PowerPoint Presentation

ATLS

A AdvancedT TraumaL Life S SupportATLS1. Preparation2. Triage3. Primary survey (ABCDE)4. Resusitation5. Adjuncts to Primary Survey And Resusitation6. Secondary Survey7. Adjuncts to Secondary Survey8. Monitoring Post Resusitation And Reevaluate9. Definite care

PREPARATIONEssential equipment: universal precaution, trauma box, airway equipment, long back boardThe used of the following protective devices is recommendedGogglesGlovesFluid-impervious gowns or apronsShoes covers and fluid-impervious leggingsMaskHead covering

Primary SurveyDewasa, anak, wanita hamil memiliki prioritas yang samaMengidentifikasi kondisi yang mengancam nyawaMaksimal dikerjakan dalam 2 menitPemeriksaan dilakukan dari neck to knee

Primary surveyPatients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms

ABCDEs of trauma careAAirway maintenance with cervical spineprotectionBBreathing and ventilationCCirculation with hemorrhage controlDDisability : Neurological statusEExposure/Environmental control : completely undress the patient,but prevent hypothermiaPrimary SurveyAirwayAirway dipertahankan dengan proteksi cervical spinePasien dianggap cedera cervical spine pada :Trauma multisistemGCS menurunGCS 8 perlu pemasangan definite airway

If the patient is able to communicate verbally, the airway is not likely to be in immediate jeopardy

Assume a cervical spine injury in any patient with multisystem trauma, especially those with an altered level of consciousness or a blunt injury above the clavicle8A (AIRWAY)Penyebab paling sering gangguan jalan napas:Tanda gangguan jalan napas:LidahBenda asingCairan (muntah)Pembengkakan lokalTrauma langsung pada jalan napas

SnoringStridorGargling Sesak

StepsManagementCek ResponsBuka jalan Nafas

Periksa jalan nafas

Pertahankan bila GCS < 8 :

Head tilt chin lift (tak dilakukan pada cedera cervical)Jaw thrustFinger sweep SuctionArtificial airwaysOropharyngealNasopharyngealETTLMA

A (AIRWAY)Primary SurveyBreathingPenatalaksanaan:Pasang pulse oxymetriBeri oksigen konsentrasi tinggiVentilasi dengan bag-valve maskRespirasiNeonatus40 x/menitBayi30 x/menitAnak yang lebih tua20 x/menitRespirasi > 40 x/menit curiga suatu distress nafas (kecuali pada neonatus)

11BreathingStepsManagementIdentifikasi : Look, Listen and FeelLook : Rate,Rhythm,,KedalamanListen : QualityFeel : Udara Tanda pernapasan tidak adekuat: Napas abnormalOtot pernapasan tambahanPernapasan cuping hidungsianosisNapas spontan: Nasal cannula,Face masks rebreathingnon-rebreathing mask Tidak bernapas:Mouth to mouthMouth to mask ventilation Bag-Valve-MaskBreathingStepManagementDiperhatikan : Pengembangan dinding dadaLaserasi dan cedera pada dada dan Deviasi trakea Pneumothorax, hemothorax, kontusio pulmonalneedle decompressiontube thoracostomyCirculationStepsManagementMenilai fungsi sirkulasi:Nadi sentral-perifer(carotis or radialis)Warna Kelembaban kulitMenilai perdarahan yang mengancam nyawa: Cepat, berasal dari arteri, jumlah masif, tensi, CRTMenilai internal hemorrhage +/-

Kontrol perdarahan:bebat tekansplint and elevatetourniquetShockImpaired tissue perfusionTissue oxygenation is inadequate to meet metabolic demandProlonged shock state leads to multiorgan system failure and cell death Clinical Signs of ShockAltered mental statusTachycardia (HR > 100) = Most common signArterial Hypotension (SBP < 120)Femoral Pulse SBP > 80Radial Pulse SBP > 90Carotid Pulse SBP > 60Inadequate Tissue PerfusionPale skin colorCool clammy skinDelayed cap refill (> 3 seconds)Altered LOCDecreased Urine Output (UOP < 0.5 mL/kg/hr)

14DisabilityMenilai tingkat kesadaran:AVPU & GCSMenilai ukuran dan respon pupilTanda-tanda sensoris dan motoris

EYEVERBALMOTORSpontaneous 4Oriented 5Obeys 6 Verbal 3Confused 4Localizes 5Pain 2Words 3Flexion 4None 1Sounds 2Decorticate 3None 1Decerebrate 2None 1GCS

Neurologisreevaluasi pupil dan derajat kesadaran, Score GCSEvaluasi sensoris dan motorisParalysisParesis

15E (Exposure/Environment)Melepas baju pasien jika diperlukanPertahankan suhu tubuh -> Mencegah hypotermiaLog roll untuk identifikasi bagian belakang tubuhRAPID ASSESSMENTLeherInspeksi/palpasi : DCAP BTLS, JVDNyeri, deviasi trakeaDadaInspeksi : DCAPP BTLSPalpasi : TICAuskultasi suara napasPerkusiAbdomenInspeksi : DCAP BTLSPalpasi: Tenderness

PelvisInspeksi/palpasi: DCAP BTLS, TICMusculoskeletal (Femur)Inspeksi/palpasi DCAP BTLS, TIC, PMS Transport decision and critical interventions

Deformities& Discolorations Contusions Abrasions Penetrations& Punctures Burns Tenderness Lacerations Swelling& SymmetryTenderness Instability CrepitationPulse motor Sensory

17ResusitasiABPastikan Paten

AksesIVDiberi OksigenasiCAdjuncts to Primary Survey and Resusitasia) Monitor EKGb) Kateter dan NGTc) Monitor BGA d) Monitor pulse oximetrye) Monitor tekanan darahf) Pemeriksaan darah untuk cross-matching dan nilai Hbg) X-ray atau studi diagnostik lain yang perlu

Secondary SurveyTidak bermula selagi primary survey tidak lengkap !Tidak bermula selagi resusitasi belum selesai !Tidak bermula selagi tanda-tanda vital pasien normal !Secondary SurveyEvaluasi head to toe !Anamnesa dan pemeriksaan fisik lengkapDilakukan pemeriksaan dari head to toeEvaluasi ulang tanda-tanda vitalPemeriksaan dikerjakan dalam10 menit !!

Anamnesa :SAMPLESign and simptoms AllergiesMedications currently usedPast illness / pregnancyLast mealEvents/Environment related to injury

History may need to be gathered from family members or ambulance service

HISTORYMechanisms of injuryBluntAutomobile collisionsSeat belt usageSteering wheel deformationDirection of impactEjection of passenger from the vehicleBurns and Cold injuryInhalation injury and CO. intoxication in fire fieldHazardous environmentPenetrateEnergy transfer factorVelocity and caliber of bulletTrajectoryDistance

Pemeriksaan fisik Pemeriksaan neurologi lengkapKepalaTrauma maxillofacialLeher dan cervical spineThoraksAbdomenPerineum/rectum/vaginaMuskuloskeletal

SECONDARY SURVEYPhysical ExaminationHead and Maxillofacial Inspect and palpate head and face (DCAP BLS, TIC) Battles sign Pupils and LOC Raccoon eyes Ears and nose for CSF Mouth Skin : pale, cyanosis, diaphoresis

Physical ExaminationHeadScalpFracturesEyes edemaPupil size -Penetrating injuryHemorrhage of conjunctivaeContact lenses-Dislocation of lense

Physical ExaminationMaxilofacialAirway obstruction , major bleedingMid maxilla beware of NG tube insertionNeed frequent reassessment

SECONDARY SURVEYPhysical ExaminationC-spine and Neck Inspect for signs of injury (DCAP BLS), tracheal deviationPalpate for tenderness, subcutaneous emphysemaAuscultate for carotid bruits

SECONDARY SURVEYPhysical ExaminationChestInspect ant, lat and post chest for injury, use of accessory (DCAPP BLS)- Palpate for TIC- Auscultate for breath sounds - Percussion

Physical ExaminationChestVisual evaluation of anterior and posterior chestOpen pneumothoraxFlail chestPain , dyspnea, hypoxiaCardiac tamponade, tension pneumothoraxDistended neck veins Distant heart soundSECONDARY SURVEYPhysical ExaminationAbdomenInspect for signs of injury or bleeding DCAP BLSPalpate for tendernessAuscultate for bowel soundsPercussion

Physical ExaminationPerinieum/Rectum/VaginaContusion , hematoma, laceration , urethral bleedingRectal examination : blood , high-riding prostate , Intergrity of rectal wall , sphincter toneFemale : Vg exam. blood , Vg lacerationPregnancy test Physical ExaminationMusculoskeletalInspect & Palpate extremities for signs of injury (DCAP BLS, TIC, PMS)Assess pelvis (DCAP BLS, TIC)MusculoskeletalInspection : contusion , deformityPalpation : tenderness , abnormal movementPelvic Fx: ecchymosison iliac wings , pubis , labia , Scrotum , pain on palpation of pelvic ring Assessment of peripheral pulsesPatients back examination

SECONDARY SURVEYPhysical ExaminationNeurologicDetermine GCS scoreRe-evaluate pupilsSensory / motor evaluation Maintain immobilizationPrevent secondary CNS injury Early neurosurgical consultationevel of consciousnesspupillarysize and responsemotor and sensoryGCS

Adjuncts to Secondary surveyStatus hemodinamikCT scanFoto kontrasFoto extremitasEndoskopiUltrasonografiMonitoring Post Resusitasi dan Evaluasi UlangReevaluasi ulang untuk mencari kelainan baru atau yang tertinggalMonitoring tanda-tanda vital, output urin,BGA, pulse oximetry dan EKGurinary output0.5 ml/kg/hr1 ml/kg/hrAnalgesik jika diperlukanObservasi perubahan kondisi yang terjadi pada pasien Reassessment SurveyTingkat kesadaranNilai ulang A B C Leher, dada, abdomen, ekstremitasPemeriksaan lebih detail terhadap area luka Pemeriksaan tindakan yang telah dilakukan, misal : posisi pipa ETT, infus, aliran O2, balut-bidai, posisi cervical collarDefinite CareSetelah identifikasi cedera pada pasienSetelah mengatasi penyebab yang dapat mengancam nyawa

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