multi trauma

83
DISKUSI MULTI TRAUMA DISKUSI MULTI TRAUMA Selasa, 3 April 2012 Selasa, 3 April 2012

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multi trauma

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Page 1: multi trauma

DISKUSI MULTI TRAUMADISKUSI MULTI TRAUMA

Selasa, 3 April 2012 Selasa, 3 April 2012

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IDENTITASIDENTITAS

Nama : Ida Bagus Putu Lila BuanaUmur : 50 tahunAlamat : Br Penyembahan Petak Kaja GianyarDx masuk : CF tibial plateau D Sch II

OF Humerus D 1/3 T gr. IIIC OF Antebrachii D 1/3 D gr. II OF Cruris D 1/3 T gr. II Union Fr. Clavicula D 1/3 T OF antebrachii S segmental gr. IIIA Vascular injury susp. Ruptur a. Axillaris DDD. Ruptur a. brachialis D

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TIME CHARTTIME CHART

Kejadian 25/3/1221.00

RSU Ganesa 25/3/12

26/3/12

01.30Mulai incisi

OrtoExt. fix

humerus D

26/3/12

02.30-06.30BTKV

Repair a + v Axillaris DGraft dari v.saphena

magna S

26/3/1206.30-09.00

OrtoDebridement+ext-fix

+backslab antebrachii DAntebrachii S

+ cruris D

Tgl 26- 28/ 3 / 12Rawat ICU

Sanglah 25/3/1223.30

SanglahMasuk OK IRD

24.00

28/3/12 23.15 meninggal

Rsu ganesa

Rs sanglah

meninggal

26/3/12

10.00-12.00thrombectomy

26/3/12

12.00 – 12.30Hacting situasi

faciotomy

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Lila Buana IB PT/L/50Lila Buana IB PT/L/50 th thRtS = RtS = 7.89, 7.89, Tarr: Tarr: 00.0000.00 Tacc : Tacc :2121..0000

Pasien datang sadar mengeluh nyeri pada tangan kanan, tangan kiri dan kaki kanan setelah mengalami kecelakaan lalu lintas 3 jam SMRS. Riwayat pingsan (-), Mual/muntah (-),. Pasien rujukan dari RS Ganesha dengan diagnosis OF humerus D+OF antebrachii S+ OF cruris D. Riwayat syok di RS ganesha (+) dan telah dilakukan resusitasi

MOI: pasien sedang mengendarai motor, terjatuh saat hendak menyalip truk, kemudian lengan atas dan bawah tangan kanan, betis kanan serta lengan bawah tangan kiri terlindas ban truk.

Primary Survey: A : lapang B : Spontan, RR : 24x/mnt,

C : Stabil TD : 100/60 mmHg, N : 100 x/mnt D : alert

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SS GCS E4V5M6kepala : CH (-) mata : RP +/+ isokor 3 mm, konj pucat

-/-maxillofacial : edema (-) , maloklusi (-), floating

maxila (-)THT : otorea-/- rhinorea -/-Thorax : simetris, jejas (-)

cor : S1S2 tunggal reguler murmur (-)po : ves +/+, rh -/- wh -/-

sonor/sonorAbd : distensi(-) jejas (-), defans (-)Ekstrimitas : status lokalis

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STATUS LOKALIS

– R. Humerus D L: edema (+), fat bubble (+), bone expose (+), bleeding

aktif (-) F : kripitasi (+), NT (+), pulsasi a.brachialis (-), M : ROM distal (-)

– R. Antebrachii D L: v.appertum (+), pucat F : NT (+), krepitasi (+), pulsasi a. radialis (-), a. ulnaris

(-) M: ROM distal (-)

– R.Antebrachii S L: v.appertum (+). F : NT (+), krepitasi (+), pulsasi a radialis (+), a.

ulnaris (+) M: ROM distal terbatas

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STATUS LOKALIS

– R. Cruris D L: edema (+), fat bubble (+), bone expose

(+), bleeding aktif (-) F : kripitasi (+), NT (+),, a. Dorsalis pedis (+) M : ROM distal terbatas

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Ass:OF Humerus D gr IIICOF Antebrachii D gr IIOF Cruris D gr IIOF Antebrachii S gr IIIAVascular injury susp ruptur axillary D

DD: arteri brachialis D

PenunjangHumerus D AP/LatAntebrachii D et S AP/LatCruris D AP/Lat SGOT

SGPTAlbBUNCRE

46,2033,103,7214,001,21

DLWBCHGBHCTRBCPLT

25,3712,7036,404,18216,50

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Dx : OF Humerus D 1/3 tgh gr IIICOF antebrachii D 1/3 distal grIIOF Antebrachii S Segmental Gr IIIAOF Cruris D 1/3 tgh gr IIUnion fr clavicula D 1/3 tghVascular injury susp ruptur a. axilaryTx:Debridement+external fixasi+repair vascular

humerus DDebridement + back slab antebrachii S dan cruris DDebridement + fasciotomy +external fixasi

antebrachii D

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HCUHCU

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IB putu Lila Buana L/50IB putu Lila Buana L/50thth

MRS: 25/3/12 MHCU 26/3/12MRS: 25/3/12 MHCU 26/3/12 Dx: Ruptur total a. axilaris D Of Humerus D 1/3 tengah Gr IIIc Of Antebrachii S Segmental Gr IIIa Cf Antebrachii D 1/3 distal gr II OF Cruris D 1/3 T Gr II

TX: BTKV: Repair vaskular - v. saphena magna graft – trombektomi ruptur m. biceps, m. brachialis, m. triceps, ruptur a-v.

axilaris D, ruptur n. Medianus, n. Ulnaris Ortho: Debridement + fasciotomy+ eksternal fiksasi + backslab

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S: DPO O: TD: 118/57 (inotropik +) CVP 7, N: 114/ Rr 12x/m On ventilatory

support, T: 37 PEEP: 5, FiO2: 100% Sa: O2 100% mata : RP +/+, isokor 2/2mm THT : OTT (+), NGT (+) Thorax : simetris, pulmo: Ves +/+ Rh -/- WH-/- Cor : S1S2 tunggal, murmur (-) Abdomen : dist.(-), BU (+) N

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Extremitas atas D: Luka post op terawat terpasang external fixasi dan back slab

CRT<2”, Sat O2 98%UG: DK (+), urin jernihCM : 3400 cc/24 jamCK : 1500 cc/24 jam

ASS : Anemia Asidosis metabolikP : lanjut perawatan intensif koreksi anemia

JamWBCHGBHCTRBCPLT

06.0510,096.0618,702,13103,50

10.059.567,2021,202,3593,10

18.249,606,8019,902,3677,00

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JAMPhPCO2PO2HCO3-SO2 %N2BEK

PT 21.00kPT 11,50APTT 71,00kAPTT 33,50INR 1,74

SGOT 260,00SGPT 248,90Alb 2,41BUN 13,00CRE 1,79

Bil. Total 0,44Indirek 0,12Direk 0,32Alkali phosp 78,00

06.057,2850,00158.0023,5099.00135.00- 6.05.00

10,057.1045.00169.0014.0099.00136.00-6.805.30

18.247.0153.0012313,4096.00141.00-8.004.00

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IB Putu Lila Buana L/50IB Putu Lila Buana L/50thth

MRS: 25/3/12 MHCU 27/3/12

Dx: Rupture total a. axilaris D OF Humerus D 1/3 tengah Gr IIIc CF Antebrachii D 1/3 distal gr II OF Cruris D 1/3 T Gr II OF Antebrachii S Segmental Gr IIIaTX: BTKV: interpositional graft, thrombektomi

ruptur m. biceps, m. brachialis, m. triceps, ruptur a-v. axilaris D, ruptur n. Medianus, n. Ulnaris

Ortho: Debridement + eksternal fiksasi + backslab

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S: DPO

O:

TD: 100/50 (inotropik +) CVP 5 N: 120 T: 38 Rr 12x/m

Cvc 500 PEEP 5 FiO2 60% Sa O2 100%mata : RP +/+, isokor 2/2mm

THT : OTT (+), NGT (+)

Thorax : simetris,

pulmo : Ves +/+ Rh -/- WH-/-

Cor : S1S2 tunggal, murmur (-)

Abdomen : dist.(-), BU (+) N

Extremitas atas D: Luka post op terawat terpasang external fixasi dan back slab

CRT<2”, Sat O2 96%

UG : DK (+), urin jernih

CM : 3150 cc/24 jam

CK : 725 cc/24 jam

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LAB:

WBC 10.27, HGB 8.50, HCT 25.40, PLT 34.80, RBC 3.13, SGOT 260/ SGPT 248/ Alb 2,41/ BUN 39 / CR 1,79/ GDS 194/

pH 7,21/PCO2 40/PO2 180/HCo3-16/TCO2 17/BE -11,9/ SO2 99/Na 137/K 5,3

ASS: anemia + trombositopenia

P: lanjut perawatan intensif

Transfusi PRC dan TC

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IB Putu Lila Buana L/50IB Putu Lila Buana L/50thth

MRS: 25/3/12 28/3/2012

Dx: Rupture total a. axilaris D OF Humerus D 1/3 tengah Gr IIIc CF Antebrachii D 1/3 distal gr II OF Cruris D 1/3 T Gr II OF Antebrachii S Segmental Gr IIIaTX: BTKV: interpositional graft, thrombektomi

ruptur m. biceps, m. brachialis, m. triceps, ruptur a-v. axilaris D, ruptur n. Medianus, n. Ulnaris

Ortho: Debridement + eksternal fiksasi + backslab

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S: DPO

O:

TD: 130/50 (inotropik +) CVP: 10 N: 120 T: 39,5 RR: 12

Cvc 500 PEEP 10 FiO2 60% 80% Sa O2 100%mata : RP +/+, isokor 2/2mm

THT : OTT (+), NGT (+)

Thorax : simetris,

pulmo : Ves +/+ Rh -/- WH-/-

Cor : S1S2 tunggal, murmur (-)

Abdomen : dist.(-), BU (+) N

Extremitas atas D: Luka post op terawat terpasang external fixasi dan back slab

CRT<2”, Sat O2 95%

UG : DK (+), urin keruh

CM : 1725 cc/17 jam

CK : 200 cc/17 jam

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Lab:Lab:

WBCHGBHCTRBCPLT

DL15,0010,8031.003,6990,00

jam05.55

7,2254,0078,0022.1092.00134.005,30-11.00

15.13

7,2256.0093.0022,9095,00132.005.90-12.05

PTkPTAPTTkAPTTINR

SGOTSGPTAlbBUNCRE

19,0012.0046,5034.201,89

2.230,001.839,002,13246,634,445

AGD :PhPCO2PO2HCO3-SO2 %NaKBE

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Jam 19.00 : pasien bradikardia RJP membaik Jam 22.45 : asistole, tensi tidak teraba resusitasi Jam 23.15 : pasien meninggal Cod

A MOF

B MULTI TRAUMA

C KLL

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TERIMA KASIHTERIMA KASIH

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““Damage Control” :Damage Control” :

Indikasi : Kontrol Perdarahan. Kontrol Kontaminasi. “Metabolic Failure” “Triad Of Death” :

1. Hipotermi.

2. Asidosis yg Persiten.

3. Koagulopati.

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COAGULOPATHYCOAGULOPATHYCOAGULOPATHYCOAGULOPATHY

Cold diuresisPlasma shift

HYPOTERMIA

Tissue hypoxia

Thrombosis microcirculation

Sludging

Viscosity HCT CO

DIC

M O D S

Acidosis

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ASIDOSISASIDOSIS

Hipotermi vasokonstriksi koagulopati Perdarahan meningkat hipotensi syok Perfusi dan oksigenasi jaringan tidak adekuat Metabolisme anaerob laktat serum Asidosis metabolik Kadar laktat serum dan base deficit

– Derajat syok– Prediksi survival/mortalitas

Kontraktilitas miokard dan CO menurun Respon terhadap katekolamin menurun Koagulopati, mortalitas meningkat

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– PIKIRKAN DAMAGE CONTROLCore temperature : < 35 o CPH : < 7,2Base defisit :

–< -15 mmol/L (<55 years)–< -6 mmol/L ( >55 years)

Serum lactate : > 5 mmol/LCoagulopathy : PPT – PTT > 50% N

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Feliciano, David V.; Mattox, Kenneth L.; Moore, Ernest E.Feliciano, David V.; Mattox, Kenneth L.; Moore, Ernest E.Title: Trauma, 6th EditionTitle: Trauma, 6th Edition

Copyright ©2008 McGraw-HillCopyright ©2008 McGraw-Hill> Table of Contents > Section III - Management of Specific Injuries > Chapter 44 - Peripheral Vascular Injury> Table of Contents > Section III - Management of Specific Injuries > Chapter 44 - Peripheral Vascular Injury

Most extremity vascular injuries manifest one or more of the obvious physical findings or “hard signs” of hemorrhage: large, expanding or pulsatile hematoma, absent distal pulses, a palpable thrill or audible bruit over the wound, and distal ischemia (the 6 Ps mentioned earlier).

These hard signs reflect a high probability of major vascular injury requiring surgical repair in the setting of injured extremities15

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Rutherford: Vascular Surgery, 6th ed., Rutherford: Vascular Surgery, 6th ed., Copyright © 2005 Elsevier Copyright © 2005 Elsevier

Although combined injuries are uncommon, the duration of ischemia is critical to the outcome. Therefore, the arterial repair should be performed first to restore circulation to the limb before the orthopedic stabilization is addressed.

Sometimes, however, massive musculoskeletal trauma renders a limb so unstable that external fixation must be placed before the vascular procedure.

Selective use of intraluminal shunts and rapid installation of an external fixator minimize limb ischemia in this setting, thus allowing an unhurried orthopedic and vascular repair

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Damage Control SequenceDamage Control Sequence

PART I - OR control hemorrhage control contamination intraabdominal packing temporary closure

PART I - OR control hemorrhage control contamination intraabdominal packing temporary closure

PART III - OR pack removal definitive repair

PART III - OR pack removal definitive repair

PART II - ICU core rewarming correct coagulopathy maximize

hemodynamics ventilatory support injury identification

(tertiary survey)

PART II - ICU core rewarming correct coagulopathy maximize

hemodynamics ventilatory support injury identification

(tertiary survey)

Transfer problemsTransfer problems

Transfer problemsTransfer problems

DSTC / KT- IKABIDSTC / KT- IKABI

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WINDOW OF OPPORTUNITY 90 MINUTESWINDOW OF OPPORTUNITY 90 MINUTESSimulation of heat loss during “damage control”Simulation of heat loss during “damage control”

Cor

e T

empe

ratu

re (

C)

Time (hours)

Operative Profiles 1 hour laparotomy at 21C 90 minutes at 21 C 90 minutes at 24 C

TherapeuticTherapeuticwindowwindow

3636

3232

3030

30 60 90 1200

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Rasa Takut

Nyeri

Ancaman

Cedera/Trauma

Luka ringan Luka berat/syok (-) Luka berat/syok (+)Perdarahan Klas III/IV

ProInflamasiPro

InflamasiAntiInflamasi

Anti/ProInflamasi

Sembuh

SIRS CARS MARS

SembuhAnergiRad O2Mediator

GOMParuGinjalHatiUsus/TranslokBakteri –Sepsis

Sepsis

GOM

Vasokonstriksi-Kulit-Otot-Hati/usus

Iskemi/nekrosis-Kulit-Otot-Hati/usus

Translok bakt sepsis

Lokal Sistemik

SIRS CARS MARS

Sembuh

Resusitasi:-operasi-hipotermi

Iskemia

Reperfusi

Asam uratPeroksidasi lipid

Oksigenradikal

leukosit

mediator

mikrotrombosis

stasis

Sel bengkak hemokonsentrasi

ATP pH

Transport Na+/K+ “Cell deformability”

Pergeseran crn

Hipoksia

Patofisiologi Trauma pada Tubuh Manusia

Hiposantin

Hipoksia

Pusponegoro AD, 2004; Menger et al, 1993

Perfusi kapiler

PermiabilitasMikrokapilarEdema interst.Tek. Jaringan

GOM-Hati/usus-Paru-Ginjal

ReperfusiRad O2Mediator

Kerusakan jaringan

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DSTC-Indonesia 43

EEXXTRTREEMITMITY TRAUMAY TRAUMA LIMB LIMB SALVAGE VS AMPUTATIONSALVAGE VS AMPUTATION

KOLEGIUM ILMU BEDAH INDONESIA

KOMISI TRAUMA IKABI

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DSTC-Indonesia 44

EXTREMITY TRAUMAEXTREMITY TRAUMA

SKIN AND SUBCUTANEOUS TISSUE

MUSCLE AND TENDON

BONE

JOINT LIGAMENT AND CARTILAGE

ARTERI AND VEIN

PERIFERAL NERVE

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DSTC-Indonesia 45

Priorities in surgical Priorities in surgical managementmanagement

SAVE LIFESAVE LIMBSAVE JOINTRESTORE FUNCTION

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DSTC-Indonesia 46

LIFE THREATENINGLIFE THREATENING

FEMORAL FRACTURE 330 – 1300 ml BLOOD LOSS

CRUSH INJURY INTRA VASCULAR DEBRIS MEDIATOR IMFLAMMATION

FAT EMBOLISMARDS

MOF ARF

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DSTC-Indonesia 47

LIMB THREATENINGLIMB THREATENING

SALVAGEAMPUTATION

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DSTC-Indonesia 48

PROTOCOL MANAGEMENT OFPROTOCOL MANAGEMENT OFSEVERE EXTREMITY INJURIESSEVERE EXTREMITY INJURIES

1.     Asses and diagnose injuries completely.

2.    Restore impaired blood circulation rapidly.

3.     Debride dead and/or contaminated tissue.

4.   Restore skeletal stability with internal or

external fixation.

5. Repair articular fracture anatomically, follow by early motion.

6.     Repair disrupted muscle-tendon unit.

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DSTC-Indonesia 49

PROTOCOL ……..PROTOCOL ……..

7.    Repair nerve lacerations.

8. Close wound as soon as adequate

debridement is assured.

9.   Replace loss bone.

10. Repair or reconstruct unstable ligament.

11. Progressively resume use of limb, while not

exceeding strength of healing tissue.

12.  Recognize and treat any complication.

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DSTC-Indonesia 50

Mangled extremityMangled extremity

High energy trauma Vascular injurySevere comminuted Soft tissue damage

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DSTC-Indonesia 51

Mangling extremity injuryMangling extremity injury

Severe injury to three of four organ system ( skin, bone, arteries, nerve)

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DSTC-Indonesia 52

Delayed amputationDelayed amputation

High morbidityBad prognosis

Age

Disability

Cost

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DSTC-Indonesia 53

COMPLICATION OF SEVERE OPEN COMPLICATION OF SEVERE OPEN FRACTUREFRACTURE

Skin and soft tissue Skin and tissue loss, wound slough, coverage failure.

Bone and fracture site Compartment syndrome with necrosis of

muscle/nerve injury

Deep infection-acut / chronic

Bone loss, Delayed union, Malunion/loss of alignment, Non union

Fixation problem-failure of hardware

Bone refracture

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DSTC-Indonesia 54

COMPLICATION ……COMPLICATION ……

Nerve Direct injury or ischaemic damage

Reflex sympathetic dystrophy

Vascular Arterial occlusion, venous insufficiencyDeep vein thrombosis

Compartment syndrome

Joint movement Associated joint surface fracture

Contracture, late arthritis

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DSTC-Indonesia 55

COMPLICATION COMPLICATION …………Secondary Ototoxicity, nephrotoxicity,myonecrosis

from antibioticSecundary spread of infection, sepsis/ MOF/death

Psychosocial Depression, loss of self-worthEconomic hardship, questionable employment status, marital problem

Functional Chronic painDisability-muscle strength/endurance,decrease in activities of daily functionLoss of ability to return work, inability to participate in recreational activities.

Cosmesis Scars, bulky flaps.

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DSTC-Indonesia 56

Mangled-Extremity-Syndrome Index

Criteria Score Criteria Score

Injury severity score Bone injury

< 25 1 Simple 1

25-50 2 Segmental 2

>51 3 Segmental comminuted 3

Integument injury Bone loss <6 cm 4

Guillotine 1 Articular 5

Crush/burn 2 Articular with bone loss >6cm 6

Avulsion/degloving 3 Delay in time to operation 1 point per hour> 6h

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DSTC-Indonesia 57

Nerve injury

Contusion 1 Age

Transection 2 < 40 0

Avulsion 3 40-50 1

Vascular injury 50-60 2

Vein transected 1 >60 3

Artery transected 1 Pre-existing disease 1

Artery thrombosed 2 Shock 2

Artery avulsed 3

 

< 20: functional limb salvage can be expected,> 20 which limb salvage is improbable

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DSTC-Indonesia 58

Predictive Salvage Index SystemPredictive Salvage Index System

CriterionCriterion ScoreScoreLevel of arterial injuryLevel of arterial injury

        Suprapopliteal        Suprapopliteal 11        Popliteal        Popliteal 22        Infrapopliteal        Infrapopliteal 33

Degree of bone injuryDegree of bone injury        Mild        Mild 11        Moderate        Moderate 22        Severe        Severe 33

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DSTC-Indonesia 59

Degree of muscle injury        Mild 1        Moderate 2        Severe 3

Interval from injury to operating room (hours)        < 6 0        6-12 2        >12 4

 Salvage < 7, amputation > 8

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DSTC-Indonesia 60

MANGLED EXTREMITY SEVERITY SCORE

Factor Score

Skeletal / soft tissue injury

 Low energy (stab, fracture, civilian gunshot wound) 1

 Medium energy (open or multiple fracture) 2

 High energy (shotgun or military gunshot wound) 3

 Very high energy (above plus gross contaminated) 4

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DSTC-Indonesia 61

Limb schema

Pulse reduce or absent but perfusion normal 1*

 Pulseless, diminished capillary refill 2*

 Patient is cool, paralysed, insensate, numb 3*

*double value if duration of ischaemia > 6 hours

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DSTC-Indonesia 62

Shock

Systolik blood pressure always > 90 mmHg 0

 Systolik blood pressure transienly < 90 mmHg 1

 Systolik blood pressure persistenly < 90 mmHg 2

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DSTC-Indonesia 63

Age

        < 30 0

        30 – 50 1

        > 50 2

  A MESS value > 7 predicted amputation

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DSTC-Indonesia 64

NISSSA Scoring System

FACTOR SCORENERVE INJURY        sensate 0        loss of dorsal 1        partial plantar 2        complete plantar 3

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DSTC-Indonesia 65

ISCHEMA        None 0        Mild 1*        Moderate 2*        Severe 3*

SOFT-TISSUE INJURY/CONTAMINATION        Low 0        Medium 1        High 2        Severe 3

* Double value if duration of schema exceeds 6 hours

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DSTC-Indonesia 66

SKELETAL INJURY        Low energy 0        Medium energy 1        High energy 2        Very high energy 3

Shock/blood pressure        Normotensive 0        Transien hypotension 1        Persistent hypotension 2

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DSTC-Indonesia 67

Age (years)        <30 0        30-50 1        >50 2

A NISSSA score >11 predicted amputation.

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DSTC-Indonesia 77

??

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DSTC-Indonesia 78

SummarySummary

The primary objective of polytrauma is survival of the patient

The Mangled Extremity Severity Score can assist in decision making, saving or amputated

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Kronologis: Kronologis: BB = 90 kg, TB 175 cmBB = 90 kg, TB 175 cm Kecelakaan jam 21.00 tgl 25/3/2012 RS ganesha riwayat syok (+) RSUP sanglah 23.30 tgl 25/3/2012 Didorong masuk ke OK jam 24.00 tgl 25/3/2012 Mulai incisi jam 01.35 oleh orthopedi utk eksternal fixation humerus dextra Jam 02.45 – 06.30 : repair vaskuler oleh BTKV pulsasi a. Radialis Dekstra (+) 06.30 – 10.00 : fasciotomy + debridement + eksternal fixation pd antebrachii

dekstra 10.00-11.00 : thrombectomy pd a.axilaris oleh BTKV 11.00 -13.45 : debridement back slab pada cruris dekstra + antebrachii sinistra 15.00 : HCU

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DL durante op :

Fluktuasi hemodinamik durante op 76-130/56-62

HR 62-110, SaO2 99-100

Evaluasi post op :Tensi : 95/51

SaO2 100%

cairan masuk kristaloid 5500 cc

koloid 1500 cc

PRC 2000 cc

FFP 500 cc

26/3/2012 03.13 08.47

WBC 10.09 9.56

RBCHGBHCTPLT

2,136,68,7103

2,357,221.293

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PerdarahanBerdasarkan HCT = ∆HCT x EBV = 3200 cc

HCT awal

Ket :

EBV = 6750 cc

ABC = 1350 cc

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IB putu Lila Buana IB putu Lila Buana L/50L/50thth

• MRS : 25/3/12• MENINGGAL : 28/3/12 (23.50)DIAGNOSA• Rupture total a. axilaris D• Of Humerus D 1/3 tengah Gr IIIc• Cf Antebrachii D 1/3 distal gr II• OF Cruris D 1/3 T Gr II• Of Antebrachii S Segmental Gr IIIaTH :• BTKV: Repair vaskular• Ortho: Debridement + eksternal fiksasi , backslab

Cod A MOFB MULTI TRAUMAC KLL

06.0610,278,5025,403,1334,80