Surgery Emergencies:

Multiple Trauma

Yonathan Adi Purnomo

Polytrauma
Multisystem trauma
Terminology:
 Injury = the result of harmful event that
arieses from the release of specific forms of
energy.
 “polytrauma” = Multisystem trauma =
injury of two or more systems, one or the
combination imperil vital signs.
Basic and Advanced
Trauma Life Support
Assessment of the injured patient
 Primary survey and resuscitation
– A = Airway and cervical spine
– B = Breathing
– C = Circulation and haemorrhage control
– D = Dysfunction of the central nervous system
– E = Exposure
 Secondary survey
 Definitive treatment
Airway and cervical spine
 Always assume that patient has cervical spine
injury
 If patient can talk then he is able to maintain own
airway
 If airway compromised initially attempt a chin lift
and clear airway of foreign bodies

 Intubate or cricothyroidotomy
 Give 100% Oxygen
 Cervical spine stabilization

 Manual In Line Stabilization - MILS

Breathing
 Check position of trachea, respiratory rate
and air entry
 If clinical evidence of tension
pneumothorax will need immediate relief
 Place venous cannula through fifth
intercostal space in the mid-axillary line
(ATLS 10th edition)
 If open chest wound seal with 3-sides
occlusive dressing
Open chest wound
Circulation and haemorrhage
control
 Assess pulse, capillary return and state of
neck veins
 Identify exsanguinating haemorrhage and
apply direct pressure
 Place two large calibre intravenous
cannulas
Give intravenous fluids (crystalloid or
colloid or blood – massive transfusion if
needed)

Dysfunction / Disability
Assess level of consciousness using AVPU
method
A = alert
V = responding to voice
P = responding to pain
U = unresponsive
Glasgow Coma Scale
Assess pupil size, equality and responsiveness
Exposure

 Avoid hypothermia

Fully undress patients

Log-roll back examination
Triage & Multiple
Causalties
Multiple casualties
 several causalties at the same
time.

1. Alarm ER services
2. Assess the scene - without puting
your safety at risk.
3. Triage
'do the most for the most'
Triage
 Ability to walk
 Airway
 Respiratory rate
 Pulse rate or capillary
return
Triage categories
Cat Definition Colour Treatment Example
Life-
P1 Red Immediate Tension pneumothorax
threatening
P2 Urgent Yellow Urgent Fractured femur
P3 Minor Green Delayed Sprained ankle
P4 Dead White
Road accidents
 fall from a bicycle …. major incident with many causalties.
 serious risks to safety - traffic
1. Make the area safe
 protect yourself, the causalty and other road users.
– Park your car safely, turn lights on, set hazard lights
flashing.
– Do not across a bussy motorway to reach other side
– Set others to warn other comming drivers
– Set up warning triangles or lights 200 metres in each
direction.

 Swich off ignition of any damaged vehicle.

2. Check all caulsalties
 quick assess
 no moving
 apply life-saving treatment
How to move unconscious
casualty
 do not move the casualty unless it is
absolutely necessary
 assume neck injury until proved otherwise
– support head and neck with your hands, so he can
breathe freely
Apply a collar, if possible
– There should be only 1 axis (head, neck, thorax)
no moving to sides, no flexion, no extension.
– with other 3-4 people
1 support head (he is directing others), other one
shoulders and chest, other one hips and abdomen,
last one - legs.
3. Treat
 in the position found
 first life-threatening or potentialy
serious injuries
4. search all area
Head and Neck Injury
 LIFE-THREATENING
HEAD INJURY
 Intracranial hemorrhage
Epidural hematoma, subdural hematoma,
intracerebral hematoma, subarachnoid
hematoma
 Diffuse axonal injury
 Management
a. Evacuation of hematoma
b. Decrease IICP and mass effect
c. Maintain cerebral perfusion
 IICP
 Symptoms
Headache, vomiting, consciousness
change
 Signs
Increase BP, decrease HR & PR
papilledema
 Neurological findings
Focal sign, pupil size and light reflex
OBSERVATION OF
HEAD INJURY

 Progressive headache
 Vomiting
 Consciousness
 Dyspnea
 Extremity weakness
 Seizure
 Mechanism of injury

 Type of injury is related to

how the injury is caused
 Look at circumstances in which an
injury was sustained and forces involved
 E.g. Side impact more serious versus frontal
collision, seat belt?
 Whiplash injury
 Cervical spine stabilization


If you HAVE to move a person you suspect
has a neck injury,

keep their head and neck immobile and move
their entire body as one unit.
Thoracic Trauma
LIFE-THREATENING
CHEST INJURY

1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Massive hemothorax
5. Pericardiac tamponade
6. Flail chest combined pulmonary
contusion
 BECK’S TRIAD

Pericardiac Tamponade
1. Decrease blood pressure
2. Distended neck vein
3. Distant or muffled heart
sounds
Abdominal Trauma
Abdominal trauma
 Abdominal Region
– 4 quadrants
– 9 regions
– Intra-peritoneal
– Retro-peritoneal
Abdominal Trauma
 Penetrating (tajam)
 Blunt (tumpul)
Hemodynamically Unstable
Which one?
 'Hemodynamically unstable' includes non-
responders and transient-responders to
initial small-volume fluid bolus
administration
 If unstable, make it stable by operation /
laparotomy
 Stop bleeding
Damage Control Principle
 Stop contamination
Hemodynamically Stable
Penetrating Abdominal Trauma
 Emergency situation: Primary Survey, Secondary Survey, initial
fluid, antibiotics, analgesics, Tetanus vaccines
 Impalement wound:
– Don’t take off
– Stabilizing with doughnut
– Radiograph examination: x-ray 2 projection (AP – Cross table) , CT scan
 Open wound:
– Peritoneal (abdominal organs prolapse / eviceration) or non-peritoneal
breach (non organ prolapse / eviceration)
– Peritonitis or local pain / tenderness (be careful with unconscious)
– Radiograph examination: US-FAST, x-ray erect, CT scan
Penetrating Abdominal Trauma
 Non-Operative management (NOM):
– Non peritoneal breach without peritonitis
 Surgery Indication:
– Foreign bodies evacuation
– Peritoneal breach
– Peritonitis (solid organ or hollow viscus organ)
– Multiple trauma
 Types of surgeries:
– Laparoscopy (diagnostic / exploration or repair)
• avoided laparotomy in 89.3% applying minimally invasive diagnosis and repair. (Johnson and colleagues)

– Laparoscopy conversion to laparotomy

– Laparotomy exploration and repair due to laparoscopy contraindication or
laparoscopy limitation
Blunt Abdominal Trauma
 Emergency situation: Primary Survey, Secondary
Survey, initial fluid (mild hypotension allowed),
antibiotics
 Abdomen examinations:
– Peritonitis or non peritonitis (be careful with unconscious)
– Blood or intestinal, bladder content peritonitis (absent of
bowel sounds, hematuria)
– Radiography examinations: US-FAST, x-ray erect, CT
scan
Blunt Abdominal Trauma
 Non-Operative management:
– Non peritonitis
– Small amount blood peritonitis from solid organ (< 500 ml / 1 region free fluid in
FAST)
 Surgery Indication:
– Intestinal / bladder content peritonitis
– Large amount blood peritonitis
– Peritonitis without solid organ injuries
– Multiple trauma (diaphragm or pelvic)
– Complication after NOM (3-5 days)
 Types of surgeries:
– Laparotomy exploration (first choice)
– Laparoscopy (diagnostic / exploration or repair)
• avoided laparotomy in 89.3% applying minimally invasive diagnosis and repair. (Johnson and colleagues)
Pelvic Trauma
Pelvic X-ray for trauma
Straddle Injury
Thermal Injury
High Mortality
Degree
Animal Bite and Tetanus
Membedakan ular berbisa
Cara membedakannya adalah
dengan melihat pada luka
gigitannya. Pada ular
berbisa akan meninggalkan
dua buah bekas taring (dan
kadang bekas-bekas kecil
yang mungkinditimbulkan
oleh gigitan ular).
Perawatan luka pada ular
tidak berbisa dapat
dilakukan seperti
perawatan vulnus punctum
Konsep Dasar
Daya toksik bisa ular:
1. Neurotoksin
2. Haemotoksin
3. Myotoksin
4. Kardiotoksin
5. Cytotoksin
6. Cytolitik
7. Enzim-enzim, termasuk hyaluronidase sebagai zat aktif
pada penyebaran luka
Derajat Gigitan Ular
1. Derajat 0
- Tidak ada gejala sistemik setelah 12 jam
- Pembebgkakan minimal, diameter 1cm
2. Derajat I
- Bekas gigitan 2 taring
- Bengkak dengan diameter 1-5cm
- Tidak ada gejala sistemik setelah 12 jam
3. Derajat II
- Sama dengan derajat 1
- Ptechie, echimosis
- Nyeri hebat dalam 12 jam
4. Derajat III
- Sama dengan derajat I dan II
- Syok dan distres nafas, ptechie, echimosis seluruh tubuh
5. Derajat VI
- Sangat cepat memburuk
Penatalaksanaan
1. Lakukan imobilisasi pada area yang tergigit dengan cara
memasang bidai, karena gerak otot dapat mempercepat
penyebaran racun.
2. Anti tetanus profilaksis
3. Serum Anti Bisa Ular (SABU) yang tersedia di Indonesia
adalah Polivalen. Yang berisikan:
- 10-50 LD50 anti bisa Ankystrodon
- 25-50 LD50 anti bisa Bungarus
- 25-50 LD50 anti bisa Naya Sputarix
Dosis SABU 2 Vial dalam 500ml NaCl 0,9% dengan
kecepatan 40-80 tetes per menit intravena.
Rabies

Post exposure: 1 dose intra muscular on day 0,3,7,14,30

Or : 2 dose, 1 dose, 1 dose in different site on day 0 and
repeat 1 dose on day 7 and 21
Tetanus

Profilaksis: 0,5 ml TT, 250 IU Tetagam / 1500 IU ATS

Therapeutic: 3000 – 6000 IU Tetagam/ 20000 IU ATS
Thank You and Take Care

#stay at home