Blunt Abdominal trauma Pelvic Fractures:

 Rapid accumulation of 1500 mL o blood in the chest cavity.  Hypoxia  Neck veins may be flat secondary to hypovolemia  Absence of breath sounds andor dullness to percussion on one side of the chest  Management: Restoration of blood volume and decompression of the chest cavity.  Indication of thoracotomy: a. Immediately 1500 mLof blood evacuated. b. 200mLhr for 2-4 hrs. c. Patient’s physiology status. d. Persistent blood transfusion requirements.

2. Cardiac Tamponade

 Cardiac tamponade is usually due to penetrating cardiac injuries and are a leading cause of traumatic death.  Diagnosis : Cardiac tamponade requires prompt recognition and treatment. Signs and symptoms range from rarely stable to Beck’s triad of hypotension, CVP above 12cc of water and muffled heart sounds  Auscultation of the thorax is performed specifically to evaluate the clarity of heart tones and breath sounds. Muffled heart tones are an indication of blood in the pericardium. A systolic - to diastolic gradient of less then 30 mmHg, associated with hypotension is consistent with cardiac tamponade.  Neck veins are distended. Central venous pressure is elevated.  The X-ray film may demonstrate a widening of the cardiac silhouette. The ultrasound scan shows presence of blood in pericardial space.  Electrocardiograph is not particularly helpful.  Prompt definitive therapy is imperative. This includes antishock therapy, pericardiocentesis possibly under U.S. guide, emergency thoracotomy and suture of the wound.

3. Tension Pneumothorax

 Tension pneumothorax develops when air enters the pleural space but cannot exit and as a result there is a progressively increasing intrathoracic pressure in the affected hemithorax resulting in impaired central venous return and mediastinal shift.  Clinically, the patient experiences dyspnea, complains of chest pains, and becomes cyanotic because of shunting in the collapse of lung and has hemodynamic instability because decrease is venous return for endopleural hypertension.  The presence of hyper-resonance and the absence of breath sounds, together with X-ray examination, should be useful in confirming the cause of the emergency.  A chest X-ray film indicates that the trachea and mediastinum are deviated to the side opposite the tension pneumothorax, while on the ipsilateral side intercostal spaces are widened and the diaphragm is pushed downward.  The emergency require immediate thoracosintesis and thoracostomy with underwater- seal drainage.

4. Blunt Abdominal trauma

 Mechanism of Injury: Medical Education Unit Faculty of Medicine Udayana University 69  Blunt Trauma: Spleen, liver, retroperitoneal hematoma  Penetrating Trauma:  Stab: Liver, small bowel, diaphragm, colon  Gunshot: small bowel, colon, liver, abdominal vascular structures.  Assessment:  History.  PE:  Inspection  Auscultation: 1. Bowel sounds  Percussion 1. signs of peritonitis 2. Tympanic diffuse dullness  Palpation 1. Involuntary muscle guarding  Evaluation of penetrating wounds: Determine the depth  Assessing pelvic stability: Manual compression  Penile, perineal and rectal examination: 1. Presence of urethral tear. 2. Rectal exam: Blunt sphincter tone, position of the prostate, pelvic bone fractures, Penetration sphincter tone, gross blood from a perforation  Vaginal examination  Gluteal examination  Intubation:  Gastric tube:  Relieve acute gastric dilatation.  Presence of blood  Urinary catheter:  Relieve urine retention  Monitoring urine output.  Caution: The inability to void, unstable pelvic fracture,blood in the meatus, a scrotal hematoma, perineal ecchymoses, high-riding prostate.  X-rays studies:  Special diagnostic studies in blunt trauma:  DPL  Ultrsonography  Computed tomography  Special diagnostic studies in penetrating trauma:  Lower chest wounds  Anterior abdominal  Flankback Indications For Celiotomy  Based on abdominal evaluation  Blunt: Positive DPL ultrasound  Blunt: Recurrent hypotension despite adequate resuscitation Medical Education Unit Faculty of Medicine Udayana University 70  Peritonitis  Penetrating: Hypotension  Penetrating: Bleeding from the stomach, rectum, GU tract.  Gunshot wounds: Traversing the peritoneal cavity  Evisceration

5. Pelvic Fractures:

 Assessment:  The flank, scrotum and perianl area should be inspected  Blood at the urethral meatus, swellingbruishinglaceration in the peritoneum, vagina, rectum, or buttock  open pelvic facture  Palpation of a high-riding prostate gland.  Manual manipulation of the pelvis should be performed only once.  Management Pelvic fracture: Exsanguination withwithout open pelvic fracture BP70mmHg Blood pressure stabilizees with difficulty and closedunstable fracture BP 90-110mmHg Blood Pressure normal and closedunstable or stable fracture BP 120 mmHg Initiate ABCDEs If transfer neccessary, apply PASG If open go to OR for possible perineal exploration and celiotomy ; if closed, supraumbilical DPL or Ultrasound to exclude intraperitoneal hemorrhage. Positive Negative After operation Red uce reduce apply apply fixation device fixation device as appropriate as appropriate Hemodynamically Abnomal Angiography Initiate ABCDEs If transfer neccessary, apply PASG supraumbilical DPL or Ultrasound to exclude intraperitoneal hemorrhage. Positive Negative After celiotomy Reduce reduce apply apply fixation device fixation as appropriate device as appropriate Hemodynamically Abnomal Angiography Initiate ABCDEs If transfer neccessary, apply PASG Evaluate for other injuries Apply fixation device if needed for patient mobility Medical Education Unit Faculty of Medicine Udayana University 71 D = Disability: neurological status Rapid neurological assessment is made to establish:  Level of consciousness, using Glasgow Coma Scale  Pupils: size, symmetry and reaction.  Any lateralising signs.  Level of any spinal cord injury limb movements, spontaneous respiratory effort. E = Exposureenvironmental control Undress the patient, but prevent hypothermia. Additional considerations to primary survey and resuscitation ECG monitoring: Urinarygastric catheters: Other monitoring:  Pulse rate, [ 12 ] blood pressure, ventilatory rate, arterial blood gases, body temperature and urinary output.  Carbon dioxide detectors may identify dislodged endotracheal tubes.  Pulse oximetry measures oxygenation of haemoglobin colorimetrically sensor on finger, ear lobe, etc.. Diagnostic procedures: X-rays most likely to guide resuscitation early on, especially in blunt trauma, include:  CXR.  Pelvic X-ray. It has been suggested that CT scans may be used in some stable patients. [ 13 ]  Lateral cervical spine X-ray.  FAST = focused assessment with sonography for trauma, eFAST = extended focused assessment with sonography for trauma andor CT scanning to detect occult bleeding. Lecture 14 : PHLEGMON LUDGIG’S ANGINA Putu Lestari Sudirman Objective : 1. To describe etio-pathogenesis and pathophysiology of phlegmon Medical Education Unit Faculty of Medicine Udayana University 72 2. To implement a general strategy in the approach to patients with phlegmon, physical examination and special technique investigations. 3. To manage by assessing and refer patient phlegmon 4. To describe prognosis patient with phlegmon Abstract Phlegmone Ludwigs angina is a diffuse cellulitis is on spasia sublingual, submental and submandibular bilateral, sometimes up about spasia pharingeal. Cellulitis starts from the bottom up. Often bilateral, but when just about one side unilateral called Pseudophlegmon. Often caused by primary infection of cellulitis come from M1, M2 lower jaw, other causes Topazian, 2002: sialodenitis submandibular gland, compund mandibular fractures, lacerations of the soft mucosa of the mouth, stab wounds basic secondary infection of the mouth and oral malignancy. Clinical symptoms of phlegmon, such as edema on both sides floor of the mouth, walked quickly spread to the neck just a few hours, the tongue uplifted, progressive trismus, chewy consistency - stiff as a board, swelling redness, neck loses its normal anatomy, often febrile increase in body temperature, pain and difficulty in swallowing, droling, sometimes up tough talk and breathe and stridor inspiratory rough sound, because the narrowing of the airways in the oropharynx, subglottic or tracheal Phlegmone Ludwigs angina requiring treatment as soon as possible, in the form of: referral for hospitalization, intravenous antibiotics high doses, typically used for initial therapy in combination with Ampisillin metronidazole, intravenous fluid replacement, drainage, as well as the handling of the airway, such as endotracheal intubation or tracheostomi if needed. Local symptoms include swelling of the soft tissue spasia, pain, heat and redness in the area of swelling, swelling caused by edema, cellular infiltration, and sometimes because of pus, diffuse swelling, chewy consistency - hard as a board, sometimes accompanied by trismus and sometimes floor of the mouth and tongue raised. Systemic symptoms such as high temperature, rapid and irregular pulse, malaise, lymph nodes, increasing the number of leukocytes, rapid breathing, face reddish, dry tongue, delirium, especially at night, dysphagia and dyspnoea and stridor. Prognosis in case of phlegmon depending on patient age, the condition of the patient come first to get treatment and also depending on conditions Systemic patients. If there are signs of systemic conditions such as malaise and high fever, presence of dysphagia or dyspnoea, dehydration or drinking less patient, thought to decrease resistance to infection, septicemia, and toxic infiltration into anatomic regions are dangerous and require general anesthesia for drainage, required serious treatment and hospital care as soon as possible. Should always be controlled airway, endotracheal intubation or tracheostomy. Four basic principles infection treatments Falace, 1995, namely: eliminating causa If the patients general condition possible to be done This procedure, by way of cause tooth extraction, drainage drainage Incision can be done intra and extra oral, or can be done simultaneously in the case - severe cases. Determining the location of the incision by spasium involved. In the administration of antibiotics to consider whether the patients had history of allergy to certain antibiotics, especially if given in Intravenous it is necessary to do skin test beforehand. antibiotics are given for 5-10 days Milloro, 2004 Suppotive Care, such as rest and adequate nutrition, administration analgesic and anti-inflammatory nonsteroidal anti-inflammatory painkillers such as diclofenac 50 mg 8 hours or Ibuprofen 400-600 mg 8 hours and if Medical Education Unit Faculty of Medicine Udayana University 73 Corticosteroids granted, it should be added pure analgesics, such as paracetamol antiinflammatory given in 650 mg 4-6 hours and or low opioids such as codeine 30mg 6 h, granting the application of external heat hot compresses or orally mouthwash. Traumatic Brain Injury Resuscitation I Pt Pramana Suarjaya IB Krisna Jaya Sutawan Learning Obyektif 1. To describe Traumatic Brain Injury TBI 2. To implement Glasgow Coma Scale to classiflying severity of TBI 3. To implement initial brain recucitation a. Primary survey i. Airway ii. BreathingVentilation iii. Circulation iv. Disability v. Exposure b. Secondary survey 4. To describe management of elevated ICP Abstract Traumatic Brain Injury TBI TBI is a nondegenerative, noncongenital insults to the brain from external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness. TBI from trauma results from two distinct processes: primary injury and secondary injury. Primary injury is the damage produced by the direct mechanical impact and the acceleration- deceleration stress onto the skull and the brain tissue, which results in skull fractures and intracranial lesions. The intracranial lesions are further classified into two types: diffuse injury and focal injury. 1. Diffuse brain injury a. Brain concussion : loss of consciousness lasting 6 hours b. Diffuse axonal injury : traumatic coma lasting 6 hours 2. Focal brain injury a. Brain contusion b. Epidural hematoma EDH c. Subdural hematoma SDH d. Intracerebral hematoma ICH Secondary injury develop within minutes, hours or days of the initial injury and cause further damage to nervous tissue. The common denominators of secondary injury are cerebral hypoxia and ischemia. Secondary injuries are caused by the following disorders: 1. Respiratory dysfunction: hypoxemia, hypercapnia 2. Cardiovascular instability: hypotension, low cardiac output CO 3. Elevation of ICP 4. Metabolic derangements Glasgow Coma Scale GCS to classifying severity of TBI Medical Education Unit Faculty of Medicine Udayana University 74 GCS is composed of three components: eye opening 1 to 4 points, verbal response 1 to 5 points and motor response 1 to 6 points. The sum of these components defines the TBI severity classification into : 1. Severe : GCS score of 3 to 8 2. Moderate : GCS score 9 to 13 3. Mild : GCS score 14 and 15 Glasgow Coma Scale for all age group 4 years to Adult Child 4 years Infant Eye Opening 4 Spontaneous Spontaneous Spontaneous 3 To speech To speech To speech 2 To pain To Pain To Pain 1 No respon No respon No respon Verbal response 5 Alert and oriented Oriented, social, speaks, interacts coos, babbles 4 Disoriented Confused speech, disoriented, consolable, aware Irritable cry 3 speaking but nonsensical Inappropriate words,inconsolable, unaware cries to pain 2 Moan or unintelligible sounds Incomprehensible, agitated, restless, unaware Moans to pain 1 No response No response No response Motor response 6 Follows commands Normal, spontaneous movements Normal, spontaneous movements 5 Localizes pain Localizes pain withdraws to touch 4 Moves or withdraws to pain Withdraws to pain withdraws to pain 3 Decorticate flexion Decoritcate flexion Decorticate flexion 2 Decerebrate extension Decerebrate extension decerbrate extension 1 No response No response No response Initial Brain Resuscitation Patients who have TBI should be either treated at a designated trauma center that has neurosurgical coverage or transferred to such a center after initial stabilization. The prompt assessment and management of TBI begin with the treatment of associated injuries that may cause hypoxia, hypoventilation and shock. This is best accomplished using a systematic approach such as the Advanced Trauma Life Support ATLS Algorithm, which consists of primary and secondary surveys.

1. Primary Survey