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PATIENT IDENTITY




Name
: Mr. SW
Age : 37 y. o
Occupation : Truck driver
Address
: Jl. Ir. Sutami

HISTORY
Chief Complaint
• Whole stomach ache
History of Present Illness
• Patient admitted to AWS’ ER 1 hour after being crushed on his
left abdomen by a truck while he was laying down under that
truck to fixing the machine. At the moment, his friend
accidentally drove the truck without knowing the patient was
still under the truck. After that, patient felt so much pain in his
whole stomach, but no sign of nausea, vomiting and no
external wound was seen. He was moaning and looks so
agitated. He was brought to ER at one of the private hospital
by his friends imidiately. There, the patient was given
intravenous fluid and other medications, and was refered to
AWS Hospital to get CT scan.

• The action that given in D Hospital
a. IVFD RL 2000 cc
b. Ketolorac inj 1 amp/ IV
c. Tranexamate acid 2 amp/ IV
d. Ranitidin 1 amp/ IV

PRIMARY SURVEY
Airway
Breathing

Circulation

Disability
Exposure

• Clear
• RR: 40x/min  NRM 11 lpm
• Symetrical breathing
• HR: 116x/min  reguler, adequate
pulse
• BP: 70/50 mmHg
• Sat: 95%
• GCS: E4 V5 M6
• Pupil: isokor (3mm/3mm)
• Pupillary reflex: (+/+)
• External wound (-)

SECONDARY SURVEY
Head

• Normochepalic, anemic (-/-),
icteric (-/-), sianotic (-/-)

Neck

• Lymphadenopathy (-)

Thorax

• Heart:
• Inspection
= Apex beat (+)
• Palpation = Apex beat (+) 1 fingerbreadth
middle to left midclavicluar line (ICS V)
• Percussion
= Within normal range
• Auscultation = S1S2 regular, mumur (-),
gallop (-)

Lung:

• Inspection
= Chest wall movement equal
and adequate
• Palpation = Chest wall movement equal D=S
• Percussion
= Sonor

Abdome
n
Extremit
y
Local
Status:
Abdomin
al
Region

• Look for Local Status
• Clammy (+), Deformity (-),
Edema (-), CRT > 2”
• Inspection: Distended (+),
bruises (-)
• Auscultation: bowel sound
(-)
• Percussion: dullness (+)
• Palpation: mucular defans
(+)

FAST US

X-RAY

LABORATORIES
FULL BLOOD COUNT

BLOOD GAS ANALYSIS












• pH
: 7.408
• pCO2 : 27.8 mmHg
• pO2
: 172.1
mmHg
• HCO3- : 17.7 mmol/L

WBC : 11.000
Hb : 8.0
HCT : 23.5
PLT : 219.000
Na : 138
K : 3.6
Cl : 113
GDS : 261
Ureum : 33.8
Creatinin : 1.4
HbsAg : 112 : -

Working Diagnosis
• Abdominal blunt trauma+ Hypovolemic shock e. c.
Internal bleeding
Planning





O2 NRM 11 lpm
PRC transfusion 5 packs
Urine catheterization
NGT
Ketorolac inj 1 amp
Emergency laparatomy exploration

Did something went wrong?
• The procedure of finding the cause of
hypovolemic shock was not
according to the guideline
• The patient was still unstable during
the refering process
• The management of hypovolemic
shock

ABDOMINAL TRAUMA
MANAGEMENT

INITIAL ASSESSMENT
Whether the patient is haemodynamically
stable

unstable

FIRST PRIORITIES PROTOCOL :
Brief clinical examination to evaluate ABC along with
cardiovascular status with blood pressure and pulse
measurement.
Accordingly, resuscitation and management of shock by
-

maintenance of ABC

-

IV fluids

-

nasogastric tube insertion

-

Catheterization

PRIMARY SURVEY
• Airway assessment
– Ensure cervical spine immobilization
– Clear mouth and airway if obvious
foreign bodies
– Jaw trust and chin lift, if required
– If Glasgow Coma Score 8, consider a
definitive airway

• Breathing and ventilation
– Give 100 per cent oxygen at high flow
– Inspect/percuss and auscultate chest
– Check for tension pneumothorax and
immediately decompress if suspected

• Circulation
– Check pulse and blood pressure
– Secure two large-bore cannulae, take
bloods and
Commence fluid resuscitation
– Examine for evidence of blood loss and
treat accordingly

• Disability
– The neurological status of the patient
should be rapidly assessed.
– The pupils are monitored for size and
reactivity, and a GCS measured.

• Exposure
– The patient must be fully exposed and
examined front and back using a
carefully controlled log roll.

• Adjuncts to the primary survey
– Blood tests – full blood count, urea and
electrolytes, clotting screen, glucose,
toxicology, cross-match
– ECG, pulse oximetry, arterial blood gas
(ABG)
– Two wide-bore cannulae for intravenous
fluids
– Urinary and gastric catheters
– Imaging

TABLE
Diagnostic Modalities in Abdominal Trauma
PERITONEAL
LAVAGE

ULTRASOUND

CT SCAN

Use

Records intraabdominal
haemorrhage in
stable/unstable
trauma

Reveals intraabdominal
haemorrhage in
stable and unstable
in patients

Reveals organ of injury
and extent of
blunt/penetrating
abdominal trauma in
stable patients

Contraindications

Urgent demand for
laparotomy
Prior abdominal
surgery
Pregnancy and
obesity

Urgent demand for
laparotomy
 Obesity and
subcutaneous
emphysema

 Need for emergency
laparotomy in an
unstable patient
 Unco-operative
patients
Allergy to contrast
material

Drawback

Unreliable in
retroperitoneal and
diaphragmatic
trauma

Failes to show small  Unreliable in detection
amount of fluid
of rupture of bowel and
diaphragmatic injuries
 Time consuming
 High cost

Secondary Survey

• The secondary survey does not begin
until after the primary survey has
been completed
– The purpose of the secondary survey is
to identify all other injuries and perform a
more thorough ‘head to toe’
examination.

• Re-evaluation
– This cannot be stressed enough. It is an
integral process in the initial assessment
of major trauma and should not stop
once the patient leaves the emergency
room. Continuous monitoring is

• BLUNT ABDOMINAL TRAUMA
GUIDELINE

• All blunt trauma patients with
unstable hemodynamic, must be
consider there is an internal bleeding
or GI tract contamination with DPL or
FAST
• Patients with stable hemodynamic
can be evaluated by CT scan. And
the decision of operation based on
affected organ and trauma severity.

SHOCK
• Shock, at its most rudimentary
definition and regardless of the
etiology, is the failure to meet the
metabolic needs of the cell and the
consequences that ensue.

• Classification of Shock
– Hypovolemic
– Cardiogenic
– Septic (vasogenic)
– Neurogenic
– Traumatic
– Obstructive

Hypovolemic/Hemorrhagi
c Shock
• The most common type
• Loss of circulating blood volume. This
may result from loss of whole blood
(hemorrhagic shock) or non
hemorrhagic shock.
• The clinical signs of shock may be
evidenced by agitation, cool clammy
extremities, tachycardia, weak or
absent peripheral pulses, and
hypotension.

Management of
Hemorrhagic Shock
• The appropriate priorities are airway
and breathing, circulation, disability,
exposure, decompression,
catheterization.
• Two IV lines needed for infusing big
amount of fluids fast.
• The amount of fluid needed can be
measured
theIIIshock.
Fluids
Class Iby grade
Class II ofClass
Class IV
Cristaloid

Cristaloid

Cristaloid
and blood

Cristaloid
and blood

Respond Evaluation
• It’s important to examined the patient’s respond
by the clinical examination, such as urine output ,
consciousness, and peripherial perfusions.
Fast Respond

Transient
Respond

No Respond

Vital Signs

Back to normal

Back to normal
temporary
Pulse and
tension
decreasing

Still abnormal

Loss of blood

Minimal (10 % - Mild ( 20 % 20 5)
40 %)

Severe (> 40
%)

Crystaloid
needed

Minimal

Lot

Lot

Blood needed

Few

Lot

Immediately

Operation

Maybe

High
probability

Almost always

Blood
Transfusion

Spesific and
crossmatch

Spesific type

Emergency

Did something went wrong?
• The procedure of finding the cause of
hypovolemic shock was not
according to the guideline
– In this case, the patient’s BP < 90
mmHg and it means this patient is
unstable patient, finding the cause of
the shock in an unstable patient is using
FAST procedure not CT scan.

• The patient was still unstable during
the referring process
– The hemodinamic of patient should be
stable before being transferred to

• The management of hypovolemic
shock
– When the patient arrives, there was no
NRM on him
– There was just one IV line instead of two
– There was no catheter to evaluate the
urine output
– There was no NGT attached
– There was no effort to do blood
transfussion, the patient just got
crystaloid.
– Why this patient had to referred to AWS
hospital from the D hospital ?

THANK YOU

HAPPY BIRTHDAY
dr. Syaiful Mukhtar, Sp.B KBD
May Allah always bless you
with happiness : )