EMERGENCY

Primary survey I will evaluate the patient according ATLS protocol to exclude life
threatening injury basicly do it simultaneously

Airway :
Ask the patients name? if unconscious
C-Spine control hard collar
(Snorring, gurgling, tongue occlusion, corpus alienum) Jaw thrust, clear foreign
body oropharyngeal tube
make sure airway patency

Breathing :
Look : chest expansion, bruise, JVP, shift trachea
Feel : breathing
RR increase → O2 supply (nasal canul 6 L , face mask 10 L), O2 saturation
Thoracocentesis : mid clavicular line ICS 2 (change tension to simple
pneumothorax), Chest tube : AAL ICS 5-6 (kanan) ICS 7-8 ( kiri) → then refer
thoracic surgeon

Circulation :

Identified the shock, put 2 large bore IV needle 2000 crystaloid bolus, take blood
sample to order blood tranfusion, put catheter.

Order blood : PRC : FFP 3:1 ( grade 4 shock order 1500 prc 500 ffp)
Control bleeding : pelvic binder (1 finger over illiac wing & distal GT & int
rotation) → to decrease the volume of pelvis (2L)

Source of bleeding: most common → venous plexus (70%) but the most cause of
death is arterial (10%)
All points of resuscitation have to be accomplished

Disability : GCS
Exposure : undress evaluate other source bleding
Emergency radiology : lateral cervical xray, thorax xray, pelvis AP

Polytrauma
A syndrome of multiple injuries exceeding a
defined severity of ISS > 17 with sequential
systemic traumatic reaction leading to
dysfunction and failure in remote organs
which themselves have not been injured.

DCO
Definition : Damage control orthopaedics is an approach that contains and
stabilizes orthopaedic injuries so that the patient’s overall physiology can
improve And avoid “second hit” phenomenon.
Phase DCO :
• Phase 0 : Damage Control Resuscitation in Pre –hospital and Emergency
Departement Settings
• Phase I : Abbreviated Surgery
• Phase II : The ICU Phase of Damage Control : Managing the Patient from
Door to Door
• Phase III : Second Operation Repair of all Injuries General and
Orthopaedics
• Phase IV : Late Reconstruction : Reconstruction of Post Traumatic Soft
Tissue Defects
Timing Priority Surgery :

I. Initial Shock “EBB” Phase

First 48 hours
II. Convalescent “FLOW” Phase
Catabolic Subphase (3-10)
Anabolic Subphase (10-60)

EBB phase :
• SHOCK → Tachycardia & Hypotension
• Energy expenditure ↓
• Body Temprature ↓
• Oxygen Consumptions ↓
• Catecholamine & Cortisol ↑
• Blood Glucose ↑ (Insulin ↓)
• FFA ↑
• Blood Lactate ↑

FLOW phase catabolic :

• Protein break down (CATABOLIC PROCESS)
• Cardiac output ↑
• Oxygen Consumptions ↑
• Basal metabolic rate ↑
• Energy expenditure ↑
• Body Temperature ↑
• Catecholamine ↑
• Blood Glucose N/↑
• Glucagon ↑ & Insulin ↑ (insulin resistance)
• FFA ↑
Neck femur fracture:
OSTEOPOROSIS
• Decreased osteoblastic formation of matrix & increased osteoclastic
absorption of bone.
• Differ from osteomalacia – decreased of calcified bone!
In osteoporosis, the bone is calcified, and normal microscopically

fixation

drugs
risendronat (Actonel)
- 5mg/day; 35mg/week ; 150mg/months PO
zolendronic acid (zometa)
- 5mg diencerkan dalam 100ml NaCl habis dalam 15 menit
ibandronat (bonviva)
- 15mg/months PO
- 3mg / 3 months IV
 Pelvic fracture :

Tile classification
o A: stable
o A1: fracture not involving the ring (avulsion or iliac wing fracture)
o A2: stable or minimally displaced fracture of the ring
o A3: transverse sacral fracture (Denis zone III sacral fracture)
o B - rotationally unstable, vertically stable
▪ B1: open book injury (external rotation)
▪ B2: lateral compression injury (internal rotation)
o B2-1: with anterior ring rotation/displacement through ipsilateral rami
o B2-2-with anterior ring rotation/displacement through contralateral rami
(bucket-handle injury)
▪ B3: bilateral
o C - rotationally and vertically unstable
▪ C1: unilateral
o C1-1: iliac fracture
o C1-2: sacroiliac fracture-dislocation
o C1-3: sacral fracture
▪ C2: bilateral with one side type B and one side type C
▪ C3: bilateral with both sides type C
Compartement syndrome

Definition : Increase of osteo fascial compartment pressure that impair the soft
tissue leading to ischemia and cell dead
Definition:
• ‘ … an elevation of the interstitial pressure in a closed osseofascial
compartment that results in microvascular compromise’
Mubarak & Hargens (1983, cited Edwards 2004:32)
• ‘ … a condition in which the circulation and function of tissues within a
closed space are compromised by an increased pressure within that
space’.
Matsen (1975, cited Singh, Trikha & Lewis 2005:468)

Cause :
• ↑ In the contents of a space
– Bleeding
– Swelling

• ↓ In the volume of a space

– External compression
– Tight closure

Diagnosis
Classic 8 P signs : Pain,Parestesi, Puffiness, Pallor,
Poikilothermie,Parese,Paralysis, Pulselessness.
Direct Measurement
1/. Injection/infusion technique (Whitesides) →
equipment inexpensive and readily available
in most hospitals, emergency rooms → NOT accurate
Boody AR; JBJS 2005: Cannot recommend the clinical
use of Whiteside app.
2/. Wick catheter (Mubarak)
3/. Slit catheter (Rorabeck)
4/. Solid state transducer intracomp catheter (STIC) :
Portable device : Stryker app.
1 – 4 : Fluid filled system
5/. Fiber optic transducer tipped → very expensive
6/. Latest device : Electronic Transducer Tipped Catheter
→ best device

Interpretation
Absolute : 30 mm Hg as cut off point
for fasciotomy
N < 10 mm Hg → + 4 mm Hg

Differential Pressure (Mc Queen) :

→ Diastolic BP minus ICP
cut off point < 30 mm Hg
Lab : - Creatin Phospho Kinase (CPK) ,
serum myoglobin, myoglobinuria (+)
- Detect level of muscle necrosis, high
CPK → rhabdomyolysis → Crush Syndrome

Fasciotomy

Treatment:
• Emergent fasciotomy of all four compartments
o dual medial-lateral incision
▪ approach
▪ two 15-18cm vertical incisions separated by 8cm
skin bridge
▪ anterolateral incision
▪ posteromedial incision
▪ technique
▪ anterolateral incision
▪ identify and protect the superficial peroneal
nerve
▪ fasciotomy of anterior compartment
performed 1cm in front of intermuscular
septum
▪ fasciotomy of lateral compartment
performed 1cm behind intermuscular
septum
▪ posteromedial incision
▪ protect saphenous vein and nerve
▪ incise superficial posterior compartment
▪ detach soleal bridge from back of tibia to
adequately decompress deep posterior
compartment
▪ post-operative
 ▪ dressing changes followed by delayed primary
closure or skin grafting at 3-7 days post
decompression
o single lateral incision
▪ approach
▪ single lateral incision from head of fibula to ankle
along line of fibula
▪ technique
▪ identify superficial peroneal nerve
▪ perform anterior compartment fasciotomy 1cm
anterior to the intermuscular septum
▪ perform lateral compartment fasciotomy 1cm
posterior to the intermuscular septum
▪ identify and perform fasciotomy on superficial
posterior compartment
▪ enter interval between superficial posterior and
lateral compartment
▪ reach deep posterior compartment by following
interosseous membrane from the posterior aspect
of fibula and releasing compartment from this
membrane
▪ common peroneal nerve at risk with
proximal dissection