1. The document discusses various types of head injuries including concussions, contusions, epidural hematomas, subdural hematomas, penetrating injuries, and blunt trauma injuries. 2. It provides definitions and descriptions of these injuries, their causes, signs and symptoms, diagnostic methods including CT and MRI scans, treatment approaches including surgery, and considerations in the emergency department. 3. The document is a reference for emergency medicine that covers classification, pathophysiology, clinical findings, radiographic findings, and management of different types of head injuries.

1. A y u W i n d y a n i n g r u m
4 0 5 0 8 0 1 4 9
PROBLEM 7 – EMERGENCY
MEDICINE

2. Definitions
Concussion:
Alteration of level of consciousness as result of closed head
injury.
Contusion:
Either high density(hge contusion) or low density(associated
edema).most common in areas where sudden deceleration
cause brain impaction on bony prominence.
Countercoup:
The force imparted to the head may cause brain to be thrust
against the skull directly opposite the blow.

3. Head Injury
 The most common cause head injudy is motor vehicle accidents
 Brain injury occurs at all ages but the peak in young adult
especially between 15-25years
 Men : women  4 : 1

4. Clssification
Mechanism of injury Closed, penetrating, crash, and blast
GCS Mild  GCS 14-15
Moderate  9-13
Severe  3-8
Intracranial lesion Fokal
• Epidural
• Subdural
• Intraserebra
Diffuse
• Concussion
• Multiple concussion
• Hypoxia / ischemic

5. Radiograpic demage in CT or MRI
• Diffuse injury I : no visible pathology
• Diffuse injury II : cisterns present, midline shift 0-5
mm and / or lession densities present and no mass
lesion > 25 mL
• Diffuse injury III : swelling, cisterns compressed or absent
with midline shift 0.5 mm and no mass lession > 25ml
• Diffuse injury IV : shift, midline shift > 5mm, no mass >
25ml
• Evacuated mass lesion : any lesion surgically evacuated
• Nonevacuated mass lesion : high or mixed-density lesion
> 25ml, not surgicaly evacuated

6. Cerebral concussion
 Concussion  a reversible traumatic paralysis of nervous
function, is always immediate (not delayed even by seconds).

7. Patofisiology
 Vasoparalysis or an arrest of circulation by an instantaneous rise
in intracranial pressure
 concussion resulted when the freely moving head was struck by
a heavy mass. If the head was prevented from moving at the
moment of impact, the same degree of force invariably failed to
produce concussion.
 the reticular formation of the upper brainstem was the anatomic
site of concussive injury.

8. Sign and symptomps
• the immediate abolition of consciousness
• suppression of reflexes (falling to the ground if standing)
• transient arrest of respiration
• a brief period of bradycardia
• fall in blood pressure following a momentary rise at the time of
impact.
Mild
• no apparent loss of consciousness or collapse
• a brief period of stunned disorientation and amnesia during
which the individual appears outwardly normal
• The vital signs return to normal and stabilize within a few
seconds while the patient remains unconscious.

9. In fatal cases of head injury the brain:
• Bruised
• swollen, or lacerated
• hemorrhages, either meningeal or intracerebral,
• hypoxic-ischemic lesions

11. Clinical findings

12. Diagnosis
assessing his mental and neurologic status (GCS)
Normal  15
Mild injury  13-14
Moderate injury  8-12
Severe injury  <7 (severe trauma and a poor critical state)

13. • CT scan

14. Acute epidural hemorragic
• epidural hematoma arises with a temporal or parietal fracture
and laceration of the middle meningeal artery or vein.
SS/
• Vomiting
• Drowsiness
• Confusion
• Aphasia
• Bradycardia (<60x/min)
• headache of increasing severity
develops
• seizures (which may be one-
sided)
• hemiparesis with slightly
increased tendon reflexes
• a Babinski sign.

15. Epidural Hematoma
Extraaxial, smoothly
marginated, lens-shaped
homogenous density
Rarely crosses the suture
line
(because dura attached
more firmly to skull at
sutures)

16. Epidural Hematoma
 Focal isodense or hypodense zones indicate active bleeding
 Air in acute EDH indicates fracture of sinuses or mastoid air
cells.
 If chronic--may appear heterogeneous from neovascularization
and granulation, with peripheral enhancement on contrast
administration

17. Epidural Hematoma
 Hematoma is biconvex
lens-shaped.
 Note the midline shift

18. Diagnosis
• CT scan
• MRI
• Lumbar puncture is contraindicated

20. Subdural Hematomas
bleeding between the dura and the arachnoid,
which usually include bleeding vein. Subdural
hemorrhage divided into acute, subacute, and
chronic
Etiology
• head injury, especially in elderly persons and in
those taking anticoagulant drugs

22. Acute Subdural Hematoma CT
 Hyperdense (white)
crescentic mass along the
inner skull table, over the
cerebral convexity in the
parietal region (most
common location)
 Midline shift present with
moderate or large SDHs
(note the shift in this
image)

23. Acute Subdural Hematoma
Another example
of acute subdural
hematoma with a
midline shift
(noncontrast CT)

24. patofisiology
 Rapidly evolving subdural hematomas are usually a result of
tearing of bridging veins, and symptoms are caused by
compression of the adjacent brain and of deep structures.

25. Sign and symtopms
The subdural hematoma forms in the posterior fossa
• Headache
• Vomiting
• pupillary inequality
• Dysphagia
• cranial nerve palsies
• stiff neck
• ataxia of the trunk and gait
• ipsilateral pupil

26. Diagnosis
 CT scanning with contrast infusion
 MRI

27. Subdural Hematoma--Surgical
Management
 Symptomatic SDH > 1cm at thickest point requires rapid
evacuation
 Smaller SDH often do not require evacuation—surgery may increase
brain injury if severe swelling & herniation thru craniotomy
 Large craniotomy flap that allows access from skull base to
midline—broad access required because these lesions are
unpredictable
 Clot removal--open dura & suction/irrigate clot
 Hemostasis--identify and cauterize bleeding vessel

28. Surgery
 Decompresion subdural hematoma

29. Head Trauma, Penetrating
Penetrating injury to intracranial contents:
• High-velocity penetrationusually bullets, which cause
trauma directly to brain tissue
• Low-velocity penetration usually knives, picks, or other
sharp objects, with direct local trauma to brain tissue

30. Etiology
 Direct penetration of the skull into the intracranial cavity by
foreign object:
 Direct or local damage to brain tissue
 Intracranial hemorrhage, including subdural, epidural, and
intraparenchymal bleeds
 A bullet that hits the skull, ricochets off, and does not fracture
the skull can still cause significant trauma to the underlying brain
tissue.

31. Sign and symtomps
 Alteration in level of consciousness and neurologic exam varies based on object and
location.
 Evidence of increasing intracranial pressure:
 Decreasing level of consciousness
 Falling Glasgow coma scale score
 Cushing response: bradycardia, hypertension, and diminished respiratory rate
 Blown pupil associated with decorticate or decerebrate posturing
 Evidence of penetrating injury to head or basilar skull fracture, or object still remaining
in head:
 Raccoon eyes: bilateral ecchymosis of orbits associated with basilar skull fractures
 Battle sign: ecchymosis behind the ear at mastoid process associated with basilar skull
fracture
 Hemotympanum
 Cerebral spinal fluid rhinorrhea or otorrhea

32. Essential Workup
 Determine the weapon type or caliber of weapon at
scene.
 Thorough exam to assess extent of injuries
 Neurologic exam:
 Alteration in level of consciousness and neurologic exam varies
based on object and location.
 Evidence of penetrating injury to head

33. Support examination
Lab
 Complete blood count
 Platelet count
 Coagulation perimeters
 Type and cross-match.
 Electrolytes, blood urea nitrogen,
and creatinine baseline levels
Imaging
 CT of head depicts location of
lesion and extent of damage.
 Skull radiographs may reveal
depth of impalement, location of
bone fragments, and presence of
fragments within the cranium.
 Cervical spine evaluation (when
indicated):
 Helical CT scanning or
anteroposterior, lateral, and
odontoid views plain radiographs

34. Differential Diagnosis
 Blunt head trauma
 Basilar skull fracture
 Any condition that alters mental status that may have induced a
fall and caused secondary penetrating trauma

35. Treatment
Pre Hospital
• Stabilize, but do not remove, foreign object (e.g., knife).
• Determine the weapon type or caliber of weapon at scene.
• Protect and manage the airway to avoid hypoxemia.
• Avoid hyperventilation.
• Maintain cervical spine precautions.
• Transport to trauma center.
• Avoid hypoxia (oxygen saturation <90%):
– 100% oxygen
• Avoid hypotension (systolic blood pressure<90 mm Hg):
– Intravenous crystalloid solutions

36. Initial Stabilization
 Airway, breathing, and circulation management
 Rapid-sequence intubation:
 For Glasgow coma scale <8, inability to protect airway, hypoxia or cerebral
herniation
 Medications include etomidate or fentanyl as induction agent, succinylcholine
(pretreat with minidose paralytic), rocuronium, or vecuronium; and morphine
sulfate for ongoing sedation
 Caution with fentanyl in the hemodynamically labile patient
 Normalize PCO2. Avoid hyperventilation or hypoventilation.
 Intravenous catheter placement
 Crystalloid solution to maintain systolic blood pressure >90 mm Hg
 Address other sources of associated trauma.
 Cervical spine precautions should be maintained.

37. ED Treatment
 Early neurosurgical consultation
 If patient has evidence of cerebral herniation (see Signs and Symptoms),
initiate measures to decrease intracranial pressure:
 Mild hyperventilation: 16–20 breaths per minute in adults, 20–24 breaths per
minute in children, and 24–26 breaths per minute in infants to keep PaCO2 about
35, which correlates to an end tidal CO2 of 32–35 mm Hg
 Elevating head of bed 20–30°
 Mannitol boluses intravenously: Do not administer mannitol unless systolic blood
pressure >100 mm Hg and patient is adequately fluid resuscitated.
 Phenytoin intravenously to prevent early posttraumatic seizures
 Glucocorticoids are not recommended to lower intracranial pressure in head
trauma patients.

38. ED treatment
 Barbiturates are not recommended in the initial emergency department
treatment.
 Transfuse as needed to keep hematocrit >30%.
 If definitive neurosurgical care is not immediately available, a single burr hole
may preserve life until neurosurgical intervention can be attained:
 Perform only in comatose patients with decerebrate or decorticate posturing on
the side of a known mass lesion/hematoma who have not responded to initial
treatment.
 Avoid hypothermia, which will increase risks of coagulopathy during surgery.
 Maintain NPO status.
 Surgery:
 Based on clinical and radiologic findings and neurosurgical consultation

39. Medication (Drugs)
 Etomidate: 0.2-0.3 mg/kg IV
 Fentanyl: 3-5 µg/kg IV:
 If systolic blood pressure >100 mm
Hg
 Mannitol: 0.25-1 g/kg IV bolus
 Morphine sulfate: 2-20 mg IV
(peds: 0.1 mg/kg up to adult
doses)
 Phenytoin: 15-20 mg/kg IV up to
1,000 mg
 Rocuronium: 0.6 mg/kg IV
 Succinylcholine: 1-2 mg/kg IV
 Vecuronium bromide: 0.1 mg/kg
IV:
 Pretreatment minidose: 0.01
mg/kg IV

40. Follow-up
 Disposition
 Admission Criteria
 Admit all patients to intensive care unit or transport directly to
surgery.
 Discharge Criteria
 Do not discharge.

41. Head Trauma, Blunt
 Blunt trauma to head resulting in a variety of injuries
ranging from closed head injury to death

42. Etiology
Blunt trauma to head may cause several types of closed head injuries:
Concussion: transient loss of consciousness or amnesia with
normal head CT
Subdural hematoma: tearing of subdural bridging veins and bleeding into the
subdural space
Epidural hematoma: dural arterial injury, especially the middle meningeal artery
often associated with a skull fracture:
• Classically, transient loss of consciousness followed
by a lucid interval, then rapid demise
Subarachnoid
hemorrhage:
bleeding into the subarachnoid space following trauma
Cerebral contusion: focal injuries to the brain characterized as coup (beneath
area of impact) or contrecoup (area remote from impact)
Intracerebral hemorrhage: mass intracranial lesion with bleeding into the brain
parenchyma
Diffuse axonal injury: microscopic injuries scattered throughout the brain in a
patient in deep coma

43. Signs and Symptoms
 Evidence of trauma to head includes:
 Scalp laceration, cephalohematoma, or ecchymosis
 Raccoon eyes: bilateral ecchymosis of orbits associated with basilar skull
fractures
 Battle sign: ecchymosis behind the ear at mastoid process associated with
basilar skull fracture
 Hemotympanum
 Cerebral spinal fluid rhinorrhea or otorrhea
 Evidence of increasing intracranial pressure includes:
 Decreasing level of consciousness, falling Glasgow coma scale score
 Cushing response, bradycardia, hypertension, and diminished respiratory
rate
 Dilated pupils associated with decorticate or decerebrate posturing

44. Support Examination
Lab
• Rapid check of blood glucose level
• Complete blood count, platelet count, and coagulation
parameters
• Type and cross-match for surgical candidates.
• Baseline electrolytes, blood urea nitrogen, and creatinine
levels
• Blood alcohol level if indicated

45. Support Examination
Imaging
Cervical spine radiographs or helical CT when indicated
Patients on Coumadin or heparin or those with a history of bleeding dyscrasias
must undergo imaging.
 Older patients (>age 60–65 years) and alcoholics are at higher risk of intracranial
hemorrhage:
 Have a low threshold for obtaining CT scan
 Head CT should be performed in patients with any of the following:
 Loss of consciousness or amnesia of
events
 Progressive headache
 Alcohol or drug intoxication
 Unreliable history or dangerous
mechanism
 Posttraumatic seizure
– Repeated vomiting
– Signs of basilar skull fracture
– Possible skull penetration or
depressed skull fracture
– Glasgow coma scale score <15
– Focal neurologic findings

46. Differential Diagnosis
 Penetrating head trauma
 Any condition that alters mental status that may have produced
a fall and caused external evidence of head trauma (e.g.,
hypoglycemic episode, seizure)

47. Treatment
Pre Hospital
• Blunt head trauma patients with risk for intracranial lesion must go to
a trauma center:
– High-risk patients include those with depressed consciousness, focal
neurologic signs, multiple trauma, or palpable depressed skull fractures.
• Moderate-risk patients should go to a hospital with availability of
prompt neurosurgical consultation:
– Moderate-risk patients include those with progressive headache, alcohol or
drug intoxication, unreliable history, posttraumatic seizure, repeated
vomiting, posttraumatic amnesia, signs of basilar skull fracture.
• Protect and manage the airway including intubation:
– Routine hyperventilation without signs of cerebral herniation should be
avoided.

48.  If evidence of cerebral herniation (see Signs and Symptoms) or
progressive neurologic deterioration, then initiate measures to
decrease intracranial pressure:
 Mild hyperventilation to keep PaCO2 about 35:
 16–20 breaths per minute in adults
 20–24 breaths per minute in children
 24–26 breaths per minute in infants
 Elevating head of bed 20–30°
 Cervical spine precautions must be maintained in all patients.
 Cautions:
 Avoid hypotension (systolic blood pressure <90 mm Hg); use intravenous
crystalloid solutions to maintain blood pressure.
 Avoid hypoxia (oxygen saturation <90%); administer 100% oxygen.
 Check blood glucose level.

49. Initial Stabilization
 Airway, breathing, and circulation management:
 Control airway as needed:
 Rapid-sequence intubation if Glasgow coma scale score <8, unable to protect
airway, or evidence of hypoxia
 Normalize PCO2, avoid hyperventilation and hypoventilation.
 Treatment with etomidate or fentanyl as induction agent, succinylcholine
(pretreat with minidose paralytic), rocuronium, or vecuronium; morphine for
ongoing sedation
 Caution with fentanyl in hemodynamically labile patients
 Intravenous catheter placement with crystalloid solution as needed to avoid
hypotension (keep systolic blood pressure >90 mm Hg)
 Cervical spine precautions

50. ED Treatment
 Early neurosurgical consultation
 If patient has evidence of cerebral herniation (see Signs and Symptoms),
initiate measures to decrease intracranial pressure:
 Mild hyperventilation: 16–20 breaths per minute in adults, 20–24 breaths per
minute in children, and 24–26 breaths per minute in infants to keep PaCO2 about
35, which correlates to an end tidal CO2 of 32–35 mm Hg
 Elevating head of bed 20–30°
 Mannitol boluses intravenously: Do not administer mannitol unless systolic blood
pressure >100 mm Hg and patient is adequately fluid resuscitated.
 Phenytoin to prevent early posttraumatic seizures
 The use of glucocorticoids is not recommended to lower intracranial pressure
in head trauma patients.

51. ED Treatment
 Barbiturates are not recommended in the initial emergency department
treatment of head-injured patients.
 If definitive neurosurgical care is not immediately available, a single burr hole
may preserve life until neurosurgical intervention can be obtained:
 Perform only in comatose patients with decerebrate or decorticate posturing on
the side of a known mass lesion who have not responded to hyperventilation and
mannitol.
 Transfuse as needed to keep hematocrit >30%.
 Avoid hypothermia, which will increase risks of coagulopathy during surgery.
 Maintain NPO status.
 Surgery:
 Surgical procedure based on findings of CT scan and neurosurgical consultation

52. Medication (Drugs)
 Etomidate: 0.2-0.3 mg/kg IV
 Fentanyl: 3-5 µg/kg IV if systolic blood pressure >100 mm Hg
 Mannitol: 0.25-1 g/kg IV bolus
 Morphine sulfate: 2-20 mg IV (peds: 0.1 mg/kg IV up to adult doses)
 Phenytoin: 15-20 mg/kg IV up to 1,000 mg
 Rocuronium: 0.6 mg/kg IV
 Succinylcholine: 1-2 mg/kg IV
 Vecuronium bromide: 0.1 mg/kg IV; minidose pretreatment: 0.01 mg/kg IV

53. Spinal Trauma
• The most common cause of spinal trauma is motor vehicle
accidents, followed by gunshot wounds.
• Men : women  4 : 1

54. Patofisiology
The initial injury of the spinal trauma occurs through 4
different mecanicsm :
1. Impact with persistent compression in burst fracture.
2. Impact with only transient compression after
hyperextention injury.
3. Distraction resulting in forcible stretching of the spinal
coloum in the axial plane, with shearing of the spinal cord
or its blood supply.
4. Laceration from missile injury, sharp bone fragment
dislocation, or severe distraction, with or without
transection.

55.  Gray matter is primarily affected and irreversible damaged
within 1 hour of injury early hemmoragic within the spinal
cord.
 White matter  spared initially but is irreversible injured
within 72 hours after initial insult as a result of hemorragic,
ischemia, and reperfution,excitotoxicity, calcium-mediated
cellular dysfungtion, fluid and electrolyte disturbances,
immunology mechanicm or appoptosis  shock with
bradycardia and hypotension.

56. Spinal Injuries and cauda equina syndrome : Clinical Findings and management
Classification mechanism stability Assosiated injuryes Immaging studies Th/
Upper cervical spine injury
Atlanto-occipital
dislocation
Traction and
disruption of
ligaments between
skull, c1, and c2
Unstable Usually none Lateral ragiograph-
clivus-odontoid
distance > 5mm
Surgical stabilization
C1/atlas fracture
Bilateral posterior
arch fracture
Compression and
extension of cervical
spine
Stable Odontoid fracture Odontoid-view
ragiograph through
patient’s open mouth
CT scan through c1
arch
Orthosis
Lateral mass fracture Fracture of ipsilateral
anterior and
posterior arched
following
compression with
lateral bending
Stable if no lateral
mass widening
Usually none Same as above Orthosis
If intermass widening
> 6.9 mm or atlanto-
dens interval > 3 mm,
traction and halo
immobilization is
required if atlanto-
dens interval > mm,
c1-c2 fusion is
indicated
Jefferson fracture Fractur-part c1
fractures from direct
axial compression
Stable if no lateral
mass widening
Retropharyngeal
swelling
Same as above Same as above

57. Hangman fracture (spondylolisthesis of axis)
I Disruption of
posterior arch,
disk, and posterior
ligament intack
stable Usually none Lateral ragiograph Orthosis
II Anterior
displacement of c2
on c3 through disk,
with intact
posterior ligament
Stable Usually none Lateral ragiograph Traction and halo
immobilization
III Fracture of arch,
facets of c2
attached to
vertebral body
unstable Usually none Same as above Surgical
stabilization

58. Lower cervical spine injuries (c3-c7)
Unilateral or
bilateral facet
dislocation
Flexion with
tension to facet
capsule and
intersponous
ligaments,
subluxation in
25 % of patiens
unstable Nerve root
involment
Lateral,
anteroposterior,
and oblique
radiograph
Traction adn
fusion
Compresion
fracture
Flexion with
25%
compression of
middle coloum
and intact
posterior
ligament
Stable or
unstable
Usually none Lateral flecion
and extension
radiograph
MRI
Orthosis if
posterior
ligament is
stable
Fusion if
posterior
ligament is
injured
Burst fracture Compression and
flexion
Stable or unstable Cord and root
compression
Lateral radiograph
CT scan
MRI
Halo immobilization
if posterior ligament
is intact and there is
no neurologic deficit
Posterior fusion and
halo immobilization
if posterior
ligaments is
ruptured and there is
no neurologic deficit
Anterior corpectomy
and fusion posterior
fusion, and halo
immobilization if
posterior ligaments

59. Thoracolumbar spine injuries
Compression
fracture
Failure of
anterior column
with intact
middle and
posterior
column
Stable Usually none Lateral
radiograph
Hyperextension-
type bracess
Burst fracture Axial load
resulting in
compression of
anterior and
middle columns
and retropulsion
of bone into
canal
Unstable Cord and rood
compression
Lateral
radiograph-
widening of
interpedicle
distance
Surgical
stabilization
Decompression
and internal
fixation if
neurologic
deficit is present
Chance fracture
or seat belt
injury
Flexion and
distraction
resulting in
failure of middle
and posterior
columns with
tension onto
anterior column
stable Ussualy none Lateral
radiograph
Brace
Cauda equina
syndrome
Traction and
pelvic fractures
following
gunshot injuries,
motor vehicle
accidents, and
falls from height
Unstable Root
compression
resulting in
paresthesias
radiating down
legs, leg
weakness,
CT
MRI
Surgical
decompressioon,
spinal nerve
reconstruction,
repair of ventral
nerves and nerve
transfer

61. Anatomy
 The Abdomen is out :
 Front of Abdomen
The abdomen is superior by a line in the section between
mammary papilla inferiorly by the pubic symphysis pubis and
inguinal ligament and lateral to the anterior axillary line by line
 Waist (flank)
Situated between the anterior and posterior axillary line, from
the ICS 6di superior to the inferior iliac krista. In contrast to the
front abdominal wall, the muscles in the thigh thicker and can
be a block of translucent/puncture wound

62. -Your Back
• Is behind the posterior axillary line line of the tip of
the scapula to krista iliac. The muscles in this area
is quite thick as a barrier of invisibility/puncture
wound
• Abdomen in
-The peritoneal cavity
Divided into upper and lower sections. The top
(thoracoabdominal) include the diaphragm, liver,
spleen, stomach, and the transverse colon. The
lower part contains the small intestine and colon
sigmoid

63.  Pelvic Cavity
The pelvic bones, was surrounded at the bottom
of the cavity, retroperitoneum contains the
rectum, bladder, blood vessels, and internal iliac
genitalia in women. An examination to determine
the structure of the pelvic injury was
compounded by the bones on it
 Space retroperitonium
Include abdominal aorta, inferior vena cava, large
parts of the duodenum, pancreas, kidney, ureter,
colon descendens. Injuries in this area hard
understood both by physical examination or FBC
(diagnostic peritoneal lavage)

65. Abdomen cavity
Jenis organ
Solid organs: hepar, lien
Main symptoms:
bleeding
Intraperitoneal organs: the liver, spleen,
stomach, intestines (colonic mostly), vesika
velea
Retroperitoneal organs: kidneys, ureters,
duodenum, pancreas, rectum, uterine vesika,
urinaria
Lumen Organs: gaster,
small intestine, colon.
Symptoms: peritonitis

66. • One of the emergency on the digestive system,
abdominal trauma is trauma/injuries of the abdomen
which causes the onset of disorders/damage to the
organs in it
• Types of abdominal trauma:
1. trauma translucent
abdominal trauma with penetration into the cavity
caused by the peritonium: wounds, cuts sticks shoot
2. blunt trauma
trauma to the abdomen without penetration into the
cavity caused by the peritonium: blows, concussion,
deselerasi, compression or seat belt
Abdominal trauma

67. • As a result of trauma to the abdomen can be a
perforation or bleeding
• Deaths due to trauma to the abdomen usually occur due
to bleeding or sepsis
• Type of injury:
• Based on the affected organs are:
1. solid Organs: hepar, spleen and the main symptoms of
bleeding
2. the hollow Organs: intestine, bile duct, with the main
symptoms of peritonitis
Abdominal trauma

68. • On the abdominal trauma usually found contusions, abrasio,
lacerasi and echimosis
• Echimosis is an indication of bleeding in intra abdominal
• There is a Echimosis on the umbilikal good Cullen's we call '
Sign ' while echimosis was found on one of the pelvis are
referred to as ' Turner's Sign '
• Sometimes found the presence of abdominal organs, namely
its prominent eviserasi out like the colon, the colonic trauma
that occurs in translucent/sharp
Abdominal trauma

69. Cullen’s sign
Turner’s sign

71. abdominal trauma
Translucent trauma Blunt trauma
Laparotomi
signs peritonitis No signs of
peritonitis
Laparotomi Lavase
peritoneum
Positif Negatif
Laparotomi Nursing dan
observation
Laparotomi
Gunfire wounds Knife wounds
No signs of peritonitis
Nursing and observation
A stable haemodynamic Not stable
Shock hipovolemik

72. Translucent Trauma
abdominal trauma with
penetration into the
cavity of the peritonium.
Puncture wounds and
shoot
.
punch, deselerasi,
explosions, collisions,
or compression of the
seat belt
Damage to the
integrity of the
skin
Shock and bleeding
Damage to gas
exchange
The high risk of
infection
Loss of all or part of the
functions of organs
sympathetic dystrophy
stress response to
hemorrhage and blood
clotting
Bacterial Contamination
cell death
Blood loss.
Bruises/injuries on the
abdominal wall.
Damage to the organs.
Pain
trauma to the
abdomen without
penetration into the
peritonium cavity
Blunt Trauma

73. SEE-THROUGH ABDOMEN TRAUMA
 Bowel  most often exposed on the abdomen, because
translucent wound gut fill most of the abdominal cavity
 Clinical manifestations:
 Peritonitis and sepsis when regarding intra peritoneal organs
are hollow
 When perforation occurs at the top for example in the area of
the stomach symptoms of peritonitis are great
 Shock and loss of consciousness difficulty in abdominal
examination
 Injuries in the abdominal wall the onset of abdominal trauma

74. BLUNT ABDOMINAL TRAUMA
 Due to the presence of deselerasi fast and the organ – organ
that has no flexibility including the liver, pancreas, and kidneys
 Clinical manifestations:
 The presence of blood or intestinal fluid  pain stimulation of
peritoneal tap, aches and pains, bladed and stiffness of the
abdominal wall
 Blood  is determined by shifting dullness
 The presence of free air  is lost or the presence of liver pekak
 Intestinal noise usually weaken or disappear
 The stimulation of the pain over in the peritoneal area
especially the left shoulder

75. • The problems that often arise in abdominal trauma
is:
• 1. Shock hipovolemik
• 2. Impaired sense of ease pain;
• 3. Impaired sense of security; anxious
• 4. fulfillment of nutrition Disorders
• 5. the risk of the spread of infection
• 6. when it is coupled with the presence of a tear in
the diaphragm then nursing problem that appears
accompanied by impaired oxygenation

76. Abdomen acute
 Acute abdomen shows a State of emergency in the abdomen that
may end with the death when not be solved with surgery
 Due to bleeding, inflammation, perforation or obstruction in the
digestive apparatus
 Primary inflammation (inflammation of the digestive apparatus:
appendisitis)/secondary pollution through the peritoneum
(perforation, perforation of peptic payer's patch, on the
abdominal typhus/perforation due to trauma)
 Main symptoms: acute pain in abdominal area
 diagnosis of enforcement physical examination, anamnesis,
additional and special examination (patient not aware/too sick 
anamnesa family/allo-anamnesa)

77.  -Nontraumatik Abnormalities that arise unexpectedly with the
main symptoms in the abdomen and required immediate
surgery measures
 -The conditions that give rise to acute abdomen:
 -Bacterial inflammation Process-chemistry
 -Mechanical Obstruction: volvulus, hernia, or adhesions
 Neoplasm/tumour:-Carcinoma, polipus, or ectopic pregnancy
 -Vascular Disorders: tromboemboli, perforation, emboli, and
fibrosis
 -Congenital Abnormalities

78. Causes of acute abdomen of tersering:
 Abnormalities of the gastrointestinal traktus: non-specific pain, bowel
obstruction, subtle kapada appendicitis and intestinal, hernia besara strangulata,
perforated bowel perforation, septic ulcers, diverticulitis Meckel, Boerhaeve
syndrome, inflammatory bowel disorders, syndromes Mallary Weiss, acute
gastroenteritis, mesenteric adenitis, gastririts
 Abnormalities of the pancreas: acute pancreatitis
 Traktus abnormalities urinarius: renal colic or obstruction, acute as
pyelonephritis, cystitis, acute renal infarction
 Abnormalities of the liver, the spleen and traktus biliaris: kolesistitis kolangitis
acute, acute, abscess, ruptured liver, hepar spontaneous tumor rupture of the
spleen, splenic infarction, acute hepatitis, Biliary colic
 Gynaecological abnormalities: ectopic pregnancy, ovarian tumors is impaired is
twisted ovarian follicle cyst, rupture, acute salpingitis, dysmenorrhoea,
endometriosis
 Vascular Disorders: ruptured aortic aneurysm and ischemia of acute visceral,
colitis, mesenteric thrombosis
 Peritoneal abnormalities: intrabdomen abscess, peritonitis, peritonitis primary
TBC
 retroperitoneal abnormalities: Retroperitoneal hemorrhage

80. Anamnesa
 The location of pain
 Radiation pain/deployment pains
 Forms of pain (constantly/colic)
 Changes the physiology of the digestive apparatus
1. appetite, nausea, vomiting
2. Defekasi, diarrhea, obstipasi
3. flatulence, colic attack
4. how long have all these changes take place
 Anatomical changes
1. a lump neoplasm
2. the existence of injuries due to trauma
3. Existence former operations

81. Physical examination
 Inspeksi
 Pain sufferers
 The pain caused by coughing
 Shallow breathing because of pain in the abdomen
 People with pale, cold swea
Anamnesa

82.  Palpasi
• Feeling the pain: the pain of feeling it there has been continuous
increase at palpation (pain and soreness off press)
• Pain  inflamasi peritoneal
• Pain looks firmly acute kolesistitis , apendisitis, divertikulitis, or acute
salpingitis
• Diffuse pain without emphasis gastroenteritis or intestinal
inflammatory process without other peritonitis
• Mass intraadbdomen
• Iliopsoas sign
• Obturator sign pain in the limb at the time made the rotation
fleksi internal or external
• Pain under ribs bladed inflammatory on diaphragm, hepar,
spleen
• Pain in the kostovertebral  Acute pielonefritis
• Muscle cramps (muscular rigidity, defense musculaire): because
of the pain in the stimulation of peritonitis due to palpation
diffusa increases proportionally reflex muscle spasm occurs.

83.  Percusion
• Percussion tenderness  parietal peritoneal irritation and pain
• Perforasion the air will be gathered under the diaphragm and
the liver removes pekak
• Timpany  the air trapped in the gut berdistensi, acute gastric
dilation.
• Free fluid in the peritoneal  shifting dullness positif
• Percussion test boxing  when there is pain a sign of
inflammation/abscess in the subfrenik between the liver and
diafraghma
 Auskultasi
• Noise increases with the intestinal colic the Central intestine
obstruction and early acute pancreatitis
• .Decreased intestinal noise
• Examination of the rectal or rectum with toucher perabaan finger
 to detect the trauma to the rectum ampulla recti whether State
contains faeces/palpable tumor
• Examination of the inguinal ring femoral neuropathy
• Pelvic examination

84.  Abdominal Trauma multiple trauma, involving trauma
where the thoraks are typically found in each section blunt
tears diaphragm, but more often left hemidafragma injury.
 The most common injury is a tear along the 5 – 10 cm and
includes a left posterolateral hemidiaframa.
 At the time of the first rontgenthoraks, then that may appear
is the terangkatnya or blurring/kaburnya hemidiafragma,
hemotroaks, the shadow of abnormal gas himidiafragma or
pipes that hide gastrik (NGT) that seems located in the chest.


85. Investigations
 For the accuracy of diagnosis
 such as Hematology (Hb, Leukocytes, Hematokrit, PT,
APTT), Radiology (BNO/photo plain abdomen,
anteroposterior lateral cervical, thoraks/AP and the
pelvis), Diagnostic Peritoneal
 Lavage/FBC, Ultrasound, CT SCAN.

86. Diagnostic examination
 Examination of the rectum: the presence of blood indicates abnormalities
in the colon
 catheterization, blood shows the presence of lesions on the urethra.
 Radiologik: when indicated to do laparatomi.
 IVP/sistogram: is only done when there is suspicion of urinary tract trauma.
 Abdominal Parasentesis: this action was performed on a blunt abdominal
trauma is beyond doubt the presence of abnormalities in the abdominal
cavity or abdominal blunt trauma accompanied with severe head trauma,
is done using a needle No. 18 or 20 that rapid thrusting through the
bottom quadrant area of the abdominal wall or the Middle, we get under
the center of the jar jar with rub first.
 Peritoneal Lavase: a and aspirations/rinsing the abdominal cavity by
inserting saline liquid through physiological kanula inserted into the cavity
of the peritonium (of MEDICINE, 1995).

87. Laboratory examination
 Routine blood examination
 Examination Of Hb & Ht
 Examination of Leukocyte > 20,000/mm without
infection bleeding pretty much
 Serum amylase  pancreatic trauma/perforated small
intestine
 transaminase reactions to trauma in hepar
 Urine routine examination: trauma to the urinary tract
when present hematuri
Clear Urine has not been able to get rid of any trauma to
the urogenital tract

88. Radiology examination
• Examination of ultrasonography and CT-scan: sufferers who
have not operated on and the suspected existence of trauma to
the retroperitoneum and hepar.
• Examination of ultrasonography and CT-scan: sufferers who
have not operated on and the suspected existence of trauma to
the retroperitoneum and hepar.
• Photo thoraks upright position remove the disorder/trauma at
thoraks (free air under the diaphragm/description of the
intestine in the cavity thoraks on diafragmatika hernia)
• Plain abdomen erect photos  free air in the cavity peritoneum,
retroperitoneal free air near the duodenum, corpus alienum,
changes in bowel description
• IVP (Intravenous Pyelogram): when there is trauma to the
kidneys

89. Special examination
 Abdominal paracentesis  determine the presence of bleeding
within the peritoneal cavity
> 100,000 erythrocytes/mm after included 100-200 ml of
solution nacl 0.9% for the last 5 minutes of the peritoneal cavity
indication for laparotomi
 Laparoscopic examination knowing directly the source cause
 Rektosigmoidoskopi  when found bleeding at anus
 Installation of a nasogastric tube (NGT)  check the fluid that
comes out of the stomach in abdominal trauma

90. Laparostomy
• Actions before surgery
• 1. General Situation before the operation after resuscitation
should be stable
• Analgetik narcotic should not given
• Enemas, laxatives should not be given to patients with
constipation until the possibility of an obstruction was removed
• 2. Hose NGT  hematemesis or repeated vomiting, bowel
obstruction, suspicions or severe intestinal paralitik
• 3. installation of the dauer-katheter
• 4. Administering parenteral antibiotics in patients with
persangkaan pads bowel perforation, severe multiple trauma or
shock.
• 5. installation of the thorax-drain pads sufferers with fracture of
the ribs, haemothoraks or pneumothoraks
• Laparotomi Incision for exploration should be median
incision/the median length.

91.  The steps in the laparotomi emergency are:
 1. exploration to find the source of the bleeding.
 2. stop the bleeding as soon as possible. When the bleeding comes from
solid organs cessation of bleeding is achieved with abdominal tampons
for a while. Bleeding from the artery of the hams is stopped with the
use of vascular clamps. Bleeding from a vein of terminated with
immediate emphasis.
 3. Anesthesia to correct blood volume
 4. intestinal Perforation/laserasi  closing holes/bowel resection with
anastomosis
 5. cleaning of the peritoneal cavity with irrigation solution of NaCl
fisiologik
 6. prior to the peritoneal cavity is closed should be a systematic
exploration was held from around the organs in the abdomen from top
right to bottom left retroperitoneal area having regard to the
duodenum and the bursa omentalis.
 7. If it appears the peritoneal cavity used drain contamination and
subkutis as well as kutis left open.

94. Complication
See-through abdomen Trauma
 Infection or abscess
formation
 Abdominal compartment
syndrome
 The intra abdominal or
retroperitoneal hemorrhage
 Visceral Edema
Blunt Abdominal Trauma
 Solid organ injury or a
hollow party continuous
bleeding, infection, or failing
organs, and death

95. Survey Primery dan Survey
Secondary

96. Management
• Primary survey
• A: Airway, keeping the airway with cervical spinal
control (cervikal spine control)
• B: Breathing, keep breathing with the vent control
(ventilation control)
• C: Circulation with control of bleeding (bleeding
control)
• D: Disability: neurological status (level of
consciousness/GCS, Pupil Response)
• E: Exposure/environmental control: open the sufferers
but barring suits hypothermia

97. Secondary survey
 Did the study in head to toe, and
haemodynamic observation client every
15 – 30 minutes once covering the vital
signs. When stable and could proceed
with the improved observation every 1
hours
 Plug the output rate cateter fluid,
fluid therapy given & notice any
bleeding in the urine.
 Patients fasted and installed NGT
(Nasogastrik tube)  clears the
hemorrhage of the gastrointestinal
tract, minimizing the risk of tract nausea
and aspirations, as well as when there is
no counter indication can be done
lavage.
 Mental status observations, vomitus,
nausea, rigid/stiff/noisy, intestines,
urinary output every 15-30 minutes.
Take note and report immediately
when there is a change in a fast
 Installation collaboration Central Venous
Pressure (CVP) to see the status of the
hydration of the client, giving the antibiotic,
analgesic and actions necessary
examination support on such diagnosis
Laboratory (AGD, hematology, PT, APTT,
leukocyte counts etc.), radiology
examination and if necessary kolaborasikan
after laparatomi surgery for actions
definitely exploration.

98. The trauma of the diaphragm
 Secondary to blunt trauma from happening or
translucent.
 Rupture occurs on the left side.
 Examination: a CT scan and laparoscopy.
 The delay in determining a diagnosis can improve
morbidity and mortality.

99. Duodenum dan pancreas
• Rare
• A direct clash in the stomach
• It could also be because the wound skewer
• Pain in the abdomen of the Middle/back
• The air in the retroperitoneum in plain images (the
air in addition to psoas)
• Elevated blood amylase
• CT: difficult to detect early, go easy

100. Pancreatic trauma
 Frequently, often seen after blunt trauma.
 The patient feels pain in the epigastric or back.
 Serum enzymes pancrease is not specific.
 Examination: a CT scan.

101. Hepar
 Intra abdominal Organ injuries most frequently
 PF is difficult
 Suspicion: haemodynamic instability
 FBC
 CT scan

102. Lien
 Especially by blunt trauma
 Haemodynamic unstable
 Kehr's sign: penjalaran to the left shoulder
 Caution on fracture of ribs 9 – 12
 FBC & ULTRASOUND in patients not stable
 Stable pake CT scan
 Operative therapy of splenektomi

103. Gaster
 Rarely by blunt trauma
 Penetrans Trauma more often
 Peritonitis is quick look –> acid stimulation
 Blood in the NGT
 Free air subdiafragma large wrote
 FBC-sensitive
 Operative therapy

104. Small intestine
 Most often at sores penetrans
 Blunt Trauma 5 – 5%
 Blow out in pseudoclosed loop
 Not as fast as gaster/perforation Peritonitis
 Free air +
 FBC
 the operative

105. Colon and rectum
 Most of the cuts came through
 Blunt Trauma usually accompanies the pelvic fracture
 Free air +
 Bleeding per anum
 Complications of  Peritonitis is slow

106. Bladder Trauma
 Occurs in patients who experience a fracture of
the pelvis.
 Hematuria.
 Review: retrograde cystogram and CT scans.

107. Pelvic Trauma
 Together with trauma to the kidneys.
 Examination: CT scans
 Retroperitoneal hematoma might get false
positive on FBC or ultrasound.

108. RENAL TRAUMA
• Introduction:
-Renal Trauma: often at Urinarius tr.
-Trauma penetrating trauma to small parenkimGeneral:
debridemen, primary repair, drainage
-Extensive Trauma may need partial/total nefrektomi example:
trauma to the hilum
-80% of kidney  penetran trauma (+) intra-abd other trauma
• Blunt Trauma minor & major (85%)
-Minor: contusio, usually conservative dith
-Mayor: laserasi cortex in dg extravasasi, perinefrik large
hematoma, trauma of Vascularity

115. Splenic
Injury
Liver Injury Pancreati
c injury
GIT injury Flank
Injury
Diagnos
a
• blunt trauma
•Left upper
quadrant pain
and
tenderness,
often with
radiation to
left shoulder
•May cause
significant
hemodynamic
instability
•CT scan is
noninvasive
and sensitive
in stable
patients; use
FAST
examination or
laparotomy for
unstable
patients
•Most common
in blunt trauma
•Right upper
quadrant pain
and tenderness,
often with
radiation to
right shoulder
•May cause
significant
hemodynamic
instability
•CT scan is
noninvasive and
sensitive in
stable patients;
use FAST
examination or
laparotomy for
unstable
patients
•Uncommo
n, usually
seen after
blunt
trauma
•epigastric
or back
pain
•Serum
pancreatic
enzyme
levels are
not
sensitive
or specific
for injury
•CT scan is
noninvasiv
e and
sensitive
•blunt and
penetrating
injuries
•Peritoneal
signs may be
delayed ,
presentation
•May be missed
on initial plain
X-rays,
ultrasound, and
CT scan
•)
•Strongly
consider the
diagnosis in
patients with
free fluid on CT
scan but no
specific solid
organ injury
identified
•May be
associated
with renal
injuries
•Retroperito
neal
hematoma
may be false
positive on
DPL or
ultrasound
•CT scan is
noninvasive
and sensitive
in stable
patients

116. SHOCK

126. HYPOVOLEMIC SHOCK

127. DEFINITION
 Medical or surgical condition in which rapid fluid
loss results in multiple organ failure due to
inadequate circulating volume and subsequent
inadequate perfusion.
 Most often, hypovolemic shock is secondary to rapid
blood loss (hemorrhagic shock).

128. CAUSES
 Blood loss can be due to:
 Bleeding from cuts
 Bleeding from other injuries
 Internal bleeding, such as in the gastrointestinal tract
 The amount of circulating blood in your body may drop
when you lose too many other body fluids, which can
happen with:
 Burns
 Diarrhea
 Excessive perspiration
 Vomiting

129. CLASSIFICATION (1)
 Class I hemorrhage (loss of 0-15%)
 In the absence of complications, only minimal tachycardia is seen.
 Usually, no changes in BP, pulse pressure, or respiratory rate occur.
 A delay in capillary refill of longer than 3 seconds corresponds to a
volume loss of approximately 10%.
 Class II hemorrhage (loss of 15-30%)
 Clinical symptoms include tachycardia (rate >100 beats per minute),
tachypnea, decrease in pulse pressure, cool clammy skin, delayed
capillary refill, and slight anxiety.
 The decrease in pulse pressure is a result of increased catecholamine
levels, which causes an increase in peripheral vascular resistance and
a subsequent increase in the diastolic BP.

130. CLASSIFICATION (2)
 Class III hemorrhage (loss of 30-40%)
 By this point, patients usually have marked tachypnea and
tachycardia, decreased systolic BP, oliguria, and significant changes
in mental status, such as confusion or agitation.
 In patients without other injuries or fluid losses, 30-40% is the
smallest amount of blood loss that consistently causes a decrease in
systolic BP.
 Most of these patients require blood transfusions, but the decision to
administer blood should be based on the initial response to fluids.
 Class IV hemorrhage (loss of >40%)
 Symptoms include the following: marked tachycardia, decreased
systolic BP, narrowed pulse pressure (or immeasurable diastolic
pressure), markedly decreased (or no) urinary output, depressed
mental status (or loss of consciousness), and cold and pale skin.
 This amount of hemorrhage is immediately life threatening.

131. SYMPTOMPS
 Anxiety or agitation
 Cool, clammy skin
 Confusion
 Decreased or no urine output
 General weakness
 Pale skin color (pallor)
 Rapid breathing
 Sweating, moist skin
 Unconsciousness
The greater and more rapid the blood loss, the more severe
the symptoms of shock.

133. Assessment Findings
 Medical
 Vomiting, history suggesting
fluid loss
 Bleeding from the mouth or
rectum
 Bright or dark red
 Coffee-ground emesis
 Melena
 Associated signs and symptoms
 Dizziness or syncope with
sitting or standing
 Orthostatic changes in vital
signs
Dysfunctions In Perfusion
 Loss of plasma/fluid
Loss of red blood cells
Inability to deliver enough
oxygen to the cells

134. PHYSICAL EXAMINATION (1)
 The physical examination should always begin with an assessment of the
airway, breathing, and circulation. Once these have been evaluated and
stabilized, the circulatory system should be evaluated for signs and
symptoms of shock.
 Do not rely on systolic BP as the main indicator of shock; this practice
results in delayed diagnosis. Compensatory mechanisms prevent a
significant decrease in systolic BP until the patient has lost 30% of the
blood volume. More attention should be paid to the pulse, respiratory rate,
and skin perfusion. Also, patients taking beta-blockers may not present
with tachycardia, regardless of the degree of shock.
 Classes of hemorrhage have been defined, based on the percentage of blood
volume loss. However, the distinction between these classes in the
hypovolemic patient often is less apparent. Treatment should be aggressive
and directed more by response to therapy than by initial classification.

135. PHYSICAL EXAMINATION (2)
 In the patient with trauma, hemorrhage usually is the
presumed cause of shock. However, it must be
distinguished from other causes of shock.
 The 4 areas in which life-threatening hemorrhage can
occur are as follows: chest, abdomen, thighs, and outside
the body.
 The chest should be auscultated for decreased breath sounds,
because life-threatening hemorrhage can occur from myocardial,
vessel, or lung laceration.
 The abdomen should be examined for tenderness or distension,
which may indicate intraabdominal injury.
 The thighs should be checked for deformities or enlargement (signs
of femoral fracture and bleeding into the thigh).
 The patient's entire body should then be checked for other external
bleeding.

136. PHYSICAL EXAMINATION (3)
 In the patient without trauma, the majority of the
hemorrhage is in the abdomen. The abdomen should
be examined for tenderness, distension, or bruits.
Look for evidence of an aortic aneurysm, peptic ulcer
disease, or liver congestion. Also check for other
signs of bruising or bleeding.
 In the pregnant patient, perform a sterile speculum
examination. However, with third-trimester
bleeding, the examination should be performed as a
"double set-up" in the operating room. Check for
abdominal, uterine, or adnexal tenderness.

137. TREATMENT GOALS
 Goals exist in the emergency department treatment of
the patient with hypovolemic shock as follows:
 Maximize oxygen delivery by ensuring an adequate airway and by
improving oxygenation through administration of high-flow oxygen
via a nonrebreather mask or mechanical ventilation.
 Control hemorrhage through basic means, such as direct manual
pressure, interventional angiography, or surgical intervention.
 Restore and maintain adequate cardiac output. To meet this goal,
I.V. fluid replacement is a top priority. (In early shock from
dehydration, oral fluid replacement may be adequate.) The I.V. fluid
of choice is an isotonic crystalloid, such as 0.9% sodium chloride
solution or Ringer's lactate solution.Also, the patient's disposition
should be rapidly and appropriately determined.

138. INITIAL TREATMENT (AT HOME)
 Get immediate medical help. In the meantime, follow
these steps:
 Keep the person comfortable and warm (to avoid hypothermia).
 Have the person lie flat with the feet lifted about 12 inches to
increase circulation. However, if the person has a head, neck, back,
or leg injury, do not change the person's position unless he or she is
in immediate danger.
 Do not give fluids by mouth.
 If person is having an allergic reaction, treat the allergic reaction, if
you know how.
 If the person must be carried, try to keep him or her flat, with the
head down and feet lifted. Stabilize the head and neck before moving
a person with a suspected spinal injury.

139. HOSPITAL TREATMENT
 The goal of hospital treatment is to replace blood and fluids.
An intravenous (IV) line will be put into the person's arm to
allow blood or blood products to be given.
 Medicines such as dopamine, dobutamine, epinephrine, and
norepinephrine may be needed to increase blood pressure and
the amount of blood pumped out of the heart (cardiac output).
 Other methods that may be used to manage shock and
monitor the response to treatment include:
 Heart monitoring, including Swan-Ganz catheterization
 Urinary catheter to collect and monitor how much urine is produced

140. Treatment Strategies
 ↑ the amount of circulating fluid (replace the blood or fluid)
 Minimize the loss of red blood cells in uncontrolled bleeding
CASE TREATMENT STRATEGY
Traumatic hemorrhage Direct pressure  usually effective in stopping
external hemorrhage
Hemothorax or hemoperitoneum Requires urgent operative intervention
Pelvic fracture Massive blood loss might improve with :
• Manual stabilization in a sling (or sheet tied
around the pelvis)
• Pneumatic antishock trousers, or
• Embolization via angiography
Femur fracture Should be splinted with an external traction
device
Nontraumatic hemorrhagic (shock
from ectopic pregnancy or AAA
Requires operative intervention

141. • FLUID EXCHANGE
A crystalloid infusion (NS or RL solution of 20 cc/kg)
There has been no demonstrated advantage of albumin or
other colloids over crystalloids
Hypertonic (7,5%) saline infusion (with or without
dextran) has shown promise but is still largely of unproven
benefit
• BLOOD AND/OR BLOOD SUBSTITUTE
Should be given early in hemorrhagic shock
patients not readily responding to crystalloid
infusion
Choice is based on the time frame :
• For immediate need in an unstable patient  use
un-crossmatched O-negative packed RBCs
• If time allows  use type-specific RBC or typed and
crossed packed RBCs

142. Others…
 Patients with GI bleeding  NGT  reduce gastric size and
monitor bleeding
 Pharmacology :
 Proton pump inhibitor, H2 blockade (for gastric bleeding)
 Octreotide infusion (for variceal bleeding)
 Endoscopy will likely be necessary for any patient exhibiting signs
of shock and GI bleeding

143. LABORATORY STUDIES
 After the history is taken and the physical
examination is performed, further workup depends
on the probable cause of the hypovolemia, as well as
on the stability of the patient's condition.
 Initial laboratory studies should include analysis of
the CBC, electrolyte levels (eg, Na, K, Cl, HCO3,
BUN, creatinine, glucose levels), prothrombin time,
activated partial thromboplastin time, ABGs,
urinalysis (in patients with trauma), and a urine
pregnancy test. Blood should be typed and cross-
matched.

144. IMAGING STUDIES
 Patients with marked hypotension and/or unstable conditions must
first be resuscitated adequately. This treatment takes precedence over
imaging studies and may include immediate interventions and
immediately taking the patient to the operating room.
 The workup for the patient with trauma and signs and symptoms of
hypovolemia is directed toward finding the source of blood loss.
 A pregnancy test should be performed in all female patients of
childbearing age. If the patient is pregnant and in shock, surgical
consultation and the consideration of bedside pelvic ultrasonography
should be immediately performed in the ED.
 If a traumatic abdominal injury is suspected, a focused abdominal
sonography for trauma (FAST) ultrasonography examination may be
performed in the stable or unstable patient. Computed tomography
(CT) scanning typically is performed in the stable patient.
 If long-bone fractures are suspected, radiographs should be obtained.

145. DIFFERENTIAL DIAGNOSES
 Abruptio Placentae
 Aneurysm, Abdominal
 Aneurysm, Thoracic
 Fractures, Femur
 Fractures, Pelvic
 Placenta Previa
 Pregnancy, Postpartum Hemorrhage
 Pregnancy, Trauma

146. COMPLICATIONS
 Neurologic sequelae
 Kidney damage
 Brain damage
 Gangrene of arms or legs, sometimes leading to
amputation
 Heart attack
 Severe shock can lead to death

147. PROGNOSIS
 Hypovolemic shock is always a medical emergency.
However, symptoms and outcomes can vary depending
on:
 Amount of blood/fluid volume lost
 Rate of blood /fluid loss
 Illness or injury causing the loss
 Underlying chronic medication conditions, such as diabetes and
heart, lung, and kidney disease
 In general, patients with milder degrees of shock tend to
do better than those with more severe shock. In cases of
severe hypovolemic shock, death is possible even with
immediate medical attention. The elderly are more likely
to have poor outcomes from shock.

148. REFERENCES
 Medscape Reference www.emedicine.medscape.com
 Medline Plus www.nlm.nih.gov/medlineplus/
 Wolters Kluwer Health, Lippincott Williams &
Wilkins Journal www.journals.lww.com
 University of Maryland Medical Centre
www.umm.edu