ABDOMINAL TRAUMA
CHAPTER I
INTRODUCTION
I. Anatomy of the abdomen
I. 1 Anatomy of the external abdominal
a. Front abdominal
Front abdominal definition is a restricted area in the superior by intermamaria line, in inferior limited by the inguinal ligament and lateral to the pubic symphysis and both anterior axillary line.
b. Waist
Is an area that lies between the anterior axillary line and posterior axillary line, from between the ribs to 6 above, down sampaicrista iliaca. At this location there is a thick wall of the abdominal muscles, as opposed to the thinner wall of muscle on the front, especially tterhadap menjadipelindung stab wounds.
c. Back
This area is located in the back of the posterior axillary line, from the lower end of the scapula to the crista iliaca. As with daerak flank, here back muscles and paraspinal muscles to protect against sharp trauma. (1)
I. 2 Anatomy of the abdomen in
There are three rooms, the peritoneal cavity, retroperitoneal cavity and pelvic cavity. The pelvic cavity contains the parts of the peritoneal cavity or retroperitoneal cavity.
a. Peritoneal cavity
Simply the peritoneal cavity is divided into two parts, the top and bottom. The peritoneal cavity is protected by the bottom of the thoracic wall which includes the diaphragm, liver, spleen, gastric and transverse colon. This section is also called a thoracoabdominal components of the abdomen. At the time of the diaphragm rises up between the ribs IV at full expiration, each rib fracture or penetrating stab wound below the intermamaria can injure organs in the abdomen. The peritoneal cavity contains the small intestine, the colon ascendens and colon descendens, sigmoid colon, and in women, internal reproductive organs.
b. Retroperitoneal cavity
Potential cavity is a cavity behind the peritoneum lining the abdominal wall, and includes the abdominal aorta, inferior vena cava, a large part of duodenoum, pancreas, kidney and ureter and the posterior part of the colon ascendens and colon descendens, and also the retroperitoneal pelvic cavity. Injury to the retroperitoneal organs are difficult to identify because this area is far from the reach of regular physical examinations, and also here in the first injury will not show any signs or symptoms of peritonitis. In addition, the cavity is not included in the sample examined in diagnostic peritoneal lavage (DPL).
c. The pelvic cavity
Pelvic cavity, which is protected by the bones of the pelvis, is actually the bottom of the intraperitoneal cavity, while the bottom of the retroperitoneal cavity. Contained therein rectum, vesica urinary, iliaca vessels, and in women, internal reproductive organs. As with the thoracoabdominal, examination of pelvic organs obstructed by parts of the bones on it. (1)
I. Regio-3 region of the abdomen
The abdomen is divided into nine regions, namely:
1. Epigastrica Regio (right and left)
2. Hipocondria Regio (right and left)
3. Umbilical region (right and left)
4. Region of the lateral (right and left)
5. Pubica Regio (right and left)
6. Inguinal region (right and left)
II. Trauma
Mechanism of Trauma
a. Blunt trauma
A direct blow, such as stir or knock the edge of the dented car door into the collision, can cause compression trauma or crush injury to the viscera organs, such as this can damage the strength of solid organ or hollow organ, and can lead to rupture, especially organs the distension (eg pregnant mothers uterus), and result in bleeding and peritonitis. Trauma drag (shearing injury) of the viscera organ is actually a crush injury that occurs when a safety device (eg seat belt or lap belt type safety component shoulder) is not used properly. Patients who were injured in a motorcycle crash can be traumatized decelerasi where there is no movement between the parts and the parts fixed to the bargerak, such as a rupturhati and liver rupture (organ engaged) in the ligamentnya (fixed to the organ). The use of air bag did not prevent people from experiencing abdominal trauma. In patients who had laparotomy for blunt trauma, the organ most often get is a lien (40-55%), liver (35-45%), and small intestine (5-10%). In addition, 15% - it had retroperitoneal hematoma. (1.2)
b. Sharp trauma
Stab wounds or gunshot wounds (low speed) will cause tissue damage due to laceration or cut off. Gunshot wound at high speed will cause the transfer of kinetic energy greater organ viscera, with the additional effect of temporary cavitation and can be broken into fragments resulting in more damage.
Stab wounds of the common hepatic (40%), small intestine (30%), diaphragm (20%), and colon (15%). Gunshot wounds result in greater damage, which is determined by the bullets of travel away, and how much kinetic energy as well as the possibility of a bullet by the reflection of the bone organ, and the effect of bone fragments. Gunshot wounds most often megenai small intestine (50%), colon (40%), liver (30%), and abdominal blood vessels (25%). (1,2)
III. Appraisal
III.1 History
Careful history taking of patients who experience motor vehicle collisions should include vehicle speed, type of collision (front to front, side collisions, terserempet, a collision from the rear or rolled), how big dents in the vehicle passenger room, the type of security used, there / no air bag, Position of the patient in the vehicle, and the status of other passengers. This information can be obtained directly from patients, other passengers, police and emergency personnel highway. Information regarding vital signs, injuries and respond to existing pre-hospital care should be given by officers of pre-hospital.
When examining a patient with a sharp trauma, a careful history should be directed to the time of the trauma, the type of weapon used (knife, pistol, shotgun), the distance from the actors (especially important in the shotgun), because the incidence of trauma to viscera is reduced when the distance is more than 3 m or 10 feet), the number of stab or gunshot, and the amount of external bleeding is noted at the scene. When possible, additional information must be obtained from the patient regarding the great and the location of any pain abdominalnya, and whether there is referred pain to the shoulder. (1)
III.2 Physical Examination
Abdominal physical examination should be done carefully and systematically: inspection, auscultation, percussion and palpation. The findings of a negative or positive well-documented on the status.
A. Inspection
Generally, patients should be examined without clothing. Front and back of the abdomen, lower chest and perineal excoriation investigated whether experienced or bruises due to safety devices, is there a laceration, puncture hole, sticking a foreign object, the bowel or omentum out, and pregnancy status.
2. Auscultation
What is important is the presence or absence of bowel sounds. Free blood in the retroperitoneum, or gastrointestinal tract may lead to ileus, which results in loss of bowel bisisng. Injury to other nearby structures such as ribs, vertebrae and pelvis can also lead to ileus, although there was no intraabdominal injury. Therefore, loss of bowel sounds is not diagnostic for intraabdominal trauma.
3. Percussion
This examination resulted in the movement of the peritoneum and sparked signs of peritonitis. By percussion we can ketahuiadanya timpani tone due to acute gastric dilatation in the left upper quadrant or the percussion dim when there hemoperitoneum.
4. Palpation
The existence of a volunteer rigidity of the abdominal wall (accidentally by the patient) resulting in abdominal examination is becoming less meaningful. In contrast, abdominal rigidity is a sign of significant involuntary for purposes of excitatory peritoneal palpation is a pain to get off sometimes within. Pain after the hand off our press release quickly showed peritonitis, which is usually by contamination of the contents of the intestine, and hemoperitoneum early stage.
5. Evaluation of stab wounds
Most cases of gunshot wounds treated with exploratory laparotomy for intraperitoneal injury incidence can reach 95%. A tangential gunshot wounds often do not really tangential, and trauma from the explosion could cause injury in the absence of intraperitoneal walaaupun entrance wound. Knife wounds are usually treated more selectively, but 30% of cases of injury or gunshot wound intraperitoneal.semua kasusu lukatusuk with hemodynamically unstable should dilaparotomi immediately.
If there is suspicion that the stab wounds that occurred did not appear to penetrate the muscle layers of the abdominal wall, usually an experienced surgeon will try to explore in advance to determine its depth. This procedure is not performed for similar injuries in the ribs because of the possibility of pneumothorax that occurs, and also for patients with hypotension or signs of peritonitis. However, since 25-33% abdominal stab wounds on the front did not penetrate the peritoneum, laparotomy in patients like this, become less productive. With sterile conditions, local anesthetic is injected and the path followed sampaiditemukan wound edges. When TEBUKTI translucent peritoneum, patients experience a greater risk for intraabdominal injury, and many surgeons consider this is an indication for laparotomy melaksanakna. Each patient is difficult due to fat exploration locally, uncooperative or because of bleeding that obscures soft jaringa assessment, should be treated for re-evaluation, or if you need to laparotomy.
6. Assess the stability of the pelvis
Manually emphasis on the Messiah or crista iliaca will cause pain and crepitus that causes suspicion in pelvic fractures in patients with blunt trauma. This action must be done with caution because these maneuvers can increase bleeding occurs.
7. Examination of the penis, perineum and rectum
Blood in urethral meatus urethral rupture caused a strong suspicion. Inspection of the scrotum and perineum made to see whether or ecchymosis or hematoma with allegations similar to the above. Purpose of examination of the rectum in patients with blunt trauma is to determine sphincter tone, the position of the prostate (prostate that is located high causing the alleged injury to the urethra) and determine the presence or absence of pelvic fracture. In patients with stab wounds, rectum examination aims to assess the sphincter tone and see the bleeding due to intestinal perforation.
8. Vaginal examination
Vaginal tear can occur due to bone fragments from pelvic fractures or stab wounds.
9. Examination glutea
Gluteal region extending from the crista iliaca to glutea folds. Stab wounds in this region are usually associated (50%) with intraabdominal injury. (1)
CHAPTER II
DISCUSSION
I. Organ injury in the abdomen
I.1 Organ intraperitoneal
A. Diaphragm
The diaphragm is located between the structure muskulotendineus thorax and abdomen and berhubingan next to the spinal dorsal with LI to L-III, next to the caudal ventral to the sternum, and on the left and right with the curved ribs. The diaphragm is penetrated by several structures. Aortic hiatus is located next to the dorsal aorta through the ductus as high Th.XII torasikus and v.azigos. esophageal hiatus is located in the ventral aorta as high Th.X hiatus esophagus and traversed by two n.vagus. V.kava hiatus in the right ventrolateral side, as high Th.IX, passed v.kava n.frenikus inferior and small branches.
Blood gets through the second diaphragm and a.interkostalis a.frenika with terminal branches of the internal a.mamaria. Diaphragm muscles innervated by n.frenikus from C.2-5. At the latitude of the spinal cord lesion level servikotorakal, intercostal also paralyzed respiratory muscles, however, the diaphragm is generally able to guarantee adequate ventilation.
N.frenikus be distracted along the way by trauma, tumor, or inflammatory processes that result in ipsilateral paralysis of the diaphragm member of the X-ray marks the location of high diaphragm.
Traumatic diaphragmatic rupture can occur due to sharp injury or blunt injury. Hernia due to blunt trauma occurs mostly on the left tendineus due to the right protected by the liver. Viscera such as the stomach can get into the thorax immediately after the trauma or gradually in the months or years. (4)
Clinical Overview
Hernia due to blunt injury may not cause symptoms or signs, depending on the number of viscera into the thoracic. Can be symptoms or signs of obstruction. Photo thorax showed a mass with no air if the omentum is entered and if the mass of air entering the stomach or intestines.
Installation of the stomach sonde can be used to confirm the diagnosis because the visible sonde veer back to the top of the diaphragm. Photo of the contrast agent is sometimes necessary if the colon stuck in it.
Management
Required surgery and repositioning of the viscera and the diaphragm closed. (4)
2. Liver and bile
The liver is soft and pliable and occupied the region of the right hypochondrium, extending to epigastric region. Convex curved surface of the liver on the bottom surface of the diaphragm. Surface of the postero-inferior or visceral surface of the adjacent viscera forming mold, the surface is related to the pars abdominalis esophagus, stomach, duodenum, flexura coli dextra, right kidney, lymph suprarenalis, and gallbladder. (8)
Extrahepatic biliary tract trauma are extremely rare because it is protected by the liver and ribs. However, both the liver tissue trauma due to blunt trauma or sharp trauma are common. The liver is the organ most commonly affected intra-abdominal trauma after spleen. Injury to the liver can be superficial and mild, but can also be in a severe laceration, which cause damage to the intrahepatic bile duct system. Blunt abdominal trauma with rupture of the liver is often found a fracture costa VII - IX. (4,5)
The bile duct because of trauma can not be separated from the liver trauma, then use the term trauma hepatobilier. (4)
Clinical Overview
Although it may be suspected before surgery, trauma hepatobilier more often just known as exploratory laparotomy. Hepatobilier trauma suspicion is based on the location of trauma and the presence of right lower rib fractures, pneumothorax, pulmonary contusion, hemorrhagic shock, and the discovery of blood and bile on peritoneal lavase. (4)
Often found in abdominal pain upper right quadrant. Defans muscular tenderness and will not appear until the bleeding in the abdomen can cause irritation of the peritoneum (± 2 hours post-trauma). Suspicion of liver laceration in blunt abdominal trauma when there is pain in the upper right abdominal quadrant. (5)
Management
Hepatobilier trauma governance encompasses three basic efforts, which control bleeding, prevent infection with the liver tissue avaskuler debridement and drainage, as well as biliary reconstruction.
The first effort is to stop the bleeding for a while do degan way of direct manual pressure to the bleeding area with a tampon, or with atraumatic vascular clamps at the foramen of Winslow. Closure with a finger ligament duodenale or vascular clamps, the so-called Pringle maneuvers, causing a.hepatika and v.porta closed completely so that the blood came back to the liver. Liver tissue can withstand up to 60 minutes of ischemia state if occlusion was performed. This time is generally sufficient to perform resuscitation and definitively stop the bleeding. (4)
3. Spleen
Is the mass of the largest single lymphoid tissue and is generally oval-shaped, and reddish. Located in the region of the left hypochondrium, with long axis lies along the X and the polar lower ribs run forward until the linea axillaris media, and can not be palpated on physical examination. Anterior limit of the spleen is the stomach, pancreas cauda, the left flexura coli. Posterior limit of the diaphragm, the left pleura (recess costodiaphragmatica left), the left lung, costa IX, X, and XI left. (8)
The spleen helps your body to fight infections in the body and filter out all the material that is no longer needed in the body as the body's cells that have been damaged. The spleen also produces red blood cells and various types of white blood cells.
The spleen is the organ most often injured in blunt abdominal trauma event. Rupture of the spleen is a life-threatening condition because of severe bleeding. The spleen is located just below the thoracic left frame, a place prone to injury. Splenic rupture caused so much blood in the abdominal cavity. Rupture of the spleen is usually caused by a blow on the left upper abdomen or lower left abdomen.
Suspicion of splenic rupture was found a fracture in costa IX and X the left, or at the upper left quadrant abdominal pain and tachycardia encountered. Usually the patient also complained of pain in left shoulder, which is manifested in the first hour or second hour after the trauma. Peritoneal signs such as tenderness and muscular defans will appear after the bleeding irritates the peritoneum. All patients with symptoms of tachycardia or hypotension and abdominal pain in the upper left quadrant there should be suspected ruptured spleen to be examined further.
Diagnosis by using CT scan. Rupture of the spleen can be resolved with splenectomy, the surgical removal of the spleen. Although men continue to live without the spleen, but can result in easy removal of the spleen infection in the body so that after removal of the spleen is recommended vaccination against pneumonia and flu, especially given antibiotics as a preventive effort against infection. (6)
I.2 retroperitoneal organs
A. Kidney
The kidneys are located in the retroperitoneum and is protected by a cavity back muscles next to the posterior and the intraperitoneal organs next to the anterior, kaena it is not uncommon kidney injury followed by injury to surrounding organs. Renal trauma is the most traumatic urogenitalia system. Approximately 10% of renal injured abdominal trauma. (3)
Diagnosis
Suspect the existence of injury to the kidneys if there is:
1. Trauma in the waist, back, chest, lower, and upper abdominal pain accompanied by a lesion or obtained in the area.
2. Hematuria
3. Lower rib fracture (T8-12) or the spinous processes of vertebrae fractures
4. Penetrating trauma to the abdomen or waist area
5. Severe deceleration injury from a fall from a height or traffic accidents
The degree of renal trauma
According to the degree of severity of renal damage, renal trauma can be divided into:
1) Minor Injuries
2) major injuries
3) Injury or renal vascular pedicle
Diagnosis, differentiate between renal laceration with bruising of the kidneys can be done with IVP or CT scan examination. Laceration of the kidney will show a leak in the dye, while the bruised kidney will seem normal image or a picture of a reddish color in the kidney stroma. The lack of visualization of the kidneys may indicate a severe rupture of the kidney or break the stalk. (9)
Management
At any sharp trauma suspected of kidney should be considered for action exploration, but in blunt trauma, most do not require surgery.
1. Conservative
Conservative measures aimed at minor trauma. In this situation made the observation of vital signs (blood pressure, pulse and body temperature), the possibility of adding mass at the waist, abdomen enlarged circle, reduced levels of hemoglobin, and urine color changes on serial examination of the urine. If during the observations obtained for signs of bleeding or leakage of urine that cause infections, surgery should be done immediately.
2. Operation
Operation directed at major renal trauma in order to immediately stop the bleeding. Further debridement may be necessary, repair the kidney (a renorafi or vascular grafting) or it is not uncommon to do a partial nefrektomi nefrektomi even total due to severe kidney damage. (3)
2. Ureter
Ureteric injuries are very rare and represents 1% of all injuries urogenitalia tract. Ceddera can occur due to trauma outside the sharp trauma or blunt trauma, or iatrogenic trauma. Operation endourology transureter (ureteroskopiatau ureterorenoskopi, stone extraction, or ureter stone lithotripsy) and operating in the pelvis (including the gynecological surgery, digestive surgery, or vascular surgery) can result in iatrogenic ureteral injuries. (3)
Diagnosis
Suspicion of ureteric injuries from external trauma is the presence of hematuria after trauma, while suspicion of iatrogenic ureteral injuries can be found at the time of surgery or after surgery.
On IVP examination looks extravasation of contrast or contrast stop in the area or there are lesions to the lateral deviation of the ureter due to hematoma or urinoma. At the time of injury may be obtained hydro-ureteronefrosis until the blockage area. Injury to the ureter from the outside is often found at the time of exploratory laparotomy for intraabdominal injury that is often not possible to advance the imaging examination.
Management (3)
Action taken against injury ureter ureteral injury depends on the time of diagnosis, patient's general condition, and location and degree of ureteric lesions. Actions that might work:
A. Ureters are connected to each other (end to end anastomosis)
2. Implantation of the ureter into the bladder (ureter neoimplantasi in a jar)
3. Uretero-kutaneostomi
4. Transuretero-reterostomi (connect the ureter with the ureter on the other side)
Nephrostomy as an act of diversion or nefrektomi.
3. Pancreas
Pancreas is located across the upper abdomen behind gastric in retroperitoneal space. On the left, the tail of the pancreas reaches the hilum of the spleen in the direction kraniodorsal. The top left of the head (upstream) pancreas associated with pancreas corpus pankeas by the neck, the width of the pancreas are usually no more than 4 cm. Superior mesenteric artery and vein in the neck of the dorsal pancreas runs in the ventral and dorsal duodenum duodenum III I, arteries and veins were encircled.
Trauma to the pancreas is very difficult to diagnosis. Most cases are known in the surgical exploration. Injury should be suspected after trauma in the middle of the abdomen, for example in the collision of a motorcycle handlebar or steering wheel impact. Injury to the pancreas has a high mortality rate. Injury to the duodenum or gallbladder channel also has a high mortality rate. (4)
Clinical symptoms
Suspicion of injury in every trauma that occurs in the abdomen. Patients may exhibit signs of pain in the upper and middle abdomen that radiates to the back. A few hours after injury, trauma to the pancreas can be seen in the presence of irritative symptoms peritonial.
Diagnosis
Determination of serum amylase is usually not very helpful in the acute process. CT scan can establish the diagnosis. Dubious cases can be examined using ERCP (Endoscopic retrogade Canulation of the Pancreas) when another injury was in stable condition.
Management
Handling can be operative or conservative, depending on the severity of trauma, and a description of other trauma-related. Surgery consultation is an action that must be done. (7)
4. small intestine
Most part, the injury that tore the walls of the small intestine due to blunt trauma to injure the small intestine. Obtained from physical examination of symptoms 'burning epigastric pain', followed by tenderness and abdominal muscular defans. Bleeding in the colon and small intestine will be followed by symptoms of general peritonitis in the next hour. While the bleeding in the duodenum is usually symptomatic of pain in the back. Diagnosis depends on detecting intestinal rupture-free air in abdominal X-ray examination. Whereas in patients with injury to the duodenum and sigmoid colon obtained on Abdominal X-ray examination results with the finding in retroperitoneal air. (6)
I. 3 organs in the pelvis cavity
A. Vesica urinary
Approximately 90% vesica urinary blunt trauma is caused by pelvic fracture. Vesica urinary fixation in the pelvic bone and diaphragm endopelvik fascia pelvis is so powerful that deceleration injury, especially if the fascia fixation point moves in the opposite direction (such as pelvic fracture), it can tear the vesica urinary. Vesica urinary rupture due to pelvic fractures can also occur due to the pelvic bone fragments tore the walls.
In a state filled urine, urinary vesica easily torn when under pressure from the outside of the impact on the lower abdomen. Vesica urinary would tear at the fundus and causes extravasation of urine into the cavity intraperitoneum.
Classification
Clinically injury vesica vesica urinary urinary divided into contusions, injuries vesica extraperitoneal and intraperitoneal injury. Contusions are bruises on the walls only, may be obtained perivesikal hematoma, but do not get out of the vesica urinary extravasation.
Intraperitoneal injury is 25-45% of all trauma vesica, while extraperitoneal injuries approximately 45-60% of all trauma vesica urinary.
Diagnosis
After an injury to the lower abdomen, the patient complained of pain in the area suprasimfisis, micturition mixed with blood, or the patient may not be able to micturition. Another clinical picture depends on the etiology of trauma, the vesica to injury is intra / extraperitoneal, the presence of other organ injuries, and complications that occur due to trauma. In this case the sign may be obtained pelvic fractures, shock, hematoma perivesika, or visible signs of peritonitis or sepsis of an abscess perivesika.
Sistografi imaging examination form by including the contrast into the urinary vesica. If there are rips, visible extravasation of contrast in the cavity perivesikal which is a sign of extraperitoneal tear. If there is contrast between the gut means that there is a tear intraperitoneal urinary vesicles.
Before performing urethral catheterization, should be assured in advance that there was no bleeding out of the mouth of the urethra. Bleeding from the mouth of the urethra is a sign of urethral injury. If there is suspected injury to the upper urinary tract in addition to injury to the urinary vesicles, can be obtained through photo sistografi IVP.
Management
At contusions, catheterization done enough for the purpose of resting the urinary vesicles. In this way the urinary vesicles are expected to recover after 7-10 days.
Intraperitoneal injury must dilakuakn exploratory laparotomy for urinary mencar tear in the vesicles as well as the possibility of injury to other organs. If not done, extravasation of urine into the cavity intraperitoneum can cause peritonitis.
In the extraperitoneal injuries, rips a simple (minimal extravasation) is recommended to install a catheter for 7-10 days, but some other experts recommend to do the sewing vesicles with urinary catheters sistostomi. But without surgery, the incidence of wound healing failure of ± 15%, and the possibility of infection in the cavity perivesika by 12%.
To ensure that the urinary vesicles have healed, before removing the urethral catheter or a catheter sistostomi, sistografi first examination in order to see the possibility of the persistence of extravasation of urine. Sistografi made on days 10-14 post-trauma. If there is extravasation, the catheter is maintained up to 3 weeks. (3)
I.4 Fractures Pelvis
Bones sacrum and innominate bones (ilium, ischium, and pubis) and its structure will form the pelvic ligaments. In the event of bone fracture or ligament injury, we know that a strong blow was experienced by the patient. Such injuries can occur to pedestrians, motorcyclists or car. Pelvic fracture is closely related to intraperitoneal or retroperitoneal injuries, both visceral organs and blood vessels. Terliht high incidence of aortic tear in patients denganfraktur thorakalis pelvis, especially the kind anteroposterior. Patients with shock, bleeding and pelvic fractures may be unstable due to blood loss:
1) Fracture of bone
2) a torn pelvic venous plexus
3) Injury to the pelvic arteries
4) Source of ekstrapelvik
Mechanical trauma and Classification
There are 4 pattern of blow that resulted in pelvic fracture;
1) Compression anteroposterior
2) Lateral Compression
3) Pull the lateral
4) The pattern of combination / complex
Anteroposterior compression can occur in a pedestrian hit by a car or motorcycle, a direct blow to the pelvis or falling from a height of more than 12 feet (3.6m). if there simfisiolisis, will be torn posterior sacroiliac ligament, sakrospinosum, sakrotuberositas fibromuskuler or floor of the pelvis, which is seen as a sacroiliac fracture with / without dislocation or fracture of the sacrum. With the opening of the pelvic ring, can occur perdarahandari pelvic venous plexus, and sometimes bleeding from the branches of the internal a.iliaka. (1)
With lateral compression injuries often occur due to motorcycle crashes that resulted in the internal rotation of the pelvis are affected. This approach encourages the rotation of the pelvis and genitourinary tract causing urethral injury or jar. In this situation typically experience pelvic pressure and volume shrink, so rarely life-threatening bleeding.
The strong pull of the vertical field on the anterior and posterior pelvic ring would tear the ligament sakrospinosum and sakrotuberosum and result in pelvic instability. (1)
Appraisal
Should be checked hips, scrotum and perianal area if there is injury, swelling, or blood in the meatus, as well as a laceration of the perineum, vagina, rectum and glutea, which indicates the possibility of open fracture of the pelvis.
Check the stability of the pelvis is done by manual manipulation. This procedure is only done once at the examination, because it will lead to repeated examinations revealed thrombus and severe recurrent bleeding. An early indication of the instability of the pelvis is the presence of different leg length and deformity of limbs eksorotasi without fracture. Because pelvic instabil can experience eksorotasi, pelvis can be closed by pressing the iliac Krista on SIAs. We bbisa merasaksan the movement by holding the Krista iliac and pelvic instabil with pressed in and out (compression-distraction maneuvers). With damage to the posterior, the affected pelvis could be pushed or pulled toward the cranial to caudal. This movement can be felt pda palpability in the posterior iliac spine, pushing-pulling the instabil the hemipelvis. Pelvic fracture can be confirmed by AP pelvis images. (1)
Handling
There are some simple techniques that can be used to transfer patients before and during resuscitation with crystalloid and blood. Techniques, among others;
1) The use of slings that can cause the limbs have endorotasi
2) The use of vacuum-type long spine splinting device ("bean bag")
3) Use of Pneumatic Antishock Garment (PASG)
Can also be done to fracture reduction asetabulumnya using longitudinal traction. (1)
REFERENS
1) American College of Surgeon, Advanced Trauma Live Support. Edisi ke-7. Ikatan Ahli Bedah Indonesia. 2004. 144 – 155.
2) Media Aesculapis, Kapita Selekta Kedokteran. Edisi Ke-3. Jakarta. 2000.302 – 303.
3) Purnomo, Basuki P. Dasar-dasar Urologi.Jakarta : Sagung Seto. 2003. 87 – 95.
4) Sjamsuhidajat R, Wim De Jong. Buku Ajar Ilmu Bedah. Edisi ke-2. Jakarta : Penerbit Buku Kedokteran – EGC. 2004. 517 - 518, 566 - 568, 596.
5) Khan, Nawas Ali. 2207. Liver Trauma. Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad Hospital, King Abdul Aziz Medical City Riyadh, Saudi Arabia. http://www.emedicine.com
6) Odle, Teresa. 2007. Blunt Abdominal Trauma. http://www.emedicine.com
7) Salomone, Joseph. 2007. Blunt Abdominal Trauma. Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine. http://www.emedicine.com
8) Snell, Richard. 1997. Anatomi Klinik Bagian 1. EGC. Jakarta
9) Gordon, Julian. 2006. Trauma Urogenital. http://www.emedicine.com
http://www.baylorcme.org/critical/presentations/wesson/presentation_text.html
http://www.trauma.org/images/image_library/11178367924spleen_rupture2.jpg
http://www.medscape.com/viewarticle/572924
http://www.itim.nsw.gov.au/index.cfm?objectid=B15D8AB5-1321-1C29-70B4081A215BCB46
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