NYERI:NYERI: Ada gunanya merupakan mekanisme proteksi badan Ada gunanya merupakan mekanisme proteksi badan Terjadi akibat kerusakan jaringan, timbul rasa sakit, walau Terjadi akibat kerusakan jaringan, timbul rasa sakit, walau

rasang sangat kecil .rasang sangat kecil . Kulit iskemia , rasa sakit dan dapat pingsangKulit iskemia , rasa sakit dan dapat pingsang Rasa sakit : - cepat 0.1 detikRasa sakit : - cepat 0.1 detik - lambat 1 detik sampai 1 menit- lambat 1 detik sampai 1 menit Cepat : benda tajam, menyengat dan mendadakCepat : benda tajam, menyengat dan mendadak Listrik, jarum , kulit teririsListrik, jarum , kulit teriris TerbakarTerbakar Tidak perlu masuk ke dalam jaringan sampai dalamTidak perlu masuk ke dalam jaringan sampai dalam Mekanik dan termalMekanik dan termal Lambat: sakit, nausea, sakit kronis, kerusakan jaringan.Lambat: sakit, nausea, sakit kronis, kerusakan jaringan. Mekanik, termal. Dan kimiawiMekanik, termal. Dan kimiawi

Reseptor sakit: akhiran saraf bebas, tersebar di Reseptor sakit: akhiran saraf bebas, tersebar di seluruh permukaan kulitseluruh permukaan kulitDi jaringan tertentu: di dalam: periosteum, Di jaringan tertentu: di dalam: periosteum, dinding pembuluh darah, permukaan artikulasio.dinding pembuluh darah, permukaan artikulasio.

Rangsangan dapat: mekanik, termal dan kimiawiRangsangan dapat: mekanik, termal dan kimiawiKimiawi: disuntikkan dibawah kulit (bradikinin, Kimiawi: disuntikkan dibawah kulit (bradikinin, ion K, dan enzim proteolitik)ion K, dan enzim proteolitik)

Jika reseptor lebih sensitif, dinamakan Jika reseptor lebih sensitif, dinamakan hiperalgesia.hiperalgesia.

Termal yang menyebabkan nyeri = 45Termal yang menyebabkan nyeri = 45ooC , C , sebanding dengan kerusakan jaringan.sebanding dengan kerusakan jaringan.

Reseptor sakit tidak seperti reseptor yang lain:Reseptor sakit tidak seperti reseptor yang lain:

Adaptasi : sangat kecil/ tidak ada sama sekali, Adaptasi : sangat kecil/ tidak ada sama sekali, dalam kondisi tertentu eksitasi menjadi bertambah dalam kondisi tertentu eksitasi menjadi bertambah besarbesar

Rangsang berjalan terus , jaringan rusak.Rangsang berjalan terus , jaringan rusak.

Jaringan iskemia , sakit sekali. Aliran darah Jaringan iskemia , sakit sekali. Aliran darah tersumbat sakit beberapa menit. Metabolisme tersumbat sakit beberapa menit. Metabolisme bertambah merasa makin sakit.bertambah merasa makin sakit.

Sakit akibat akumulasi asam laktat di jaringanSakit akibat akumulasi asam laktat di jaringan

Kejang otot merasa sangat sakit, sindroma Kejang otot merasa sangat sakit, sindroma sakitsakit

Reseptor sakit, mekanosensitif (langsung)Reseptor sakit, mekanosensitif (langsung)

Rusak pembuluh darah iskemia (tidak Rusak pembuluh darah iskemia (tidak langsung)langsung)

Dual transmisi signal sakit menuju ke SSP:Dual transmisi signal sakit menuju ke SSP: fast, sharp pain pathwayfast, sharp pain pathway slow ,chronic pathwayslow ,chronic pathway

Dual, cepat jalan dulu, memberitahu sakit, Dual, cepat jalan dulu, memberitahu sakit, kemudian hindari, beberapa menit sampai kemudian hindari, beberapa menit sampai otakotak

Jalan sampai otak: Jalan sampai otak: traktus neospinotalamus untuk fast pain traktus neospinotalamus untuk fast pain

berhenti di brain stem dan talamus berhenti di brain stem dan talamus Mekanis, termalMekanis, termal

traktus paleospinotalamus untuk slow paintraktus paleospinotalamus untuk slow pain

Pain Suppression: bervariasi untuk Pain Suppression: bervariasi untuk menekan sakitmenekan sakit

Otak sendiri menahannya untuk tidak ke Otak sendiri menahannya untuk tidak ke sistem saraf,sistem saraf,

Dengan mengaktifkan sistem kontrol sakit Dengan mengaktifkan sistem kontrol sakit

= sistem analgesia= sistem analgesia

Sistem analgesia terdiri dari 3 Sistem analgesia terdiri dari 3 komponen:komponen:

1.1. periaqaeductal dan periventrikuler di periaqaeductal dan periventrikuler di mesensefalon dan pons ventrikel 3 mesensefalon dan pons ventrikel 3 dan 4 signal dari neuron-neuron dan 4 signal dari neuron-neuron dikirim kedikirim ke

2.2. nukleus rafe magnus di pons bawah nukleus rafe magnus di pons bawah medula atas, Diteruskan turun kemedula atas, Diteruskan turun ke

3.3. kornu dorsalis, medula spinaliskornu dorsalis, medula spinalis

Rangsang elektrik: dibawa ke periaqaeduct dan Rangsang elektrik: dibawa ke periaqaeduct dan nukleus rafe magnusnukleus rafe magnusDapat menekan signal sakit (kuat) pada waktu Dapat menekan signal sakit (kuat) pada waktu masuk ke dorsal spinal rootsmasuk ke dorsal spinal roots

Periaqaeduct, periventrikuler menekan sakit Periaqaeduct, periventrikuler menekan sakit tidak terlalu kuattidak terlalu kuatNeurotransmitter , supres sakit (sistem Neurotransmitter , supres sakit (sistem analgesia): enkefalin Serotoninanalgesia): enkefalin Serotonin

Nuklei periventrikuler dan periaqaeduct ke saraf Nuklei periventrikuler dan periaqaeduct ke saraf

ujung-ujung mensekresikan enkefalin.ujung-ujung mensekresikan enkefalin.Juga rafe magnus mensekresikan enkefalinJuga rafe magnus mensekresikan enkefalin

serabut-serabut asal dari nuklei ini dan berakhir serabut-serabut asal dari nuklei ini dan berakhir di kornu dorsalis medula spinalis mensekresikan di kornu dorsalis medula spinalis mensekresikan serotonin pada ujung-ujungnyaserotonin pada ujung-ujungnya

serotonin secara setempat merangsang sekresi serotonin secara setempat merangsang sekresi enkefalinenkefalin

enkefalin : presinaps inhibisi dan possinaps enkefalin : presinaps inhibisi dan possinaps inhibisiinhibisiPada serabut-serabut sakit A dan C dengan Pada serabut-serabut sakit A dan C dengan sinapsnya di kornu dorsalis dengan cara sinapsnya di kornu dorsalis dengan cara presinaps inhibisi dan blok kanal ion Ca, presinaps inhibisi dan blok kanal ion Ca, Ion Ca melepas transmiter di sinaps blok Ion Ca melepas transmiter di sinaps blok presinaps inhibisipresinaps inhibisi

Pemblok dapat kerja di sistem analgesik Pemblok dapat kerja di sistem analgesik mulai dengan menit sampai jammulai dengan menit sampai jam

Sistem analgesi dapat dihambat di Sistem analgesi dapat dihambat di permulaan masuk korda spinalispermulaan masuk korda spinalis

Sistem analgesia dapat menghambat Sistem analgesia dapat menghambat transmisi sakit di perjalanan di nuklei transmisi sakit di perjalanan di nuklei retikuler, batang otak, dan talamusretikuler, batang otak, dan talamus

Sistem opiat otak: endorfin dan enkefalinSistem opiat otak: endorfin dan enkefalin

Irritasi/rusak jaringan menghasilkan bahan-Irritasi/rusak jaringan menghasilkan bahan-bahan kimia seperti:bahan kimia seperti:

prostaglandin, kinins, dan ion kalium prostaglandin, kinins, dan ion kalium yang merangsang nociceptoryang merangsang nociceptor

Kondisi yang meningkatkan sakit:Kondisi yang meningkatkan sakit:

Jaringan meregang berlebihanJaringan meregang berlebihan

Kontraksi otot yang berkepanjanganKontraksi otot yang berkepanjangan

Kejang, iskemia (aliran darah kurang)Kejang, iskemia (aliran darah kurang)

Phantom Limb SensationPhantom Limb Sensation::

Seorang pasein yang telah diamputasi Seorang pasein yang telah diamputasi kakinya merasa sensasi seperti gatal, kakinya merasa sensasi seperti gatal,

tertekan tertekan atau sakit seakan-akan datang datang dari atau sakit seakan-akan datang datang dari kaki yang sudah diamputasikaki yang sudah diamputasi

Mengapa? Mengapa?

1)1) Korteks serebral menerima impuls datang dari Korteks serebral menerima impuls datang dari bagian proksimal saraf kaki yang telah hilangbagian proksimal saraf kaki yang telah hilang

3)3) Di otak sendiri ada jaringan neuron-neuron yang Di otak sendiri ada jaringan neuron-neuron yang menimbulkan sensasi pertahanan tubuh (neuron menimbulkan sensasi pertahanan tubuh (neuron masih aktif memberikan sensasi palsu)masih aktif memberikan sensasi palsu)

Kadang-kadang dirasa sangat sakit, dengan Kadang-kadang dirasa sangat sakit, dengan obat-obatan tidak meredaobat-obatan tidak mereda

VISCERAL PAINVISCERAL PAIN

Referred PainReferred Pain

Pain is initiated in area of the visceral organs Pain is initiated in area of the visceral organs and referred to an area on the body surfaceand referred to an area on the body surface

Pain may be referred to an area of the body Pain may be referred to an area of the body not exactly coincident with the location of the not exactly coincident with the location of the area producing the painarea producing the pain

The pain receptors adapt very little and The pain receptors adapt very little and sometimes not at allsometimes not at all

The average person first begins to The average person first begins to perceive pain when the skin is heated perceive pain when the skin is heated above 45above 4500CC

Pain receptor are free nerve endings in Pain receptor are free nerve endings in the skin and other tissuesthe skin and other tissues

They are widespread in the superficial They are widespread in the superficial layers of the skin, and internal tissues layers of the skin, and internal tissues (periosteum, arterial walls,joint surfaces, (periosteum, arterial walls,joint surfaces, and peritoneum)and peritoneum)

Pain is elevated by noxcious stimuli on Pain is elevated by noxcious stimuli on nociceptor (a sesory receptor cell sensitive nociceptor (a sesory receptor cell sensitive to xoxious stimuli)to xoxious stimuli)

Pain is importantPain is important

= is mainly a protective mechanisms for the = is mainly a protective mechanisms for the bodybody

= occurs whenever any tissues are being = occurs whenever any tissues are being damagedamage

= causes the individual to react to remove = causes the individual to react to remove the pain stimulusthe pain stimulus

Referred pain is important in clinical Referred pain is important in clinical diagnosis, because may visceral ailments diagnosis, because may visceral ailments cause no clinical signs except referred paincause no clinical signs except referred pain

Mechanical of referred painMechanical of referred pain

Branches of visceral pain fibers are shown Branches of visceral pain fibers are shown to synapse in the spinal cord on the same to synapse in the spinal cord on the same order of neuron that receive pain signals order of neuron that receive pain signals from the skinfrom the skin

When the visceral pain fibers are When the visceral pain fibers are stimulated, pain signal from the stimulated, pain signal from the viscera are then conducted through viscera are then conducted through at least some of the same neurons at least some of the same neurons that conduct pain signals from the that conduct pain signals from the skin, and the person has feeling that skin, and the person has feeling that the sensations originate in the skin the sensations originate in the skin itselfitself

Ischemia caused by occluding the blood Ischemia caused by occluding the blood supply to a large area supply to a large area stimulates many stimulates many diffuse pain fibers at the same time and can diffuse pain fibers at the same time and can result in extreme painresult in extreme pain

Ischemia causes visceral pain in the same Ischemia causes visceral pain in the same way that it does in other tissuesway that it does in other tissues

Presumebly because of the formation of Presumebly because of the formation of acidic metabolic end product or tissue acidic metabolic end product or tissue degeneration product such as bradykinin, degeneration product such as bradykinin, proteolytic enzymes, or others that stimulate proteolytic enzymes, or others that stimulate the pain nervesthe pain nerves

Pain threshold:Pain threshold:

The smallest intensity of a painful stimulus at The smallest intensity of a painful stimulus at

which a person perceives pain. which a person perceives pain.

All individuals have the same pain thresholdAll individuals have the same pain threshold

Pain tolerance:Pain tolerance:

The greatest intensity of painful stimulation The greatest intensity of painful stimulation

that a person is able to tolerate that a person is able to tolerate

Individuals vary in their tolerance to painIndividuals vary in their tolerance to pain

Analgesia, dengan cara menghambat Analgesia, dengan cara menghambat sintesis prostaglandin yang merangsang sintesis prostaglandin yang merangsang nociceptorsnociceptors

Dapat dengan memberikan obat atau zat Dapat dengan memberikan obat atau zat yang menghambat enzim yang yang menghambat enzim yang menyebabkan reaksi arakhidonat menjadi menyebabkan reaksi arakhidonat menjadi prostaglandin (siklooksigenase) prostaglandin (siklooksigenase)

Headache of Intracranial OriginHeadache of Intracranial Origin

The brain tissues themselves are almost The brain tissues themselves are almost totally insensitive to paintotally insensitive to pain

Therefore, it is likely that much or most of Therefore, it is likely that much or most of the pain of headache is not caused by the pain of headache is not caused by damage within the brain itselfdamage within the brain itself

HEADACHESHEADACHES

Headaches are a type of pain referred to the Headaches are a type of pain referred to the surface of the head from deep head surface of the head from deep head structuresstructures

Some headaches result from pain stimuli Some headaches result from pain stimuli arising inside the cranium, but others result arising inside the cranium, but others result from pain arising outside the cranium such from pain arising outside the cranium such as from the nasal sinusesas from the nasal sinuses

Conversely, tugging on the venous sinuses Conversely, tugging on the venous sinuses around the brain, damage or stretching the around the brain, damage or stretching the dura at the base of the brain can cause dura at the base of the brain can cause intense pain that is recognized as headache intense pain that is recognized as headache (trauma, blood vessels of meninges)(trauma, blood vessels of meninges)

Headache of Extracranial OriginHeadache of Extracranial Origin

Headache resulting from muscle spasmHeadache resulting from muscle spasm Emotional tension often causes many of the Emotional tension often causes many of the

muscles of the head, especially those muscles of the head, especially those muscles attached to the scalp and the neck muscles attached to the scalp and the neck muscle attached to the occiput, to become muscle attached to the occiput, to become spasticspastic

Headache caused by irritation of nasal and Headache caused by irritation of nasal and accessory nasal structuresaccessory nasal structures

The mucous membranes of the nose and The mucous membranes of the nose and nasal sinuses are sensitive to painnasal sinuses are sensitive to pain

Irritative processes in widespread areas of Irritative processes in widespread areas of the nasal structure often summate and the nasal structure often summate and cause headache , --> referred behind the cause headache , --> referred behind the eyeseyes

Also, pain from the lower sinuses such as Also, pain from the lower sinuses such as from the maxillary sinuses, can be felt in the from the maxillary sinuses, can be felt in the face face

Headache originate in the eyes or the extra Headache originate in the eyes or the extra occular spasm of the muscle, the pain is occular spasm of the muscle, the pain is referred to the surface of the head or retro-referred to the surface of the head or retro-orbitally.orbitally.