Blok 29

Kegawatdaruratan 1
Fanny Indarto, dr. Sp.B

Sylabus

Acute abdomen & strategi emergensi

Trauma tumpul abdomen
Luka bakar
Fraktur & penanganan emergensi

Acute Abdomen

Schein's Common Sense, 2007

Acute abdomen & Strategi

emergensi

 Laboratory : CBC, electrolytes,blood

glucose, renal function,
amylase,lipase,lactate
ECG
Imaging : chest errect radiograph,
plain abdominal photo, USG,
Abdominal CT

Trauma tumpul abdomen

General principles
The physician evaluating the abdomen should answer
two questions: (a) Is there an intra-abdominal injury and
(b) does this injury require operative repair?
While addressing these issues, two principles should not
be violated: (a) the ABCs should be adequately assessed
before focusing on the abdomen and (b) clinical
examination should be the most important element of
the evaluation.
Clinical examination can determine the need for
emergent exploration following abdominal trauma by the
presence of one or both of two signs: (a) peritonitis and
(b) hemodynamic instability. In the absence of these two
signs, there is time for more detailed investigations.
Trauma Manual, 2008

Hemodynamic instability
Hypotension may occur in the
presence of spinal cord injury without
blood loss. Hypertension may occur
even in the presence of blood loss
due to increased intracranial
pressure and a Cushing's reflex.

Peritonitis
A significant part of the trauma population is
simply nonevaluable because of associated head
injuries, spinal cord injuries, or intoxication. Such
patients receive the most benefit from additional
studies. Intoxication, unless profound, should not
be a reason to avoid clinical examination. Most
patients with mild or moderate intoxication will
manifest abdominal tenderness on careful
evaluation, if intra-abdominal structures are
injured and the reliability of clinical examination
is not impaired.8,9

 FAST : Focus of Abdominal

Sonography for Trauma
Diagnostic Peritoneal Lavage
Abdominal CT
Diagnostic laparoscopy : left
thoracoabdominal injury

FAST

ACS 2007

Diagnostic Peritoneal
Aspiration

Shock
Hemorrhagic

Spinal

Source : thoracic,
abdominal/pelvic,
femur fractures
Hypotension,
tachicardia, tachipneu
Low urine output
Cold extremity,
prolonged capillary
refill time

Source : spine fracture

Hypotension,
bradicardia
Urine output normal

Blunt trauma
If hemodynamic instability is caused by pelvic
retroperitoneal bleeding, long-bone fractures, blunt
myocardial contusion, spinal cord injury, or intrathoracic
trauma, an unnecessary laparotomy may be profoundly
detrimental.
Along the same lines, unevaluable blunt trauma
patients need further diagnostic work-up before a
decision for laparotomy is made.
The presence of a sealbelt mark sign is associated
with an incidence of about 20% of intraabdominal
injuries. These patients should be evaluated very
carefully and the threshold for laparotomy should be low

Management
Spleen : splenectomy/splenoraphy
Liver : suturing
Bowel : resect and anastomotic,
stoma
Damage control surgery

Pelvic Wrapping

Luka bakar
Location plays a major role in the risk
for and treatment of a burn.

Sabiston,2017

 Severe burns covering more than 20%

TBSA in adults and 40% TBSA in
pediatric patients are typically followed
by a period of stress, inflammation,
and hypermetabolism, characterized
by a hyperdynamic circulatory
response with increased body
temperature, glycolysis, proteolysis,
lipolysis, and futile substrate cycling

 Burned patients must be removed from the

source of injury and the burning process stopped.
Inhalation injury should always be suspected,
and 100% oxygen should be given by face mask.
All rings, watches, jewelry, and belts should be
removed because they retain heat and can
produce a tourniquet-like effect.
Room temperature water can be poured on the
wound within 15 minutes of injury to decrease
the depth of the wound.

 Airway injury must be suspected with facial

burns, singed nasal hairs, carbonaceous
sputum, and tachypnea.
Upper airway obstruction may develop rapidly,
and respiratory status must be continually
monitored to assess the need for airway control
and ventilatory support.
Progressive hoarseness is a sign of
impending airway obstruction, and endotracheal
intubation should be instituted early before
edema distorts the upper airway anatomy.

 Small doses of intravenous morphine may be

given after complete assessment of the patient
and after it is determined to be safe by an
experienced practitioner.
Lactated Ringer solution without dextrose is the
fluid of choice except in children younger than
2 years, who should receive 5% dextrose in
lactated Ringer solution.
The initial rate can be rapidly estimated by
multiplying the TBSA burned by the patients
weight in kilograms and then dividing by 8.

 colloid solutions should not be used

in the first 24 hours until capillary
permeability returned closer to
normal.

 All patients with burns of more than

10% TBSA should receive 0.5 mL of
tetanus toxoid.
If prior immunization is absent or
unclear or the last booster dose was
more than 10 years ago, 250 units of
tetanus immune globulin are also
given.

 When deep second- and third-degree

burn wounds encompass the
circumference of an extremity,
peripheral circulation to the limb can
be compromised

 Each wound should be dressed with an appropriate

covering that serves several functions.
First, it should protect the damaged epithelium,
minimize bacterial and fungal colonization, and
provide splinting action to maintain the desired
position of function.
Second, the dressing should be occlusive to reduce
evaporative heat loss and to minimize cold stress.
Third, the dressing should provide comfort over the
painful wound.

Fraktur & penanganan

emergensi
In the surgical management of
musculoskeletal injury, the priorities
are (1) to save the patient's life, (2)
to save the endangered limb, (3) to
save the affected joints, and (4) to
restore function; these priorities are
pursued in accordance with
advanced trauma life support (ATLS)
guidelines
ACS 2007

Gustillo Anderson

Campbell 2007

 Damage control orthopaedics,

in the form of rapid
immobilization of fractures with
external fixation to obtain
stability and recover length,
while allowing full evaluation of
the extremity, is now standard
care

ACS 2007

 Terima Kasih