PENANGANAN AWAL PADA PASIEN TRAUMA

MAXILLOFASIAL INJURY

Departemen Anestesiologi dan Terapi Intensif FKG – USU

2011

FKG AN - 2

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

TRIAGEPRIMARY SURVEYSECONDARY SURVEYSTABILISATION TRANSFERDEFINITIVE CARE

TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF

Emergency Medicine

Survei Primer

• Periksa cepat berurutan• Selesai dalam 2 menit• Terapi segera apa yang ditemukan

( treat as you

find )

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

Jangan terpukaukelainan yang jelas terlihat

Ikuti Sistematika A - B - C - D

Korban ledakan tabung elpiji

Muka hangusPneumotoraks (blast injury)

Luka bakar luasFraktura betis kiri

AIRWAY yang sulit

AIRWAY yang sulitmasker oksigentetap bermanfaat

Triage

RESUSITASI & STABILISASI

Survei primerSurvei sekunder

KamarOperasi

ICU

Hanya 50%pasien traumaperlu operasi

Terapi definitif/ rujukan

Emergency Medicine

RS lain

Derajat kegawatankorban berbeda-beda

Triage

Sorting of patients according to :•ABCDEs•Available resources

Multiple casualties Mass casualties

Preparation

Prehospital System Transport guidelines /protocols On-line medical direction Mobilization of resources Periodic review of care Closest appropriate facility

Preparation

Inhospital Preplanning essential Equipment, personnel, services Standard precautions Transfer agreement

Standard Precautions

• Cap • Gown• Gloves• Mask• Shoe covers• Goggles/face • Shields

Resuscitation Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia

Survei Primer

AirwayBreathingCirculationDisabilityExposure

Sumbatan jalan nafas pasien tak sadar paling sering disebabkan pangkal lidah

Airwaymenilai jalan nafas

• Kesadaran (bisa bicara?) • Look, Listen and Feel• Gerak dada• Gerak otot nafas tambahan • Warna kulit, mukosa, kuku

Airwaymengatasi 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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20

Walaupun tanpa intubasi masih banyakpasien dapat ditolong

JN OropharynxJN NasopharynxJaw thrust

JN Nasopharynx

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X

Neck lift

Head tilt

Chin-lift

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

Primary Survey

C-spine injury Pitfalls

• Equipment failure• Inability to intubate • Occult airway injury• Progressive loss of airway

Establish Patent Airway

Caution

Primary Survey

Suspect C-Spine InjurySpinal 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

Survei Primer

AirwayBreathingCirculationDisabilityExposure

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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- Pneumotoraks tension- Fr costa / Flail chest - Hemotoraks berat- Kontusio paru

- Pneumotoraks terbuka

Jejas di dada:

Breathingwaspada

Dekompresi pneumotoraks (tension)harus dikerjakan dalam Primary Survey

Survei Primer

AirwayBreathingCirculationDisabilityExposure

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

Circulationmengatasi perdarahan

• Beri infus cairan, 1000 ml cepat – RL (Ringer Laktat)– NaCl 0.9% (Garam Fisiologis)– RA (Ringer Asetat)– Hypertonic Saline Dextran 250 ml

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

Circulationwaspada & cari lokasi perdarahan

• Cedera intra-abdominal• Cedera dada• Patah tulang panjang• Patah tulang pinggul• Luka tusuk / tembus • Luka kulit kepala

Primary Survey

Circulatory Management Control hemorrhage Restore volume Reassess Pitfalls Elderly Children

Athletes Medication

Caution

Survei Primer

AirwayBreathingCirculationDisabilityExposure

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)

A- V - P - U

Pupil

Primary Survey

Disability Baseline neurologic evaluation

• GCS scoring • Pupillary response

Observe for neurologic

deterioration Caution

Survei Primer

AirwayBreathingCirculationDisabilityExposure

Exposurepemaparan

• Lepaskan semua pakaian untuk pemeriksaan teliti menyeluruh, ada jejas apa saja

• Periksa punggung!– miringkan pasien cara Log-roll

• Cegah hipotermia (kedinginan)

Primary SurveyExposure / Environment • Completely undress the patient

Prevent hypothermiaCaution

Survei Primer

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

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

Adjuncts to Primary SurveyVital sign

ECG ABGs Urinary Adjuncts Pulse Output oximeter

and CO₂

Urinary/gastric catheters unless contraindicated

© ACS

Adjuncts to Primary Survey Diagnostic Tools• Chest and pelvic x-ray• DPL• Ultrasound

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

Sistematika Emergency Medicine

TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF

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 ABC

memburuk lagi

Pemeriksaan kepala

• Kulit kepala (robekan, memar, laserasi) • Tengkorak (nyeri tekan, depresi tulang)• Mata (pupil, fundus, lensa, conjunctiva)• Cairan CSF / darah dari telinga, hidung,

mulut

Ada darah mengalir, tetapi dari mana ?

• Glasgow Coma Score• Pupil

– ukuran, simetri, refleks cahaya• Fungsi motorik• Fungsi sensorik• Refleks-refleks

Periksa kesadaran dan syaraf

Secondary SurveyHead Complete neurologic examination GCS score determination Comprehensive eye/ear examPitfalls Unconscious patient Periorbital edema Occluded auditory canal

Secondary Survey

The complete history and physical

examination

Secondary SurveyKey Components History Physical examination : Head-to-toe “Tubes and finger in every orifice” Complete neuro exam Special diagnostic tests Reevaluation

Secondary Survey

HistoryA Allergies M MedicationsP Past IllnessesL Last meal E Events/Environment

© ACS

Secondary SurveyMechanisms of Injury

Maxillofacial Trauma-Physical Exam

• Penetrating Injuries– Occult globe penetration– Eyelid lacerations

• Nose– Septal hematoma– CSF Rhinorrhea

• Ears– Subperichondral hematoma– Hemotympanum– Battle sign

Maxillofacial Trauma-Physical Exam

• Oral and Mandibular Exam– Mandible deviation– Teeth malocclusion– Paresthesia– Tongue Blade Test

• 95% Sensitive

• 65% Specific

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

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

Maxillofacial Trauma-Specific Fractures

• Maxillary Fractures– High-energy injury– 100x gravity– Malocclusion– Facial lengthening– CSF rhinorrhea– Periorbital ecchymosis

LeFort Fractures

Maxillofacial Trauma-Specific Facial Fractures

• Mandibular Fractures– Second most common facial fracture– Often multiple– Malocclusion– Intraoral lacerations– Sublingual ecchymosis– Nerve injury

Pemeriksaan leher (1)

• Lihat / inspeksi • Palpasi (nyeri tekan, deformitas)• Anggap leher cedera• Imobilisasi pada posisi netral

Secondary SurveyCervical Spine Palpate for

tenderness Complete motor/

sensory exams Reflexes C-spine imaging

Pitfalls • Altered LOC for any reason• Other severe , painful injury

Pemeriksaan dadamencari ulang kerusakan

• Lihat / inspeksi• Palpasi• Perkusi• Auskultasi• Foto sinar-X dada (jika ada)• ECG ( jika ada)

Secondary SurveyChest Inspect Palpate Percuss Auscultate X-ray

Pitfalls • Elderly • Children

Secondary Survey

Abdominal Evaluation

Blunt trauma Penetrating trauma

Secondary SurveyAbdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies Pitfalls

• Hollow viscus and retroperitoneal injuries• Excessive pelvic manipulation

Secondary SurveyPerineum

Rectum

Vagina

Pitfalls

Contusions, hematomas,lacerations, urethral blood

Sphincter tone , high –ridingprostate pelvic fracture,rectal wall integrity, blood

Blood lacerations

Urethral injury in women, pregnancy

Ekstremitas / anggota gerak

• Inspeksi – deformitas, robekan, memar, laserasi

• Palpasi• Palpasi nadi arteria distal• Ingat compartment syndrome• Jangan lupa periksa punggung

Log-roll

Cari luka, robekan, memar, nyeri tekan, deformitas tulang belakang

4 orang

Pemberi komandoinstruksiyang jelas

Log-roll

Digulingkan serentak pelan-pelan

Foto sinar-x

• Dikerjakan waktu survei sekunder• Dada• Tulang leher - 7 segmen vertebra• Pelvis / panggul• Lokasi lain sesuai indikasi

– (misal fr tulang paha dll)

Secondary Survey

Musculoskeletal : Extreminities Contusion , deformity Pain Perfusion Peripheral neurovascular status X- rays as needed

Definitive Care

Local Facility

??Transfer agreements?? Local resources ??

??

Trauma SpecialtyCenter Facility

Reevaluate

Proceed to Secondary Survey After : Primary survey completed ABCD Es are reassessed Vital functions are returning to

normal

END

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