KGD – Pemicu 3

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Triage
TRIAGE
SORTING
By using triage, patients are sorted based on objective criteria on how
they present. The severity of injury and therefore treatment and/or
transport priority in triage is sorted by color code. Triage tags contain
these colors so treatment and transport crews can see at a glance
which patients have been triaged to which level
COLOR CODES
• GREEN - Minor injury (walking wounded)
• YELLOW - Delayed- can wait
• RED - Immediate!
• BLACK - Deceased
SCENE SIZE UP
1. Conduct a scene size up.
a. Assure well being of responders
b. Determine if (or render as possible) the scene
safe prior to entering
2. Take BSI
3. Determine the number of patients. If there are
multiple or mass casualties, communicate that fact
through the proper channels, establish command,
and establish a medical officer and triage officer
Now its time to start triage.
• You may encounter people self evacuating the scene as you arrive.
Direct these people to an appropriate area of refuge so they can be
monitored and evaluated.
• These people would be considered non-injured or “walking wounded”
• As you approach the actual scene, you may encounter people with a
variety of injuries from superficial to life threatening.
• Your first step is to clear out the remaining “walking wounded”. Do this
by simply announcing “if any of you are well enough to stand up and
walk out of here, do so now”
• Do not let then wander aimlessly  These victims shall be categorized
GREEN. If you believe some of the uninjured victims are capable of
assisting you, keep them near you to help if needed.
• Now all you should be left with are those victims who are injured
severely enough to not be able to get up and walk out on their own.
But where do you start? Who do you go to first? The loudest? The
bloodiest? The youngest? None of the above
START WHERE YOU STAND.
R. P. M.
• R = Respiratory
• P = Perfusion
• M = Mental Status
RESPIRATORY
The first thing we check for is
presence of respiration.
Respirations:
NONE?
Open the airway
Still none?
Tag BLACK, deceased
Were respirations restored?
Tag RED, immediate
Respirations:
PRESENT?
Assess respiratory rate
RATE ABOVE 30 breaths per minute?
Tag RED, immediate
RATE BELOW 30 breaths per minute?
Move on to assess perfusion criteria
PERFUSION
Radial Pulse Absent or Capillary Refill > 2 secs
Tag RED, immediate
Radial Pulse Present or Capillary Refill < 2 secs
Move on to assess mental status
MENTAL STATUS
Cannot follow simple commands?
(unconscious or altered mental status)
Tag RED, immediate
CAN follow simple commands.
Tag YELLOW delayed
Now that the patients have been triaged, more focused treatment can
begin.
Moving victims to treatment areas may be needed. Those tagged RED
or immediate are trated (or moved to treatment areas) first, followed
by those tagged YELLOW or delayed.
Patients tagged BLACK can be left in place
Spinal Cord Injury
Spine trauma
• Trauma to the spine can cause a vertebral spinal column injury, a
spinal cord injury or both
• Functional anatomy :
• Vertebral column
• Spinal cord

Tintinalli’s Emergency Medicine 8th edition

• Pre hospital care :
• Recognition of patients at risk
• Appropriate immobilization
• Triage to an appropriate facility

Tintinalli’s Emergency Medicine 8th edition

• Initial ED stabilization :
• Airway
• Hypotension
• Spine immobilization

Tintinalli’s Emergency Medicine 8th edition

• Clinical features :
• History  pay particular attention to any symptoms indicating present or
impending respiratory compromise, including dyspnea, palpitations,
abdominal breathing, and anxiety  high cervical spine injury
• Physical examination :
• Presence or absence of midline neck or back tenderness
• Test motor function for muscle groups
• Sensory loss and investigate proprioception
• Saddle anesthesia
• Deep tendon reflexes

Tintinalli’s Emergency Medicine 8th edition

Tintinalli’s Emergency Medicine 8th edition
 Guidelines for Screening Patients with
Suspected Spine Injury
• Suspected Cervical Spine Injury
• 1. The presence of paraplegia or quadriplegia is presumptive evidence of spinal
instability.
• 2. Patients who are awake, alert, sober, and neurologically normal, and have no
neck pain or midline tenderness, or a distracting injury: These patients are
extremely unlikely to have an acute c-spine fracture or instability. With the
patient in a supine position, remove the c-collar and palpate the spine. If there is
no significant tenderness, ask the patient to voluntarily move his or her neck
from side to side. Never force the patient’s neck. When performed voluntarily by
the patient, these maneuvers are generally safe. If there is no pain, have the
patient voluntarily flex and extend his or her neck. Again, if there is no pain, c-
spine films are not necessary.
• 3. Patients who are awake and alert, neurologically normal,
cooperative, and do not have a distracting injury and are able to
concentrate on their spine, but do have neck pain or midline
tenderness: The burden of proof is on the clinician to exclude a spinal
injury. Where available, all such patients should undergo multi-
detector axial CT from the occiput to T1 with sagittal and coronal
reconstructions. Where not available, patients should undergo lateral,
AP, and openmouth odontoid x-ray examinations of the c-spine with
axial CT images of suspicious areas or of the lower cervical spine if not
adequately visualized on the plain films
• Assess the c-spine films for:
• bony deformity
• fracture of the vertebral body or processes
• loss of alignment of the posterior aspect of the vertebral bodies (anterior extent of the vertebral canal)
• increased distance between the spinous processes at one level
• narrowing of the vertebral canal
• increased prevertebral soft tissue space
• If these films are normal, remove the c-collar. Under the care of a knowledgeable clinician,
obtain flexion and extension, and lateral cervical spine films with the patient voluntarily
flexing and extending his or her neck. If the films show no subluxation, the patient’s c-spine
can be cleared and the c-collar removed. However, if any of these films are suspicious or
unclear, replace the collar and obtain consultation from a spine specialist.
• 4. Patients who have an altered level of consciousness or are too young to
describe their symptoms: Where available, all such patients should undergo
multi-detector axial CT from the occiput to T1 with sagittal and coronal
reconstructions. Where not available, all such patients should undergo lateral,
AP, and open-mouth odontoid films with CT supplementation through suspicious
areas (e.g., C1 and C2, and through the lower cervical spine if areas are not
adequately visualized on the plain films). In children, CT supplementation is
optional. If the entire c-spine can be visualized and is found to be normal, the
collar can be removed after appropriate evaluation by a doctor/consultant skilled
in the evaluation/ management of patients with spine injuries. Clearance of the
c-spine is particularly important if pulmonary or other care of the patient is
compromised by the inability to mobilize the patient.
• 5. When in doubt, leave the collar on
• 6. Consult: Doctors who are skilled in the evaluation and management
of patients with spine injuries should be consulted in all cases in
which a spine injury is detected or suspected.
• 7. Backboards: Patients who have neurologic deficits (e.g.,
quadriplegia or paraplegia) should be evaluated quickly and removed
from the backboard as soon as possible. A paralyzed patient who is
allowed to lie on a hard board for more than 2 hours is at high risk for
pressure ulcers.
• 8. Emergency situations: Trauma patients who require emergency
surgery before a complete workup of the spine can be accomplished
should be transported carefully, assuming that an unstable spine
injury is present. The c-collar should be left on and the patient
logrolled when moved to and from the operating table. The patient
should not be left on a rigid backboard during surgery. The surgical
team should take particular care to protect the neck as much as
possible during the operation. The anesthesiologist should be
informed of the status of the workup.
• Suspected Thoracolumbar Spine Injury
• 1. The presence of paraplegia or a level of sensory loss on the chest or
abdomen is presumptive evidence of spinal instability.
• 2. Patients who are awake, alert, sober, neurologically normal, and
have no midline thoracic or lumbar back pain or tenderness: The
entire extent of the spine should be palpated and inspected. If there
is no tenderness on palpation or ecchymosis over the spinous
processes, an unstable spine fracture is unlikely, and thoracolumbar
radiographs may not be necessary.
• 3. Patients who have spine pain or tenderness on palpation,
neurologic deficits, an altered level of consciousness, or in whom
intoxication is suspected: AP and lateral radiographs of the entire
thoracic and lumbar spine should be obtained. Thin-cut axial CT
should be obtained through suspicious areas identified on the plain
films. All images must be of good quality and interpreted as normal by
an experienced doctor before discontinuing spine precautions.
• 4. Consult a doctor skilled in the evaluation and management of spine
injuries if a spine injury is detected or suspected.
Thermal Injury
Immediate lifesaving measures
• Clinical indication of inhalation injury:
• Face / neck burns
• Singeing of the eyebrows and nasal vibrissae
• Carbon deposits in the mouth / nose and carbonaceous sputum
• Acute inflammatory changes in the oropharynx, including erythema
• Hoarseness
• History of impaired mentation / confinement in a burning environment
• Carboxyhemoglobin level greater than 10% in a patient who was involved
in a fire
• Stop the burning process:
• All clothing should be removed. Do not peel off adherent clothing
• IV access :
• Any patient with burns over more than 20% of body surface requires fluid
resuscitation
Estimation of burns
based on the body
surface area

Advanced Trauma Life Support

Student Course Manual 9th Edition
Depth Of Burn
Classification According to Extent

Infant Rule of Nines

• Mild: 10% (for quick assessment of
total body surface area
• Moderate:
affected by burns)
10-30% Anatomic Surface
• Severe: > 30% structure area
Head 18%

• Hospitalization for Anterior Torso 18%

> 10% of body Posterior Torso 18%
surface area Each Leg 14%
Each Arm 9%
Perineum 1%
 Kinds of Burns
• Scald Burn: most frequent in home injuries; hot
water, liquids and foods are most common causes;
above 65o C, cell death
• Flame Burn: due to gasoline, kerosene, liquified
petroleum gas (LPG) or burning houses
• Chemical Burn: common in industries and
laboratories but may also occur at home; acid is
more common than alkali
• Electrical Burn: worse than the other types; with
entrance and exit wounds; may stop the heart and
depress the respiratory center; may cause
thrombosis and cataracts
• Radiation Burn: from X-ray, radioactive radiation
and nuclear bomb explosions
 Physiological Response
• Typically, biphasic response
• The initial period of hypofunction manifests as: (a)
Hypotension, (b) Low cardiac output, (c) Metabolic acidosis,
(d) Ileus, (e) Hypoventilation, (f) Hyperglycemia, (g) Low
oxygen consumption and (h) Inability to thermoregulate
• This ebb phase occurs usually in the first 24 hours and
responds to fluid resuscitation
• The flow phase, resuscitation, follows and is characterized by
gradual increases in (a) Cardiac output, (b) Heart rate, (c)
Oxygen consumption and (d) Supranormal increases of
temperature
• This hypermetabolic hyperdynamic response peaks in 10-14
days after the injury after which condition slowly recedes to
normal as the burn wounds heal naturally or surgically closed
by applying skin grafting
 MANAGEMENT
• PREHOSPITAL
• Stop the burning process (remove the involve
clothing)
• Adequacy of airway and ventilation and
assessment of the cardiac status and
peripheral perfusion.
• Compromised airway  endotracheal intubation
• Inhalation injury (CO) or cyanide intoxication 
100% oxygen delivered by a non-rebreather mask.
• Prehospital intravenous fluid (Ringer lactate) is
beneficial in patients with extensive burns (greater
than 20% TBSA)
• Burns should be covered with a clean dressing.
(Care should be taken to minimize
hypothermia)
 MANAGEMENT
• Emergency Department
1. Airway Management 
Endotracheal intubation; stiff burn
eschar  Escharotomies
2. Patients with severe burns require
a catheter to monitor urine output,
continuous cardiac and oxygen
saturation monitoring, arterial blood Burn patients should be resuscitated
pressure. with only
3. Circulation and fluid resuscitation as much fluid as is necessary to
maintain organ perfusion.
• Patients with small burns (less than 20%
TBSA in adults and less than 10-15% TBSA Organ perfusion can be estimated
in children) can be successfully treated by heart rate, blood pressure, level
with oral fluids only of consciousness, capillary refill,
• Larger burns, intravenous fluid and a urine output of
resuscitation is required to restore 0.5 to 1.0 mL/kg/hr in adults
intravascular volume and prevent the or 1.0 to 1.5 mL/kg/hr in children
development of hypovolemic shock
Pharmacologic Therapies
• Minor pain :
• Oral acetaminophen (1 g in adults or 15 mg/kg in children every 4 to 6 hours)
or
• an NSAID such as ibuprofen (400-800 mg in adults or 10 mg/kg in children)
every 6 to 8 hours.
• Moderate to severe burn pain is managed with parenteral opioids;
• Morphine sulfate 0.05-0.1 mg/kg
ELECTRICAL INJURY
• Direct contact
• Caused by generated electrical current passing through the
body. 
• Symptoms range from skin burns, damage to internal
organs and other soft tissues to cardiac arrhythmias and
respiratory arrest. 
• The severity of electrical injury depends on Kouwenhoven’s
factors :
• Type of current (direct [DC] or alternating [AC])
• Voltage and amperage (measures of current strength)
• Duration of exposure (longer exposure increases injury severity)
• Body resistance
• Pathway of current (which determines the specific tissue
damaged)
ELECTRICAL INJURY
• Tissue damage due to electrical exposure is caused primarily by the
conversion of electric energy to heat, resulting in thermal injury.
• If skin resistance is high, more electrical energy may be dissipated at
the skin, resulting in large skin burns but less internal damage.
•  If skin resistance is low, skin burns are less extensive or absent, and
more electrical energy is transmitted to internal structures.
ELECTRICAL INJURY
• Low electrical field strength causes an immediate, unpleasant
feeling (being “shocked”) but seldom results in serious or
permanent injury.
• Application of high electrical field strength causes thermal or
electrochemical damage to internal tissues
• Damage may include hemolysis, protein coagulation,
coagulation necrosis of muscle and other tissues, thrombosis,
dehydration, and muscle and tendon avulsion.
• Massive edema may also cause hypovolemia and hypotension.
Muscle destruction can result in rhabdomyolysis and
myoglobinuria, and electrolyte disturbances. Myoglobinuria,
hypovolemia, and hypotension increase risk of acute kidney
injury.
ELECTRICAL INJURY

DIAGNOSIS TREATMENT
• Head to toe examination • Shutting off current
• Sometimes ECG, cardiac enzyme
• Resuscitation
measurement, and urinalysis
• Analgesia
• Cardiac monitoring for 6 to 12 h
• Wound care
Thoracic Trauma
Primary Survey
• The principal aim of the primary survey is to identify and treat
immediately life-threatening conditions. The life-threatening chest
injuries are:
• Tension Pneumothorax
• Massive Haemothorax
• Open Pneumothorax
• Cardiac Tamponade
• Flail chest
Secondary Survey
• The secondary survey is a more detailed and complete
examination, aimed at identifying all injuries and planning
further investigation and treatment. Chest injuries identified on
secondary survey and its adjuncts are:
• Rib Fractures & flail chest
• Pulmonary contusion
• Simple pneumothorax
• Simple haemothorax
• Blunt aortic injury
• Blunt myocardial injury
• monitoring adjuscts
• oxygen Saturation
• End-tidalCO2(if intubated)
• diagnostic adjuscts
• Chest X-ray
• FAST ultrasound
• Arterial Blood Gas
• Intervention
• chest drain
• Thoracotomy
 Chest injuries
ö TENSION PNEUMOTHORAX :
ö Pathophysiology “one-way valve” :
ö Penetrating / blunt chest injury
ö Parenchymal lung injury fails to seal
ö Inspiration: air  pleural
ö Expiration: air stucked in pleural

ö Signs :
ö Chest pain, Tachycardia, Hypotension
ö Tracheal deviation away from the affected side
ö Lack of/decreased breath sound on affected side
ö Subcutaneous emphysema on the effected side
 Chest injuries
ö TENSION PNEUMOTHORAX :
ö Management :
ö Immediate decompression
ö 14-gauge angiocatheter in the 2nd ICS in the midclavicular
line of the affected side
ö Repeated reassessment is necessary
ö Definitive treatment : insertion of a chest tube
Tension pneumothorax
Needle decompression
 Chest injuries
ö Open Pneumothorax :
ö Large defects of the chest wall that remain open
results in an open pneumothorax ( sucking chest
wound )

ö Pathophysiology :
ö If wound is 2/3 of the tracheal  chest wall defect
with each respiratory effort  effective ventilation
is impaired

ö Signs : Hypoxia, Hypercabia

 Chest injuries
ö Open Pneumothorax :
ö Management :
ö Closing the deffect
ö Sterile oclusive dressing
ö Large, overlap the wound
ö Taped securely on 3 side
ö Inspiration: prevented air entering
ö Expiration: air escape from pleural
ö Definitive treatment: surgical closure
open pneumothorax
Dressing for treatment
Massive Hemothorax
• Accumulation of blood >1500 mL or 1/3 or more of the patient’s blood
volume in chest cavity
• Sign and symptoms:
• Neck veins may be flat or distended
• Dullness
• Hypotension
• Absence of breath sounds
• Management
• Large caliber IV line and crystalloid
• Type specific blood is adminiestered
• Chest tube (at the nipple level, just anterior to the midaxillary line)
Flail Chest and Pulmonary Contusion
• Occurs when a segment of the chest wall does not have bony continuity
with the rest of the thoracic cage.
• This condition results from trauma associated with multiple rib fractures.
• Diagnosis :
• Inspection :Flail chest may not be apparent initially if patient’s chest wall has
been splinted  move air poorly, movement of the thorax will be asymmetrical
and uncoordinated.
• Palpation : abnormal respiratory motion and crepitation of rib or cartilage
fractures
• Chest x-ray  multiple rib fractures
• Initial treatment of flail chest includes adequate ventilation,
administration of humidified oxygen, and fluid resuscitation.
• Definitive treatment is to ensure adequate oxygenation, administer
fluids judiciously, and provide analgesia to improve ventilation.
Myocardial Rupture
• Acute traumatic perforation of ventricle or atria, but may also include
othe part of heart
• Delayed rupture may occur as a result of necrosis or infarcted
myocardium
• A rupture occurs during closure of the outflow track when there is ventricular
compression of blood-filled chambers by a pressure sufficient to rupture the
chamber wall, septum, or valve. (occurs in diastole or early systole)

• The atria are most susceptible to rupture by sudden compression in late

systole when these chambers are maximally distended with venous blood and
the atrial ventricular valves are closed

• The immediate ability of the patient to survive cardiac rupture depends on the
integrity of the pericardium. Two thirds of patients with cardiac rupture have
an intact pericardium and are protected from immediate exsanguination.
• In a review of survivors of myocardial rupture, common symptoms
and signs included hypotension (100%); elevated CVP (95%);
tachycardia (89%); distended neck veins (80%); cyanosis of the head,
neck, arms, and upper chest (76%); unresponsiveness (74%); distant
heart sounds (61%); and associated chest injuries (50%).
• The following findings are suggestive of pericardial rupture:
1. Hypotension disproportionate to the suspected injury
2. Hypotension unresponsive to rapid fluid resuscitation
3. Massive hemothorax unresponsive to thoracostomy and fluid
resuscitation
4. Persistent metabolic acidosis
5. The presence of pericardial effusion on echocardiography or
elevation of CVP and neck veins with continuing hypotension despite
fluid resuscitation
Abdominal Trauma
Abdominal
Injury
Abdominal trauma
• Abdominal trauma accounts for 15% to 20% of all trauma deaths
• The most common mechanism for blunt abdominal trauma is a motor
vehicle collision
• Patient who survive the initial traumatic insult are at risk for infection
and suffer mortality or morbidity secondary to sepsis

Tintinalli’s Emergency Medicine 8th edition

• Blunt abdominal trauma :
• Motor vehicle collision  compressive, shearing or stretching, and
acceleration/deceleration forces impact the abdominal cavity differently 
abdominal wall, solid organ or hollow viscous injuries

Tintinalli’s Emergency Medicine 8th edition

• Penetrating abdominal trauma :
• Stab and gunshot wounds and the transmitted energy of the blast; secondary
missiles as fragmented bone  traumatic burden

Tintinalli’s Emergency Medicine 8th edition

• Clinical features :
• Physical examination :
• Inspect the abdomen for external signs of trauma
• Palpate the abdomen in all quadrants  tenderness, tympany, or rigidity
• Abdominal wall injuries :
• Direct blow or indirectly via a sudden muscular contraction  contusions of the
abdominal wall musculature

Tintinalli’s Emergency Medicine 8th edition

• Solid organ injuries :
• Due to blood loss  increase pulse pressure, tachycardia, hypotension
• Splenic injuries  referred pain into the left shoulder or arm
• Hollow viscous and mesenteric injuries :
• Combination of blood loss and peritoneal contanmination by Gi contents

Tintinalli’s Emergency Medicine 8th edition

• Retroperitoneal injuries :
• Pancreatic injuries  from rapid deceleration
• Duodenal injuries  asymptomatic on presentation and a small hematoma of
the duodenum may go undiagnosed  gastric outlet obstruction develop
• Diaphragmatic injuries :
• Spasm  secondary or direct blow to the epigastrium
• Rupture  penetrating injury or blunt trauma

Tintinalli’s Emergency Medicine 8th edition

• Diagnosis :
• USG (FAST)  accurate, rapid, noninvasive, repeatable, and portable and
involves no nephrotoxic contrast material or ionizing radiation exposure to
the patient
• CT scan with IV contrast  gold standard

Tintinalli’s Emergency Medicine 8th edition

• Treatment :
• Laparotomy  gold standard therapy

Tintinalli’s Emergency Medicine 8th edition

Pelvic Trauma
PELVIC TRAUMA
What Type Of Fracture(s) Is It?
Lateral Compression Injuries
The most common type of pelvic fracture
The causative force is delivered laterally, as might occur in a “Tbone”
motor vehicle crash or when a pedestrian is struck from the side.
Laterally directed forces cause inward displacement of the ipsilateral
hemipelvis, hinging on the sacroiliac joint.

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Anterior-Posterior Compression Injuries
Anterior-posterior compression fractures account for
20% to 30% of pelvic ring injuries.51 The force vector is
delivered directly to the front of the patient, as might
occur during a head-on motor vehicle crash or when a
pedestrian is struck in the same manner.
A force vector delivered to the anterior elements of the
pelvic ring causes diastasis of the symphysial
ligaments and/or fracture of the pubic rami. With
progressive disruption of the anterior elements of the
pelvis, the posterior ring is pulled apart, usually
through the sacroiliac joint. These injuries are often
referred to as “open book” pelvic fractures.
Vertical Shear Injuries
Vertical shear injuries may result from a fall on the
extended extremity or from a headon motor
vehicle crash in which the occupant has the leg
braced against the brake pedal or the floorboard.
Significant vertically oriented forces cause disruption
of both the anterior and posterior pelvic rings,
forcing one hemipelvis up relative to the other.
Severe ligamentous injury is the rule.
Pelvic injuries
• Clinical presentations :
• Tenderness, laxity, or instability on palpation of the bony pelvis
• Hematuria
• A hematoma over the ipsilateral flank, inguinal ligament, proximal thigh, or in
the perineum
• Neurovascular deficits in the lower extremities
• Rectal bleeding
Pelvic injuries
• Complications :
• The incidence of deep venous thrombosis ↑
• Continued bleeding from fracture or injury to pelvic vasculature
• GU problems from bladder, urethral, prostate, or vaginal injuries : the
incidence of urethral injuries varies by the type of pelvic fracture
• Sexual dysfunction, infections from disruption of bowel or urinary system,
chronic pelvic pain ( more so if the sacroiliac joints are involved )