fisiologi trauma
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Tinjauan Anatomi, Fisiologi pada TraumaIrfannuddinBlok 19
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Fisiologi Trauma Page 2
Mengapa Trauma Dapat Menyebabkan Kematian ?
Urun Pendapat ??
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Bagaimana manusia bisa hidup ?
Ingat reaksi kimia terpenting bagi tubuh ? (blok 6)
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Bila anda :
Tidak dapat bernafas, berapa lama bertahan hidup ??
Tidak makan & minum, berapa lama bertahan hidup ?
Apa yang harus ditakuti segera, hipoksia ?? / hipoglikemia ??
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Prinsip Tatalaksana Pasien Trauma & Gawat Darurat
A Airway
B Breathing
C Circulation
D Disability,/ Do – it
E ExposurePada dasarnya menjamin oksigenasi jaringan
-Ingat macam-macam hipoxia-Anoxic, stagnant, anemic, histotoxic
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Kapan Trauma mengancam nyawa ??
Bila mengancam oksigenasi jaringan di seluruh organ, terutama ke organ penting (otak, jantung, ginjal)
- Pada gangguan : A, B, C, D (otak)
Kapan mengancam organ
- Bila mengancam oksigenasi jaringan secara lokal
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Bagaimana Tinjauan Aspek Fisiologi dan Anatomi pada Trauma ??
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Airways menjadi prioritas no.1 karena pintu masuk (pangkal) oksigenasi ke tubuh
Anatomi saluran nafas :
Gangguan Airways
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Apa yang terjadi pada ‘airway’nya ?
- Sumbatan :- - Total- - Parsial
- Berkumur (gurgling)
- Ngorok (snoring)
- Serak (stridor)
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Pasti ada gurgling karena pendarahan
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Mengapa penurunan kesadaran mengancam patensi airway ? Ngorok
Bila sadar otot-otot lidah/faring menahan lidah dan nasofaring supaya tidak menutup airway
Saat tidak sadar (coma) refleks menahan lidah hilang
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Mengapa stridor mengancam airways ?
Laring mengalami peradangan:-Trauma mekanik-Trauma panas (inhalasi)
Terjadi edema laring
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Menjamin patensi airway
Manuver chin-lift atau jaw trust- Mengangkat lidah
Suction- Membersihkan darah, cairan benda asing
Orofaring airway- Menahan lidah jatuh
Airways definitif- Intubasi endotracheal- Cricotiroidektomi- Trakeostomi
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Breathing ventilasi (pertukaran) O2-CO2
Ventilasi udara terjamin- Bila paru bisa mengembang
Paru mengembang bila- Dinding dada bebas bergerak- Ruang rongga toraks luas- Tekanan intra pleura negatif
Ggn pengembangan paru- Ggn gerak dinding dada nyeri
- Kontusio, fraktur
- Ggn volume toraks- Hemotoraks
- Ggn tekanan pleura- Pneumotoraks
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Bagaimana ventilasinya ???
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Pneumotoraks
Tek intrapleura negatif Dinding dada /cavum pleura robek Mekanisme katup Paru (balon) menyusut Lanjut , mendorong sisi sehat
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Pneumotoraks
Simple pneumotorax Tension pneumotorax
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Hemotoraks
Pendarahan di intratorakal
Darah mengisi toraksRadiologi:
- Radio opaq- Air-fluid level
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Hemotoraks massive
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Bagaimana mengenali gangguan breathing ??
Look- Sesak Nafas- Cyanosis- Bila kena hemitoraks : gerak nafas asimetris
Listen- Hemotoraks/pneumotoraks ada halangan
- Bising nafas menjauh Feel
- Ggn dinding dada nyeri raba- Fraktur: krepitasi- Perkusi:
- Hemotoraks redup- Pneumotoraks hipersonor
Tension pneumotoraks trakea bergeser, JVP ↑
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Menjamin breathing/ ventilasi
Oksigenasi (10-12 L/mnt)- Pakai masker
Ggn gerak dinding dada karena nyeri (kontusio/fraktur) - Analgesik- Apakah kostae boleh di bidai ??
Pneumotoraks, hemotoraks- Chest-tube + Water Shield Drainase (WSD)
Khusus Tension Pneumotoraks- Waktu menjadi musuh
- Neddle decompressi chest-tube + WSD
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Neddle decompressi
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Chestube
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Circulation
Apa peran sistem sirkulasi ?- Oksigen menumpang di Hb
Bagaimana mekanisme sistem sirkulasi ? - Bagaimana air sampai ke bak mandi di rumahmu?
- Butuh: pipa, pompa, listrik Syok : Gangguan perfusi (aliran) oksigen ke jaringan.
- Why ? pipa bocor, pompa macet, listrik mati- Syok hipovolemik/hemoragik, kardiogenik, neurogenik
Untuk kasus trauma !!!!- Bila terjadi syok, pikirkan dahulu karena pendarahan/hipovolemik- Trauma Bersifat akut & mekanik : syok septik & anafilaktik sangat jarang !!
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Apa akibat syok berlarut ??
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Apa saja penyebab syok hipovolemia pada trauma ?
Seluruh aspek yang menyebabkan kerusakan pembuluh darah besar
- Luka robek- Ruptur arteri- Fraktur tulang besar (panjang, pelvis)- Hemotorak massive- Pendarahan intra abdomen
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Pendarahan intra abdomen
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Bagaimana mengenali syok ?
Ingat !!, bila pasien trauma mengalami syok pikirkan syok hipovolemia Pendarahan awal
- Kompensasi simpatis (katekolamin):- Takikardi : (ingat blok 10) CÓ = SV x HR- Kulit pucat & dingin (autoregulasi arteriole)- Cemas, gelisah, hiperhidrosis- Tek Darah masih stabil TD = CÓ x RP
Pendarahan lanjut- CÓ tidak bisa dipertahankan TD ↓- Hipoperfusi O2
- Ke otak penurunan kesadaran- Ke otot lemas
- Urin output ↓ (obyektif) Hipoksia berlanjut asidosis sesak dalam
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Bagaimana mengatasi syok karena pendarahan
Prinsip: tambal pipa yang bocor, ganti air yang hilang
- Stop bleeding, fluid resuscitation Stop bleeding
- Balut tekan
- Imobilisasi fraktur (bidai, gurita)
- Rujuk !! Intervensi bedah Resusitasi cairan
- IVFD, 2 jalur
- Cairan RL hangat 39C ?? Tetesan: guyur- Mengapa RL ??, mengapa bukan D5%/NaCl ?? isotonis, kristaloid
- Transfusi darah Boleh/ tidak diberi vasokonstriktor ?
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Syok Kardiogenik pada Trauma
Tekanan perikardium Tamponade Jantung
Pendarahan mediastinum
Gejala Tamponade:Trias Beck-Suara jantung menjauh-TD ↓↓ S-D rapat : misal 80/70-JVP ↑
Atasi dengan dekompresi (perikardiosintesis)
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Syok neurogenik karena trauma Medulla Spinalis
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Fraktur Vertebra
Gejala:Hipotensi, bradikardia
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Disability
Organ terpenting dalam tubuh susunan saraf pusat
sebagai pusat kontrol
Otak berupa organ yang berada di dalam rongga kranial- Punya tekanan intrakranial
Pendarahan intra kranial- TIK ↑↑
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Of ACS
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Kematian terjadi karena ↑ TIK ↓ CBF
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Cegah secondary brain injury
Kompensasi TIKCerebral Blood Flow tergatung pada Cerebral perfusion pressure
CPP = MAP – ICP Normal
- CPP : 90 – 10 = 80
Trauma kepala tanpa syok- CPP = 90 – 30 = 60
Trauma kepala + syok- CPP = 60 – 30 = 30
Syok tanpa trauma kepala- CPP = 60 – 10 = 50
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Bagaimana mendeteksi gangguan SSP
Kesadaran- Glasgow Coma Scale
- Eye : 1 – 4- Movement : 1 – 6- Verbal : 1 – 5
Lateralisasi (kanan/kiri)- Refleks pupil/cahaya
- Isokor/an-isokor- Bagaimana bila:
- Isokor tapi ke-2nya lambat ?
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Trauma Spinal
Gangguan - Sensorik- Motorik- Otonom
Setinggi dermatom
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Dermatom
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Fraktur
Merusak Jaringan Sekitar Cegah
Compartment Syndrome
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Compartment Syndrome
Ggn perfusi jaringan karena ↑ TI Compartment
Gejala:- Pain- Pale- Paresthesia- Paralysis- Pulse-less- Swelling
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Apa tindakan terbaik sebagai dokter umum ??
Trauma spinal- Imobilisasi
Fraktur- Imobilisasi
Bila Fraktur terbuka- Stop bleeding- Tutup luka terbuka
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Gagal Ginjal Akut karena Trauma
Kerusakan otot luas - Myoglobin keluar dari sel
otot- Menyumbat glomerulus- Acute tubular necrosis
Terjadi pada:- Crush syndrome- Trauma listrik
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