TRAUMA ABDOMEN & PELVIS

Dr. Hitaputra A.W., SpB FINACS

 Mekanisme trauma abdomen
Trauma tumpul
Luka tembak
Luka tusuk
 Mekanisme trauma abdomen
Mekanisme yang terjadi pada trauma tumpul :
• Kompresi eksternal pada abdomen dapat
terjadi peningkatan tekanan intraabdominal
dan dapat menyebabkan diafragma pecah dan
terjadi hernia diafragmatika yaitu isi rongga
perut masuk ke dalam rongga thorax.
• Jika yang terbentur areanya kecil dan gaya
cukup kuat dapat menyebabkan ruptur organ
padat maupun laserasi organ berongga.
 Trauma Abdomen

• Kematian karena trauma abdomen 

perdarahan intraabdomen yang tidak
terdeteksi

• 6 % kasus  Laparatomy
 Trauma Abdomen

Pemeriksaan fisik dipersulit dg adanya

• Alkohol, obat-obatan
• Trauma kepala, spinal cord injury
• Trauma dinding dada, pelvis, tulang belakang
 Frekuensi

 Lien 46 %
 Hepar 33 %
 Mesenterium 10 %
 Urology 9%
 Pancreas 9%
 Usus halus 8%
 Kolon 7%
 Duodenum 5%
 Mekanisme Trauma

Trauma Tumpul

• Lien, hepar, organ berongga

• Trauma kompresi
• Crush injury
• Deselerasi ( organ yang terfiksir )
 Mekanisme Trauma

Trauma Tembus

• Hepar, usus halus, kolon

• Laserasi ( << )
• Energi kinetik ( >> )
 Anamnesis

Trauma Tumpul

 Kecepatan
 Posisi
 Sabuk pengaman
 Arah trauma
 Benturan
 Anamnesis

Trauma Tembus

 Jenis
 Jarak
 Patofisiologi
• Ruptur organ padat => perdarahan => syok
• Perforasi organ berongga => perdarahan dan
tumpahan isi organ berongga => peritonitis
Bagaimana Penatalaksanaan
trauma abdomen?
 Primary Survey

• A
• B
• C
• D
 Secondary Survey

 Inspeksi
 Palpasi
 Perkusi
 Auskultasi
 Pemeriksaan Penunjang

 DPL ( diagnostic peritoneal lavage )

 USG FAST ( focused abdominal sonography for
trauma )
 CT Scan Abdomen
 Laparoscopy
 Diagnostic Peritoneal Lavage

Kontraindikasi

Absolut  indikasi laparotomy

Relatif  riwayat operasi

obesitas
kehamilan
Diagnostic Peritoneal Lavage (DPL)
 DPL – Interpretasi Hasil

• Darah > 10 ml
• Eritrosit > 100.000/mm3
• Leukosit > 500 / mm3
• Amilase > 175 u/dL
• Enteric content
• Bakteri
Keuntungan(+) Kerugian (-)

• Tidak dapat identifikasi cedera organ

Cepat
• Komplikasi
Trauma Retroperitoneal
minimal
• Sensitifitas
Positif palsu–(spesifitas
1% ) > 90% ( deteksi
• darah intra abdomen
Laparatomy )
non terapeutik
 USG FAST :
Focused Abdominal Sonography for Trauma

• Ada / tidaknya cairan bebas intraabdomen

• Hepatorenal, splenorenal, rectovesica

 USG FAST :
Focused Abdominal Sonography for Trauma

Akurasi  98 %
Sensitifitas  79 – 81 %
Spesifitas  96 – 99 %
 USG FAST :
Focused Abdominal Sonography for Trauma
Keuntungan
 Non invasif
 Murah
 Cepat, portable
 Dapat dilakukan di ruang resusitasi
 Pemeriksaan serial
 USG FAST :
Focused Abdominal Sonography for Trauma
Kerugian
 Operator dependent
 Penyulit : - emfisema sub kutis
- obesitas
- distensi ( gas )
 Tidak dapat deteksi jenis cairan
 Deteksi perforasi organ berongga tdk adekwat
 Akurasi  pmx berulang
 25% cedera organ solid  tdk terdeteksi
 USG FAST :
Focused Abdominal Sonography for Trauma

Koleksi cairan (+) di hepatorenal

Koleksi cairan splenorenal (+)
 CT Scan Abdomen

• Akurasi  91 – 97 %

• Tidak dianjurkan pada px tidak stabil

 CT Scan Abdomen

Keuntungan

• Non invasif
• Deteksi cedera organ
• Hemoperitoneum > 100ml
• Evaluasi retroperitoneum
 CT Scan Abdomen

Kerugian

• Transfer
• Pasien tdk kooperatif
• Komplikasi kontras
• Radiasi ionisasi
• Waktu
• Mahal
CT Scan – Splenic injury
CT Scan – Liver Injury
CT Scan – Liver injury with fluid collections
A large hematoma (closed arrow) of the left kidney
(open arrow)
 Laparoscopy Diagnostik

Keuntungan

• Menunjang CT Scan
• Visualisasi langsung
• Evaluasi ongoing bleeding
 Laparoscopy Diagnostik

Kerugian

• Tidak untuk penderita yang tidak stabil

• Dilakukan di kamar operasi
• Sulit evaluasi seluruh organ berrongga,
retroperitoneum
• Invasif
• Tenaga terlatih
 (+) (-)
Physical exam easy distracting injury
accurate altered mental status
DPL sensitive too sensitive
hollow organ invasive
retro injury missed
CT most useful transport
not for unstable
USG rapid not spesific
sensitive operator dependent
portable, serial
Laparascopy peritoneal anasthesia
penetration not reliable for blunt
Algoritm ( Manual Trauma )
Blunt Abdominal Trauma
ABCs
Haemodinamically Stable Unstable 

CT Abdomen
Solid organ injury Hemoperitoneum
Hemoperitoneum No solid organ injury
Hollow organ
Pancreatic injury
No injury Solid organ injury
Peritoneal fluid Min hemoperitoneum

DPL > 500WBC Laparotomy

Becomes unstable
< 500 WBC Observation
 Haemodinamically Unstable

DPL Ultrasound

grossly (+) significant hemoperitoneum (+)

Laparotomy

Microscopically No hemoperitoneum
Negative

Consider other causes of shock

 Penetrating Injury ( Algoritm )
Gun shot? Explore wound
Evisceration? No under local
Rigid silent abdomen? anesthesia
Free gas on radiography?

Is peritoneum
intact?

Yes Positive

DPL No Yes

Negative

Laparotomy Debride suture

Consider discharge
Admit, observe
TRAUMA PELVIS
 Mekanisme trauma
• Tumpul (tersering)
• Tajam
• Peluru
• Jatuh dari ketinggian
• Straddle injury
• A pelvic fracture is when
one or more of the pelvic
(hip) bones are broken.
Your pelvis is made up of
five bones, shaped in a
circle. The five bones are
the sacrum, coccyx, ilium,
pubis, and ischium. Your
pelvis protects and
supports organs inside
your body.
 Klinis yang terjadi
• Fraktur pelvis
• Ruptur buli
• Ruptur uretra anterior
• Ruptur uretra posterior
• Ruptur rektum dan perianal
 Fraktur Pelvis
• Fraktur pada ring pelvis
• Dapat terjadi perdarahan retroperitonial yang
cukup signifikan o/k putusnya bridging vein
pada sacroiliac joint, terutama pada tipe open
book.
• Inhibisi intraperitonial mungkin terjadi.
• Seringkali terjadi gangguan hemodinamik
• Tes stabilisasi pelvis dilakukan sekali (tidak
boleh berulang-ulang)
• Tindakan pada fraktur pelvis unstable =>
pasang C-klem atau pelvic sling
External fixator in situ - the lower Anteroposterior view of external
transverse bars have been fixator and percutaneous
removed to facilitate sitting sacroiliac screw.
 Ruptur Buli Ruptur uretra Ruptur uretra
anterior posterior

Tidak bisa kencing (+) k/ ekstravasasi (+) k/ obstruksi (+) k/ obstruksi

urine ke cavum pelvis uretra oleh jendalan uretra oleh jendalan
Buli kosong darah/spasme uretra darah/spasme uretra
Retensi urine Retensi urine
Bloody discharge ± + +
Hematoma suprapubic perianal perianal
RT Prostat normal Prostat normal Prostat melayang
Pasang DC Indikasi Kontraindikasi Kontraindikasi
Tes provokasi +
Radilogi Foto pelvis Foto pelvis Foto pelvis
Sistografi Uretrografi Uretrografi
Tindakan emergensi - Sistostomi Sistostomi
Tindakan definitif Repair buli Endoscopic Endoscopic
Realigment Realigment
Urethra, trauma. Normal retrograde urethrogram. Pericatheter
retrograde urethrogram is negative for urethral trauma and shows
continuous filling of contrast material through the extent of the
urethra and into the bladder without extravasation.
Urethra, trauma. Straddle injury. Retrograde urethrogram shows
a type V urethral injury with extravasation of contrast material
from the distal bulbous urethra.
Urethra, trauma. Retrograde urethrogram reveals tear at the
urogenital diaphragm (solid arrow) and a type IV urethral
disruption at the bladder neck (dashed arrow).
Urethrogram demonstrating Urethrogram demonstrating
partial urethral disruption. complete urethral disruption.
CLASSIFICATION OF SEVERITY OF HYPOVOLEMIC SHOCK
Class I—Compensated: Loss of < 15% of circulating blood volume.
Little or no clinical manifestations.
Class II—Partially compensated: Loss of 15–30% of blood volume.
Manifestations include mild tachycardia, tachypnea, anxiety,
orthostatic hypotension, decreased pulse pressure, and oliguria.
Reduced splanchnic and renal blood fl ow.
Class III—Uncompensated: Loss of 30–40% of blood volume.
Hypotension, oliguria, marked tachycardia, and confusion.
Class IV—Life threatening: Loss of > 40% of circulating blood
volume.

All of the above plus lethargy, mental status change, severe

hypotension, and oliguria or anuria. Needs operative control of
bleeding.
Estimated fluid and blood losses based on patient’s presentation
(Adapted from American College of Surgeons’ Committee on
Trauma, 2004)
CLASS 1 CLASS II CLASS III CLASS IV
Blood loss (ml) Up to 750 750–1,500 1,500–2,000 >2,000
Blood loss Up to 15% 15–30% 30–40% >40%
(% blood volume)
Pulse rate (bpm) <100 >100 >120 >140
Blood pressure Normal Normal Decreased Decreased
(Sistolic - mmHg) 90 – 110 < 90
Respiratory rate 14–20 20–30 30–40 >40
Urine output (ml/h) >30 20–30 5–15 Negligible
CNS/Mental status Slightly anxious Mildly anxious Anxious, confused Confused,
lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid Crystalloid
(3:1 rule) and blood and blood
 Terima kasih
Semoga bermanfaat