2.

AIRWAY AND VENTILATORY MANAGEMENT

AIRWAY
PROBLEM RECOGNITION
 Takipneu
 Verbal respons
 Altered level of consciousness
 Maxilofacial trauma
 Neck Trauma
 Laringeal trauma : hoarsemess, subcutan emphysema, palpable fracture
 Inhalation trauma
 Aspiration
OBJECTIVE SIGN OF AIRWAYS OBSTRUCTION
1. Observe patient agitated (hypoxia) or obtunded (hypercarbia), cyanosis, retractions
muscle, pulse oxy
2. Abnormal sounds : noisy breathing, snoring, gutgling, stridor, hoarseness

VENTILATION
PROBLEM RECOGNITION
 Direct trauma chest, rib fracture
 Eldery with pulmonary dysfungtion
 Intracranial injury
 Cervical spinal cord injury >> respiratory muscle paresis (injured below C3
(intercostal and abdominal muscle))
 Seesaw pattern of breathing
OBJECTIVE SIGNS OF INADEQUATE VENTILATION
1. Look symmetrical rise and fall of chest and adequate
2. Listen movement of air on both side
3. Pulse oxy, BGA
4. Use capnography

AIRWAY MANAGEMENT
PREDICTING DIFFICULT AIRWAY MANAGEMENT
  Assess patient’s airway to predict difficulty of the manuver
o Factors : c spine injury, severe arthritis of the c-spine, maxilo mandibular
trauma, limited mouth opening, obesity, anatomical variations, pediatric
patients

AIRWAY MAINTENANCE TECHNIQUES

To establish an airway , restriction of cervical spinal motions
 Chin Lift Manuver
 Jaw Thrust Manuver
 Nasopharyngeal Airway
 Oropharyngeal Airway
 Extraglottic and Supraglottic Devices (LMA, LTA, Multilumen esophageal airway)

DEFINITIVE AIRWAYS
Criteria for having definitive airways :
A – inability to maintance patent airways by other means
B – inability to maintanace adequate oxygenation by facemask or presence of apnea
C – Obtundation or cabativeness resulting from cerebral hypoperfusion
D – Obtundation indicating the presence of a head injury . GCS <=8 , sustained
seizure, the need to protect lower airway from aspiration
 Endotrakheal Intubation
 o Nasotracheal intubation, contraindication : facial, frontal sinus, basilar skull,
cribiform plate fracture (Basis cranii Fracture)
o Orotracheal intubation
 Drug Assisted Intubation
o The technique :
1. Have a plan in the event of failure that includes the possibility of
performing a surgical airway
2. Ensure that suction and the ability to deliver positive pressure
ventilation are ready
3. Preoxygenate with 100% oksigen
4. Apply pressure over the cricoid cartilage
5. Administer an induction drug (etomidate 0,3mg/kg) or sedative
6. Administer 1-2 mg/kg succinylcholine iv (usual dose is 100 mg)
7. After the px relax, intubate orotracheally
8. Inflate the cuff and confirm tube placement
9. Release cricoid pressure
10. Ventilate the patient
o Etomidate/amidate drug : depress adrenal function, provide adequate sedation
o Succinylcholine drug : potential of hyperkalemia (caution fot severe crush
injury, major burns, electrical injury, CHF, chronic paralysis, chronic
neuromuscular disease)
o Thiopental / sedative :potential for hypovolemia

SURGICAL AIRWAY
Indicated when :
o Edema of the glottis
o Fracture of the larynx
o Severe oropharyngeal hemorage that obstructs the airways
o Inability to place an endotracheal tube through the vocal cords

Needle Cricothyroidotomy
Insertion of a needle through the cricothyroid membrane into the trachea. With canula 12 to
14 for adult and 16-18 for children through the cricothyroid membrane. The canula is then
connected to oxygen at 15L/min with a Y-connector or a side hole cut in the tubing
Surgical Cricothyroidotomy
Isn’t recommended for child under 12 yo
Management of oxygenation
At least nrm 10 lpm
Adequate if spo2 >94%
 III. SHOCK

SHOCK PATHOPHYSIOLOGY
Basic Cardiac Physiology
Cardiac Output = Heart rate x Stroke Volume
Stroke Volume = Preload, Myocardial contractility, afterload
Preload = venous capacitance, volume status, difference between mean venous systemic
pressure and right atrial flow
Blood Loss Pathophysiology
Release of endogenous catecholamines > increase peripheral vascular resistance > increase
diastolic blood pressure and reduces pulse pressure.
In early hemorrhagic shock , venous return is preserved by compensatory mechanism of
contraction in venous system
Inadequate perfusion > aerobic metabolism cell > formation of latic acid > acidosis
metabolism

INITIAL PATIENT ASSESSMENT

Recognition of Shock
Pulse rate, pulse character, respiratory rate, skin perfusion, and pulse pressure
Takikardia :
>160 in infant
>140 in preschool aged child
>120 in children from school age to puberty
> 100 in adult
Clinical Differentiation of Cause of Shock
Overview of Hemmorhagic Shock
Overview of Non Hemmorhagic Shock
Cardiogenic Shock
Myocardial dysfunction can be caused by blunt cardiac injury, cardiac tamponade, an
air embolus, myocardial infarction
Cardiac Tamponade
Takikardia, muffled heart sounds, and dilated, engorged neck veins with hypotension
and insufficient response to fluid therapy
Tension pneumothorax can mimic cardiac tamponade. However, absent breath sounds
and hyperresonant percussion are not present with tamponade
FAST can indentify pericardial fluid
Treatment : pericardiocentesis (temporary), operative intervention
Tension pneumothorax
 Acute respiratory distress, subcutaneous emphysema, absent respiratory unilateral
breath sound, hyperresonance to percussion, tracheal shift
Treatment : thoracic decompression
Neurogenic Shock
injured brainstem
hypotension without tachycardia or cutaneus vasoconstriction
Septic Shock

HEMORRHAGIC SHOCK
Definition of Hemmorhage
Acute loss of circulating blood volume. Normal adult blood volume is 7% of ideal body
weight
For chilf is 8-9% of body weight
Physiologic Classification

Confounding Factors
 Patient age
 Severity of injury
 Time lapse between injury and initiation of treatment
 Prehospital fluid therapy
 Medications used for chronic conditions
Fluid Changes Secondary to Soft Tissue Injury
Blood loss can ocure in major fracture (tibia, pelvic), tissue injury (edema) particulary in
obese and elderly induviduals
INITIAL MANAGEMENT OF HEMORRHAGIC SHOCK
Physical Examinations
Airway and breathing
Provide oxygen to maintain spo2 > 95%
Circulation : Hemorrhage Control
External bleeding controlled by direct pressure to the bleeding site, or with tourniquet.
Internal bleeding controlled by angioembolization or surgical
Dissability : Neurological Examination
To assessing cerebral perfusion.
Exposure : Complete examination
Prevent hypothermia
Gastric Dilation : Decompression
Can cause unexplained hypotension, or cardiac dysrhythmia, usually bradikardia from
excessive vagal stimulation
Urinary cathetherization
To assess hematuria, monitoring urine output
Contraindication : blood at the urethral meatus or perineal hematoma/bruising

Vascular Access
Use two large caliber (minimal 18-gauge). If peripheral access cant be obtained, consider
placement of an intraosseous needle for temporary access. If circumtances prevent use
peripheral veins, clinicians may initiate large caliber, central venous (ie femoral, jugular, or
subclavian vein access)

Initial fluid therapy

The usual dose is 1 liter for adults and 20 ml/kgbb for pediatric weighing less than 40 kg
Absolute volumes based on patient response to fluid administration
Measuring Patient Response to Fluid Therapy
The return of normal blood pressure, pulse pressure, and pulse rate
The volume of urine output = renal perfusion
 Adequate if 0.5 ml/kgbb/hr for adult ; 1 ml/kgbb/hr for pediatric and 2 ml/kgbb/hr for
child < 1 yr
Patterns of Patient Response
Rapid Response
Transient Response
Minimal or no response

BLOOD REPLACEMENT
Crossmatched, Type Specific, and Type O Blood
The main purpose of blood transfusion is to restore the oxygen carrying capacity of the iv
volume
Prevent Hypothermia
Autotransfusion
Massive Transfusion
Coagulopathy
Give tranexamic acid

SPECIAL CONSIDERATIONS

4. THORACIC TRAUMA

PRIMARY SURVEY : LIFE THREATENING INJURIES

AIRWAY OBSTRUCTION
Result from swelling, bleeding, or vomitus that is aspirated into the airway
In primary survey :
look for retractions, foreign body obstruction
listen air movement, stridor
feel crepitus over the anterior neck
Tracheobronchial tree injury
Patients typically present with hemoptysis, cervical subcutaneous emphysema, tension
pneumothorax, and/or cyanosis.
BREATHING PROBLEMS
Tension Pneumothorax
One way valve air leak occurs from the lung or through the chest wall.
The mediastinum displaced to the opposite side, decreasing venous return > shock,
compressing the opposite lung.
Sign and symptoms :
Chest pain, air hunger, tachpnea, respiratory distress, hypotension, tracheal deviation ,
unilateral absence of breath sounds, elevated hemithorax without respiratory movement, neck
vein distention, cyanosis
Tatalaksana : needle cecompresion, with 8 cm catheter > 90% reach pleural space
Open Pneumothorax
Large injury to the chest wall that remain open
Treatment : close the defect with a sterile dressing, tape securely only three side
Massive Hematothorax
Trearment : insert chest tube

CIRCULATION PROBLEMS
Massive Hematothorax
Result from the rapid accumulation of more than 1500 ml of blood or one third or more of the
patient;s blood volume in the chest cavity
Shock with absence of breath sounds or dullness to percussion on one side of the chest
Neck vein may be flat because hypovolemia or distended because tension pneumothorax
Treatment : large caliber iv line, infuse crystalloid, transfusion, chest tube (28-32 french at
the fifth ics, anterior midaxillary line
Thoracotomy required when there is continuing blood loss (200 ml/hr for 2 to 4 hours), or
penetrating anterior chest wound medial to the nipple line and posterior medial to the scapula
(the mediastinal box) >> potential damage of great vessel, hilar structures, and the heart
Cardiac Tamponade
Compression of the heart by an accumulation of fluid in the pericardial sac
Traumatic Circulatory Arrest
SECONDARY SURVEY
Potentially Life Threatening Injuries
Simple Pneumothorax
Treatment : chest tube in ics 5, anterior midaxillary line
Hemothorax
Flail chest
Pulmonary contusion
Blunt cardiac Injury
Traumatic aortic disruption
Widened mediastinum
Obliteration of the aortic knob
Deviation of the trachea to the right
Depression of the left mainstem bronchus
Elevation of the right mainstem bronkus
Obliteration of the space between the pulmonary artery and the aorta
Deviation of the esophagus to the right
Widened paratracheal stripe
Eidened paraspinal interfaces
Presence of a pleural or apical cap
Left hemothorax
Fractures of the first or second rib or scapula
Initial treatment :
Pain killer
Short acting beta blocker to a goal heart rate less than 80 bpm, if contraindicated can be
diganti ca chanel blocker / nikardipin ( jika tidak ada hipotensi)
Blood pressure control with goal MAP 60-70 mmHg
Traumatic Diaphragmatic injury
In x ray can be seen elevated diaphragm, the appearace of peritoneal lavage fluid in the chest
tube drainage
Blunt esophageal rupture
Other manifestations of chest injuries
Subcutaneous emphysema
Crushing injury to the chest
Rib, sternum, and scapular fractures

5. ABDOMINAL AND PELVIC TRAUMA

ANATOMY OF THE ABDOMEN

The anterior abdomen
The thoracoabdomen
The flank
The back
The pelvic cavity

MECHANISM OF INJURY
Blunt
A direct blow
Penetrating
Blast
ASSESSMENT AND MANAGEMENT
 History
Vehicle speed, type of collision, types of testraints, deployment of air bags, patient
position, and status of other occipants
Time of injury, type of weapon, distance from the assailant, number of stab wounds,
amount of external bleeding noted at the scene
Physical Examination
Inspection auscultation, percussion, and palpation
Examine anterior and posterior abdomen, lower chest and perineum, abrasions, and
contusions, lacerations, penetrating wounds, foreign bodies
Pelvic assessment
Urethral. Perineal, rectal, vaginal, and gluteal examination
The presence of blood in uretral meatus, ecchymosis or hematoma in scrotum and
perineum
Do not place urinary catheter in a urethral injury
Adjuncts to physical examination
Gastric tubes and urinary catheters
Therapeutic goals of ngt is to relief acute gastric dilatation and stomach decompression
before performing DPL, reduce incidence of aspiration, look for the presence of blood in
the gastric suggest injury to the esophagus or upper gastrointestinal tract
Goals for urinary catheter is to relieve retention, identify bleeding, monitoring urinary
output, decopress the bladder before DPL. Gross hematuria indicate trauma in
genitourinary tract, including kidney, urether, and bladder
Other studies
Patients with the following rewuire further abdominal evaluation :
 Altered sensorium
 Altered sensation
 Injury to adjacent structures, such as lower ribs, pelvis, and lumbar spine
 Equivocal physical examination
 Prolonged loss of contact with patient anticipated
 Sealt belt sign with suspicion of bowel injury
x-ray for abdominal trauma
focused assessment with sonography for trauma (FAST)
FAST includes examination of four regions :
The pericardial sac, hepatorenal fossa, splenorenal fossa, and pelvis or pouch of douglas
Diagnostic Peritoneal Lavage (DPL)
Requires gastric and urinary decompression for prevention of complications
Contraindications : previous abdominal operations, morbid obesity, advanced chirrosis, and
preexisting coagulopathy
CT Scan
Diagnostic Laparoscopy or Thoracoscopy
Contrast Studies
Urethrography
Cystography
Iv pyelogram
Gastrointestinal contrast studies

EVALUATION OF SPECIFIC PENETRATING INJURIES

Thoracoabdominal Wounds
Anterior abdominal wounds : nonoperative management
Non operative management can be done when hemodynamically normal px without
peritoneal signs or evisceration with serial physical examinations over a 24 hour period
Flank and back injuries : nonoperative management
serial physical examinations, double or triple contrast ct scans, and DPL. DPL may not detect
retroperitoneal colon injuries

Indications for laparotomy

 Blunt abdominal trauma with hypotension with positive FAST ot clinical evidence of
intraperitoneal bleeding, or without another source of bleeding
 Hypotension with an abdominal wound that penetrates the anterior fascia
 Gunshot wounds that tranverse the peritoneal cavity
 Evisceration
 Bleeding from the stomach, rectum, or genitourinary tract following penetrating
trauma
 Peritonitis
 Free air, retroperitoneal air, or rupture of the hemidiaphragm
 Contrast enhanced ct that demonstrates ruptured gastrointestinal tract, intraperitoneal
bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt
or penetrating trauma
 Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents,
vegetable fibers, or bile from DPL, or aspiration of 10 cc or more of vlood in
hemodynamically abnormal patients
Evaluation of other specific injuries
Diaphragm injuries
Cxr : elevation or blurring of the hemidiaphragm, hemothorax, an abnormal gas shadow that
obscures the diaphragm
Duodenal injuries
A bloody gastric aspirate or retroperitoneal air on an abdominal radiograph or CT
Pancreatic injuties
Genitourinary injuries
Contusions, hematomas, and ecchymoses of the back or flank. Gross hematuria
Hollow viscus injuries
A transverse, linear ecchymosis on the abdominal wall or lumbar distraction fracture
Solid organ injuries
Shock, hemodynamic abnormality, or evidence of continuing hemorrhage are indications for
urgent laparotomy
Pelvic Fractures and associated injuries
Sacral fracture, a sacroiliac fracture, and or dislocation of the sacroiliac joint
Mechanism of injury and classification
Pelvic fractures are classified into four types, based on injury force patterns :
AP compression, lateral compression, vertical shear, and combined mechanism
Management
Rapid hemorrhage control and fluid resuscitation, temporary fixation of the pelvis
 6. Head Trauma

Anatomy review
Scalp
Skull
Meninges : duramater, arachnoid mater, pia mater
Brain
Ventricular system
Intracranial compartments

Physiology review
Intracranial Pressure
Elevation of ICP > reduce cerebral perfusion > exacerbate ischemia
Normal ICP for px in resting state is 10 mmHg
Monro-Kellie Doctrine
The doctrine states that the total volume of the intracranial contents must remain constant
Cerebral Blood Flow
CPP ( Cerebral Perfusion Pressure) = MAP – ICP (Intra Cranial Pressure)

Classifications of head injuries

Severity of Injury
Severe brain injury = GCS score of 8 or less
Moderate injury = GCS score 9 to 12
Mild injury – GCS score 13 to 15
Morphology
Skull Fractures
Clinical signs of a basilar skull fractures include periorbital ecchymosis (raccoon eyes),
retroauricular ecchymosis (battle’s sign), CSF leakage from the nose (rhinorrhea), or ear
(otorrhea) and dysfungtion of cranial nerves VII and VIII (facial paralysis and hearing
loss)
Intracranial Lesions
Difusse Brain Injuries
CT scan normal ,or the brain may appear diffusely swollen, and the normal gray-white
matter is absent.
Severe diffuse injuries often result from hypoxic , ischemic result to the brain from
prolonged shock or apnea occurring immediately after trauma
Focal Brain Injuries

Epidural hematomas
This hematomas typically become biconvex or lenticular in shape as they push the
adherent dura away from the inner table of the skull
The classic presentation is a lucid interval between the time of injury and neurological
deterioration
Subdural hematomas
more common. Subdural hematomas often appear to conftorm to contours of the brain in
CT scan. Damage more severe than epidural hematomas
Contusions and intracerebral hematomas
Evidence-based treatment guidelines
Management of mild brain injury
Obtain CT scan for all patients with suspected brain injury who have clinically suspected
open skull fracture, any sign of basilar skul fracture, and more tha two episodes of
vomiting, also patient who older than 65 years
Management of moderate brain injury

Management of severe brain injury

Primary survey and resuscitation
Secondary survey
Diagnostic procedures
Medical therapies for brain injury
Surgical management
Prognosis
Brain death