PRESENTASI KASUSPembimbing:dr. Jumadi, Sp.BU
Presentan:Andrew Octovianus Wijaya2013.061.157Kepaniteraan Klinik Ilmu BedahFakultas Kedokteran Universitas Katolik Indonesia Atma Jaya2014
IdentitasNama: Tn. SUmur: 44 tahunAlamat: Kp. Geman, SukawarnaPekerjaan: Buruh serabutanAgama: IslamStatus: Sudah MenikahTanggal masuk (IGD): 28 Mei 2014
AnamnesaKeluhan utama:Nyeri disertai perdarahan di daerah kelamin.Retensi urine
Keluhan tambahan: -
Riwayat Penyakit Sekarang3 Hari SMRS (25/05), pasien jatuh terduduk (terkangkang) saat memasang lampu. Pasien mengalami perdarahan terus menerus di daerah kelamin. Pasien juga mengeluhkan sulit berkemih, dan nyeri saat berkemih. Pasien datang ke RS Pelabuhan Ratu 3 hari setelah kejadian, di RS pasien ditangani dengan pemasangan Blast Pungsi, lalu pasien di rujuk.
Riwayat Penyakit dahuluRiwayat tekanan darah tinggi disangkalRiwayat kencing manis disangkalRiwayat alergi, asma disangkalRiwayat operasi sebelumnya disangkal
Pemeriksaan Fisik 28 April 2014Keadaan umum: Tampak sakit sedangKesadaran: Compos MentisTanda-tanda vitalTekanan darah: 110/70 mmHgLaju nadi: 90 x/menitLaju napas: 20 x/menitSuhu aksila: 36,5 C
Pemeriksaan FisikKepala: Normochepali, deformitas (-)Mata: Konjungtiva anemis -/-, sklera ikterik -/Pupil isokor, diameter 3mm/3mm, refleks cahaya +/+Hidung: Hiperemis -/-, edema -/-, sekret -/-Mulut: Mukosa oral basahLeher: Tidak ada perbesaran KGB
Pemeriksaan FisikThorax paruI : pergerakan dinding dada simetris kiri dan kanan, statis dinamisP: stem fremitus kiri = kananP: sonor pada kedua lapang paruA: VBS +/+, Rh -/-, Wh -/-
Thorax jantung I : ictus cordis tidak terlihatI: ictus coerdis terabaP: Ukuran jantung dalam batas normalA: BJ I & BJ II reguler, murmur (-), gallop (-)
Pemeriksaan FisikAbdomenI : Terpasang Blast PungsiA : BU (+) 4-5x/menitP : supel, nyeri tekan (-)P : timpani
EkstremitasAkral hangat, edema -/-, CRT < 2 detik
Terdapat perdarahan masiv di daerah kelamin
Pemeriksaan PenunjangFoto Polos Pelvis (28 Mei 2014)Terpasang blast pungsi pada vesica urinariaTidak terlihat fraktur pelvisGinjal dalam batas normal
Pemeriksaan Penunjang
Pemeriksaan Penunjang28 Mei 2014
Tes pemeriksaanHasil Nilai normalKeteranganHB11,9 g/dl14-18 d/dlmenurun Leukosit10.000/ul4000-9000/ulmeningkatHematokrit33,1%40-50%menurunGlukosa Sewaktu100 mg/dl
DiagnosisRetensio urin e.c. Ruptur urethra e.c. Straddle injury
TatalaksanaMobilisasi bebasDiet bebasIVFD RL 2000 cc/24 jamCek Lab 1Obat:Ceftriaxone 2 x 1 g IVRanitidine 2 x 1 amp IVKetorolac 2 x 3 mg IV
TatalaksanaCek lab 1 & lab 2Konsul IPD untuk penilaian cardiopulmonalPrimary endoscopic realignmentUrethrocytography bipolar
Pemeriksaan Penunjang29 Mei 2014
Tes pemeriksaanHasil Nilai normalKeteranganSGOT18,5 U/L/37C
Pemeriksaan Penunjang01 Mei 2014
Tes pemeriksaanHasil Nilai normalKeteranganHB11,8 g/dl14-18 d/dlmenurun Leukosit6900/ul4000-9000/uldbnHematokrit34,6%40-50%menurunGlukosa Sewaktu118 mg/dl
TINJAUAN PUSTAKATrauma Urogenital
Introduksi10% - 20% dari trauma melibatkan urogenitalJarang mengancam nyawa Seringkali tidak diperhatikanKomplikasi jangka panjang:ImpotensiInkontinesiaTangani Life threatening injuries terlebih dahulu
DefinisiBagian atasGinjalUreterBagian bawahBladderUrethraGenitalia eksterna
Staging American Association for Surgery of TraumaSource: From Moore EE, Shackford SR, Pachter HL, et al: Organ & injuryscaling: Spleen, liver, and kidney. J Trauma 29:1664, 1989.
GradeDescription of injury1Contusion or nonexpandiing subscapular hematomaNo laceration2Nonexpanding perirenal hematomaCortical laceration 1 cm without urinary extravasation4Laceration: through corticomedullary junction into collectingsystemorVascular: segmental renal artery or vein injury with containedhematoma5Laceration: shattered kidneyorVascular: renal pedicle injury or avulsion
Grade IContusion
HematomaSubcapsularNon expandingNo laceration
Grade IIHematomaPerirenalNonexpanding
Laceration< 1.0 cmRenal cortex onlyNo urinary extravasation
Grade III
Laceration> 1.0 cmRenal cortex onlyNo urinary extravasationIntact collecting system
Grade IVLacerationRenal cortexRenal medullaCollecting system
VascularMain renal artery/vein injury with contained hemorrage.
Grade VCompletely shattered kidney.
Avulsion of renal hilum (pedicule) which devascularizes kidney.
TatalaksanaOperasi eksplorasi dari midline abd.Identifikasi a.Renalis kontrol pendarahanWatertight closure collecting system injuryEksisi jaringan matiLigasi pembuluh darah segmentalBila kontrol luka sulit + jar. Hidup sedikit nephrectomy
Trauma UreterJarang terjadiSebagian besar karena trauma tajamBiasa ditemukan saat pemeriksaan radiologiPemeriksaan:IV pyelogramRetrograde pyelogramCT-Scan dengan kontras
TatalaksanaPerbaikan dengan bedah tergantung tingkat perlukaan dan panjang segmen luka.debridementWatertight closure + tension freeBladder flaps tension freeTunika adventisia dipertahankan suplai darah
Trauma Kandung KemihHematuria (gross/microscopic)Sering pada fraktur pelvis (90%)
Pemeriksaan radiologiRontgent pelvisRetrograde cystogramCT cystogram
TatalaksanaRuptur EkstraperitonealKonservatifDrainase dengan katheter
Ruptur IntraperitonealLaparotomi eksplorasi
Trauma UrethraLaki-laki > WanitaKomplikasiStrikturInkontinensiaImpotensiJika tidak terdeteksi:Dapat menimbulkan ruptur parsial atau komplitPenanganan tidak akuratKontra indikasi pemasangan foley catheter
Trauma UrethraManifestasi Klinis:Perdarahan pada meatusRetensi urinPerineal hematomPemeriksaan:Retrograde urethrogram
AnatomiBladderSimfisis
Urethra posteriorUrethra pars prostatica + pars membranousTerjadi pada fraktur pelvisTatalaksana:Bila memungkinkan pasang foley catheterBila tidak pasang suprapubic tube/blast pungsi
Urethra anteriorUrethra pars bulbosa + pars pendulosaBiasa disebabkan straddle injuryTrauma langsung pada penisTatalaksana:Eksplorasi Proksimal perineal inscisionDistal circumferential, subcoronal inscision, degloving the penisHigh-velocity gunshot suprapubic cystostomyDebridementPerbaikan langsung
PenisLuka tajam jarang terjadiLakukan evaluasi dgn urethrogramBila ada trauma pada urethra lakukan perbaikanTatalaksana:Penutupan ruptur pada tunica albuginea
Daftar PustakaBrunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE. Schwartz Manual of Surgery 8th edition. McGraw-hill Medical Publishing Division, United States of America; 2006.Franois Dufresne. Genitourinary Trauma. McGill Emergency Medicine; February 13th 2002.
GU trauma, because of its very often non life-threatening injuries and its subtle presentation, is very often overlooked and poorly recognized in the emergency departement. However, approximateley 10-20% of all injured patients have some kind of GU involvement which can lead to very debilitating long term sequalae such as incontinence and impotence.Although the more life-threatening injuries of the primary survey must be addressed first, we must be alert to the clues pointing to the presence of GU injuries.So in the OVERALL management of all trauma patients, it is very important that we have a complete understanding of GU injuries, how to deal with it and how it can impact on patient outcome.Being good at managing trauma patients doesnt only mean being good at putting chest tubes.
*for purposes of investigation and staging of urologic injuries, GU traum is divided intoEach category is futher subdivided on the basis of a blunt or penetrating mechanism of injury.Im going to focus on BLUNT trauma during my talk.
*Female: severe pelvic fracture and bony displacement along with lacerations through the bladder neck and vagina are present in cases of urethral trauma.Morbidity: 15% (stress) incontinence in this study by Andrich: Men from 19-51! In previous studies, depending on the method used to repair the urethra, the rate of Incontinence/impotence is up to 70%, needing RE-operation to correct the problem.Journal of Urology, 1996 Oct.: Stricture:49-97%. Impotence:0-36%. Incontinence: 0-21%. (Impotence and incontinence is a complication of procedures with less strictures.and as you learned in your ATLS, Foley catheter is C.-I. if you suspect urethral trauma.
*Male urethra divided into four segments:Prostatic urethraurogenital diaphragm: Membranous urethraBulbous urethraPendulous urethra
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