NOTES FROM dr MICHAEL

ATLS
1)Apa yang kamu lakukan saat menerima pasien di UGD?? Pasien dengan trauma
TRIASE

Pediatrik

Bedah (Trauma) Non-Bedah (Non-trauma) 2)Standar hari-hari Tidak gawat tidak darurat -- Gawat tidak darurat Darurat tidak gawat -- Gawat darurat 3)AVPU Alert, Verbal, Pain, Unresponsive Parameter : (Open Eyes) unconsciousness lanjut dengan PRIMARY SURVEY Goals: Life Threatening or not?? A : Ada sumbatan/tdk ? B : Bernafas/tdk ? C : Ada sirkulasi/ tdk ?
ATM

Assessment, Treatment, Maintain

4)Trauma Case : Airway + C-spine control

Breathing + ventilation Circulation + Bleeding control Disability Exposure No tools VS with tools

5)AIRWAY : Assessment (menilai fungsi) VS Examination ( memeriksa ) L ( Look) , L ( Listen ), F ( Feel) 2 version ATLS : Airway ACLS : Breathing -Obstruction padat / cair (foreign body)remove, anatomical obstruction (tongue) pakai

oropharyngeal tube / ETT kalau tdk ada alat how? head tilt & chin lift, atau jaw thrust (pada susp fraktur C-spine injury) -bagaimana pangkal lidah blh menyumbat airway involuntary pada GCS 8 tone (-), gag reflex (-). -maksilofasial injury -open the mouth (if close) using method : finger thrust, cross finger &finger swab Question : batas antara airway & breathing (anatomically) ?? Airway mulai dari hidung/cavum oris faring Laring Trakhea Bronkus Bronkiolus -pasien yang bisa diajak bicara airway paten (A,B,C,D)dilakukan simultan A: bisa bicara, B: kalimat panjang, C: muscles work, D : orientasi

Listen

bunyi tambahan : snoring, gurgling, stridor. If (+) partial onstruction : Total obstruction & clear airway silent, no sound

Feel

check for trachea deviation

6)BREATHING : Assessment

Look,

Listen,

Feel

Chest expansion asimetris/x?--> pneumothorax Breath sound Breath flow If (-) respiratory failure ARREST Treatment : breathing support (bantuan napas) how? Mouth to mouth/ mouth to nose for children. : Ambu Bag for ventilation (normally negative ventilation when sucked in & positive ventilation when push in )

Breathing support for how long? until spontaneous breathing if not, use ventilator Maintain : oksigenation 7)CIRCULATION Assessment : Cek nadi (arteri besar,sentral) klau (-) CPR (heart compression) Treatment : CPR (BS + CC) 30:2 sampai kapan? Spontan & kelelahan

Push fast, push hard, 100 bpm Maintain : IV line

8)DISABILITY : GCS (EMV) 15-3

FRACTURE
1)Open fracture classification of Gustilo-Anderson Panjang Luka Kontaminasi Grade I < 1 cm Mild Grade II 1-10 cm Moderate Grade III A >10 cm Severe Grade III B >10 cm Severe Grade III C >10 cm severe -Type of fracture ( Burn injury, Gun shot injury) Soft Tissue Coverage (+) (+) (+) Periosteal/ stiffning (+) Any vascular injury that need to repair

2)Debridement best solution for pollution is dilution remove all devitalized soft tissue (muscle,bone,soft tissue) preserve skin. I : 3L II : 6L III : 9L -Antibiotics -4 C for muscle viability (colour is red, contractility (+), consistency kenyal, capability to bleed tidak ada) 3) open reduction internal fixation External fixation -skin degloving -crush injury -External fixation temporary Perawatan luka Fiksasi Frenkel Classification: Useful/not Not Motoric strength 0 Sensoric (-)

B C D E Muscle Strength : 0 5 0 1 2 3 4 5

Not Not Useful useful

0 1-2 3-4 5

(+) (+) (+) (+)

No contraction Contraction (+), motion (-) Move, gravity eliminated Against gravity Little resistance Normal

4) Physical Finding : Look, Feel, Move Look : Deformities, swelling, haematome, colour? Feel : Tenderness (NT) ROM : active & passive NVD : Sensibility, Pulsasi Arteri Distal, CRT 5) X-ray (Rules of Two) : 2 position : AP & Lateral 2 joints 2 limbs (in children) 2 times 6) Diagnosis CF : closed fracture 1/3 proximal Elbow : Ossification CRI TO E CRM TO L

Capitulum Radial head Medial epicondylar Trochlear olecranon lateral epicondylar Ossification primary Secondary meta-epiphysis physis (epiphyseal growth plate)

Physis fracture (Type I-V) SALTR I : separate/ slipped / split II : Above most common III: Lower IA IV: Through IA V : Right at crush injury 7) Toleransi Remodelling Bone healing, Tendon healing 8)-closed fracture 1/3 middle left ulna + closed fracture 1/3 proximal left radius -closed fracture distal left radius 9)1/3 middle / prox / distal Metaphysic (cancellous bone) Diaphysis (cortical bone) Epiphysis (intraarticular) 10) Type of fracture line (depends on Mechanisme of Injury) Transverse High energy Oblique< 30 Moderate energy Spiral >30 derajat Low energy Comminuted > 3 fragment (butterfly fr.) High energy -oblique fr. Panjang garis fraktur 2x diameter tulang 11)Healing : Bone Healing : Haematome Inflammation Soft Callus Hard Callus Remodelling Soft tissue injury Anatomical Reduction

x-ray (-), clinically union (sticky)

Q : spiral fr VS tranverse fr which one healing faster? 12)Deformity (x-ray)

AP Lateral Angulation Angulation Valhus/Varus Shortening Shortening 13)Fracture Disease caused by prolong immobilization joint stiffneff Atrophy muscle Contracture 14)Management conservative & operative 15)Indication: Conservative -closed fr, -undisplaced -minimally displaced with tolerable angulation -children Remodelling phase (Bone healing) -open fr -rotational fr -Displacement -nerve injury & vascular injury explore

Operative

16)Displacement Reforming forces

muscle (origo & insertion) Gravity (upper)

17) conservative : -skin traction -arm sling / figure of 8 / verban -Gips (slab/splint & circular /cast) -skeletal traction -pelvic sling / bandage 18)Skin traction : maximum weight (3,5-4kg) why? skin Therapy : definitive (children-reduce)& paliatif (dws-pain reliever) 1/7 dari BB + X-ray Just for femur fr

19)Skeletal traction (femur fr?) invasive (pin site) adult definitif Gips = POP (plaster of Paris) Acute : splint / slab Sign : 5 P compartment syndrome Pain out of proportion Pale/pallor Paresthesia Pulselessness paralysis Neuro Vasc Neuro Vasc ?

What damage are you afraid? muscle Pain out of proportion analgesic. Sign : passive stretch test. Emergency : Fasciotomy 20) 4 R (Recognition, Reductionimmobile, Retain, Rehabilitationearly mobilization, CPM) -isometric :pjg otot tetap, tonus meningkat -isotonic : tonus tetap, panjang otot berubah -CPM : continous passive motion -Diagnosis pasti Compartment Syndrome tekanan >30 mmHg Diastole 21) Complication fr. Compartment syndrome Shock hypovolemic (I-IV)takikardia & hipotensi Shock Neurogenik 22)Pem fisik Spine Injury: (motorik, sensorik, reflex) Motorik Upper -shoulder abduction c5 -elbow flexion & wrist extension c6 -elbow extension & wrist flexion & finger extensionc7

Sensorik refleks

-finger flexion c8 -finger abduction & addction T1 -Netter -biceps reflex c5 -brachioradialis reflexc6 -triceps reflexc5

23)Dermatom menentukan level of injury in spinal cord (SCI) C5 bedge area T4 papilla mammae (Nipple) T7 Solar plexus T10 Umbilicus T12-L1 Inguinal L3 knee S1 heel S3 anus