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:
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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
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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
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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,
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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.
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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
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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
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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
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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