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Second problem plenary

Catastrophic Blast
Group 3

5th october 2017


Emergency Medicine Blok – Group 3

• Tutor: dr. Christian • Members:


• Leader: Windi Datu – Audrellia maretha putri
Aprilia – Budi Setiawan
• Secretary: Astrie – Anggun Tsabitah
Juwitasari – Albert Edo
• Writer: Roderick Samuel – Stefanus Evan
– Fanny Sekar Ayu
– Ayu Saraswati
– Dila nur Fitriani
– Madeline
Second problem
There was a suicidal bomb blast in a certain political rally which injured a lot of people. The bomb blast was followed by
multiple secondary fiery explosions. You are one of the emergency response team called to the incident site. When you arrive
at the scene, you found 6 bomb victim laying on the ground. The conditions of the 6 bpmb victims are as follow:
The first patient, a young male, conscious and alert. He has a small penetrating wound in his lower neck, just to the left side of
the trachea, his neck appears swolle, his voice hoarse and there is no apparent bleeding. His initial vital signs examination
reveals that his blood pressure is 108/74 mmHg, heart rate is 180 beats per minute and respiratory late is 26 breaths per
minute.
The second patient, a young female, appears to breathe rapidly and shallow. There is apparent tachypnea, cyanosis and
multiple small penetrating wounds on the left side of her cheast. Her blood pressure is 103/64 mmHg, heart rate is 110 beats
per minute and repiratory rate is 34 breaths per minute.
The third patient, a middle-age male, has multiple pentrating wounds to his left side of abdomen and left flank, pale and
complaining of severe abdominal pain. There are second and third degree burns visible over his lower abdomen. His blood
pressure is 88/54 mmHg, heart rate is 120 beats per minute and respiratory rate is 22 breaths per minute.
The fourth patient, an elderly male, appears dyspneic and coughing up bloodstained sputum, disoriented and there are visible
bruises and lacerations over his upper torso. His blood pressure is 132/77 mmHg, heart rate is 92 beats per minute and
respiratory rate is 30 breaths per minute.
The fifth patient, a young male, has burn wounds all over his upper torso and face. His clothes seemed to have caught fire from
the secondary blast and burnt him. He is writhing in pain and his voice sounds hoarse. There are burn wounds on his chest,
back and right arm. His blood pressure is 110/82 mmHg, heart rate is 121 beats per minute and respiratory rate is 28 breaths
per minute.
The sixth patient, a young male, conscious and is shouting for help. He has standing on a two storey tall platform when the
blast happened and knocked him down to the ground in a sitting position. There is an open wound on his left thigh with bone
protrusions but ni apparent bleeding. He complains of severe pain on his back, but he did not complain of any pain nor any
other feeling on his lower part of body starting from his navel. He also says that he is unable to move his lower extremities. His
blood pressure is 90/54 mmHg, heart rate is 118 beats per minute and respiratory rate is 28 breaths per minute.
After initial prehospital care, all of the patient are to be transferred to hospitals with trauma center with nearest one is 1 hour
away. However, there are only 2 available ambulances to transport the patient.
Discuss the case, assess the condition of all the patient, make a priority plan to transfer the patient and plan proper treatment
while considering all possibilities!
Learning issues
1. Management in mass casuality event
2. Burn injuries (sign and symptoms, degree,
therapy, primary survey, complication and
prognosis)
3. Chest and abdomen injuries*
4. Pelvic injuries*
5. Spinal cord injuries*

* (primary survey, sign and symptoms, therapy,


complications and prognosis)
Management in mass casuality
event

LI 1
Triage Multiple casualties Primary Survey
• Triage involves the • In multiple-casualty • Patients are assessed, and their
sorting of patients based incidents, although there is treatment priorities are
on their needs for
treatment and the
more than one patient, the established, based on their
resources available to number of patients and the injuries, vital signs, and the
provide that treatment. severity of their injuries do injury mechanisms.
• Treatment is rendered not exceed the capability of
based on the ABC the facility to render care.
priorities (Airway with • In such situations, patients
cervical spine protection, with life-threatening
Breathing, and Circulation
with hemorrhage
problems and those
control). sustaining multiple-system
• Other factors that may injuries are treated first.
affect triage and Mass casualties
treatment priority include • In mass-casualty events, the
injury severity, number of patients and the Adjunct to primary survey dan
salvageability, and severity of their injuries resuscitation
available resources. • Adjuncts that are used during the
• Triage also includes the
exceed the capability of the
facility and staff. primary survey include
sorting of patients in the
field so that a decision • In such situations, the electrocardiographic monitoring;
can be made regarding patients having the greatest urinary and gastric catheters; other
the appropriate receiving chance of survival and monitoring, such as ventilator rate,
medical facility. requiring the least arterial blood gas (ABG) levels,
expenditure of time, pulse oximetry, blood pressure, and
equipment, supplies, and x-ray examinations (e.g., chest and
personnel, are treated first. pelvis)
Advanced Trauma Life Support ed. 9th
Burn injuries
LI 2
Pathophysiology
• Cell damage occurs at temperatures of >45°C
• Results in a spectrum of local and systemic
homeostatic disorders that contribute to burn
shock.
• Local effects of thermal injury include the
liberation of vasoactive substances, disruption of
cellular function, and formation of edema
Rule of 9

Advanced Trauma Life Support ed. 9th


Advanced Trauma Life Support ed. 9th
Tintinalli’s Emergency Medicine 7th ed
Tintinalli’s Emergency Medicine 7th ed
Burn Management
• Prehospital care, • Pre hospital care
– Stop the burning process;
• ED resuscitation and
– Assess and, if necessary,
stabilization, and secure the airway;
• Admission or transfer to a – Initiate fluid resuscitation;
specialized burn center – Relieve pain;
– Protect the burn wound; and
– Transport the patient to an
appropriate facility
ED Management
Initial 2. Fluid resuscitation
– Urine output should be 0.5 to 1.0
• Obtain history
mL/kg/h.
• Assess the adequacy of, or need – In children weighing <25 kg, a goal
for, cervical immobilization urine output of 1.0 mL/kg/h is
necessary. Add 5% dextrose to
• Assess the patient’s respiration maintenance fluids for children
and circulation and initiate weighing <20 kg due to smaller
glycogen stores
stabilization
3. Wound Care
• Endotracheal intubation if
4. Escharotomy
indicated
https://s3.amazonaws.com/pharmacytimes/d_media/_upload_image/_inDoc/burnst2.png
Prognosis
• The severity of the burn,

• The presence of inhalation injury,

• Associated injuries,

• The patient’s age,

• Comorbid conditions, and

• Acute organ system failure


Chest and abdomen injuries
LI 3
Chest injury
Signs and symptoms
• Pain  worsens with • Decreased breath sounds can
breathing if the chest wall is result from pneumothorax or
injured, and sometimes hemothorax; percussion over
shortness of breath the affected areas is dull with
• Common findings include hemothorax and
chest tenderness, ecchymoses, hyperresonant with
and respiratory distress; pneumothorax.
hypotension or shock may be • The trachea can deviate away
present. from the side of a tension
• Neck vein distention can occur pneumothorax
in tension pneumothorax or • the flail segment is often
cardiac tamponade if patients palpable.
have sufficient intravascular
volume
Treatment
• Supportive care
• Treatment of specific injuries
Immediately life-threatening
injuries are treated at the
bedside at the time of
diagnosis:
• Suspected tension
pneumothorax: Needle
decompression
• Respiratory distress or shock
and decreased breath sounds:
Tube thoracostomy
• Shock with suspected cardiac
tamponade: Pericardiocentesis
• Suspected hypovolemic shock:
Fluid resuscitation
Complication
• Breathing very painful  patients often limit
inspiration (splinting).
– A common complication of splinting is atelectasis,
which can lead to hypoxemia, pneumonia, or
both.
• Patients treated with tube thoracostomy,
particularly if a hemothorax is incompletely
drained  may develop purulent intrathoracic
infection (empyema).
Tension Pneumothorax
Mediastinum displaced to the opposite side,
compressing the opposite lung & decreasing
venous return  obstructive shock

Etiology
• Penetrating/ blunt chest trauma  simple
pneumothorax  tension pneumothorax
• misguided attempt at subclavian / internal
jugular venous catheter insertion
• Traumatic defect in chest wall
Clinical Features

■ Chest pain
■ Air hunger
■ Respiratory distress
■ Tachycardia
■ Tracheal deviation away from the side of injury
■ Unilateral absence of breath sounds
■ Elevated hemithorax without respiratory movement
■ Neck vein distention
■ Cyanosis (late manifestation)

*distinguished from cardiac tamponade by : hyperresonant on


percussion, deviated trachea & absent breath sounds over the affected
hemithorax
Treatment

Immediate decompression
:

• inserting a large-caliber
needle (initial treatment)
• insertion of a chest tube
into the fifth intercostal
space (Definitive
treatment)
• Needle depression converts the tension pneumothorax into
Tension pneumothorax - needle
an open pneumothorax; needle decompression is a
temporizing measure and should be followed promptly with
tube thoracostomy

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Open Pneumothorax
Effective ventilation impaired : hypoxia &
hypercarbia  Equilibration between
intrathoracic pressure & atmospheric pressure is
immediate

Treatment
• closing the defect with a sterile occlusive
dressing (initial treatment)
• definitive surgical closure of the defect is
frequently required
Massive Hemothorax
Etiology :
• penetrating wound that disrupts the systemic or
hilar vessels
• Blunt trauma

Clinical Features :
• neck veins may be flat  if severe hypovolemia
present
• distended neck veins  if there’s an associated
tension pneumothorax
• absence of breath sounds / dullness to
percussion on one side of the chest
Treatment

• Initially simultaneous restoration of blood volume &


decompression of the chest cavity
• Large caliber i.v lines  rapid crystalloid infusion & type-
specific blood administered as soon as possible
• single chest tube (36 or 40 French) is inserted 
decompression of the chest cavity

Thoracotomy indications :
• 1500 mL of fluid is immediately evacuated
• less than 1500 mL of fluid, but continue to bleed (200 mL/hr
for 2 to 4 hours)
*decision is also based on the patient’s physiologic status
Cardiac
Tamponade
Rapid, unchecked increase in
pressure in the pericardial sac
 compress the heart, impairs
diastolic filling & reduces
cardiac output

Etiology
 Commonly penetrating injury
 Blunt injury
Clinical Features
• Classic diagnostic Beck’s triad : venous pressure
elevation, decline in arterial pressure & muffled
heart tones
• Kussmaul’s sign
• PEA
• Elevated CVP

Additional diagnostic methods :


 echocardiogram
 FAST sonography
 pericardial window
Treatment

 Surgery
 Initial i.v fluid will raise the venous pressure
and improve cardiac output transiently while
preparations are made for surgery
 Pericardiocentesis (if surgery is not possible)
 not be diagnostic / therapeutic when the
blood in the pericardial sac has clotted
Abdominal trauma
• Injuries are often categorized by type of
structure that is damaged:
– Abdominal wall
– Solid organ (liver, spleen, pancreas, kidneys)
– Hollow viscus (stomach, small intestine, colon,
ureters, bladder)
– Vasculature
Abdominal injury
Signs and symptoms
• Abdominal pain
– Pain from splenic injury sometimes radiates to the left
shoulder.
– Pain from a small intestinal perforation typically is
minimal initially but steadily worsens over the first
few hours.
– Patients with renal injury may notice hematuria.
• hypovolemia (tachycardia) or shock (eg, dusky
color, diaphoresis, altered sensorium,
hypotension)
inspection
• Penetrating injuries  break in the skin.
• Cutaneous lesions are often small, with minimal
bleeding, although occasionally wounds are large,
sometimes accompanied by evisceration
• Blunt trauma  ecchymosis (eg, the transverse,
linear ecchymosis termed seat belt sign)
• Abdominal distention  indicates severe
hemorrhage (2 to 3 L)
palpation
• Abdominal tenderness
– Although not very sensitive, when detected,
peritoneal signs (eg, guarding, rebound) strongly
suggest the presence of intraperitoneal blood
and/or intestinal contents.
• Rectal examination  gross blood due to a
penetrating colonic lesion
• there may be blood at the urethral meatus or
perineal hematoma due to GU tract injury
Blunt trauma

Direct blow Cause compression and crushing injuries


to abdominal viscera and pelvis 
rupture, with secondary hemmorrhage,
contamination by visceral contents, and
associated peritonitis
Shearing injuries Form of crushing injury that can result
when a restraint device is worn improperly
The organs most The spleen (40% to 55%)
frequently injured Liver (35% to 45%)
Small bowel (5% to 10%).
Penetrating trauma
• Stab wounds and low-velocity gunshot wounds cause tissue
damage by lacerating and cutting
• High-velocity gunshot wounds transfer more kinetic energy
to abdominal viscera
• Can cause increased damage surrounding the track of the
missile due to temporary cavitation
• Stab wounds  liver (40%), small bowel (30%), diaphragm
(20%), and colon (15%)
• Gunshot wounds  small bowel (50%), colon (40%), liver
(30%), and abdominal vascular structures (25%)
• Explosive devices cause injuries  penetrating fragment
wounds and blunt injuries from the patient being thrown or
struck.
Treatment
Laparotomy
• Laparotomy remains the gold standard therapy for
significant intraabdominal injuries
• All patients with persistent hypotension, abdominal wall
disruption, or peritonitis need surgical exploration.
• In addition, the presence of extraluminal, intra-
abdominal, or retroperitoneal air on plain radiograph or
CT should prompt surgical exploration.
• Some patients with positive DPL or FAST examination can
be managed nonoperatively.
• In smaller medical centers or community hospitals,
transfer to a trauma center may best serve such patients.
DISPOSITION AND FOLLOW-UP
– Patients with significant intra-abdominal injury need
admission to the surgical or trauma service for definitive
surgical intervention or observation.
– Given the high rate of concomitant injuries, even patients
who suffer minor abdominal injury may need
hospitalization to manage other injuries.
– In patients in whom ED discharge is considered, discuss
appropriate follow-up and careful instructions for return
to the ED.
– Patients who develop fever, vomiting, increased pain, or
symptoms suggestive of blood loss (e.g., dizziness,
weakness, fatigue) should return promptly for
reevaluation.
Pelvic injuries
LI 4
Pelvic Injury
• Etiologies • Principal mechanisms of
– Pedestrian accidents injuries that cause a pelvic
– Minor falls in older persons (falling ring fracture are due to a
of a chair) high energy impact as fall
– Major falls from height, sports, road
– Crush injuries traffic collision (pedestrian,
motorcyclist, motor vehicle,
• Mortality rates  5% and about
cyclist), person stuck by
20% in complex pelvic fractures
vehicles
• May produce deficits at any levels
from the nerve root to small
peripheral branches
Pelvic Injury
• Pelvic ring is a close compartment of bones • Hemorrhage from pelvic fractures  4
containing
potential sources
– urogenital organs,

– rectum, – Surface of fractured bones

– vessels and – Pelvic venous plexus


– Nerves
– Pelvic arterial injury
• Among the different fracture patterns affecting
– Extra-pelvic sources
the pelvic ring each has a different bleeding
probability • Classically venous hemorrhage is said to
• High grade injuries account for 90% of bleeding from pelvic
– Thoraco-abdominal associated (80%)
fractures, and arterial only 10%
– Bladder, urethra (1.6-25%)

– Vagina, nerves, sphincters, and rectum (18-64%)

– Soft tissues injuries (up to 72)


Pelvic Injury (Clinical Assessment)
• Inspect • Patients with suspected pelvis
– Ecchymoses, deformity, fractures also need careful
asymmetry, wounds
examination of
• Palpate skeletal wounds
– Rectum
– Pubic symphisis, iliac crests, the
posterior sacroiliac joints, – Perineum and genitalia
ischial tuberosities, the spine – Lower limb length discrepancy
extending inferiorly to the and malrotation, and neurology
sacrum and coccyx
– The abdomen
• Clinical presentations :
– Tenderness, laxity, or instability on palpation of the bony
pelvis
– Hematuria
– A hematoma over the ipsilateral flank, inguinal ligament,
proximal thigh, or in the perineum
– Neurovascular deficits in the lower extremities
– Rectal bleeding
Pelvic Injury
• ABC stabilization
• Trauma radiographs (AP views of the chest and pelvis)
• FAST  identify intraperitoneal fluid. Indication:
hemodynamically unstable
• Rectal and pelvic examination  rule out the presence
of an open fracture
Complications:
– The incidence of deep venous thrombosis ↑
– Continued bleeding from fracture or injury to pelvic
vasculature
– GU problems from bladder, urethral, prostate, or vaginal
injuries : the incidence of urethral injuries varies by the type
of pelvic fracture
– Sexual dysfunction, infections from disruption of bowel or
urinary system, chronic pelvic pain ( more so if the sacroiliac
joints are involved )
Spinal cord injuries
LI 5
Spine trauma - flexion

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – flexion rotation

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – flexion
Distraction

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – Vertical
compression

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – Extension

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – combination

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – combination

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – physical
examination

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – diagnosis

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – imaging
X-ray CT cervical
• Standard radiography for the • Multidetector CT is more sensitive
identification of bony cervical and specific than plain
injury includes three views of the radiography for evaluating the
cervical spine: lateral, anterior- cervical spine in trauma patients
posterior, and odontoid and can be performed quickly
• The main advantages of plain – useful at the craniocervical
radiography are that it can be and cervicothoracic regions,
done at the bedside, exposes the where the sensitivity of plain
patient to only small amounts of films is most limited
ionizing radiation, and has a • Furthermore, a cost analysis
relatively low cost showed CT to be cost-effective to
• One of the main disadvantages of screen for cervical spine injuries in
plain films is that they are poor for moderate- to high-risk patients
imaging C1 and C2 • In addition, if plain radiography is
– In addition, visualization of the chosen as the primary imaging
entire cervical spine by plain Tintinalli J.modality, a CT
Tintinalli's Comprehensive guide of should be8th ed.
emergency medicine. ordered
New York: McGraw-Hill; 2016
Spine trauma – imaging (spinal
cord & tissue)
• MRI is the diagnostic test of choice for describing the
anatomy of nerve injury. Entities such as herniated
disks or spinal cord contusions can also be delineated
on MRI
• MRI is indicated in patients with neurologic findings
with no clear explanation after plain films and/or CT
scanning

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – Prehospital care
• Prehospital care for spinal injuries traditionally involves
immobilization of the entire spine at the scene with a
rigid cervical collar (or similar devices) plus a long
backboard
– In contrast, cervical collars and long backboards can induce
complications such as pressure sores, patient discomfort, and
respiratory compromise
• In contrast, spinal immobilization is no longer
recommended for fully conscious, neurologically intact
patients with isolated penetrating neck injury because
collars can delay resuscitation and obscure neck
injuries

Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma
Airway Hypotension
• Unstable spine lesions above C3 • Although hypotension
can cause immediate respiratory
arrest, and lesions affecting C3- and relative bradycardia
C5 can affect the phrenic nerve are classic signs of
and diaphragm function neurogenic shock,
– For this reason, some experts bradycardia can also be
recommend that any patient
with an injury at C5 or above associated with
should have the airway intraperitoneal bleeding
secured by endotracheal or prior medication with
intubation
• Maintain in-line spinal stabilization
calcium channel blockers
while intubating, because human or β-blockers
cadaver studies demonstrate less
cervical motion and glottis
• Hypotension is initially
visualization with in-line treated with IV crystalloid
Tintinalli J. Tintinalli's comprehensive guide of emergency medicine. 8th ed. New york: mcgraw-hill; 2016
Spine trauma – spine
immobilization
• Long spine boards are • Hard cervical collars
associated with pressure are associated with
sores, so remove them as patient discomfort and
soon as possible
pressure sores of the
• Some experts recommend neck
the “6+ lift and slide
maneuver” because it • Do not overtighten the
produces less spine cervical collar on head-
motion than log rolling injured patients,
– The 6+ maneuver consists because jugular venous
first of unstrapping the
patient from the board. Next,
compression can raise
one person maintains inline intracranial pressure,
stabilization at the head, although Stifneck® and
while six others positioned at
the chest, pelvis, and lower Miami J® collars may
extremities levels lift the be better than other
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – treatment
Cervical S&C
• Until transfer of care to a • In general, transverse
fractures through the body
surgeon, spine are most significant in that
precautions should be they cause injury to part or
maintained, associated all of the cauda equina
injuries stabilized, and • Longitudinal fractures may
the patient carefully cause radiculopathy
monitored for respiratory • Sacral fractures that involve
the central sacral canal can
or neurologic produce bowel or bladder
deterioration dysfunction
• Treatment is symptomatic
with analgesics and use of a
rubber doughnut pillow
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – treatment
(corticosteroid)
• High-dose • Patients who received
methylprednisolone high-dose
remains a controversial methylprednisolone and
treatment in acute blunt
spinal cord injury and
longer duration
should not be given protocols were more
routinely likely to develop
– Believed to work is in its complications such as
inhibition of free radical– severe sepsis, severe
induced lipid peroxidation
pneumonia, wound
– Increase levels of spinal
cord blood flow, increase infection and delayed
extracellular calcium, and healing, pulmonary
prevent loss of potassium embolism and deep
from injured cord tissue
– Methylprednisolone is vein thrombosis, GI
advocated in preference to bleeding, and death
other steroids because it Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016

crosses cell membranes


more rapidly
Conclusions and suggestions
Conclusions Suggestions
• According to the patient’s • We should quickly
condition:
– The first patient  small categorize patients in triage.
penetrating wound in his lower Then conducted a primary
neck
– The second patient 
survey (ABCDE) and
suspicious pneumothorax continued with a secondary
– The third patient and the fifth survey
patient  burn injuries
– The fourth patient  chest
injuries
– The sixth patient suspicious
spinal cord injuries and pelvic
injuries
References
• Rosens’s emergency medicine 9th edition
• Tintinalli’s Emergency medicine A
comprehensive Study Guide 7th edition
• Advanced Trauma Life Support . Student
course manual 9th edition