Third Problem

“Destructive Giant Mushroom”

Group 17&18
Emergency Block
Friday, October 14th 2022
Tutor : SHIRLY GUNAWAN dr., Sp. FK.
Discussion Leader : OLIVIA LARISSA
Writer : SILVIE ANASTASYA GINTING
Secretary : WINDY HAZMI FADHILAH
Group 17 Group 18

No. NIM Nama No. NIM Nama

1. 405190002 NADILA PUTRI MAHARANI 1. 405190013 WINDY HAZMI FADHILAH

2. 405190012 SILVIE ANASTASYA GINTING 2. 405190019 WENDY TAN

3. 405190020 MARIA EDELIN FORTUNA 3. 405190043 BELINDA JUNITIA

4. 405190088 LOUIS VALDO 4. 405190084 FAIZ AGUNG HERMAWAN

5. 405190100 IDA BAGUS PUTRA SURYA 5. 405190121 ALIFIA NADYRA FASYA

WIBAWA

6. 405190170 MICHELLE CATHERINE 6. 405190161 TALITHA ZHAFIRAH

7. 405190185 OLIVIA LARISSA 7. 405190192 I GUSTI AYU TANIA DWI

CAHYANTI

8. 405190197 FATHIYAH 8. 405190196 ALBERT HENDRICO

 THIRD PROBLEM
“Destructive
A massive explosion rocked a busy harbour Giant
in the morning, Mushroom”
flattening one of the city port's block. More than 100 people
were killed and many were injured. You are a part of the emergency response team who are stationed in an emergency
department near the scene. At that moment, 4 victims who were evacuated from various distance around the epicentre are
brought to the ED.

The first patient, a middle-aged female, saved from the rubble. She is coughing and has multiple bruises on her left side of
abdomen and left flank. She looks pale and is complaining of severe abdominal pain. There are visible swellings over her
left flank. She also says that her hip feels painful and cannot move her legs. Her blood pressure is 80/50 mmHg, heart rate
is 110 beats per minute and respiratory rate is 28 breaths per minute. Her hip appears deformed and she groans with pain
whenever she tries to move.

The second patient, a young boy, is conscious. He is crying for help because he cannot move any of his extremities and
needs to be carried. There is a hematoma on his back without any apparent bleeding. He says that his arms and legs feel
numb and he cannot move neither his arms nor his legs. His blood pressure is 80/50 mmHg, heart rate is 118 beats per
minute and respiratory rate is 26 breaths per minute.

The third patient, an elderly female, appears drowsy, breathless and disoriented. A piece of steel stabbed her left chest.
She also has a laceration wound at her forehead, just an inch to her right eye. Her GCS is 8, blood pressure is 90/60
mmHg, heart rate is 58 beats per minute and respiratory rate is 36 breaths per minute.

The fourth patient, a young male, has burns all over his trunk. His clothes seemed to have caught on fire while he was
trapped in the scene. He is writhing in severe pain. There are also burn injuries on his back and neck and. His blood
pressure is 100/60 mmHg, heart rate is 110 beats per minute and respiratory rate is 26 breaths per minute.

Discuss the cases, assess the condition of all the patients, make a priority plan to transfer the patients and plan proper
treatment while considering coronavirus pandemic situation and all possible differentials!
Learning Issues
1. MM. Triase
2. MM. Tanda & Gejala Kegawatdaruratan, awal manajemen, komplikasi, & prognosis, Primary
& Secondary Survey
a. Trauma Abdomen (Blunt Wounds & Luka Penetrasi)
b. Trauma Pelvis (Pelvic Fracture)
c. Trauma dada (tension pneumothorax, cardiac tamponade, pulmonary contusion, open
pneumothorax, hemothorax)
d. Trauma kepala (EDH SDH SAH ICH)
e. Spinal Cord trauma ( Complete spinal transection & acute medulla compression)
f. Luka bakar (Chemical & electrical), Menghitung derajat luka bakar, trauma inhalasi
3. MM. Rehidrasi cairan untuk resusitasi cairan
4. MM. Obat Anestesi pada kasus emergensi
LI 1 MM. Triase

• Assessment triage: RPM

• Respiration
• Perfusion
• Mental status

Tintinalli’s Emergency Medicine: A Comprehensive

Study Guide. 7th ed. 2011
Rosen’s Emergency Medicine. 2017
https://chemm.nlm.nih.gov/StartAdultTriageAlgorithm.pdf
https://chemm.nlm.nih.gov/StartPediatricTriageAlgorithm.pdf
Management
• Primary survey & resusitasi awal: (ABCDE assessment in 10 secs → tanya nama dan apa yg
terjadi, jk bisa menjawab tanpa hambatan tdk tdp ggn respirasi atau ggn kesadaran)
• Airway maintenance with restriction of cervical spine motion:
• patenkan jalan napas dan pastikan tidak ada trauma servikal
• jk ada trauma servikal segera imobilisasi servikal
• Breathing and ventilation:
• Oksigenasi
• Pasang pulse oximetry u/ memantau oksigenasi
• Circulation with hemorrhage control:
• Lihat warna kulit (t.u di wajah dan ekstremitas) u/ mengetahui perfusi
• Cek pulsasi
• Cari adanya sumber perdarahan external → dab perdarahan → jk tdk berhasil, pasang torniket (hati2 iskemik)
• Disability(assessment of neurologic status):
• Pemeriksaan GCS
• Exposure/Environmental control:
• Hindari hipotermia
ATLS. 10th ed. 2018
 LI 2 Blunt Abdominal Trauma
•A direct blow, such as contact with the
lower rim of a steering wheel, bicycle or
Diagnosis
motorcycle handlebars, or an intruded
door in a motor vehicle crash.
•Shearing injuries are a form of crush
injury that can result when a restraint
device is worn inappropriately.
•The organs most frequently injured :
spleen (40% to 55%), liver (35% to 45%),
and small bowel (5% to 10%).

Clinical features
Abdominal wall injuries : Contusions of the abdominal wall musculature may result
either from a direct blow or indirectly via a sudden muscular contraction. Symptoms
include pain and possibly soft tissue swelling or a hematoma.
Solid organ injuries : Signs and symptoms of a solid organ injury are generally due to
pain and blood loss. As blood loss continues, heart and respiratory rate increase and
urinary output drops. Patients may also become anxious and confused. Hypotension
may not occur until the circulating blood volume significantly decreases.
Hepatic and splenic injuries are at high risk for hemorrhage in both penetrating and
Source : ATLS 10TH Edition Student Manual.
blunt abdominal trauma.
Treatment

•Laparotomy : the gold standard therapy

for significant intraabdominal injuries. It is
definitive, rarely misses an injury, and
allows for complete evaluation of the
abdomen and retroperitoneum.

Source: Clinical Emergency Medicine-McGraw-

Hill_Lange(2014): Scott C. Sherman et al.

Source : Tintinalli's emergency medicine: a comprehensive

study guide
 Penetrating Abdominal Trauma
● Stab wounds and low-velocity gunshot wounds → tissue damage
by lacerating and cutting
● High-velocity gunshot wounds → increased damage surrounding
the track of the missile due to temporary cavitation
● Stab wounds
→ liver (40%), small bowel (30%),
diaphragm (20%), and colon (15%)
● Gunshot wounds
→ small bowel (50%), colon (40%), liver (30%), & abdominal vascular
structures (25%)
● Explosive devices cause injuries
→ penetrating fragment wounds and blunt injuries from the patient being
thrown or struck

Advanced Trauma Life Support (ATLS), 10th Edition. American College of Surgeon; 2018.
Clinical Emergency Medicine Lange
 Indications for Laparotomy

Tintinalli’s Emergency Medicine

Rosen's Emergency
Medicine - Concepts
and Clinical Practice
 Pelvic Fractures
Mechanism of Injury and Classification
• Pelvic ring injury can occur following a motor vehicle crash, motorcycle
crash, pedestrian–vehicle collision, direct crushing injury, or fall.
• Pelvic fractures are classified into four types, based on injury force patterns:
AP compression, lateral compression, vertical shear, and combined
mechanism.

ATLS 2018
https://www.bjaed.org/action/showPdf?pii=S2058-5349%2818%2930050-7
Pelvic Fractures
• A sheet, pelvic binder, or other device
can produce sufficient temporary
fixation for the unstable pelvis when
applied at the level of the greater
trochanters of the femur
• External pelvic binders are a temporary
emergency procedure. 🡪 Tight binders
or those left in position for prolonged
time periods can cause skin breakdown
and ulceration over bony prominences.
• Angiographic embolization is
frequently employed to stop arterial
hemorrhage related to pelvic fractures.
🡪 Preperitoneal packing is an
alternative method to control pelvic
hemorrhage when angioembolization
is delayed or unavailable.

ATLS 2018
Pelvic Fractures
Definitive management of
patients with hemorrhagic
shock and pelvic fractures
Significant resources are
required to care for patients
with severe pelvic fractures.
Early consideration of transfer
to a trauma center is essential.

ATLS 2018
 Tension Pneumothorax
Pneumothorax, which is the accumulation of air in the pleural
space, is a common complication of chest trauma.
It is reported to be present in 15% to 50% of patients who sustain
significant chest trauma and is invariably present in those with
transpleural penetrating injuries.

Clinical Features
❏ Chest pain, air hunger, tachypnea, respiratory distress,
tachycardia, hypotension, tracheal deviation away from the
side of the injury, unilateral absence of breath sounds, neck
vein distention, cyanosis (late manifestation).

Advanced Trauma Life Support. 10th Edition.

Rosen’s Emergency Medicine Concepts and Clinical Practice. 9th Edition.
 Tension Pneumothorax
Diagnostic Testing Management

❏ Radiografi ❏ Chest tube

❏ Ultrasound

Advanced Trauma Life Support. 10th Edition.

Rosen’s Emergency Medicine Concepts and Clinical Practice. 9th Edition.
 Open Pneumothorax

The clinical signs and

symptoms
❏ Pain, difficulty
breathing,
tachypnea,
decreased breath
sounds on the
affected side, and
noisy movement of
air through the chest
wall injury.
Advanced Trauma Life Support. 10th Edition.
Rosen’s Emergency Medicine Concepts and Clinical Practice. 9th Edition.
 Chest trauma - Pulmonary Contusion
• Pulmonary contusion → bruise of the
lung.
• Blood and other fluids accumulate →
interfering with ventilation → hypoxia.
• Can occur without rib fractures or flail
chest, particularly in young patients
without completely ossified ribs.
• Children have far more compliant chest
walls than adults
• In adults is most often encountered with
concomitant rib fractures & potentially
lethal chest injury.
ATLS 2018
 Chest trauma - Pulmonary Contusion
• Initial treatment of flail chest and
pulmonary contusion includes
administration of humidified oxygen,
adequate ventilation, and cautious fluid
resuscitation.
• Hypoxia & other medical conditions →
intubation and ventilation within the
first hour after injury.
• Definitive treatment of flail chest and
pulmonary contusion involves ensuring
adequate oxygenation, administering
fluids judiciously, and providing
analgesia to improve ventilation.
ATLS 2018
Hemotoraks
•Accumulation of more than 1500 ml of
blood or one-third or more of the
patient’s blood volume in the chest
cavity -> compromise respiratory efforts
by compressing the lung and preventing
adequate ventilation.
•Physical examination:
•Shortness of breath and dyspnea
•Hypotension and shock
•Dullness percussion can suggests a massive
hemothorax
Management
•Airway, breathing, and circulation
•Hypotensive -> IV line fluid resuscitation (crystalloid /
lactated Ringer solution), including blood transfusion as
necessary
•Evaluate for the possibility of tension pneumothorax. Needle
decompression of a tension pneumothorax may be necessary
•Chest tube
•Respiratory distress à thoracostomy
Cardiac Temponade
pericardiocentesis
Trauma Kepala
Epidural hematoma
EDH
Subdural Hematoma
● A subdural hematoma (SDH), which is a collection of venous blood between the dura mater and the
arachnoid, results from tears of the bridging veins that extend from the subarachnoid space to the
dural venous sinuses.
● Subdural hematomas have been classified as acute, subacute, or chronic.
● Acute subdural hematoma develops immediately after head trauma and can be lifethreatening.
● Headache is the most common symptom, with contralateral hemiparesis, seizures, and a wide
variety of cortical dysfunction also common.
● If sufficiently large→increased intracranial pressure with a resulting alteration in the level of
consciousness.
● Chronic subdural hematoma typically develops after mild head trauma, and is more common in the
elderly, particularly those who are anticoagulated.
● Like the acute variety, chronic subdural hematoma results in a variety of neurologic symptoms,
including hemiparesis, seizures, and behavioral changes.

Tintinalli's Emergency Medicine: A

Comprehensive Study Guide 7th ed
Blueprints Neurology
 Evaluation
● On CT-scan, acute subdural hematomas are
hyperdense (white), crescent shaped lesions
that cross suture lines.
● Subacute subdural hematomas are isodense
and are more difficult to identify. CT scanning
with IV contrast or MRI can assist in
identifying a subacute subdural hematoma.
● A chronic subdural hematoma appears
hypodense (dark) because the iron in the
blood is phagocytized.

Tintinalli's Emergency Medicine: A

Comprehensive Study Guide 7th ed
Treatment
● The definitive treatment of subdural hematoma depends on the type and on associated brain
injuries.
● Mortality and the need for surgical repair are greater for acute and subacute subdural hematomas.
● Acute subdural hematoma may require treatment with surgical drainage depending on the severity
and progression of the clinical deficit.
● A chronic subdural hematoma may resolve on its own; indications for operation include rapidly
expanding lesions and progressive clinical deficits.
● Anticoagulation should be discontinued to offer the best chance of resolution.

Tintinalli's Emergency Medicine: A

Comprehensive Study Guide 7th ed
Blueprints Neurology
Subarachnoid Hemorrhage
Subarachnoid hemorrhages are life-
threatening and result from the accumulation
of blood between the arachnoid and pia
mater.

Patel, S., Parikh, A. & Okorie, O.N. Subarachnoid hemorrhage in the emergency department. Int J Emerg Med 14, 31 (2021). https://doi.org/10.1186/s12245-021-00353-w
 Diagnosis Treatment
•ABC (Airway, Breathing, Circulation)
•If presence of hydrocephalus à
placement of an external ventricular drain
•Tight control of blood pressure until an
aneurysm is also secured is necessary.
•BP maintan < 160 mmHg (optimally
within the 140 mmHg range)
•Seizure prophylaxis should be initiated
•Glasgow coma scale (GCS) score < 8 à
secure an airway.
•Early intervention to secure an aneurysm

Ziu E, Mesfin FB. Subarachnoid Hemorrhage. [Updated 2021 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK441958/ti
Patel, S., Parikh, A. & Okorie, O.N. Subarachnoid hemorrhage in the emergency department. Int J Emerg Med 14, 31 (2021). https://doi.org/10.1186/s12245-021-00353-w
 Prognosis Complications

Prognosis -> The prognosis depends -Seizures

on the cause and grade of
subarachnoid hemorrhage, and the -Vasospasm
presence of other complications. -Re-bleed
-Hydrocephalus
-Increased intracranial pressure
-Brain herniation
-Cerebral infarction
-Medical complications
-Neurogenic pulmonary edema
-Death
Ziu E, Mesfin FB. Subarachnoid Hemorrhage. [Updated 2021 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK441958/ti
Patel, S., Parikh, A. & Okorie, O.N. Subarachnoid hemorrhage in the emergency department. Int J Emerg Med 14, 31 (2021). https://doi.org/10.1186/s12245-021-00353-w
 Intracerebral Hemorrhage
• Hemorrhage directly into the brain
parenchyma
• The two major underlying causes of ICH are
hypertensive vasculopathy and cerebral
amyloid angiopathy
• The classic presentation:
• the sudden onset of headache, vomiting,
severely elevated BP, and focal neurologic
deficits that progress over minutes.
• a motor and sensory deficit contralateral to the
brain lesion.

Rosen's Emergency medicine

Clinical Emergency
Medicine Lange,
2014.
Rosen's Emergency
medicine
Treatment:
● Supportive care
involving attention to
airway management
and perfusion is of the
highest priority.
● BP reduction,
anticoagulation reversal,
and hemostatic therapy.

Rosen's Emergency medicine

Clinical Emergency Medicine Lange,
2014.
 Spinal Cord Trauma
•Spinal cord injury (SCI) is a serious medical condition, which often results in severe
morbidity and permanent disability. It occurs when the axons of nerves running through the
spinal cord are disrupted, leading to loss of motor and sensory function below the level of
injury. Injury is usually the result of major trauma, and primary injury is often irreversible.
Etiology
•the leading cause of spinal cord injury is motor vehicle collisions, constituting 38% of new
SCI each year. 30% are due to falls, 13% due to violence, 9% from sports injuries, and 5%
from medical and surgical etiologies.
Pathophysiology
•Spinal cord injuries are most often due to either direct trauma to the spinal cord or from
compression due to fractured vertebrae or masses such as epidural hematomas or
abscesses. Less commonly, the spinal cord may become injured due to compromise of blood
flow, inflammatory processes, metabolic derangements, or exposure to toxins.
https://www.ncbi.nlm.nih.gov/books/NBK560721/
 Complete Transection of the Spinal Cord
SCI is graded using the American Spinal Injury Association (ASIA)
•These injuries typically demonstrate complete Impairment Scale. The grading system varies based on the severity of
bilateral loss of motor function, pain sensation, injury from letters A to E.
temperature sensation, proprioception, vibratory
sensation, and tactile sensation below the level of 1.ASIA A: Complete injury with loss of motor and sensory function.
injury.
2.ASIA B: Incomplete injury with preserved sensory function, but
•Lumbosacral injuries will present with paralysis and
complete loss of motor function.
loss of sensation in the lower extremities. These
injuries may also result in loss of bowel control, loss 3.ASIA C: Incomplete injury with preserved motor function below the
of bladder control, and sexual dysfunction. injury level, less than half these muscles have MRC (Medical Research
•Thoracic injuries lead to the same deficits as Council) grade 3 strength.
lumbosacral injuries and, in addition, may result in
loss of function of the muscles of the torso, leading 4.ASIA D: Incomplete injury with preserved motor function below the
to difficulty maintaining posture. injury level, at least half these muscles have MRC (Medical Research
Council) grade 3 strength.
•Cervical injuries lead to the same deficits as
thoracic injuries and, also, may result in loss of 5.ASIA E: Normal motor and sensory examination.
function of the upper extremities leading to
tetraplegia. Injuries above C5 may also cause
respiratory compromise due to loss of innervation of
the diaphragm.

https://www.ncbi.nlm.nih.gov/books/NBK560721/
 Treatment
•Prehospital care:
•Spine motion restriction: immobilization of the entire spine at the scene with a rigid cervical collar
(or similar devices) plus a long backboard.

•Initial ED stabilization:
•ABC:
•any patient with an injury at C5 or above should have the airway secured by endotracheal
intubation.
•Hypotension is initially treated with IV crystalloid
•Fluid resuscitation is often ineffective in such patients and may result in fluid overload. Thus, when
there is persistent hypotension despite fluids, we recommend vasopressor support with
norepinephrine to be started at 0.05 μg/kg/min and titrated upward to a maximum dose of 1
μg/kg/min to achieve an MAP of 85 mmHg
•A Foley catheter inserted to prevent bladder distention and monitor fluid output.

•Tatalaksana Spesifik
•Bedah: mengatasi gangguan spinal cord yg diebabkan benda asing, herniasi diskus, fragmen fraktur
tulang atau epidural hematoma; stabilisasi trauma tulang berat; mengurangi dislokasi vertebra
Rosen’s Emergency Medicine. 2017
Acute Medulla Compression
• Kompresi medula akut adalah
penekanan pada medula
Etiologi Gambaran Klinis
• Nyeri ditemukan pada 90-95%
spinalis yang disebabkan oleh • Osteoarthritis pasien
tumor,abses trauma dan
penyakit tertentu yang dapat
• Scoliosis • Nyeri punggung local
• Nyeri radicular
menekan medula spinalis dan • Injury to the spine
mengganggu fungsi • Kelemahan pada kaki
normalnya.
• Spinal tumor
• Kelainan sensoris
• Kompresi medulla akut • Certain bone diseases • Disfungsi anatomis
termasuk dalam kategori • Rheumatoid arthritis
Medical Emergency
dikarenakan perlunya
• infection
penanganan dan diagnosis Fraser Health Hospice Palliative Care Program

secara cepat untuk mencegah Symptom Guidelines. Spinal Cord Compression.

terjadinya disabilitas jangka

panjang
Indonesia, K. K.akibat
2012. Standarefek ireversibel
kompetensi dokter Indonesia.

dari kompresi medulla spinalis

Jakarta: Konsil Kedokteran Indonesia.
Diagnosis Klinis & Diagnosis
Penunjang
• Pemeriksaan neurologis
• Pemeriksaan lokasi tumor primer
• Pemeriksaan foto polos vertebra
• MRI vertebra
• Tidak dianjurkan melakukan Pungsi Lumbal
bila dicurigai adanya kompresi medula
spinalis
Terapi Farmakologi Terapi Non-Farmakologi
● Dexametason 10-100 ● Radioterapi
mg iv kemudian 16-96 ● Terapi bedah
mg/hari tapering off
dalam 10-14 hari
apabila ada perbaikan.

The management of acute spinal cord compression. Journal of

neurology,neurosurgery, and psychiatry,
 Thermal Burn

Rosen's Emergency Medicine Concepts and Clinical Practice. 9th Edition. Volume 1. Tintinalli’s Emergency Medicine Manual-McGraw-Hill. 2017. ATLS 2018. 10 Edition
 Primary Survey
1. Stop the burning process
2. Airway Control
3. Breathing control
4. Circulation

Rosen's Emergency Medicine Concepts and Clinical Practice. 9th Edition. Volume 1. ATLS 2018. 10 Edition
Secondary Survey
• Documentation
• Evaluations for Patients with
Major Burns
• Gastric Tube Insertion
• Acetaminophen (500mg/6hrs) or
NSAID (ibuprofen 400mg/8hrs) 🡪
mild to moderate pain
• Opioid (fentanyl 1-2 mcg/kg or
morfin 0,1mg/kg) 🡪 more severe
pain

Rosen's Emergency Medicine Concepts and Clinical Practice. 9th Edition. Volume 1. Tintinalli’s Emergency Medicine Manual-McGraw-Hill. 2017. Burn injury - PMC (nih.gov) ATLS 2018. 10 Edition
Chemical Burn

Tintinalli’s Emergency Medicine Manual-McGraw-Hill. 2017.

ATLS 2018. 10 Edition
Tintinalli’s Emergency Medicine Manual-McGraw-Hill. 2017.
LI 3 MM. Rehidrasi Cairan Signs and Symptoms:
1. Mild Hypovolemic Shock (<20% blood volume):
Untuk Resusitasi Cairan • Cold extremities
• Increased capillary refill time
Trauma → Hemoragic Shock • Diaphoresis Collapsed veins Anxietyhypovolemic
Management and treatment: 2. Moderate hypovolemic shock (20-40% blood volume)
• placing the patient in an elevated position, maintaining the • Same, plus:
airway, and administering IV fluid resuscitation or with a • Tachycardia, Tachypnea, Oliguria, Orthostatic hypotension
central venous catheter The pressure (CVP) or intra-
arterialroute
3. Severe hypovolemic shock (>40% blood volume)
• Same plus:
• Fluid given is isotonic saline dripping rapidly (be careful of • Hemodynamic instability, symptomatic tachycardia, hypotension, altered
hyperchloremic acidosis) or Lactated Ringer's. consciousness
administration of 2-4L in 20-30 minutes is expected to
restore hemodynamic conditions
• if hemodynamics is not stable, meaning bleeding or fluid
loss has not been resolved. blood loss with Hb level <10
g/dL requires blood replacement by transfusion
• in severe or prolonged hypovolaemia, inotropic support
with dopamine, vasopressin or dobutamine can be given.

Fluids : Crystaoid or Coloid

Thermal Injury Fluid Resucitation
LI 4 MM. Obat Anestesi Pada Kasus Emergensi
Local Anesthesia
● Anesthetic agents (except cocaine) → vasodilators →
which tend to shorten the duration of anesthesia.
Injection of the solutions into vascular tissues,
increases systemic absorption and the chance of
systemic toxicity when larger doses are used →
epinephrine is often added to local anesthetic solutions

Rosen’s Emergency Medicine Concept and Clinical Practice. 9th Edition.

 Topical Anesthesia
Topical Anesthetics Applied to Intact Skin
1. Eutectic Mixture of Local Anesthetics (EMLA) 2. Ethyl Chloride and Fluoromethane Sprays

• • Used for superficial analgesia

Should be applied to the desired area with an
occlusive dressing 30-60 minutes before the • The agents evaporate quickly and cool the
procedure is performed skin, providing brief (<1-minute) local
anesthesia due to the sensation → any
• The duration of action after a 60-minute injection or incision should be made
application is 1-5 hours. immediately after the application of the
agent
• Indications → venipuncture, arterial puncture,
lumbar puncture, or arthrocentesis when a 30-
to 60-minute delay in performing the
procedure is not an impediment

Rosen’s Emergency Medicine Concept and Clinical Practice. 9th Edition.

 Agents Applied to Mucosal Agents Applied to
Surfaces Open Skin
Cocaine Frequently used in the nose, for which a 4% (40 mg/mL) solution • Lidocaine, Epinephrine and
provides rapid anesthesia for the treatment of epistaxis and other
nasal procedures. Although the maximum safe dose is unknown,
Tetracaine
no more than 200 mg is typically applied in adults. Cocaine
should not be used in patients with known coronary artery
• The combination of lidocaine,
disease due to the potential for coronary artery vasoconstriction. epinephrine, and tetracaine, 5-
10 mL, may be applied to an
Lidocaine Both 2% and 4% lidocaine solutions are available in a viscous open wound using sterile
matrix for use on mucosal surfaces. Gel lidocaine can be used in
nasal procedures, including the passing of nasogastric tubes and cotton, which is then covered
gastric lavage tubes. It can also be used for urethral anesthesia and held in place for 10-20
(Foley catheter placement). Lidocaine spray (4% or 10%) is
useful for upper airway anesthesia, including intranasal use for
minutes.
nasogastric tube insertion.

Tetracaine Used for surface anesthesia of the cornea. Tetracaine stings when
placed in the eye, but only for 10-15 seconds, after which there is
excellent corneal anesthesia.

Benzocaine Almost insoluble in water, benzocaine remains on mucous

membranes in the mouth and is commonly used to provide
superficial analgesia for oral procedures and pain.

Rosen’s Emergency Medicine Concept and Clinical Practice. 9th Edition.

Case Discussion
References
• https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Cardiology/
CardiacTamponadeManagementClinicalGuideline.pdf
• Rosen’s emergency medicine: concepts and clinical practice, 9 th Edition. Philadelphia: Elsevier, 2018.
• Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2011
• https://chemm.nlm.nih.gov/StartAdultTriageAlgorithm.pdf
• https://chemm.nlm.nih.gov/StartPediatricTriageAlgorithm.pdf
• ATLS. 10th ed. 2018
• https://www.bjaed.org/action/showPdf?pii=S2058-5349%2818%2930050-7
• Blueprints Neurology
• https://www.ncbi.nlm.nih.gov/books/NBK560721/
• Indonesia, K. K. 2012. Standar kompetensi dokter Indonesia. Jakarta: Konsil Kedokteran Indonesia.
• The management of acute spinal cord compression. Journal of neurology,neurosurgery, and psychiatry.