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Wokshops on Trauma

Update
XII Edition
The Late Warko Karnadihardja
Kiki Lukman
Division of Digestive Surgery
Department of Surgery,
Medical Faculty of UNPAD/ Hasan Sadikin Hospital
Bandung
Objectives :

To discuss the recent updates in


trauma management
To provide exercises for the
participants in the application of
recent update of trauma management
To provide the opportunities for the
participants to discuss trauma cases
in a team
Participants

This workshop is tended for:

Acute Care Surgeons


General Surgeons
Sub specialist from various disciplines
Anesthesiologist
Intensivists
Interventional Radiologist
Emergency physicians
Recommended Basic Courses

ATLS
Definitive Surgery for Trauma Care
TNT
LLL ESPEN Courses
Perioperative Care for Acute Care
Surgery Courses
Introduction

Trauma remains a major cause of


morbidity and mortality in the US
The third most frequent cause of death
The leading cause of death beyond the
first few days after the incident is head
injury
The second most frequent cause is
infection
PHTLS & Prevention 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 Secondary Brain Injury
heart Extradural
Subdural
Hemopneumothorax
Pelvic fractures
Long bone fractures
DEATHS

Abdominal injuries

ee ks e eks
2w 4w
1 hour 3 hours
Decreased Incidence of
Preventable Death due to Traffic
Accidents in Australia
Introduction

Incidence of Infection in Major Trauma


Infection following a laparotomy is at least
15% - 20%
Bacteremia is at least 10%
Gunshot wounds tend to have an
incidence of abdominal infection rate that
is 5 to 10 times higher
Colon injuries, those requiring colostomy
infection rate exceeding 20 %
Factors Contribute to Vulnerability to Infection

Protective barriers are disrupted by the


injury as well as by procedures undertaken
for repair (skin, mucous membrane)
Invasive life support devices
Nutritional depletion
Multiple transfusion
Trauma
Depress many components of
immune system
MAJOR TRAUMA

Associated with
Severe hemorrhage
Low-flow conditions
Tissue destruction and debris
Gut bacterial translocation

Leading to:
Massive dyshomeostasis of
immunoinflammatory response
MASSIVE DYSHOMEOTASIS INDUCED
BY MAYOR TRAUMA

Faist E, Angele M & Wichmann M, Trauma 5th


TRAUMA AS IMMUNE DISEASE
POST TRAUMATIC IMMUNE DYSFUNCTION

Trauma patients who survive the early


post injury period may develop a
compensatory anti-inflammatory response
syndrome with suppressed immunity and
significant risk of developing an infection
The resultant infection can then lead to
late MODS and death
Mengapa penanganan trauma
harus terorganisasi?

20-35% pasien yg sampai ke RS meninggal di UK, yg sebetulnya


dapat dicegah
Anderson ID et al : Br Med J 1988;296 : 1305-8

Majoritas preventable deaths di USA : karena tidak terdiagnosa


jadi tak ditindaklanjuti adanya perdarahan intra abdominal
West JC et al : Arch Surg 1979; 112: 455-60

3223 trauma tumpul : risiko cedera intraabdominal meningkat bila


arterial base difisit > 3 mmol/L, adanya trauma toraks, trauma
pelvik dan hipotensi
Mackersie RC et al : Arch Surg 1989;124: 809-13
Mengapa Spesialis Bedah Harus
Memahami & Terlibat dalam
Penanganan Kasus-Kasus yang
Gawat ?
MASALAH TRAUMA
Penyebab kematian utama pasca bedah adalah:
Sepsis & multiple organ failure
Secondary brain injury
Trauma dapat diartikan sebagai multisystem disease dan juga
immune disease
Harus ada kerjasama aktif multidisipliner
Penguasaan basic sciences untuk diaplikasikan pada keadaan
klinik, maka perawatan bedah masa kini menikmati keuntungan
kemajuan ilmu critical care agar outcome lebih baik.
A 12-YEAR PROSPECTIVE STUDY OF
POSTINJURY MULTIPLE ORGAN FAILURE

Other factors contribute to improvement of outcome

Concept of damage control surgery (1990)


Recognition of abdomnal compartment syndrome and
decompressive laparotomy (1990)
Improvement in respiratory support such as lung protective
ventilation (1996)
Improved outcome following ARDS (2000)
The use of intensive insuline therapy (2001)
Cortisol replacement therapy for acute adrenal insufficiency
(2003)
Ongoing observation:
Damage control resuscitation (2004)
DAMAGE CONTROL

Two types of damage control (since 2004 after


starting Iraqi large scale conflict)
DAMAGE CONTROL SURGERY
Stop bleeding
Stop contamination
Temporary abdominal closure
DAMAGE CONTROL RESUSCITATION
Early management of coagulopathy
And other component of lethal triad
MANAGEMENT TREE OF COMPLEX INJURIES OF THE
EXTREMITIES
Extremity injury

Stop hemorrhage

Check for:
1. Peripheral perfusion
2. Motor/sensory function
3. Bone integrity
4. Soft tissue integrity

Three or more
Components
involved

no yes
DCO:

Systemic injuries Damage control


With higher priority
DCO orthopedics

no successful unsuccessful
yes
Definitive Early
repair amputation
Chiara, O, Cimbanasi S and Vesconi S : Critical Bleeding in Blunt Trauma Patients in 2006 Year Book of Intensive Care and Emergency Medicine,Springer 2006
MANAGEMENT TREE FOR BLEEDING
INTRAPERITONEAL INJURIES

Hemodynamically Hemodynamically
ATLS protocol
stable unstable

CT scan Hollow viscus or


US-fast
Diaphragmatic injuries

Contrast extravasation celitomy

If:
Acidosis
Hypothermia
Ongoing
Angiography-embolization > 8 PRBC
bleeding
coagulopathy

N.O.M D.C.S
NOM: nonoperative management
DCS:damage control surgery
Chiara, O, Cimbanasi S and Vesconi S : Critical Bleeding in Blunt Trauma
US : Ultrasound
Patients in 2006 Year Book of Intensive Care and Emergency Medicine,
PRBC: Pached red blood cells Springer 2006
Writtened report on wound
dressing

MAJ Alec C Beekley, MD, Surg Clin N Am 86 ,2006, 689-709