COMPREHENSIVE APPROACH IN THE MANAGEMENT OF EMERGENCY CASES

Fachry Ambia Tandjung

Dicky Mulyadi

INTRODUCTION
To have a good strategies of comprehensive approach in emergency traumatology / non traumatic
cases we should have:
1. A good fasicilities hospital:
2. A good and welltrained doctors
3. A good and welltrained nurse and para medic
4. A good facilities supporting department
5. A good welltrained supporting personals involve in emergency room.

Emergency cases
 Trauma
 Non trauma: stroke, hearth attack, diabetetic etc
 Not too much different.
 The principle and phylosophy are the same
 The aim : saving life and maintain function

Personal in emergency room

1. To evaluate the patients ( fast and correct)
2. To do resucitation accordingly
3. To decide wether the patient need more facilities in other spesific hospital
4. To arrange the consultation ( what, who, when and how)
5. To guarrante that the maximum management have been done in his hospital

TRIAGE
 Based on their needs for treament and resources available to provide appropiate treatment.
 ABC priorities. AIRWAY. BREATHING AND CIRCULATION.
At the low standard hospital
 Sorting px  send px to prefer hospital if needed
 indication: severity according to primary survey, and local condition

ABCDEs trauma care

 Airway cervical spine protection
 Breathing and ventilation
 Circulation and haemorrhagic control
 Dissability neurologic status
 Exposure and environmetal ( temperature) control

Primary Survey
Px assessed, th/ priorities established based on their injuries, vital sign and injury mechanism.
Must be done rapidly
Th/ : rapid resuscitation of vital sign.
Again ABCDE repeated as needed
 Special consideration :
1. Children
2. Pregnant women
3. Elderly
Must recognize life threatening  overcome
Aim
 To have a correct diagnostic & properly treatment
 To consider which one (therapy) coming first.
 Reffer to other hospital ? What hospital? Where?
 In orthopedic: save life and limbs
 In orthopedic / musculoskeletal: recognized the result of trauma by good history, physical
examination, special investigation / imaging.
 Basic life support and minimal invasive splinting
 Advanced trauma life support
Airway and cervical control
 Material that obstruct airway  chin lift or jaw thrust.
 Assess the GCS score
 GCS < 8 need airway definitive.
 Protection of cervical spine; even when we do something on the neck. At least we need two
well trained experienced person

BREATHING
 Clinical examination is very important.
 Must be able to recognize: Tension pneumothorax, flail chest, hematothorax, contussio
pulmonum, rib fracture
 Which condition that it is not allowed to insert endotracheal tube.
 If you don’t know  it will become worse.
 So : know yourself.
 A good airway doesn’t garranty a good ventilation.
 lung function.
 Chest wall.
 Diafragma
must be evaluated .
The chest must be open to evaluate as a whole
Tension pneumothorax:
 Def: progressive build of air within the pleura space usually due to lung laceration
which allows air to escape into the pleura but not to return
  medially or laterally shift of mediastinum
 Obstruct venous return to the heart.
 Circulatory instability
Tension pneumothorax
1. Classic sign: deviation of trachea, hyper expanded chest that moves little with
respiration.
2. Central venous pressure increased
3. Tachycardia, tachypneu, and hypoxia. Follow by circulatory collaps hypotension
traumatic arrest and pulsesless electrical activity.
4. It could happen while the px is undergoing investigations
CIRCULATION
1. Level of consiousness.
2. Skin color
3. Pulse.
BLEEDING
 Must be detected during primary survey.
 External bleeding can be stop (pneumatic splinting).
 Internal bleeding: thorax, abdominal, pelvic, long bone and retroperitoneal.
 What is the clinical symptom and signs? How to differentiate it.
DISSABILITY
 Neurogenic dissability: level of consciousness, pupil, level of spinal cord injury.
 GCS is simple useful tool .
 Reduced of consciousness: reduced oxygen will decrease brain perfusion
 Alcohol / drugs must be put in mind
EXPOSURE
 Complete examination of the body.
 All clinical signs and symptoms must be evaluate  to have a good working diagnosis
 Eq: to differentiate abdominal bleeding and retroperitoneal bleding etc.
  Warm blanket and iv line , enough space
RESUCITATION
 Must be done rapidly, correctly. Again we have to check ABCDE
 Monitor EKG
 Urine catheter and gaster tube.
 Radiology examination and other further investigation needed. What x ray or other /further
investigation needed

After primary survey and resuscitation. Must give clear information to the referring hospital. A good
facilities of transportation. A well trained nurse or paramedic that accompanied the px

SECONDARY SURVEY
to re evaluate the patient’s condition

SHOCK
 Def: ketidak normalan dalam sitem peredaran darah yang mengakibatkan perfusi organ dan
oksigenisasi jaringan yang tidak adekuat .
 Yang sangat penting adalah mengetahui penyebab shok tersebut sehingga dapat
memberikan pengobatan yang terarah
etiology
1. Shock hemorrhagic
2. Shock non haemorrhagic:
a) Cardiogenic
b) Tension pneumothorax.
c) Neurogenic
d) Septic

I II III IV

Blood loss >750 750-1500 1500-2000 >2000

Blood loss% >15% 15-30% 30-40% >40%
Pulse <100 >100 >120 >140
Blood presure Normal Normal Decreased decreased

Respiration 14-20 20-30 30-40 >

Urine >30 20-30 5-15 <
CNS status Sedikit cemas Agak cemas Cemas bingung

Factors That Influence

 Age
 Severity of the damage
 Time between injury and treatment
 Management pre hospital and usage of pneumatic anti shock
 Medicine use before accident
 Evaluation of our management is utmost important

Initial management of haemorraghic shock

1. Clinical examination
2. Vascular axcess. 2 iv lines
 3. Innitial crystaloid infuse.
4. Acid base equilibrium
  evaluate the respond : fast, transient or minimal or no respond at all.

SPECIAL CONSIDERATION
to equolize blood pressure and cardiac output
 Age
 Atlete
 Pregancy
 Medicine before
 Hypothermia
 Pacemaker
TRAUMA
Musculoskeletal trauma
1. Soft tissue: muscle, tendon, neurovevascukar
severity of injury must be determine
2. Hard tissue/ bone: fractur (closed /open), type etc
3. joint: haemarthrosis, cartilage lession, ligament tear, dislocation.
 General management of fracture: 4 R
1. Recognation
2. Reduction
3. Retaining
4. Rehaabilitaion
The result depend on:
 Skill and knowledge of doctor and surgeon
 Hospital facilities
 Patient condition
A good rest to the organ
 R est
 I ce
 C ompression
 E levation

Trauma Thorax
 Pneumothorax / haemothorax
 Lung contussion
 Tracheobronchial injury
 Cor blund trauma
 Aortic disruption
 Diaphragma injury
 Mediastinum injury

Trauma abdomen
 Intra abdomen injury : liver, spleen, gaster, intestine, etc
 Recognize intra abdominal bleeding
 Progressivity of the bleeding

Trauma retro peritoneal

 Kidney
 Ureter
Burn
 Neck and face
 Dyspneu
Endo tracheal tube might be necessary.
Refer : > 10%, less 10 years old or > 50, grade > II, chemical burn

Medula spinalis trauma

 ABCDE is a must
 Assesment level of injury
 transportion of the px to radiology.
log roll
 long spine board