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Transcript of multi trauma
DISKUSI MULTI TRAUMADISKUSI MULTI TRAUMA
Selasa, 3 April 2012 Selasa, 3 April 2012
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
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
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
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
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
STATUS LOKALIS
– R. Cruris D L: edema (+), fat bubble (+), bone expose
(+), bleeding aktif (-) F : kripitasi (+), NT (+),, a. Dorsalis pedis (+) M : ROM distal terbatas
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
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
HCUHCU
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
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
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
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
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
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
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
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
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
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
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
TERIMA KASIHTERIMA KASIH
““Damage Control” :Damage Control” :
Indikasi : Kontrol Perdarahan. Kontrol Kontaminasi. “Metabolic Failure” “Triad Of Death” :
1. Hipotermi.
2. Asidosis yg Persiten.
3. Koagulopati.
COAGULOPATHYCOAGULOPATHYCOAGULOPATHYCOAGULOPATHY
Cold diuresisPlasma shift
HYPOTERMIA
Tissue hypoxia
Thrombosis microcirculation
Sludging
Viscosity HCT CO
DIC
M O D S
Acidosis
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
– 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
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
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
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
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
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
DSTC-Indonesia 43
EEXXTRTREEMITMITY TRAUMAY TRAUMA LIMB LIMB SALVAGE VS AMPUTATIONSALVAGE VS AMPUTATION
KOLEGIUM ILMU BEDAH INDONESIA
KOMISI TRAUMA IKABI
DSTC-Indonesia 44
EXTREMITY TRAUMAEXTREMITY TRAUMA
SKIN AND SUBCUTANEOUS TISSUE
MUSCLE AND TENDON
BONE
JOINT LIGAMENT AND CARTILAGE
ARTERI AND VEIN
PERIFERAL NERVE
DSTC-Indonesia 45
Priorities in surgical Priorities in surgical managementmanagement
SAVE LIFESAVE LIMBSAVE JOINTRESTORE FUNCTION
DSTC-Indonesia 46
LIFE THREATENINGLIFE THREATENING
FEMORAL FRACTURE 330 – 1300 ml BLOOD LOSS
CRUSH INJURY INTRA VASCULAR DEBRIS MEDIATOR IMFLAMMATION
FAT EMBOLISMARDS
MOF ARF
DSTC-Indonesia 47
LIMB THREATENINGLIMB THREATENING
SALVAGEAMPUTATION
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.
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.
DSTC-Indonesia 50
Mangled extremityMangled extremity
High energy trauma Vascular injurySevere comminuted Soft tissue damage
DSTC-Indonesia 51
Mangling extremity injuryMangling extremity injury
Severe injury to three of four organ system ( skin, bone, arteries, nerve)
DSTC-Indonesia 52
Delayed amputationDelayed amputation
High morbidityBad prognosis
Age
Disability
Cost
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
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
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.
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
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
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
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
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
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
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
DSTC-Indonesia 63
Age
< 30 0
30 – 50 1
> 50 2
A MESS value > 7 predicted amputation
DSTC-Indonesia 64
NISSSA Scoring System
FACTOR SCORENERVE INJURY sensate 0 loss of dorsal 1 partial plantar 2 complete plantar 3
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
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
DSTC-Indonesia 67
Age (years) <30 0 30-50 1 >50 2
A NISSSA score >11 predicted amputation.
DSTC-Indonesia 68
DSTC-Indonesia 69
DSTC-Indonesia 70
DSTC-Indonesia 71
DSTC-Indonesia 72
DSTC-Indonesia 73
DSTC-Indonesia 74
DSTC-Indonesia 75
DSTC-Indonesia 76
DSTC-Indonesia 77
??
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
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
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
PerdarahanBerdasarkan HCT = ∆HCT x EBV = 3200 cc
HCT awal
Ket :
EBV = 6750 cc
ABC = 1350 cc
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