermia → Coagulopathy and worsening acidosis
• Vasopressors are contraindicated as a first-line treatment of hemorrhagic
shock
INITIAL RESPONSE TO FLUID RESUSCITATION

In patient with minimal or no

response → Non
hemmoraghic shock
diagnosis should be on
priority
 BLOOD REPLACEMENT
• Crossmatched, Type-Specific, and Type O Blood
• AB plasma
• O Rbc
• Rh (-) Negative
• Blood replacement is needed to prevent hypothermia
• Careful for coagulopathy → check for PT, PTT, INR, CT/BT, platelet
count
MASSIVE TRANSFUSION PROTOCOL

DEFINITION
Minimal 10 units of pRBCs within the first 24 hours of admission
or more than 4 units in 1 hour
Special consideration
• Equating Blood Pressure to Cardiac Output → BP ≠ CO → bisa karena
vasokinstriksi
• Advanced Age
• Deficit chatecolamin receptor
• Polypharmacy → ß-adrenergic blockade , anti platelet
• Atherosclerotic
• Heart and lung compliance ↓
• Pregnancy and athlete
• Hypothermia
• Pacemaker
DISABILITY
 GLASGOW COMA
SCALE
Pada pasien yang minum alkohol sulit dinilai tunggu
hingga sadar baru menilai/ anggap turun akibat trauma
kepala hingga terbukti sebaliknya
EXPOSURE AND
ENVIRONMENTAL CONTROL
EXPOSURE AND ENVIRONMENTAL
CONTROL
• Undress the patient → Explore other trauma
• Prevent hypothermia
• Warm fluod
• Blanket
 THERMAL INJURY

The most significant difference between burns

and other injuries is that the consequences of
burn injury are directly linked to the extent of the
inflammatory response to the injury.
PRIMARY SURVEY
• Stop the burning process
PRIMARY SURVEY
• Establish Airway Control
• Signs of airway obstruction (hoarseness, stridor, accessory respiratory muscle
use, sternal retraction)
• Extent of the burn (total body surface area burn > 40%–50%)
• Extensive and deep facial burns
• Burns inside the mouth
• Significant edema or risk for edema
• Difficulty swallowing
• Signs of respiratory compromise: inability to clear secretions, respiratory
fatigue, poor oxygenation or ventilation
• Decreased level of consciousness where airway protective reflexes are
impaired
PRIMARY SURVEY
• Adequate Ventilation
• Breathing concerns arise from three general causes:
• Hypoxia
• Carbon monoxide poisoning → 4 hour without oxygen
• Cherry Red skin
• Headache and nausea (20%–30%)
• Confusion (30%–40%)
• Coma (40%–60%)
• Death (>60%)
• Smoke inhalation injury

• TREATMENT : Remove the sticky clothes, Oxygen 100% for 4-6 hours, Escharatomy,
Elevated patient head on 30°
PRIMARY SURVEY
• Circulation

Teknik pemberian
• ½ in 8 hour
• ½ in 16 hour
• Hanya untuk
BURN TIPE 2 dan 3
PRIMARY SURVEY
•Circulation
•RULE OF NINE
GRADING BURN
1st degree : SUNBURN
2nd degree
A. BULLAE + PAIN +
B. BULLAE + PAIN –
3rd degree : PAIN – PALE +
ADDITIONAL CHECK UP
• Complete blood count (CBC)
• type and crossmatch/screen
• Arterial blood gas with HbCO (carboxyhemoglobin)
• Serum glucose
• Electrolytes
• Pregnancy test in all females of childbearing age.
ADDITIONAL MANAGEMENT
• Gastric Tube Insertion
• Narcotics, Analgesics, and Sedatives
• Antibiotics And tetanus
• Wound Care
• Do not break blisters or apply an antiseptic agent.
• Do not cold Compress
• Irigation with nasal saline and Cover with sheet
• Watch out for circumeferential burn → COMPARTEMENT SYNDROME
OTHER BURN
• Chemical burn
• Alkali burns are generally MORE SERIOUS than acid burns, as the alkali penetrates more deeply by
liquefaction necrosis of the tissue
• If dry powder is still present on the skin, brush it away before irrigating with water → 20-30 minutes using
water (longer in alkali trauma)
• Alkali in eye → 8 hours for irigation

• Electrical Burns
• Establishing an airway and ensuring adequate oxygenation and ventilation, ECG monitoring, and placing
an indwelling bladder catheter
• Resusistate with 4 mL/kg/%TBSA to ensure a urinary output of 100 mL/hr in adults and 1–1.5 mL/kg/hr
in children weighing less than 30 kg → urine is clear → titrate till 0.5 ml/kg/hr
• Tar burn
• Mineral oil to dissolve the tar
HEAT INJURIES

Management
• Rapid cooling improves survival. The goal is to decrease body
temperature to < 39°C within 30 minutes.
ADJUNCTS TO PRIMARY SURVEY
• ECG
• Pulse oximetry
• BGA dan Capnography
• Lactat
• NGT dan kateter
• X-Ray , FAST,DPL
FAST
SECONDARY SURVEY
• HEAD TO TOE
• DON’T INTERFERE THE UNSTABLE PART
SECONDARY SURVEY
• Anamnesis
• Pemeriksaan fisik : HEAD TO TOE
SECONDARY SURVEY
SECONDARY SURVEY
• Head
• Visus, pupil size , Perdarahan konjungtiva, trauma penetrasi , Contact lens
(segera keluarkan), dislokasi lensa, Compartement syndrome
• Maxillofacial structure
• Tanda tanda perdarahan basis cranii
• Cervical spine and neck
• Semua pasien dengan trauma wajah / tidak sadar asumsikan memiliki trauma
servikal, seatbelt mark, luka pada plastisma (JANGAN DI OTAK ATIK!), cedera
saraf servikal
SECONDARY SURVEY
• Chest
• Pneumothorax, flail chest, Becks triad
• Abdomen and pelvis
• Pasien dengan unknown hypotension post trauma → DPL
• Perineum and pelvis
• SEMUA WANITA USIA SUBUR WAJIB TES KEHAMILAN
• Muskulokskeletal
• Fraktur dan cedera soft tissue pada ekstrimitas
THORACIC TRAUMA
PRIMARY SURVEY
• Airway
• Posterior dislocation of the clavicular head, laryngeal injury ,crepitus over the
anterior neck
• Tracheobronchial Tree Injury
• 1 inch (2.54 cm) of the carina
• Hemoptysis, cervical subcutaneous emphysematension pneumothorax, and/or cyanosis,
continued large air leak after placement of a chest tube
• Surgery → wait for the edema resolved
PRIMARY SURVEY
• Breathing
• Tension pneumothorax
• Open pneumothorax
• Massive Hemothorax
 PRIMARY SURVEY
• Tension pneumothorax
• a “one-way valve” air leak occurs from the lung or through the chest wall
• Caused by mechanical positive-pressure in lung
• Sign and Simptoms
• Chest pain , Air hunger, Tachypnea ,Respiratory distress , unilateral absence of breath sounds,
Elevated hemithorax without respiratory movement ,hyperresonant note on percussion
• Tachycardia ,hypotension, Neck vein distention
• Tracheal deQviation
• Treatment : Large IV chateter 5th interspace, slightly anterior to the midaxillary
line → tension pneumothorax to a simple pneumothorax → Tube Thoracostomy
PRIMARY SURVEY
Open pneumothorax / sucking chest wound
• Plastic wrap or petrolatum gauze) →
three sides → flutter-valve effect
 PRIMARY SURVEY
• Circulation
• Massive hemothorax
• Cardiac tamponade,
• Traumatic circulatory arrest.
PRIMARY SURVEY
• Massive Hemothorax
• Accumulation of >1500 ml of blood
• Treatment : Chest tube
 PRIMARY SURVEY
• Massive hemothorax
• Restoring blood volume and decompressing the chest cavity
• Chest tube (28-32 French) is inserted, usually at the 5th ICS, just anterior to the
midaxillary line → Thoracotomy (1500 cc BL, 200 mL/hr for 2 to 4 hours )
PRIMARY SURVEY
• Cardiac Tamponade
• Penentrating wound
• Trias Beck (Hypotension , JVP distention, Muffled heart sound)
• eFAST check!!
• T : Pericardiocentesis
PRIMARY SURVEY
• Traumatic Cardiac Arrest
• ACLS
SECONDARY SURVEY
• Flail chest
• Pulmonary contusion
• Blunt cardiac injury
• Traumatic aortic disruption
• Traumatic diaphragmatic injury
• Blunt esophageal rupture
 SECONDARY SURVEY
• Flail chest and pulmonary
contusion
• Flail chest → multiple rib fracture
+/- >1 fracture in one rib
• Pulmonary contusion → bleeding
in the internal lung → Resolving
spontaneously
• Treatment :
• Oxygen → PaO2 < 60 / SaO2 <
90%) → Intubate
• Fluid
• Analgesic
TRAUMA ABDOMEN
ANATOMY OF ABDOMEN
ASSESMENT AND MANAGEMENT
Taking History
• Blunt /Direct blow→Bucket
handle Injuries
• Penetrating → Stab wound →
liver , Gunshot → Small bowel
• Most abdominal gunshot wounds
are managed by exploratory
laparotomy
• Blast → mixed injury
• Pelvis Assesment
 ASSESMENT AND MANAGEMENT
Physical examination
• Abdomen
• After rapid physical exam, cover the patient with
warmed blankets to help prevent hypothermia
• Pelvis
• Ruptur uretra /Gross hematuri
• Instable pelvis
• NGT + Chateter (check for Contraindication )
 ASSESMENT AND MANAGEMENT
• Diagnostic finding→ Contraindication for laparotomy candidate
• Upright chest x-ray
• FAST
• DPL contraindicate for previous abdominal operations, morbid obesity, advanced
cirrhosis, and preexisting coagulopathy
• Aspiration of gastrointestinal contents, vegetable fibers, or bile / 10 cc or more of blood →
Laparotomy
• CT Scan is contraindicated if a delay until the scanner is available, an
uncooperative patient who cannot be safely sedated, and allergy to the contrast
agent
• Diagnostic Laparoscopy or Thoracoscopy
• Contrast Studies → urethrogram , cystogram, Intravenous pyelogram
ASSESMENT AND MANAGEMENT
 INDICATION FOR LAPAROTOMY
• Blunt abdominal trauma with hypotension, with a positive FAST /clinical evidence of
intraperitoneal bleeding/without another source of bleeding
• Hypotension with an abdominal wound that penetrates the anterior fascia
• Gunshot wounds that traverse the peritoneal cavity
• Evisceration
• Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma
• Peritonitis
• Free air, retroperitoneal air, or rupture of the hemidiaphragm
• CT positive finding due to organ rupture
• Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents
Evaluation of other injury
• Diaphragm Injuries
• Duodenal Injuries
• Genitourinary Injuries
• Hollow Viscus Injuries
• Solid Organ Injuries
• Pelvic Fractures and Associated Injuries → Pelvic binder
MANAGEMENT
TRAUMA KEPALA
The primary goal of treatment for patients
with suspected TBI is to prevent secondary
brain injury
NEUROLOGICAL DESCRIPTION
 Anatomy and physiology
• The presence of blood in the CSF can impair its reabsorption, resulting in increased intracranial pressure
• Region of brain
• Frontal lobe → executive function, emotions, motor function, and, on the dominant side, expression of speech (motor speech
areas)
• Parietal lobe → sensory function and spatial orientation
• Temporal lobe → memory functions
• Occipital lobe → vision
• Midbrain and upper pons → Alertness
• The cerebellum → Coordination and balance
• Ipsilateral pupillary dilation associated with contralateral hemiparesis is the classic sign of uncal herniation
• CBF tend to be normal in comatose patient
• CPP= MAP-ICP (50-150 mmHg)
• Temporal lobe (uncal) herniation is dilation of the pupil and loss of the pupillary response to light.
CLASSIFICATION OF TBI

Concussion is a transient loss of neurologic function following

a head injury.
CLASSIFICATION OF TBI

The classic presentation of an epidural hematoma is with a

lucid interval between the time of injury and neurological
deterioration
MANAGEMENT OF TBI
MANAGEMENT
OF MILD TBI
 Management of
Moderate Brain Injury
(GCS Score 9–12)
These patients can still
follow simple
commands, but they
usually are confused
or somnolent and can
have focal
neurological deficits
such as hemiparesis
 Management of
Severe Brain Injury
(GCS Score 3-8)
These patients unable
to follow a simple
command
TATALAKSANA SECARA UMUM
• Airway and breathing → prevent hyperventilation & Oxygen target >98%
• Circulation → TBI CANT CAUSE SHOCK
• Maintain systolic blood pressure (SBP) at ≥ 100 mm Hg for patients 50 to 69 years
or at ≥ 110 mm Hg or higher for patients 15 to 49 years or older than 70 years
• D→ GCS score, pupillary light response, and focal neurological deficit
• Do not use long-acting paralytic and sedating agents during the primary survey →
altered the judgement
• KERJAKAN CT-SCAN HANYA KETIKA KONDISI PASIEN STABIL
GOALS THERAPY FOR TBI
MEDICAL THERAPY FOR TBI
• Intravenous Fluids → Ringer’s lactate solution or normal saline is thus recommended for
rsuscitation; Hyponatremia should be prevented
• Correction of Anticoagulation
• Prevent hyperventilation and hypercarbia
• Mannitol 20% solution (20 g of mannitol per 100 ml of solution)
• Bolus of mannitol (1 g/ kg) rapidly (over 5 minutes) and transport her or him immediately to the CT
(Use 0.25–1 g/kg)
• Indication : Dilated pupil, has hemiparesis, or loses consciousness
• Hypertonic Saline → Hypertonic saline is also used to reduce elevated ICP, in concentrations of 3%
to 23.4%
• Barbiturate
• Anti Convulsant
ANTICOAGULATION REVERSAL
 SEIZURE IN TBI
• Risk factor for seizure : Intracranial hematoma, and a depressed skull
fracture
• Anticonvulsants can inhibit brain recovery
• Phenytoin (Dilantin) and fosphenytoin (Cerebyx) → acute phase
• 1 g of phenytoin intravenously given no faster than 50 mg/min. The usual
maintenance dose is 100 mg/8 hours
• Valium (Diazepam) or ativan (Lorazepam) is frequently used in addition to
phenytoin until the seizure stops → FAST befor 30-60 minutes ( secondary
brain injury)
 SURGERY IN BRAIN INJURY
• Scalp wounds
• Depressed skull fractures
• Intracranial mass lesions
• Penetrating brain injuries

Treatment : 10-15 burr hole craniotomy

BRAIN DEATH
• Glasgow coma scale score = 3
• Non reactive pupils
• Absent brainstem reflexes (e.G., Oculocephalic, corneal, and
doll’s eyes, and no gag reflex)
• No spontaneous ventilatory effort on formal apnea testing
• Absence of confounding factors such as alcohol or drug
intoxication or hypothermia

Ancillary studies that may be used to confirm the diagnosis of

brain death include:
• Electroencephalography:
• No CBF
• Cerebral angiography
TRAUMA MEDULLA SPINALIS
Overview
• Terjadi paling banyak di leher 55%
• Brief exclusion of spinal cord injury:
• No neurological deficit, pain or tenderness along the spine, evidence of
intoxication, or additional painful injuries
• No use LSP for too long
• Injury to C3 can cause paralysis of phrenic nerve → sudden death
• Flexible joint appear in child until 12 y.o
• A cervical collar may not fit obese patients, so use bolsters to support
the neck
• Clinicians should not attempt to reduce an obvious deformity
ANATOMY
ANATOMY
ANATOMY
NEUROGENIC AND SPINAL SHOCK
SPINAL CORD INJURIES
• Spinal cord injuries can be classified according to…..
• Level
• Severity of Neurological Deficit
• Complete /incomplete paraplegia (thoracic)
• Complete /incomplete tetraplegia (cervical)
• Incomplete: Sensation or voluntary movement in the lower extremities, sacral sparing,
voluntary anal sphincter contraction, and voluntary toe flexion
• Sacral reflexes, such as the bulbocavernosus reflex or anal wink, do not qualify as sacral
sparing
• Spinal Cord Syndromes
• Morphology (SCIWORA) → X-RAY NORMAL
Posterior Cord
Syndrome

Disturbance of
vibration and
propioception
WHEN TO SCAN?
LOGROLL
MANAGEMENT OF SPINAL INJURY
• IV LINE For vasopressor (Phenylephrine hydrochloride, dopamine, or
norepinephrine is recommended)
• MEDICATION → Steroid is not recommended
• TRANSFER
MUSCULOSKELETAL
TRAUMA
 OVERVIEW
● Fracture means high forces injury → EVALUATE FOR LIFE THREATENING
CONDITION→ BLOOD LOSS AND INFECTION

● Severe crush injuries cause the release of myoglobin from the muscle
→ RENAL FAILURE

● FAT EMBOLISM, can lead to uncommon but highly lethal

complication of long-bone fractures → PULMONARY FAILURE

● Swelling into an intact musculofascial space → ACUTE

COMPARTMENT SYNDROME
PRIMARY SURVEY
 PRIMARY SURVEY

● Recognize hemorrhage
● Hemorrhage control is best achieved with direct pressure
● If the fracture is open, apply the sterile pressure dressing
● Traumatic Amputation → Tourniquet

Asses for vitality → Look, Feel, Measure

 CRUSH SYNDROME
● Traumatic rhabdomyolysis effects of injured
muscle acute renal failure and shock
● Most often to a thigh or calf
● Rhabdomyolisis produces dark amber urine
and serum creatine kinase of 10,000 U/L
● Rhadomyolisis metabolic acidosis,
hyperkalemia, hypocalcemia → Chovteksign
, trosoue sign
 MANAGEMENT
● Initiating early and aggressive INTRAVENOUS FLUID THERAPY
during resuscitation

● Myoglobin-induced renal failure can be prevented with IV fluid

expansion, IV bicarbonate, and osmotic diuresis

 MANAGAMENT II
● Apply splints ASAAP!! → control hemorrhage and pain
● Remove gross contamination + antibiotics as early as
possible in patients with open fracture
● Assess the neurovascular status → SENSORIC
SECONDARY
SURVEY
HISTORY
○ Mechanism of Injury (The
clinician should mentally
reconstruct the injury scene)
○ Environment
○ Preinjury Status and Predisposing
Factors (AMPLE history )
○ Prehospital Observations and Care
HISTORY
PHYSICAL EXAMINATION
● UNDRESS the patient
● Identify life-threatening injuries
● Identify limb-threatening injuries
● CONTINUOUS RE-EVALUATION
PHYSICAL
EXAMINATION
X-ray Examination
● Obtain x-ray films →hemodynamically
normal.
● X-ray examination →before treating a
dislocation or a fracture is the presence of
vascular compromise or impending skin
breakdown.
LIMB-THREATENING
INJURIES
FRACTURES

A break in the continuity of the bone

cortex
Assessment
● LOOK- FEEL -MOVE
● X-ray films
MANAGEMENT

● Immobilization must include the joint above and

below the fracture. After splinting, be sure to
reassess the neurologic and vascular
status of the extremity.
PAIN CONTROL
● Appropriate use of splints
● Analgesics (narcotics)
● Administer sedatives cautiously in patients with
isolated extremity injuries, such as when reducing a
dislocation
● Appropriate resuscitative equipment and naloxone
(Narcan) must be immediately available.
OPEN FRACTURES AND OPEN JOINT INJURIES
Communication Between The external Environment and The Bone Or Joint

The presence of intraarticular gas on a CT/X-ray identifying

open joint injury.
MANAGEMENT
● IV antibiotics
● Remove gross contamination moist sterile dressing.
● Immobilisation
● Prompt surgical consultation

Tetanus prophylaxis should be administered

COMMON CAUSE INFECTION

www.Orthobullets.com/osteomyeiti
s
Reference : Hatzenbuehler J, Pulling TJ. Diagnosis and
Management of Osteomyelitis. Am Fam Physician. 2011 Nov
1;84(9):1027–33.
TETANUS RULE OF SHOT
COMPARTMENT SYNDROME
Increased pressure within a
musculofascial compartment causes
ischemia and subsequent necrosis.
Compartment
Syndrome

Common areas for

compartment syndrome
include The lower leg, forearm,
foot, hand, gluteal region, and
thigh
ETIOLOGY
● Close Fracture
● Tight dressings or casts
● Severe crush injury to muscle
● Localized, prolonged external pressure to an extremity
● Increased capillary permeability secondary to reperfusion of
ischemic muscle
● Burns
● Excessive exercise
 5P
1. PAIN
2. PARESTHESIA
3. PALOR
4. PARALYSIS
5. PULSELESSNESS
OTHER EXAMINATION
● Compartement pressures of greater than 30 mm Hg
suggest decreased capillary blood flow

Compartment syndrome is a clinical diagnosis. Pressure

measurements are only an adjunct to aid in its diagnosis.
Management
● Release all constrictive dressings, casts,
and splints applied over the affected
extremity
● Immediately obtain a surgical consultation.

The only treatment for a compartment

syndrome is a FAS C IOTOMY .
NEUROLOGICALINJURYSECONDARYTOFRACTUREOR
DISLOCATION
NEUROLOGICAL INJURY SECONDARY
TO FRACTURE OR DISLOCATION
 CONTUSIONS AND LACERATIONS

LACERATION CONTUSION

Lacerations require Pain, localized swelling, and

debridement and closure tenderness

R-I-C-E
JOINT AND LIGAMENT INJURIES

When a joint has sustained significant

ligamentous injury but is not dislocated, the
injury is not usually limb-threatening
Asessment
● INFLAMMATION throughout the affected joint.
● A hemarthrosis is usually present unless the joint
capsule is disrupted and the bleeding diffuses into
the soft tissues.
● Passive ligamentous testing of the affected joint
reveals instability
Asessment

X-ray examination is usually negative,

although some small avulsion fractures
from ligamentous insertions or origins may be
present radiographically.
Management
● RICE
● Neurovascular
Evaluation
Thank you