penanganan awal pada pasien trauma maxillofasial injury - fkg an-2

8/15/2019 Penanganan Awal Pada Pasien Trauma Maxillofasial Injury - Fkg an-2

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PENANGANAN AWAL PADA

PASIEN TRAUMA

MAXILLOFASIAL INJURY

Prof. dr. Achsanuddin Hanafie SpAn. KIC. KAO

Departemen Anestesiologi dan Terapi Intensif

FKG – USU

2013

FKG AN - 2


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Etiology and Incidence

• Multisystem injury 20-50%

• Nasal and mandibular fractures most common

in community ED’s

• Midface and zygomatic injuries most common

in Trauma centers

• 25% of women with facial trauma result of

domestic violence

• Incidence of concomitant cervical spine

injuries with facial fractures


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TRIAGE

PRIMARY SURVEY

SECONDARY SURVEY

STABILISATION

TRANSFER

DEFINITIVE CARE

TRIASE

SURVEI PRIMER

SURVEI SEKUNDER

STABILISASI

RUJUKAN

TERAPI DEFINITIF

Emergency Medicine


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Survei Primer

• Periksa cepat berurutan

• Selesai dalam 2 menit

• Terapi segera apa yang ditemukan

( treat as you find )


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Tujuan Survei Primer

• Secepat mungkin menemukan kelainan

yang mengancam jiwa (cepat mematikan)

– di sektor A - B - C - D• Memberikan pertolongan yang memadai

untuk menyelamatkan jiwa

• Pertolongan meliputi : – Resusitasi

– Stabilisasi


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Jangan terpukaukelainan yang

jelas terlihat

Ikuti Sistematika A - B - C - D

Korban ledakan tabung elpiji

Muka hangus

Pneumotoraks (blast injury)

Luka bakar luas

Fraktura betis kiri


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AIRWAY yang sulit


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AIRWAY yang sulit

masker oksigen

tetap bermanfaat


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Triage

RESUSITASI

& STABILISASI

Survei primer

Survei sekunder

KamarOperasi

ICU

Hanya 50%

pasien trauma

perlu operasi

Terapi definitif

/ rujukan

Emergency Medicine

RS lain

Derajat kegawatan

korban berbeda-beda


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Triage

Sorting of patients according to :

•ABCDEs

•Available resources

Multiple casualties

Mass casualties


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Preparation

Inhospital

Preplanning essential

Equipment, personnel, services

Standard precautions

Transfer agreement


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Standard Precautions

• Cap

• Gown

• Gloves• Mask

• Shoe covers

• Goggles/face• Shields


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Resuscitation

Protect and secure airway

Ventilate and oxygenate

Stop the bleeding

Vigorous shock therapy

Protect from hypothermia


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Survei Primer

Airway

BreathingCirculation

Disability

Exposure


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Sumbatan jalan nafas pasien tak sadar

paling sering disebabkan pangkal lidah


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Airway

menilai jalan nafas

• Kesadaran (bisa bicara?)

• Look, Listen and Feel

• Gerak dada

• Gerak otot nafas tambahan

• Warna kulit, mukosa, kuku


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Airway

mengatasi obstruksi / sumbatan jalan nafas

• Lakukan chin lift / jaw thrust

• Bersihkan rongga mulut (suction?)

• Pasang jalan nafas oro / nasopharynx

• Lindungi tulang leher

• Intubasi trachea


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19


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20

Walaupun tanpa intubasi

masih banyak

pasien dapat ditolong

JN OropharynxJN NasopharynxJaw thrust

JN Nasopharynx


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21

X

Neck lift

Head tilt

Chin-lift


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Emergency Management and

Resuscitation

• Airway

– Most urgent complication-Airway compromise

– Simple interventions first

– No mandible?

• Intubation

– Avoid nasotracheal intubation

– May not want RSI

• Benzodiazepines

• Ketamine

• Etomidate

– Be Prepared and Be Creative


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Primary Survey

C-spine injury

Pitfalls• Equipment failure

• Inability to intubate

• Occult airway injury• Progressive loss of airway

Establish Patent Airway

Caution


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Primary Survey

Suspect C-Spine Injury

Spinal protection

C-spine X-ray when appropriate


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Previously recommended hand

positions for manual in-line

stabilisation of the cervical

spine.

Currently recommended hand

positions for manual in-line

stabilisation of the cervical

spine.

Lindungi leher dari gerakan


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Survei Primer

Airway

BreathingCirculation

Disability

Exposure


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Breathingmenilai pernafasan

• Adakah udara keluar masuk

– Look, Listen, Feel

• Frekwensi nafas

• Gerak cuping hidung

• Cekungan sela iga


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Breathingmembantu pernafasan

• 1. Oksigen (jika ada)

• 2. Pernafasan

buatan

1.

2. 2.


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Dekompresi pneumotoraks (tension)

harus dikerjakan dalam Primary Survey


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Survei Primer

Airway

Breathing Circulation

Disability

Exposure


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Circulationmengatasi perdarahan

• Hentikan perdarahan

• Posisi shock• Pasang infus besar x 2

• Ambil sampel darah

– u/ darah donor dan periksa Hb• Beri infus cairan, 1000 ml cepat


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Circulation

mengatasi perdarahan

• Beri infus cairan, 1000 ml cepat

– RL (Ringer Laktat)

– NaCl 0.9% (Garam Fisiologis)

– RA (Ringer Asetat)

– Hypertonic Saline Dextran 250 ml


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Shock ?

• Perfusi : – pucat - dingin - basah

– cap. refill time lambat (kuku, telapak)

• Nadi > 100• Tekanan darah < 100 (atau 90) mmHg

Nadi masih teraba di :

– radialis > 80 mmHg – femoralis > 70 mmHg

– carotis > 60 mmHg


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Circulation

waspada & cari lokasi perdarahan

• Cedera intra-abdominal

• Cedera dada

• Patah tulang panjang

• Patah tulang pinggul

• Luka tusuk / tembus

• Luka kulit kepala


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Primary Survey

Circulatory Management

Control hemorrhage

Restore volume Reassess

Pitfalls

Elderly ChildrenAthletes Medication

Caution


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Survei Primer

Airway

Breathing

Circulation

Disability

Exposure


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Disabilitymenilai kesadaran

• Periksa Pupil (besar, simetri, refleks cahaya)

• Periksa kesadaran

– A = Awake (sadar penuh)

– V = responds to Verbal command(ada reaksi terhadap perintah)

– P = responds to Pain

(ada reaksi terhadap nyeri)

– U = Unresponsive (tak ada reaksi)


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A- V - P - U

Pupil


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Primary Survey

Disability

Baseline neurologic evaluation

• GCS scoring• Pupillary response

Observe for neurologic

deteriorationCaution


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Survei Primer

Airway

Breathing

Circulation

Disability

Exposure


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Exposure

pemaparan

• Lepaskan semua pakaian untuk

pemeriksaan teliti menyeluruh,

ada jejas apa saja

• Periksa punggung!

– miringkan pasien cara Log-roll

• Cegah hipotermia (kedinginan)


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Primary Survey

Exposure / Environment

• Completely undress the patient

Prevent hypothermiaCaution


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Survei Primer

Foto Dada sinar-X / Chest X-Ray ( jika ada)

Tulang leher / C - Spine(lateral)Panggul ( Pelvis )

Abdominal USG


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Adjuncts to Primary Survey

Vital sign

ECG ABGs

Urinary Adjuncts Pulse

Output oximeter

and CO₂

Urinary/gastric catheters

unless contraindicated


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© ACS

Adjuncts to Primary Survey

Diagnostic Tools• Chest and pelvic

x-ray

• DPL

• Ultrasound


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Survei Sekunder

• Lanjutan dari survei primer

• Hanya bila ABC sudah stabil• Teliti kepala sampai jari kaki

• Kembali ulang survei primer jika pasien

tidak stabil / kondisi memburuk


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Sistematika Emergency Medicine

TRIASE

SURVEI PRIMER

SURVEI SEKUNDER

STABILISASI

RUJUKAN

TERAPI DEFINITIF


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Survei sekunder

• Mencari cedera yang mengancam jiwa

atau cacad ekstremitas (life or limb)

• Pemeriksaan teliti dari kepala sampai kaki

• Dikerjakan setelah survei primer selesai

• Dikerjakan jika ABC sudah stabil

• Segera kembali ke survei primer jika ABCmemburuk lagi


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Pemeriksaan kepala

• Kulit kepala (robekan, memar, laserasi)

•

Tengkorak (nyeri tekan, depresi tulang)• Mata (pupil, fundus, lensa, conjunctiva)

• Cairan CSF / darah dari telinga,

hidung, mulut


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Ada darah mengalir, tetapi dari mana ?


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• Glasgow Coma Score

• Pupil

– ukuran, simetri, refleks cahaya

• Fungsi motorik

• Fungsi sensorik

• Refleks-refleks

Periksa kesadaran dan syaraf


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Secondary Survey

Head Complete neurologic examination

GCS score determination

Comprehensive eye/ear examPitfalls

Unconscious patient

Periorbital edema

Occluded auditory canal


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Secondary Survey

The complete

history andphysical

examination


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Secondary Survey

Key Components History

Physical examination : Head-to-toe

“Tubes and finger in every orifice”

Complete neuro exam

Special diagnostic tests

Reevaluation


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Secondary Survey

History

A Allergies

M Medications

P Past Illnesses

L Last mealE Events/Environment


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Maxillofacial Trauma-Physical Exam

• Penetrating Injuries

– Occult globe penetration

– Eyelid lacerations

• Nose – Septal hematoma

– CSF Rhinorrhea

•

Ears – Subperichondral hematoma

– Hemotympanum

– Battle sign


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Maxillofacial Trauma-Imaging

• Head, chest and abdominal trauma takes

precedence

• PE detects up to 90% of fractures

• Plain Films

• CT

– Orbital fractures

– 3D images available


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Maxillofacial Trauma-Specific Fractures

• Frontal Sinus/Bone Fractures – Direct blow

– Frequent intracranial injuries

– Mucopyoceles – Consult with NS for treatment, disposition and

antibiotics

• Nasoethmoidal-Orbital Injuries

– Lacrimal apparatus disruption

– Bimanual palpation if medial canthus pain

– CT face


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Maxillofacial Trauma-Specific

Fractures• Maxillary Fractures

– High-energy injury

– 100x gravity – Malocclusion

– Facial lengthening

– CSF rhinorrhea

– Periorbital ecchymosis

LeFort Fract res


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LeFort Fractures

Ma illofacial Tra ma Specific


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Maxillofacial Trauma-Specific

Facial Fractures

• Mandibular Fractures

– Second most common facial fracture

–

Often multiple – Malocclusion

– Intraoral lacerations

–

Sublingual ecchymosis – Nerve injury


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Pemeriksaan leher (1)

• Lihat / inspeksi

• Palpasi (nyeri tekan, deformitas)

• Anggap leher cedera

• Imobilisasi pada posisi netral


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Secondary Survey

Cervical Spine

Palpate for

tenderness Complete motor/

sensory exams

Reflexes C-spine imaging

Pitfalls

• Altered LOC for

any reason

• Other severe ,

painful injury


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Pemeriksaan dada

mencari ulang kerusakan

• Lihat / inspeksi

• Palpasi

• Perkusi

• Auskultasi

• Foto sinar-X dada (jika ada)

• ECG ( jika ada)


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Secondary Survey

Abdomen

Inspect, auscultate, palpate, and percuss

Reevaluate frequently

Special studies

Pitfalls

• Hollow viscus and retroperitoneal injuries• Excessive pelvic manipulation

Secondary Survey


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Secondary Survey

Perineum

Rectum

Vagina

Pitfalls

Contusions, hematomas,

lacerations, urethral blood

Sphincter tone , high –riding

prostate pelvic fracture,

rectal wall integrity, blood

Blood lacerations

Urethral injury in women,

pregnancy


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Ekstremitas / anggota gerak

• Inspeksi

– deformitas, robekan, memar, laserasi

• Palpasi• Palpasi nadi arteria distal

• Ingat compartment syndrome

• Jangan lupa periksa punggung Log-roll

L ll


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Cari luka, robekan, memar, nyeri tekan,

deformitas tulang belakang

4 orang

Pemberi

komando

instruksiyang jelas

Log-roll

Digulingkan serentak pelan-pelan


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Foto sinar-x

• Dikerjakan waktu survei sekunder

• Dada• Tulang leher - 7 segmen vertebra

• Pelvis / panggul

• Lokasi lain sesuai indikasi – (misal fr tulang paha dll)


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Secondary Survey

Musculoskeletal : Extreminities

Contusion , deformity

Pain Perfusion

Peripheral neurovascular status

X- rays as needed


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Definitive Care

Local Facility

??

Transfer agreements?? Local resources ??

??

Trauma Specialty

Center Facility

Reevaluate


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Reevaluate

Proceed to Secondary Survey After : Primary survey completed

ABCD Es are reassessed

Vital functions are returning to

normal


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END

penanganan awal pada pasien trauma maxillofasial injury - fkg an-2

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