KEBIJAKAN KEMENKES DALAM SISTEM PENANGGULANGAN GAWAT DARURAT TERPADU (SPGDT) DAN BENCANA

GAWAT DARURAT TERPADU (SPGDT) DAN BENCANA.KEGAGALAN FUNGSI ORGAN AKIBAT MULTIPLE TRAUMA.Dr.Yuzar Harun,SpB.INDONESIA.Bencana Gempa bumi dan letusan gunung berapiRing of Fire terdapat empat Zona aktif gunung berapi(Zona Sunda,Zona Minahasa,Halmahera ,Banda).Resiko terjadinya tsunami.maupun bencana lainnya.

Peta Rawan Bencana Nasional3Ada beberapa istilah :BENCANA: Suatu kejadian yang menyebabkan/menimbulkan kesusahan,kerugian dan penderitaan.KORBAN MASAL/Mass Casualties: keadaan dimana jumlah korban melebihi kemampuan fasilitas medis yang ada.MAJOR INCIDENT: Semua kejadian yang melibatkan manusia dimana lokasi,jumlah korban,beratnya cedera dan tipe korban memerlukan sarana kesehatan yang diluar kebiasaan.Major Incident dapat berupa:1. Natural/Ulah manusia yang melibatkan jumlah manusia(Mass Gathering)seperti pada gempa,banjir,api,KLL,olah raga,demo,hazardeous Material(HAZMAT)/Nuklir.Biologi dan Kimia,dll2. Simple major Incident(infrastruktur intak).3. Compound Major Incident(infrastruktur rusak)4. Compensated Major Incident(dapat diatasi dengan eskalasi Sistim Penanggungan Gawat Darurat(SPGDT) sehari hari.5. Uncompensated Major Incident dimana sistim kolaps seperti WTC,Bom Bali,Gempa dan Tsunami Aceh dan Gempa Jogjakarta.KEGAGALAN FUNGSI ORGAN AKIBAT MULTI TRAUMAThe most common causes of cell injuryHypoxia-anoxia Trauma (physical, chemical, radiation)InfectionCell injuryShock in trauma and critical ill pts lead to cellular injury due to tissue hypoxia [hypoxemia] :

Oxygen distributionOxygen utilization

Associated with anaerobe metabolismPhysiological abnormalityCell structure derangement9Tissue hypoxia:Abnormality of physiologyNO metabolismDestruction of membraneIonic compartmentalization Arachidonic acid metabolismDestruction of structureComplement systemFibrinolytic coagulation system

Trauma and the sepsis cascade Defects of microcirculation Endothelial response, adhesion to leukocyte and platelet Capillary permeability Hypovolemia shockActivation of cytokines & lymphokines cascadeSIRS and MODS10CAPILLARY PERMEABILITY TRAUMACELL INJURYTISSUE INJURYHYPOVOLEMIASIRSMODSTotal body fluid

Adult:male 60%BWfemale 70%BWChildren & elder 80%BWNewborn 90%BW60%30%10%Intra cellularExtra cellularCirculation: Plasma 7.5% Lymph 2.2% Trans-cell 0.3%ICITIVIV intravascular IT Interstitial IC IntracellularMacro circulationCerebralCardiacPulmonarySplanchnicRenalMusclesCentralPeripheralSkinCerebralCardiacRenalMusclesCentralPeripheralSkinPulmonarySplanchnicOthersOthersNormalHypovolemic Shock

ORGANFlow at restml/minBrain650 (13%)Heart215 (4%)Skeletal muscle1030 (21%)Skin430 (9%)Kidney950 (19%)Abdominal Organs1200 (24%)Other525 (10%)Total5000 (100%)The distribution of circulation according organ and splanchnic circulation

Ischemic mucosa leads to villi atrophy and mucosal disruptionGastric juice production No hyperacidityGut barrier

Atrophy of the villi mucosa10X40XSplanchnic hypoperfusion [formerly: constriction]

Mucosal disruptionIntolerance, malabsorption syndrome and any unexplainable diarrhea1 EnterocolitisGI bleeding [formerly: stress ulcer]Bacterial translocation Bacteremia, Septicemia and toxemia (Sepsis)2Muscularis mucosa involvement: Ileus No correlation to infection Broad spectrum antimicrobial treatmentAnaerobe antimicrobial treatmentAntacids and H2 Receptor Antagonist Splanchnic hypoperfusion [formerly: constriction]

Mucosal disruption: Gut dysfunctionHepatic, Pulmonary, Myocardial dysfunctionMultisystem Organ Dysfunction Syndrome [MODS]Gut is motor of MODSDiagnosis19The assessment and monitoringShock: impaired cellular perfusionSystemic circulation [haemodynamic], fluid and electrolyte imbalanceBlood pressure, heart-rate, urine outputCVP, MAP, PAWPGlobal and regional oxygenation decaysDelivery Oxygen (DO2), Oxygen Consumption (VO2), Oxygen Extraction Ratio (OER), Mixed Venous Oxygen Saturation (SVO2)Blood Gas AnalysisMetabolic changes

20HbAlveolusCirculationArteryVeinO2O2O2O2CO2CO2CO2CO2AerobePyruvateLactateAcetyl-CoAPDH36ATPTCAThe assessment and monitoringAnerobePyruvateLactateLactate + H+ Lactic acidLDH2ATPADP + P + H+Serum Lactate >3X N Lactic acidosis [lethal]Glucose22INSULT: ~ HIPOKSIA ~ CEDERA JAR ~ SEPSISSIRSKAPILER BOCOR : PLASMA PROT ELEKTROLIT AIRE D E M A

HistaminePolymorphs/Cytokines[ V ]Daur umpan balik yang berakibat gagal organ multipel. Injury mewakili serangan inflamatori berat. (Gosling P)Sindroma kebocoran kapiler klinis

Picasso. Science and CharityThank you !