T R A U M A U P D AT E

T R A U M A C E N T R E R S U P P R O F. D R . I . G . N . G . N G O E R A H D E N PA S A R
Trauma Patient
• Fifth leading cause of death overall
• Major cause of death and disability ages 16 to 54
years
• Leading cause of death of teens; 11 teens die in
MVCs each day
• Often associated with drugs and alcohol
• Financial implications
• Treatment
• Rehabilitation
• Disability
TERGOLONG
PENYAKIT APA
TRAUMA ITU?
• Trauma dapat didefinisikan sebagai Multi-System-
Disease
• Cedera pada satu organ akan berpengaruh secara
Sistemik
• Maka prinsip utama pada resusitasi trauma adalah
Oxygen Delivery yang cukup sampai ke sel yang
cedera, yaitu dg menjamin airway yang baik dan
mempertahankan minute ventilation 1.5-2 kali normal
Keadaan Gawat
Darurat

Suatu Keadaan Apabila Tidak Mendapatkan

Pertolongan Dengan Cepat, Tepat dan Akurat
akan Mengakibatkan Korban Kehilangan
sebagian Anggota Tubuh atau Meninggal
Dunia.
Keadaan Gawat
Darurat
Suatu Gangguan Pada
Fungsi Vital Yaitu :
• Fungsi Jalan nafas
• Fungsi Pernafasan
• Fungsi Sirkulasi
• Fungsi Otak/Kesadaran

Pada Tahap Akhir : Suatu

Kematian
 01 Rapid Primary survey

02 Resuscitation

03 Adjuncts to primary survey

/resuscitation
Prinsip 04 Detailed secondary survey
Penilaian 05 Adjuncts to secondary

Awal Trauma survey

06 Reevaluation

07 Definitive care
Primary Survey

• Done in 1 to 2 minutes
• Airway patency (with C-spine immobile)
• Breathing effectiveness
• Circulation, including hemorrhage and pulses
• Disability (overview of neurological status)
• Expose the patient, remove clothing, warm patient and
trauma room
• Identify life-threatening injuries accurately to establish
priorities
Secondary • Performed after life-threatening injuries are identified
Survey and treated
• Examination of all body systems:
• Full set of vital signs; focused interventions, family
presence
• Give comfort measures
• History and more thorough head-to-toe assessment
• Inspect posterior surfaces
• Maintain C-spine immobilization until cleared by x-ray
• X-ray studies (as determined by injury)
• Laboratory studies
• Tetanus toxoid administration
• Specialty physician consults
Siapa Trauma
Team Leader ? PROBLEMS
 Potential airway obstruction
 Maxillofacial LF II fracture
 Hypovolemic shock class III/IV
 Blunt abdominal injury
 Severe head injury
 Closed fracture of the left lower arm
Penetrating Injury, Mr. Muk, 40 yrs, 02-
06-07
Trauma Thoraks, Trauma Diafragma,
Trauma Abdomen

 Planning…..?
 Terapi difinitif…?
 Follow up….?
Massive dyshomeostasis induced by major trauma

Major Trauma Central asphyxia Hemorrhage

Low flow conditions
Airway obstruction
Debris
Severe chest injury
Bacterial/endotoxin
translocation
Immuno-inflammatory
response
Inflammation Sequential events
dyshomeostasis

Bacterial invasion 

Counter Inflammation
Immuno depression

SEPSIS
Faist E, Angele M & Wichmann M, Trauma 5th edit. 2004
 Traumatologist = Total Care
Three peaks of trauma related deaths
First peak
Laceration of brain
Third peak
brainstem
Sepsis
aorta
Multi organ failure
spinal cord Second peak
heart Extradural
Subdural
DEATHS

Hemopneumothorax
Pelvic fractures
Long bone fractures
Abdominal injuries

ee ks ee k
s
2 w 4 w
1 hour 3 hours
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 Bertujuan untuk mencegah/memperbaiki lethal diamond: Resusitasi
Damage hipotensif, resusitasi hemostatic, Damage Control Surgery (DCS).
Control
Resuscitation 1. Resusitasi hipotensif
(DCR)
Mempertahankan tekanan darah sistolik 80-100 mmHg
Restriksi cairan kristalloid untuk mencegah terjadinya koagulopati
karena berlebihan cairan.

Pasien cedera otak/spine: kontraindikasi resusitasi hipotensif, tekanan

sistolik direkomendiskan >100mmHg pasien usia 50-69 tahun, >110
mmHg pada <49 tahun atau >70 tahun.

Parra, M.W., Ordoñez, C.A., Herrera-Escobar, J.P., Gonzalez-Garcia, A. and Guben, J. (2018). Resuscitative endovascular balloon occlusion of the aorta for placenta percreta/previa. Journal of Trauma and Acute Care
Surgery, 84(2), pp.403–405. doi:https://doi.org/10.1097/ta.0000000000001659
Damage
Control 2. Resusitasi hemostatik
Resuscitation
Pemberian cairan resusitasi kristaloid atau koloid atau transfusi
(DCR) darah dengan perbandingan rasio optimal.

Target resusitasi: Hb ≥8g/dL, platelet ≥100,000/dL.

Transfusi darah:

Rekomendasi perbandingan PRC : FFP : platelet : cryoprecipitates

adalah 1 : 1 : 1 : 1.

Parra, M.W., Ordoñez, C.A., Herrera-Escobar, J.P., Gonzalez-Garcia, A. and Guben, J. (2018). Resuscitative endovascular balloon occlusion of the aorta for placenta percreta/previa. Journal of Trauma and Acute Care
Surgery, 84(2), pp.403–405. doi:https://doi.org/10.1097/ta.0000000000001659
Resuscitation Done in ICU for prevention or correction of trauma diamond of death; hypothermia,
phase : acidosis and coagulopathy.

This achieved by: 1. Rewarming.

2. Correction of coagulopathy
3. Correction of acidosis.
4. Optimizing pulmonary functions.
Resuscitation :
Rewarming
oHeat loss during major trauma patient may be as
high as 4.5 ºC per hour.

oHypothermia is correcting by increase room

temperature, avoid unnecessary skin exposure,
use of blood and fluid warmer, etc.
Resuscitation:
Reversing • Thrombocytopenia results from massive
coagulopathy blood transfusion → coagulopathy; corrected
by platelets transfusion.

• Large volumes of crystalloids and packed

RBCs → diluting coagulating proteins
corrected by clotting factors and fibrinogen.
Resuscitation :
Reversing
acidosis • Metabolic acidosis induced by Lactic acid
accumulation that produced by shock.

• Aggressive treatment of shock by fluids, blood,

fresh frozen plasma, inotropic agents are
needed.

• Use of i.v. sodium bicarbonate and follow the

PH estimation.
Optimizing
pulmonary
functions :
• Following DCS patients are intubated
in ICU and maintained on mechanical
ventilation.
• Goal are to achieve oxygen saturation
more than 92%.
• Those patients usually require deep
sedation and pain medication.
Damage
Control Surgery

• Patients with multiple injuries

• Staged surgeries
• Repair stages:
• Life-threatening injuries
• Definitive repair
• Hemodynamic stabilization
• Correction of metabolic acidosis and coagulopathies
FUNDAMENTAL
OF DAMAGE
CONTROL
SURGERY Immediate, abbreviated laparotomy with the
following goals :
1. Control surgical hemorrhage
2. Control gastrointestinal spillage
3. Inserting surgical packs
4. Applying temporary abdominal closure
Indications for
DCS:
1. Exanguinating patient with hypothermia and
coagulopathy who is hemodynamically
unstable.

2. Inability to control bleeding by direct

hemostasis.

3. Inability to close abdomen without tension.

4. Expected long time operation.

ABSOLUTE
INDICATIONS
FOR DCS Base deficit > 8 mEq/L
pH < 7,2
Hypotension < 90 mmHg systolic
Hypothermia < 340 C
PTT > 60 seconds
Operative “clinical” coagulopathy
Damage Control Surgery

consist of 3 phases:

Part I - OR Part II - ICU Part III - OR

• Control of • Continued resuscitation • Pack removal

hemorrhage • Core Rewarming and • Definitive repair
• Control of management acid-base • Closure
contamination derangement
• Intraabdominal • Correct coagulopathy
packing • Maintained
• Temporary closure hemodynamic
• Ventilatory support
Definitive
operation or
planned re-
Principals of re-operation:
operation:
Re-operation done
1. Removal of clots and abdominal packs.
within 24 – 72 hours 2. Complete inspection of abdomen to detect
missed injuries.
3. Restoration of intestinal integrity.
4. Abdominal wound closure.
Unplanned re-
operation :
Indications:

a. Continued bleeding despite normalization

of coagulation functions.

b. Intra abdominal pressure greater than 25

cm water with complication of abdominal
compartment syndrome.
Complications of
DCS:-
1. Abdominal compartment syndrome
(ACS).
2. Multiple organ failure.
3. Intraabdominal abscess (between 12%
- 67%).
4. Other septic complications in chest
and abdomen.
KESIMPULAN

Banyak kematian akibat trauma sebetulnya dapat dicegah

(preventable death).
Trauma dapat diartikan sebagai penyakit multi
system/systemic desease.
Prinsip penanganan multi trauma/major trauma dengan DCR
dan DCS
Penanganan sebaiknya dengan pendekatan tim,
TERIMA KASIH