Widjoseno GardjitoDepartment of UrologyMedical School Airlangga University - Dr. Soetomo HospitalSurabaya1

PATOFISIOLOGI TRAUMADefinisi :

TRAUMA adalah semua jenis kekerasan yang menimpa tubuh sehingga terjadi kerusakan/gangguan pada struktur dan fungsi jaringan/organ tubuh yang terkena, bahkan secara sistemik dapat berdampak pada aspek fisiologis, kejiwaan dan kondisi sosial insan yang bersangkutan.2

TRAUMA pada JARINGAN/ORGAN KERUSAKAN PERDARAHAN NYERI3

JENIS TRAUMALedakan benda berkecepatan tinggi, benda tajam (tusukan, irisan, sabetan), benda tumpulSuhu tinggi/rendah uap panas luka bakar frostbite (suhu dingin)Arus listrik tegangan tinggiBahan kimiaRadiasi, ionisasiGigitan, sengatan4

KERUSAKAN AKIBAT TRAUMABentuk :Diastase (kerobekan), memar, erosi, lecet, hancur (crush injury), jaringan hilang

Lokalisasi : Jaringan lunak + kulit: - luka terbuka - luka tertutup

Tulang / sendi: fraktura / dislokasi Organ berongga (lambung, usus): perforasi Organ Padat (hati, limpaa, ginjal, otak: ruptur, memar5

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AKIBAT TRAUMA SEMBUH CACAT (anatomis + fisiologis + psikologis) MENINGGAL10

TRAUMAHEBATRINGANTUNGGAL GANDAREAKSI TUBUH(Bagian dari proses Penyembuhan secara alami)LOKALSISTEMIKTANDA + GEJALA11

INSULT HEBAT / BERAT

4 I - s

Injury Infection Inflammation IschemiaS I R S(Systemic Inflammatory Response Syndrome) 12

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SIRS can be identified by the presence of two or more of the following manifestations :

1. A body temperature greater than 38C or less than 36C.2. Heart rate greater than 90 beats per minute3. Tachypnea (respiratory rate > 20 breaths per minute or Pa CO2 < 32 mmHg4. White blood cell count greater than 12.0 x 109/L or less than 4.0 x 109/L or the presence of more than 10% immature neutrophils (bands).14

SIRS and MODSInflammatory and organ dysfunction responses to injury. Normal response to an injury or insult may decrease after 3 to 5 days or be reactivated by a complication. A continuous inflammatory response is seen with systemic inflammatory response syndrome (SIRS) and can eventually progress to organ dysfunction (reprinted from 4).Beal et al, JAMA, 1994;271;226-23315

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SEPSIS :

SIRS plus a documented infection site (documented by positive culture for organisms)18

Severe Sepsis :Sepsis associated with organ dysfunction, hypoperfusion abnormalities, or hypotension.Hypoperfusion abnormalities include but are not limited to :1. lactic acidosis,2. oliguria3. or an acute alteration in mental status

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Septic Shock :Sepsis-induced hypotension despite fluid resuscitation PLUS hypoperfusion abnormalities20

MODSOrgan Dysfunction associated with Severe Sepsis and Septic Shock :

Lungs : early fall in arterial PaO2 , Acute Respiratory Distress Syndrome (ARDS):

Capillary-leakage into alveoli; tachypnea, hyperpneaKidney : (acute renal failure): oliguria, anuria, azotemia, proteinuria

Liver : elevated levels of serum bilirubin, alkaline phosphatase, cholestatic jaundice

Digestive tract : nausea, vomiting, diarrhea and ileus21

MODSOrgan Dysfunction associated with Severe Sepsis and Septic Shock :

Skin : ecthyma gangrenosum (think Pseudomonas aeruginosa in neutropenic patients), Petechia or purpura (think Neisseria meningitidis or Rickettsia rickettsia (if evidence of tick bite)), Hemorrhage or bullous lesions in patient who has eaten raw oysters (Vibrio vulnificus), generalized erythroderma (Toxic Shock Syndrome= Staphylococcus aureus or Streptococcus pyogenes)

Heart : cardiac output is initially normal or elevated,

Brain : confusion22

OSLERS DICTUM

Patients usually die of complications of their disease, rather than from the disease itself23

SIRS MODSMOF

BUKAN PENYAKITBUKAN SINDROMA

MERUPAKAN PERUBAHAN BERKELANJUTAN DARI FUNGSI ORGAN YANG MENYANGKUT ASPEK FISIOLOGIS DAN METABOLIK SEBAGAI RESPONS TERHADAP SUATU INSULT YANG SERIUS.HUBUNGAN ANTARA RESPONS-RESPONS SERIAL DAN FUNGSI ORGAN BERSIFAT DINAMIS DAN BERKELANJUTAN24

SIRSSystemic Inflammatory Response SyndromeMODSMultiple Organ Dysfunction SyndromeMOFMultiple Organ FailureMSOFMultiple-Sytem Organ FailureARDSAcute Respiratory Distress SyndromeDICDisseminated Intravascular Coagulation25

DEAR SIRSWE ARE SORRY TO SAYTHAT WE DONT LIKE YOU26

Sir Isaac Newton :To every action is always an equal reactionorThe mutual action of two bodies upon each other are always equal, and directed to contrary parts

Philosophiae Naturalis principia Mathematica1687Bone RC Crit. Cave Med, 1996;24:1125-112827

BIOLOGICAL SYSTEMS, such as the human body, are more complicated than the simple physical systems Sir Isaac was describing28

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MACROPHAGE ( morfologi ) :Sel besarInti bulat/indentedGolgi apparatus developedVakuol endositotik >Lisosom + fagolisosomPlasma membrane diselubungi mikrovili/ruffles30

MACROPHAGE ( fungsi ) :Nonspecific phagocytosis/pinocytosisSpecific phagocytosis opsomized microorganisms (Fc receptors + complement receptor)Killing ingested microorganimsDigestion + presentation of antigens to T + B lymphocyteSecretion of : enzymes : lysozyme, collagenases, elastase, acid hydrogenases complements + coagulation factors some prostaglandins and leukotrienes several regulatory molecules (interferon, Interleukin-1)31

MACROPHAGE ( jenis ) :HistiositSel KupfferOsteoclastsMicroglial cellsSynovial type A cellsInterdigititating cellsLangerhans cell Langerhans, epitheloid cellsMultinucleated giant cellsInflamed tissues32

MACROPHAGE

Mononuclear phagocytes di dalam jaringan :Bone marrow: STEM CELL

monoblast

promocyte

Blood (40 hours): MONOCYT

Tissue: MACOPHAGES : - size - phagocytic activity - lysosomal enzym content33

MEDIATOR

Bahan yang dilepaskan oleh sel sebagai hasil interaksi antigen-antibodi atau antigen dengan sel limfosit yang sudah mengalami sensitisasi34

CYTOKINE (SITOKIN) : (cyto + kinesis)

Nonantibody protein released by one cell population (eg. Primed T-lymphocytes) on contact with specific antigen, which act as intercellular mediators, as in the generations of immune response. Examples include : Lymphokines, monokinesmovement35

SITOKIN

Anggapan: sitokin ~patologi

Sitokin: Melindungi tubuh tapi juga bisaSIRS

Mulai ditemukan antogonis sitokin

Mencegah SIRS ?36

Proses dilepasnya

Pro inflamatori sitokin + mediator-mediator merupakanMekanisme pertahanan tubuh

melokalisir + menetralisir kuman yang menyerang membersihkan sel yang mati / rusak memulihkan jaringan

NAMUNAktivasi yang berkelanjutan / berlebihan justruMERUGIKAN37

NORMAL STRESS RESPONSE

PERUBAHAN KARDIOVASKULER takikardi, kontraktilitas, curah jantung (CO), konsumsi oksigen

RESPONSE SISTEM NEUROENDOKRIN Dilepasnya katekolamin, kortisol, ADH, Growth Hormone, glukagon, insulin.

CASCADE : - koagulasi - komplemen - sistem fibrinolitik

Puncak reaksi: 3 5 harireda 7 10 hari38

PATOGENESIS SIRS

4 - I (Injury Infection Ischemia Inflammation)

Stage ILokal: Sitokin

(penyembuhan luka merangsang sel mematikan organisme patogen)39

SITOKIN

Circulating form (misal : IL-1 beta) (sistemik) Cell associated form (misal : IL-1 alpha) (lokal)

Asumsi : lokal prekursor sistemikBila produksi sitokin lokal melampui batasambang tumpahsistemik40

Stage II

Sejumlah kecil sitokin masuk sirkulasi

merekrut : makrofag, trombosit

growth factor

Terjadi reaksi akut :

terkendalitidak terkendalipro inflamm, mediator endogenous antogonist (misal : IL-1 receptor antagonist) Stage IIIantibodi

Luka sembuhInfeksi teratasiHomeostasis pulih41

Stage III

Homeostasis tak berhasil dipulihkan

SitokinDestruktif( semula protektif )

Sirkulasi penuh dengan mediator inflamasi

Intergritas dinding kapiler rusak

Sitokin masuk organ / jaringan

M O D42

Figure 1. First hit, second hit, and sustained hit that can occur with systemic inflammatory response syndrome (SIRS). ARDS, adult respiratory distress syndrome; MODS, multiple organ dysfunction syndrome.43

Figure 2. Three stages of the systemic inflammatory response syndrome reactionCrit Care Med 1996 Vol. 24, No. 144

TRAUMA

may be considered to be an inflammatory disease

KADAR :- berbagai mediator- indikator respons inflamasipada trauma berat.

MARKERS inflamasi dapat digunakan : menilai beratnya trauma meramalkan prognosis (outcome)45

TRAUMA BERAT dan KEMATIANPOLA DISTRIBUSI TRI MODAL

Kematian Sesaat (Immediate Deaths)Segera setelah trauma

Kematian Dini (Early Deaths)Beberapa jam setelah trauma

Kematian Lambat (Late Deaths)Berhari-hari hingga berminggu-minggu setelah trauma46

TRAUMA BERAT dan KEMATIANPOLA SITRIBUSI TRI MODALTRAUMA BERAT47

JALAN TOL menuju kematian

Trauma multipel Sumber infeksi Immunocompromised

SistemPenunjang berbagai organ(ICU)

SIRS

MODSARDS, DIC, ARF, KARDIOMIOPATI

Meninggal48

CerraJAMA Vol. 271, 199449

1991Concensus Conference

Dirintis konsistensi Memperhatikan aspek-aspek : Klinik (bedside) Laboratorium Literatur terkait50

SIRSMODS/MOF MORTALITAS TINGGI

KEGAGALAN1 ORGAN: 30% - 40%2 ORGAN: 60%3 ORGAN: > 90%

USIA > 65 TAHUN: RISIKO20%

Beal & Cerra

PREVENTION IS THE BEST TREATMENT(prevention is the only good answer)Baue51

Prognostic test

yang meramalkan terjadinya organ failure (OF)

tidak bermanfaat

bila gambaran klinik OF sudah manifes52

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