Sesak Nafas Setelah Dipukul....

Sesak Nafas Setelah Dipukul....Step 1step 2 1. Mengapa penderita kesadarannya menurun ?2. Mengapa penderita tampak sesak nafas dan sianosis ?3. Kenapa didapatkan RR 40x/mnt dangkal tekanan darah 90/60 nadi 120X/mnt teraba lemah dan kecil ?4. Kenapa didapatkan kepalanya hematom didaerah temporal kanan ?5. Kenapa didapatkan dada asimetris dan ada luka tusuk dihemithoraks kanan setinggi ICS 5 pada garis axilaris anterior kanan6. Kenapa suara nafas hemithoraks kanan menghilang ?7. Mengapa kondisi penderita semakin menurun setelah diberikan oksigen dengan face mask ?8. Penanganan masalah dari skenario ?9. DD ?10. Apa interpretasi GCS 11?11. Mengapa dilakukan pemeriksaan abdomen ?12. Pemeriksaan penunjang ?

step 31. Mengapa penderita kesadarannya menurun ?

Pusat kesadaran :

2. Mengapa penderita tampak sesak nafas dan sianosis ?

3. Kenapa didapatkan RR 40x/mnt dangkal tekanan darah 90/604. Kenapa didapatkan kepalanya hematom didaerah temporal kanan?

The importance of cerebral vasoactivity and its relationship to systemicPCO2 and partial pressure of oxygen (PaO) has been known for sometime. This relationship acts as the foundation for the use of hyperventilation in the acute setting to control presumed increased ICP after severe head injury. Because PCO2 decreases with hyperventilation, cerebral vasoconstriction usually occurs. This vasoconstriction results in decreased parenchymal blood volume, which, in turn, may buffer the effects of increasing edema or an expanding hematoma within the rigid cranial vault; however, a significant reduction in systemic PCO2 levels caused by prolongedhyperventilation can result in severe vasoconstriction at the adjacent or penumbra regions of injured brain tissue, causing brain ischemia and cell death [1214]. For these reasons and because of the risk for reperfusion injury, the use of prophylactic hyperventilation and prolonged hyperventilation in the ICU is not recommended (Fig. 4) [14].ICP is related directly to the volume of intracranial contents, includingblood, cerebrospinal fluid (CSF), and brain parenchyma. This relationshipis explained by the Monro-Kellie doctrine [15,16]. In the United States,the use of ICP monitoring and control has become standard in cases ofmoderate and severe TBI, despite the lack of prospective controlled research studies showing clear efficacy as an individual patient treatment modality. The role of ICP monitoring in the initial emergency department (ED)

Fig. 4. Neurologic effects of hypocapnia. Systemic hypocapnia results in cerebrospinal fluid alkalosis, which decreases CBF, cerebral oxygen delivery, and, to a lesser extent, cerebral blood volume. The reduction in ICP may be lifesaving in patients in whom the pressure is severely elevated; however, hypocapnia-induced brain ischemia may occur because of vasoconstriction (impairing cerebral perfusion), reduced oxygen release from hemoglobin, and increased neuronal excitability, with the possible release of excitotoxins, such as glutamate. Over time, cerebrospinal fluid pH and, hence, CBF, gradually return to normal. Subsequent normalization of the partial pressure of arterial carbon dioxide can result in cerebral hyperemia, causing reperfusion injury to previously ischemic brain regions. (From Laffey JG, Kavanagh BP. Hypocapnia. N Engl J Med 2002;347:44; with permission. Copyright 2002, Massachusetts Medical Society

5. Kenapa didapatkan dada asimetris ada luka tusuk dihemithoraksPATHO-PHYSIOLOGY IN PENETRATING WOUNDS OF THE CHESTPenetrating injuries of the chest produce ill-effects as aresult of the following factors:1. Blood-loss and shock.2. Impairment of pulmonary ventilation owing to:(a) presence of air and blood in the pleural space,causing partial or complete collapse of lung,(b) injury to pulmonary parenchyma, diaphragmand chest wall,(c) pain with fixation of the hemithorax, and(d) phenomenon of 'pendelluft'.3. Reduced cardiac output owing to:(a) reduced venous return, due to loss of negativepressure within the thoracic cage, loss of circulatingblood volume by internal or externalhaemorrhage or kinking of large veins due tomediastinal shift, and(b) cardiac tamponade.The collapse of the lung may have to its credit abeneficial effect, in that it causes a reduction of thevolume of circulating blood and air within it, and solessens the loss of blood and air from the injured lung.This is why progressive increase of a haemothorax orpneumothorax is uncommon. When it does occur, it isusually due to involvement of a major bronchus or vesselsuch as hilar, intercostal or internal mammary vessels.These are the cases that frequently die within a few hoursof injury or fail to respond to adequate resuscitativemeasures.

6. Kenapa suara nafas hemithoraks kanan menghilang ?

Primary surveyPhysical examinationPhysical examination is the primary tool for diagnosis of acute trauma to the chest (Figure 2), but it may be very difficult to do in a noisy Accident and Emergency department. Signs of sig-nificant thoracic injury may be subtle or even absent even under ideal conditions. The process of physical examination should be concise and done simultaneously with resuscitation: time must not be wasted. The position of the patient will affect the clinical findings on examination (Figure 3). A haemothorax will be dull to percussion with absent breath sounds at the bases in the erect patient; signs will be posterior in the supine patient.

7. Mengapa kondisi penderita semakin menurun setelah diberikan oksigen dengan face mask ?

8. Apa interpretasi GCS 11?9. Pemeriksaan penunjang ?Radiologi : Px lab : 10. Penanganan masalah dari skenario ?11. DD ?

OPEN PNEUMOTHORAX

Penetrating chest wound A sucking or hissing sound with inhalingDifficulty breathingImpaled object in chestFroth or bubbles around injuryCoughing up blood or blood-tinged sputumPain in chest or shoulder

CLOSSED PNEUMOTHORAX

TENSION PNEUMOTHORAX

Difficulty breathing Chest painUnilateral decreased/absent breath soundsAnxiety or agitationIncreased pulseTracheal deviationJugular venous distention (JVD)Cyanosis

HEMOTHORAX

12. Kenapa dilakukan pemeriksaan abdomen ?Untuk menyingkirkan diagnosis banding

Multiple traumaStep 4

Trauma thoraksTrauma kapitis