kuliah kegawatdaruratan di bagian penyakit dalam

7/26/2019 Kuliah Kegawatdaruratan Di Bagian Penyakit Dalam

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TATA LAKSANA

KEGAWATDARURATAN DIBIDANG ILMU PENYAKIT DALAM


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Pendahuluan

Pendekatan gawat darurat berdasarkan tandadan gejala

Basic Life Support

43 topik kajian dalam modul IMELS, temadisajikan berdasarkan kekerapan ditemui dalamkeseharian pasien2 penyakit dalam

Menjaga serta meningkatkan kompetensi dokter

SpPD Mampu memberikan pelayanan kegawatdarutan

yg optimal demi peningkatan pelayanan bagimasyarakat


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Kegawatdaruratan Di BidangIlmu Pena!it Dalam

Syok hipo!olemik

Syok ana"laktik

#enti jantung

$ntoksikasi dengan an%aman hidup

Sindrom distres perna&asan akut

Pneumonia berat

Pneumotoraks

'&usi pleura masi& (ejas paru karena suhu )trauma inhalasi*

'mboli paru

+agal hati akut


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'nse&alopati hepatikum

olangitis akut

Pankreatitis

olesistitis akut

#ematemesis melena

#ematoske-ia

$leus paralitik

risis hipertensi #ipokalemia

#iperkalemia

#iponatremia


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#ematuria masi&

+angguan ginjal akut

.radikardia simtomatik

/akikardia denganpulse

Sindroma koroner akut

'dema paru akut kardiogenik

Sindrom delirium akut

oagulasi intra!askular diseminata Sindrom !ena ka!a superior

Sindrom lisis tumor

etoasidosis diabetikum


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#ipoglikemia

risis tiroid

Sepsis

0eptospirosis )sindrom Weil*

Malaria berat

/i&oid toksik

era%unan makanan

/ertelan -at korosi&

+igitan binatang berbisa

Sengatan panas


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Sh"#!

De"nition

'pidemiology

Physiology and Pathophysiology 1lasses o& Sho%k

1lini%al Presentation

Management 1ontro!ersies


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De$niti"n

A %h&i"l"gi# &tate #hara#teri'ed( $nadeuate tissue per&usion

)lini#all mani*e&ted ( #emodynami% disturban%es

rgan dys&un%tion


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E%idemi"l"g

M"rtalit Septi% sho%k 356478 )9 month

mortality*

1ardiogeni% sho%k :76;78

#ypo!olemi% sho%k !ariable


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Ph&i"l"g

.asi% unit o& li&e = %ell

1ells get energy needed to stay ali!eby rea%ting o>ygen with &uel )usuallyglu%ose*

?o o>ygen, no energy

?o energy, no li&e


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Ph&i"l"g

)ardi"+aular S&tem/ransports o>ygen, &uel to %ells

@emo!es %arbon dio>ide, waste produ%ts

&or elimination &rom body

)ardi"+aular &&tem mu&t(e a(le t" maintain &u,#ient-"w thr"ugh #a%illar (ed& t"meet #ell.& "/gen and *uel

need&


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Alow =Per&usion

Bdeuate Alow

= BdeuatePer&usion

$nadeuate Alow

= $ndeuatePer&usion

)#ypoper&usion*

#ypoper&usion = Sho%k


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Ph&i"l"g

What i& needed t" maintain%er*u&i"n0 Pump C #eart

Pipes C .lood !essels

Aluid C .lood

1"w #an %er*u&i"n *ail0 Pump Aailure Pipe Aailure

0oss o& olume


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Path"%h&i"l"g

$mbalan%e in o>ygen supply and demand

1on!ersion &rom aerobi% to anaerobi%metabolism

Bppropriate and inappropriate metaboli%and physiologi% responses

)hara#teri'ed ( three &tage& Pre&h"#!)warm sho%k, %ompensated sho%k*

Sh"#!

End "rgan d&*un#ti"n


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Path"%h&i"l"g

)"m%en&ated &h"#! 0ow preload sho%k ta%hy%ardia, !aso%onstri%tion,

mildly de%reased .P

0ow a&terload )distributi!e* sho%k peripheral

!asodilation, hyperdynami% state Sh"#!

$nitial signs o& end organ dys&un%tion

/a%hy%ardia

/a%hypnea Metaboli% a%idosis

liguria

1ool and %lammy skin


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Path"%h&i"l"g

End 2rgan D&*un#ti"n Progressi!e irre!ersible dys&un%tion

liguria or anuria

Progressi!e a%idosis and de%reased 1

Bgitation, obtundation, and %oma

Patient death


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)la&&i$#ati"n

S%hemes are designed to simpli&y%omple> physiology

Ma3"r #la&&e& "* &h"#! 1%"+"lemi#

)ardi"geni#

Di&tri(uti+e


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1%"+"lemi# Sh"#!

@esults &rom de%reased preload

Eti"l"gi# #la&&e& #emorrhage 6 eg trauma, +$ bleed,

ruptured aneurysm

Aluid loss 6 eg diarrhea, !omiting,burns, third spa%ing, iatrogeni%


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1%"+"lemi# Sh"#!

1em"rrhagi#Sh"#!Parameter I II III IV

Blood loss (ml) 2000

Blood loss (%) 40%

Pulse rate(beats/mi) 100 >120 >140

Blood !ressure "ormal #e$reased #e$reased #e$reased

es!irator& rate

(b!m) 1420 2030 3040 >35

'rie out!ut(ml/our) >30 2030 515 "eliible

*"+ s&m!toms "ormal ,-ious *o.used etari$

)rit )are4 56678 9:;?>@

>94


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)ardi"geni# Sh"#!

Re&ult& *r"m %um% *ailure De%reased systoli% &un%tion

@esultant de%reased %ardia% output

Eti"l"gi# #ateg"rie& Myopathi%

Brrhythmi%

Me%hani%al

'>tra%ardia% )obstru%ti!e*


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Di&tri(uti+e Sh"#!

@esults &rom a se!ere de%rease inS@ asodilation redu%es a&terload

May be asso%iated with in%reased 1

Eti"l"gi# #ateg"rie& Se%&i&

Neur"geni# &%inal

2ther :ne/t %age%eptions earlydistributi!e, terminal sho%k*

liguria

1hange in mental status

Metaboli% a%idosis


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E+aluati"n

Done in parallel with treatmentH

#IP help&ul to distinguish type o& sho%k

Aull laboratory e!aluation )in%luding #I#,

%ardia% en-ymes, B.+* .asi% studies 1>@, '+, JB

.asi% monitoring S, JP, 1P, B6line

$maging i& appropriate ABS/, 1/ '%ho !s PB %atheteri-ation

1, PBS


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Treatment

Manage the emergen%y

Determine the underlying %ause

De"niti!e management or support


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Manage the Emergen#

Lour patient is in e>tremis ta%hy%ardi%, hypotensi!e, obtunded

#ow long do you ha!e to managethis

Suggests that many things must bedone at on%e

Draw in an%illary staN &or supportH

Khat must be done


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Manage the Emergen#

ne person runs the %odeH

1ontrol airway and breathing

Ma>imi-e o>ygen deli!ery

Pla%e lines, tubes, and monitors

+et and run $A on a pressure bag

+et and run blood )i& appropriate* +et and hang pressors

1all your senior


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Determine the )au&e

&ten ob!ious based on history

/rauma most o&ten hypo!olemi%)hemorrhagi%*

Postoperati!e most o&ten hypo!olemi%)hemorrhagi% or third spa%ing*

Debilitated hospitali-ed pts most o&ten septi%

Must e!aluate all pts &or risk &a%tors &or M$

and %onsider %ardiogeni%

1onsider distributi!e )spinal* sho%k in trauma


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)a&e

O5 y


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De$niti+e Management

1%"+"lemi# Aluid resus%itate )bloodor %rystalloid* and %ontrol ongoing loss

)ardi"geni#6 @estore blood pressure

)%hemi%al and me%hani%al* and pre!entongoing %ardia% death

Di&tri(uti+e Aluid resus%itate,

pressors &or maintenan%e, immediateab>


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)"ntr"+er&ie&

IC Re&uitati"n 0imited resus%itation in penetrating trauma

Jse o& hypertoni% saline resus%itation in

trauma 'ndpoints &or prolonged resus%itation

Pre&&"r& .est pressors &or distributi!e sho%k

M"nit"ring Most appropriate timing and use &or PB

%atheteri-ation or intermittent e%ho%ardiogram

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