Download - Geriatric Trauma
GERIATRIC TRAUMA
By
Dr. HARDY, SpB
PENGERTIAN LANSIA
Proses menua merupakan suatu keadaan yang fisiologis, pasti akan dialami oleh setiap orang.
Menurut UU No 13 tahun 1998 orang dikatakan lanjut usia → usia > 60 tahun.
Menurut WHO lanjut usia meliputi:
1. Usia pertengahan (middle age) ialah kelompok usia 45 sampai 59 tahun.
2. Lanjut usia (elderly) antara 60 - 74 tahun
3. Lanjut usia tua (old) antara 75 - 90 tahun
4. Usia sangat tua (very old) di atas 90 tahun
Geriatri : cabang ilmu kedokteran yang mempelajari masalah kesehatan pada lansia.
Aspek Geriatri :
1. Promotion (penyuluhan)
2. Preventif
3. Kuratif
4. Rehabilitasi
5. Aspek psikososial lansia.
PENDAHULUAN
Angka harapan hidup bangsa meningkat :
1. Kemajuan ilmu pengetahuan dan teknologi
2. Perbaikan lingkungan hidup
3. Kemajuan ekonomi
4. Pembangunan nasional
MENINGKATNYA POPULASI LANSIA
Jumlah lansia bertambah secara pesat
terutama di negara berkembang pada
dekade pertama abad Millennium ini.
DI INDONESIA
- Tahun 2000 proporsi penduduk
lanjut usia (lanjut usia) adalah 7,18
%
- Tahun 2010 meningkat sekitar 9,77
%,
- Tahun 2010 : proporsi penduduk lanjut usia
hampir menyamai proporsi penduduk balita.
- Thn 2020 : diperkirakan proporsi lanjut usia
dari total penduduk Indonesa dapat sampai
11,34 %
- Pada saat ini penduduk lanjut usia berjumlah
sekitar 24 juta dan tahun 2020 diperkirakan
sekitar 30-40 juta jiwa.
DI USA
- Thn 2000 : usia ≥ 65 thn mencapai 35 juta jiwa
- Thn 2030 : usia ≥ 65 thn kemungkinan
mencapai 70,3 juta jiwa atau ± 20 % dari total
populasi
- Dari 12 % populasi : 36 % memerlukan
transportasi ambulans, 25 % memerlukan
perawatan di RS
What the Elderly say???
“Pada Saat Kita berusia lanjut, mungkin Kita mulai menyadari
bahwa Kita tidak sekuat, setangkas atau gesit seperti dahulu. Mungkin
Kita akan terkejut akan menurunnya kemampuan atau kekuatan Kita”
WHAT THE ELDERLY SAY ???
POPULASI LANSIA ↑
TRAUMA PADA LANSIA ± 10 – 12 % DARI KORBAN TRAUMA
± 25 % MEMERLUKAN PERAWATAN
MORBIDITAS ↑ MORTALITAS ↑ LAMA PERAWATAN ↑ BIAYA KESEHATAN ↑
Trauma pd lansia
Penyebab kematian ke-5
↓ Fungsi fisiologi
Comorbid : penyakit/medication
Outcome : tergantung pd penanganan
dini/awal dan agresif
POLA TRAUMA
- FALLS (TERJATUH)
- PEJALAN KAKI VS SEPEDA MOTOR
- PENGEMUDI MOBIL
- LUKA BAKAR
- ATTEMP SUICIDE
BEBERAPA ALASAN TERJADINYA TRAUMA
- Impaired balance and gait
- Postural hypotension
- Increased reaction time
- Syncope
- Cognitive dysfunction
- Visual loss
Orang usia lanjut saat ini mempunyai resiko yg meningkat untuk terjadinya trauma (injuri) o.k meningkatnya aktifitas sehari-hari dan penurunan dari fungsi indra dan kognitif.
Thirty percent of persons over 65 years of age fall each year; of these falls, 6 percent result in fractures, 10 to 30 percent result in significant trauma, and 7 percent lead to mortality. Falls from a standing position account for half of all rib fractures in the elderly population.
Geriatric Considerations
Pada pasien usia lanjut yang mengalami trauma dalam penanganannya harus dipertimbangkan adanya perubahan fisiologis sistem organ dan adanya penyakit yg menyertainya, seperti pada :
Cardiovascular considerations Respiratory considerations Renal considerations
EFFECTS ON THE ELDERLY
Mortality is increased across all phases of the death curve in the elderly: prehospital, early, and late. Early mortality can be reduced by aggressive resuscitation, liberal radiographic evaluation, early monitoring, and surgery. Late mortality is reduced by meticulous attention to changes in patient status.
Complication rates of 33 percent are reported in the elderly, compared with 19 percent in younger patients. Cardiovascular events (23 percent) and pneumonia (22 percent) are the most common and significant complications.
In the emergency department, the two most useful scores are the Trauma Score (TS) and Revised Trauma Score (RTS).
The TS assesses blood pressure, respiratory rate, respiratory effort, Glasgow Coma Score (GCS), and
capillary refill to produce a minimum score of zero and maximum score of 16.
The RTS is similar, but does not account for respiratory effort or capillary refill (scores 0–8).
Trauma Considerations
Beberapa faktor yang dapat mempengaruhi mortaliti pada usia tua :- Osteoporosis- Reduced cardiac reserve- Decreased respiratory function- Impaired renal function- Decreased elasticity in the peripheral blood vessels
Management
The elderly have increased mortality across all categories of the trimodal death curve: immediate (ie, at the scene), early (ie, within the first 24–48
hours), and delayed (ie, after 48–72 hours).
Head Injury
• Dapat terjadi hanya dengan trauma yang ringan• Peningkatan ICP terjadi secara perlahan• Pasien sering lupa dengan trauma yang menimpanya
Cervical Injury
OSTEOPOROSIS
• Mudah terjadi fraktur hanya dengan trauma yang kecil
Arthritic changes• Kanalis spinalis menyempit• Resiko injury meningkat
• Hanya dengan gerakan yang tiba-tiba dapat menyebabkan cedera spinal kord tanpa adanya fraktur
• Penurunan sensasi nyeri dapat mengaburkan adanya fraktur
Orthopedic Injuries—Common Fractures in the Elderly
• Hip or pelvis fractures• Proximal humerus• Distal radius• Proximal tibia• Thoracic and lumbar bodies
BurnsFaktor-faktor yang mempengaruhi tingginya angka
kematian pada luka bakar : Higher mortality than any group except infants Preexisting disease Thin skin Poor immune response Reduction in organ system reserve Inability to meet metabolic demands of burn injury Increased risk of shock Fluid administration critical to prevent renal failure
Priorities of trauma care for older patients are similar to those for all trauma patients
Special consideration should be given to the older patient’s:
Transport strategies should be given special consideration
Management Considerations
How would you backboard?
Modifications in positioning, immobilization, and packaging may be necessary in the elderly patient.
BASIC PRINCIPLES
TRAUMA
DEATH MORBIDITY
PRE HOSPITAL
- Transport guidelines/protocolsOn-line
medical direction
- Mobilization of resources
- Periodic review of care
PHASES OF TRAUMA CARE
INHOSPITAL
- TRIAGE
- PRIMARY SURVEY
- RESUSCITATION
- SECONDARY SURVEY
- CONTINUED MONITORING
- DEFENITIVE TREATMENT
PHASES OF TRAUMA CARE
CHILDREN YOUNGER
ADULT ELDERLY
PREGNANT WOMEN
PRIORITIES ARE THE SAME
TRAUMA IN
OBJECTIVE
Identifikasi prioritas managemen
Aplikasi prinsip2 primary dan secondary survey
Lakukan resusitasi & monitoring
Perhatikan riwayat kejadian & biomekanik
injury
Antisipasi bahaya/kesulitan2 yang tersembunyi
TRAUMA TRIAGE
INITIAL CARE EVALUATION
BASED ON
ANATOMIC INJURY PHYSIOLOGIC STABILITY
PRIMARY SURVEYElderly, adult, younger, children, pregnant women : Priorities are the same
A : Airway + C-spine protectionB : BreathingC : Circulation + hemorrhage controlD : DisabilityE : Exposure/Environment
TERIMA KASIH
PRIMARY SURVEY
A = AIRWAY / C – SPINE ≈ JALAN NAFAS /TL BELAKANG CERVIKAL PASTIKAN BAHWA JALAN NAFAS
BERSIH - BENDA ASING- MANUVER
KASUS SPESIAL IN LINE TRACTION = TRAKSI SEGARIS RESIKO TINGGI CEDERANYA C – SPINE PITFALLS (HAL2 YG TERSEMBUNYI)
PRIMARY SURVEY
B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASIBERSIHNYA JALAN NAFAS SAJA TDK MENJAMIN VENTILASI YANG ADEKUAT
PASIEN TRAUMA MEMBUTUHKAN PERTUKARAN GAS YANG ADEKUAT
EVALUASI DINDING DADAAUSKULTASI PARU-PARUPERKUSI ADANYA CAIRAN / DARAH
PRIMARY SURVEY
B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASIMAJOR INJURIES :
TENSION PNEUMOTHORAXFLAIL CHESTMASSIVE HAEMOTHORAXOPEN PNEUMOTHORAX
MINOR INJURIES : RIB FRACTURES
SIMPLE HAEMO / PNEUMOTHORAXPULMONARY CONTUSION
PRIMARY SURVEY
B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASI
THE PATIENT IS DYSPNOE, TACHYPNOE RR = 35 X/i
YOU DECIDE TO INTUBATE / VENTILATE
PRIMARY SURVEY
C = CIRCULATION AND CONTROL OF BLOOD LOSS≈ SIRKULASI DAN KONTROL PERDARAHAN
STATUS HAEMODYNAMIC PENDERITA DI ASSESS SECARA CEPAT
HYPOTENSION YG MENYERTAI TRAUMA ADALAH HYPOVOLEMIC KECUALI KENYATAAN SEBALIKNYA
HAEMORRHAGE ADALAH PENYEBAB KEMATIAN KE-2 PASCA TRAUMA
PRIMARY SURVEY
C = CIRCULATION AND CONTROL OF BLOOD LOSS
CLINICALLY, ASSESS
1. LEVEL OF CONSCIOUSNESSBLOOD LOSS
C.V.P.
2. SKIN COLOUR
3. PULSE
PRIMARY SURVEY
CONTROL BLEEDING
DIRECT PRESSURE BEFORE
USING TOURNIQUETS
BEFORE USING CLAMPS
PRIMARY SURVEY
CONTROL BLEEDING≈ KONTROL PERDARAHAN
THINK OF THE SITE THORAX
ABDOMEN
RETROPERITONEUM
FRACTURE SITE
PENETRATING THORAX
PRIMARY SURVEY
PITFALLS REGARDING BLOOD LOSS
BEWARE OF THE ELDERLY AND CILDREN
BEWARE THOSE ON BETA – BLOCKERS
BEWARE FIT MALES (ATLIT)
The Lethal Triad SHOCK Prolonged hypotension
Coagulopathy
Metabolic Acidosis
Hypothermia
DEATH
Rotondo MF, Zonies DH. Surg Clin North Am 1997; 77(4): 761-777
PRIMARY SURVEY
D = DISABILITY → NEUROLOGICAL EVALUATIONDONE AT THE END OF THE PRIMARY SURVEY
DROP IN LVL. OF CONSCIOUSNESSRE – EVALUATE OXYGENATION, VENTILATION, AND PERFUSIONIS IT A DIRECT CEREBRAL INJURY ?ARE THERE ALCOHOL OR DRUGS INVOLVED ?
AVPU GCS
PRIMARY SURVEY
E = EXPOSURE / ENVIRONMENT
EXPOSURE IS IMPORTANT
LOGROLL THE PATIENT
MAINTAIN THE CORE TEMPERATURE
THE RESUSCITATION PHASE
AGGRESSIVELY RESUSCITATE PATIENTS TO INCREASE SURVIVAL
AIRWAY BERSIHKAN, BEBASKAN, LINDUNGI IF THE PATIENT CAN’T MAINTAIN AIRWAY INTEGRITY
PLACE A DEFINITIVE AIRWAYINTUBATE WITH CONTINUOUS C – SPINE PROTECTION !!!
THE RESUSCITATION PHASE
BERIKAN CAIRAN – CRYSTALLOID OR COLLOID ??
ATASI HYPOVOLEMIA DAN HAEMORRHAGE !!!
HAMPIR SEMUA SHOCK PD TRAUMA ADALAH HYPOVOLEMIC !!!!
HENTIKAN PERDARAHAN, BUKAN BERIKAN CAIRAN
PULIHKAN VOLUME INTRAVASCULAR
MONITORING DURING RESUSCITATION
ECG MONITORING SINUS TACHYCARDIAST CHANGESATRIAL FIBRILLATIONPEA (Pulseless Electrical
Activity) BRADYCARDIA
TUBESURINARY CATHETERSNASOGASTRIC DECOMPRESSION
MONITORING DURING RESUSCITATION
TUBES
INSTRUMENT THE UNCONSCIOUS PATIENT CAREFULLY
BEWARE OF URETHRAL TRANSECTION
MONITORING DURING RESUSCITATION
MONITORINGRESUSITASI YG ADEKUAT DI ASSESS DENGAN PARAMETER FISIOLOGIS- HR- BP- PULSE PRESSURE- RR- ABG ANALYSIS- URINE OUTPUT
MONITORING DURING RESUSCITATION
RE – EVALUATE ALL PARAMETERS
ALL THE TIME
SECONDARY SURVEY
JANGAN DIMULAI SAMPAI ABCDE’s (PRIMARY SURVEY) TERSELESAIKAN
JANGAN DIMULAI SAMPAI KEADAAN PASIEN MEMBAIK
JANGAN DIMULAI SAMPAI FASE RESUSITASI MEMBAIK
SECONDARY SURVEY
HISTORY AMPLEMECHANISM OF INJURY
FULL EXAMINATIONHEAD AND FACENECKCHESTABDOMENMUSCULOKELETALNEUROLOGICAL
IMAGING
IMPORTANT POINTS IN TRAUMA
FULL ASSESSMENT
EVALUASI BERKELANJUTAN DAN
SELALU DIULANGI
MULTIDISCIPLINARY APPROACH
IMPORTANT EXAM POINTS IN TRAUMA
BERPEGANG PD BASIC PRINCIPLES
SETIAP PERMASAALAHAN TRAUMA SECARA GLOBAL DI ASSESSMENT DENGAN MENGGUNAKAN ATLS / ACLS PROTOCOLS
TERIMA KASIH