Kasus Ujian Tahap i (Endang Sw)

8/13/2019 Kasus Ujian Tahap i (Endang Sw)

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Nama: Endang Sri Wahyuni, Tahap I, Mei 2013

KASUS UJIAN TAHAP I

Seorang laki-laki 30 thaun di bawa ke RSDK, dimana anda jaga tahap I, keluarga

menjelaskan selesai berkelahi tertusuk di perut 4 jam yang lalu. Muntah dan berak

darah disangkal. Tensi 110/85, nadi 104 x/mnt, RR 30 x/mnt, tidak Nampak

anemis, terdapat luka robek di bibir atas 1 cm, sudah tidak berdarah, thoraks

pernafasan dan auskultasi simetri kanan dan kiri. Abdomen datar, luka di region

epigastrium 3 cm sisi kiri linea mediana, 4 cm di atas umbulikus, panjang luka 1

cm, lebar 3 mm, tidak keluar darah maupun organ intra abdominal, palpasi nyeri

tekan ringan sekitar luka yang lain supel, defence muskuler (-), pekak hepar (+),

peristaltic (+), RT: tidak kolaps, tinja (+) warna kuning.

1. Kesimpulan tentang tensi dan nadi pada pasien ini pasca trauma adalah

Tensi 110/85mmHg

Nadi 104 x/mnt

Rr 30 x/mnt

Pada pasien ini hemodinamik stabil

MAP = [(2 x diastolic) + systolic] / 3 (2X85)+110/3= 93,33

HEMODINAMIK STABIL

MAP > 80

Nadi < 120

Urine > 50cc/jam

Tidak ada tanda-tanda klinis syok



2.Diagnosis banding pada kasus ini

Trauma tusuk abdomen hemodinamik stabil dd/ gasterDuodenum

Ileum

Colon transversum

Usulan : cek darah lengkap, O2 masker 10 lt, pasang DC

USG abdomen / MSCT Scan abdomen

Sumber:

NORTON

Modalitas penunjang pada trauma abdomen

1. DPL

1000 cc Nacl dimasukkan lewat kateter lavase

Di indikasikan pd pasien dengan syok, cedera organ serius, tidak sadar Positif 100.000 sel/mm3 (T. Tumpul)

1000 – 50.000 sel /mm2 (T. Tembus)

2. CT Scan

Sensitifitas dan spesifisitas tinggi pada T. Tumpul staging solid

organ

Memungkinkan untuk manajemen non-operative pada kasus2 tertentu

(CT Scan serial)

Kerugian kemungkinan miss dalam deteksi cairan intraperitoneal

yang minimal pada T. Tumpul



3. USG

FAST 4 lokasi hepatic dan spleenic gutter, perivesika/pelvis dan

perikardium4. Laparoskopi Diagnostik

Indikasi evaluasi pada tangensial gun shot wound dan assessment

pada kemungkinan cedera diafragma

Major diagnostic modalitas dalam Trauma Abdomen

1. DPL

2. CT Scan Abdomen (Kontras IV dan kontras per rektum/colon – Double

contrast)

3. USG

4. Diagnostic laparoscopy (DL)

(Feliciano, David V.; Mattox, Kenneth L.; Moore, Ernest E. Trauma, 6th Editio

Copyright ©2008 McGraw-Hill)

2. Melihat lokasi luka tusuk dan cara memegang pisau, jelaskan lapisan

dinding perut yang bias robek dan organ apa saja yang bias mengalami

kerusakan luka di region epigastrium 3 cm sisi kiri linea mediana, 4 cm di

atas umbulikuS

Organ yg bias terkena adalah gaster, duodenum

Lapisan-lapisan dinding perut1.Stratum superficialis:

Cutis

Subcutis(fascia abdominalis superficialis)



-lamina superficialis

-lamina profunda

2.stratum intermediusFascia abdominalis

Otot-otot dinding perut

Aponerosis otot dinding perut

3.stratum profunda/lapisan dalam

Fascia transversalis

Panniculus adiposus preperitonealis/ preperitoneal fat

Peritoneum parietale

FAST menunjukkan black strip line tipis antara ginjal kiri dan lien serta

hypoechoic disertai enhancement di belakangnya di luar vesica urinaria yang terisi

penuh.

4.Kesimpulan tentang hasil FAST: Ada cairan bebas dalam rongga intraperitonium

5.apa kasus ini memerlukan foto thorax

Perlu, karena Pada pasien luka tusuk di atas umbilicus, patut dicurigai cedera

thoracoabdominal dengan rontgen foto thorax tegak bermanfaat

untuk menyingkirkan hemo atau pneumothorax, ataupun untuk mengetahui adanya

udara bebas intraperitoneal

6.apakah sdh ada indikasi laparotomi?

Sudah, karena adanya cairan bebas dalam intraperitonium yang berarti adanya

darah, artinya luka tusuk sudah melewati peritoneum



Nilailah respon penderita terhadap pemberian cairan awal

Nilai perfusi organ ( nadi, warna kulit, kesadaran dan produksi urin ) serta awasi

tanda-tanda syokPemberian cairan selanjutnya berdasarkan respon terhadap pemberian cairan awal.

Respon cepat

Pemberian cairan diperlambat sampai kecepatan maintenance

Tidak ada indikasi bolus cairan tambahan yang lain atau pemberian darah

Pemeriksaan darah dan cross-match tetap dikerjakan

Konsultasikan pada ahli bedah karena intervensi operatif mungkin masih

diperlukan

Respon Sementara

Pemberian cairan tetap dilanjutkan, ditambah dengan pemberian darah

Respon terhadap pemberian darah menentukan tindakan operatif

Tanpa respon Perlu tindakan operatif sangat segera( operasi laparotomi)

( Advanced Trauma Life support for doctor, student course manual eighth

edition 2008)

Resusitasi dan vital organ support

- Menilai keadaan umum dan tanda vital pasien

-

Pasang CVC untuk menilai CVP- Pasang oksimetri untuk menilai saturasi O2 dan HR

- Pasang DC untuk memantau fungsi ginjal dan melihat produksi

urine



- Cek lab elektrolit

- Kemudian prinsip penanganan pertama sesuai ABCDAir way diharapkan diperoleh air way yang paten sebelum beralih ke

terapi selanjutnya

Breathing dinilai frekuensi nafasnya, irama nafasnya

Circulation penerapan EGDT ( Early Goal Direct Treatment ) dengan

menerapkan EGDT.

Fluid chalange dengan menggunakan cairan kristaloid 1000cc

atau 300-500 cc koloid pada 30 menit pertama.

Target dalam 6 jam adalah:

- Central Venous Pressure 8-12 mm Hg (12-15 in ventilator pts)

- Mean arterial pressure > 65 mm Hg

- Urine output > 0.5 mL/kg/jam

- ScvO 2 or SvO 2 ≥ 70% atau mixed venous ≥ 65%



Kursus Perioperatif, Acute Care Surgery,Kolegium Bedah Indonesia, 2010Protocol for Early Goal-Directed Therapy

Supplement O2Endotracheal intubations

Mechanical ventilation

Central venous andarterial catheterization

Sedation, Paralysis(if intubated), or both

CVP

MAP

ScvO2

Crystalloid

Colloid

< 8 mmHg

Vasoactive agents< 65 mmHg

> 90 mmHg

8 – 12 mmHg

65 – 90 mmHg

≥ 70%

Goalachieved

Transfusion of RCuntil Ht ≥ 30%

≥ 70%

< 70%

Inotropic agents

Hospital admission YesNo

< 70%

Ket:Target pertama adalah CVP mencapai 8-12 mmhg. Jika dari 8 mmHg maka dapat

dilakukan terapi dengan kristaloid ataupun dengan koloid.

Jika target pertama sudah tercapai maka lanjut ke target ke dua yaitu MAP 65-

90mmHg. Jika belum tercapai dapat diberikan vasoactive agent.

Kemudian jika sudah tercapai target yang kedua maka masuk ke target yang ke 3, yaitu ScvO2

≥70. Jika belum sesuai maka dapat diberika transfusi atau pemberian inotropik



The choice of resuscitation fluid depends on the condition of the patient. The use

of a warmed balanced salt solution such as Ringer's lactate is considered safe andeffective. A bolus of 2 L is given to the adult patient with hypotension,

and 20 mL/kg to the child. If a hemodynamically normal state is restored, the

Ringer's lactate solution can be continued.

If the patient remains unstable a second bolus is utilized while blood is being

obtained. If the patient's vital signs have not returned to normal after 1 to 2 boluses,

blood should be administered. If the need is urgent, type-specific blood may be

used. When this is not available, low-titer type O-positive blood for men or O-

negative blood for women is acceptable.

The patient who needs uncross-matched blood usually needs to be in the operating

room (Feliciano, David V.; Mattox, Kenneth L.; Moore, Ernest E. Trauma, 6th

Editio Copyright ©2008 McGraw-Hill)

9. Bilamana pasien ini supel, tetapi muntah darah apa yg anda duga?Tindakandiagnostic yang dilakukan dan tindakan pengobatan yang dilakukan?

Jawab: ada perdarahan gaster, dilakukan endoscopy.

10. Metode Saftan dalam pengelolaan luka tusuk abdomen adakah pengelolaan

untuk itu?

Jawab: In 1960, Shaftan developed an approach of selective conservatism for

penetrating abdominal injury and revolutionized abdominal stab wound

management .[3]



Investigators in this field continue to study various protocols and investigative

tools. Despite impressive advances in investigative techniques, the optimal method

to determine the need for laparotomy has yet to be definitively established.

The objective is to reduce the number of patients with trivial or no intraperitoneal

injury who are subjected to laparotomy. However, a high degree of diagnostic

accuracy must be maintained to limit the frequency of missed injury. A reduction

in unnecessary hospitalization is also targeted.

In asymptomatic patients with stab wounds to the anterior abdomen, the following

2 methods are widely used to help determine the need for laparotomy:

Abdominal stab wound exploration (subsequent diagnostic peritoneal lavage

[DPL], serial clinical evaluation, or both are used to further assess patients in

whom an exploration cannot definitively exclude peritoneal penetration.)

Serial clinical evaluation

Other modalities that have been studied include DPL alone, CT, laparoscopy, and

ultrasonography .[4, 5] These strategies of selection for laparotomy are explored in

greater detail below.

Abdominal stab wound exploration forms part of a strategy developed by surgeons

to allow a more selective approach. It is a safe, rapid, and cost-effective tool in the

management of asymptomatic patients who present with an anterior abdominal

stab wound .[6, 7]

This approach has no place in the treatment of patients who areunstable, who have peritonitis, or who have evisceration.

Patients with peritonitis and those who are hemodynamically unstable should

undergo mandatory laparotomy. The authors advocate abdominal stab wound



exploration in asymptomatic patients who present with an anterior abdominal stab

wound. An exploration with negative findings is reliable and highly sensitive . [8, 9]

More than 25% of anterior abdominal stab wounds do not penetrate the peritoneal

cavity .[7, 10, 11]

A wound exploration that demonstrates an intact posterior rectusfascia (superior to the arcuate line) or transversalis fascia (inferior to the arcuate

line) allows the safe discharge of these patients from the emergency department .[12]

(abdominal stab wound exploration,jurnal)

11. Kalau pasien ini perdarahan, pada Hb berapa mutlak diperlukan transfuse

darah?jelaskan,jenis darah apa yang diberikan? Mengapa demikian?

Bila Hb <7, diberikan PRC sesuai dengan hasil kebutuhan koreksinya, karena

yang kurang adalah sel darah merah maka diberikan PRC

Volume resuscitation of the trauma patient requires repletion of oxygen-carrying

capacity with red blood cell transfusion

and restoration of intravascular volume to replace extracellular losses. However,

blood transfusion carries inherent risksincluding transfusion reaction, infection, and systemic immunosuppression.

Several reports have attempted to clarify

what levels of hemoglobin (Hgb) and hematocrit are appropriate in critically ill

patients. A prospective, randomized trial

demonstrated that Hgb levels as low as 7.0 to 9.0 g/dL did not increase mortality in

critically ill patients compared to a

group transfused to Hgb levels of 10.0 to 12.0 g/Dl

In summary, the decision to transfuse erythrocytes must be individualized to the

patient. The healthy 30-year-old patient



with euvolemia without ongoing blood loss and a hemoglobin of 7 g/dL is less

likely to benefit from transfusion than the

70-year-old patient with hypovolemia with ongoing hemorrhage and a hemoglobin

of 9 g/dL.It is the clinician's responsibility to combine the available clinical, laboratory, and

physiologic data as previously described to make rational

transfusion decisions.

In general, the adage "the sicker the patient, the higher the hemoglobin" provides

the surgeon and

intensivist the rationale to consider transfusion.



12. Kalau setelah 2 minggu setelah dipulangkan pasien sesak nafas mendadak dan

paru-paru kiri bawah timpani pada perkusinya apa kecurigaan anda.

Bagaimana memastikan diagnosis dan apa tindakan lanjutnya?

Jawab:

Kecurigaan trauma pada diafragma.

Memastikan diagnosis dengan foto rontgen thorax AP/Lat atau CT scan

Tindak lanjutnya cito laparotomi.

Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in

about 5% of cases of severe blunt trauma to the trunk.Diagnostic techniques

include X-ray, computed tomography , and surgical techniques such as

laparotomy . Diagnosis is often difficult because signs may not show up on X-ray,

or signs that do show up appear similar to other conditions. Signs and symptoms

included chest and abdominal pain, difficulty breathing, and decreased lung

sounds. When a tear is discovered, surgery is needed to repair it.

http://en.wikipedia.org/wiki/X-ray


http://en.wikipedia.org/wiki/Computed_tomography


http://en.wikipedia.org/wiki/Laparotomy





Kasus Ujian Tahap i (Endang Sw)

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