Anesthesiology

BIMBELUKDIMANTAP
dr.AndreasWWicaksono
dr.AnindyaKZahra
dr.AriusSuwondo
dr.M.DzulfikarLinggaQM
dr.MarikaSuwondo
Algorhythm
 PatientAssesment

Levelofconsciousness
Spontaneouseffortvsapneu

Airway andcervicalspineinjury
Chestexpansion
Signofairwayobstruction
Signsofrespiratorrydistress
Protectiveairwayreflexes
 AirwayandC Spinecontrol
PasienBerbicaraLancar>
TraumaMaksilofasial airwaybaik

Adakahpatensijalan
ProblemAirway TraumaLeher nafas?

Look:Agitasi,penkes,
TraumaLaryngeal retraksi,ototbantunafas
Listen:suaranafasabnormal
Feel:lokasitrakea

Gurgling liquidorsemisolidforeignmaterialinthemainairway >Suctioning

Snoring pharyng ispartiallyoccludedbysoftpalateorepiglottis.

Crowing soundoflaryngealspasm.

Inspiratory stridor obsruction atlaryngeallevelorabove.

Expiratorywheeze obstructionofthelowerairway.
 PengelolaanJalanNafas NPA

Oksigenasidanpasangpulseoxymetri

Bersihkanjalannafasdaricorpal,suctioning

Chin liftmanuverataujaw trustmanuver(pada OPA

curigaCspineterganggu>dipertahankandengan
nasofaringealairwayatauorofaringealairway

Dapatteroksigenasi Definitifairway
NO surgical
Assessairwayanatomy> Callassistance
LEMON Difficult orAwake Intubation
Intubation drug assistance intubation
Cricoidpressure

unsuccesfull
Consideradjunct>GEB/LMA/LTA

Definitifarway
surgical
 OpeningtheAirway TripleAirway
Maneuver

Slightlyextendneck
(whencervivalspine
injurynot suspected)
Elevatedmandible
Openmouth

HeadPosition
OropharingealAirway
Digunakanuntukventilasisementarapadapasienyangtidak
sadarsementaraintubasipasiensedangdisiapkan
Tidakbolehdigunakanpadapasienyangsadar karenadapat
menyebabkansumbatan,muntahdanaspirasi.

NasopharingealAirway
Prosedurinidigunakanapabilapasienterangsanguntuk
muntahpadapenggunaanOPA

LaryngealMaskAirway
Digunakanuntukpertolongandenganairwayyangsulituntuk
intubasiendotrachealataubagmaskgagal.IngatLMAbukan
definitif
LaryngealTubeAirway
Suatualatairwaydiluarglotisuntukmemberiventilasipasien
denganbaik.

GumElaticBougie
DiikenaldengannamaEschmanntrachealtubeintroducer
(ETTI)

MultilumenEsophagealAirway
Dapatdihunakanapabilaairwaydefinitbelumdapat
dilakukan.
Alatinimemilikilubangudarayangmengarahkesaluran
nafas.Sedangkanlubanglainmengarahkeesofagus.
 OrotrachealTube
NasotrachealTube
Airwaydefinitif Airwaysurgical:
Krikotiroidotomi
Trakheostomi

KebutuhanUntuk PERLINDUNGAN Kebutuhan UntukVENTILASI

AIRWAY
Penurunan Kesadaran(GCS<9) Apneu:
Paralisis neuromuscular
Tidaksadar
FrakturMaxilofacialberat UsahaNafastidakadekuat
Takipneu
Hipoksia
Hiperkarbia
Sianosis
ResikoAspirasi :Perdarahan,muntah Cederakpalatertutupberatyang
muntah membutuhkanhiperventilasi
ResikoSumbatan:Hematomaleher, Kehilangandarahyangmasifdan
cedera laring,trachea,stridor memerlukanresusitasivolume
 Nasotrachealintubation

Cricothyroidotomy Tracheostomy
BronchusPrimarius
Bronchoscopy

isan endoscopic technique

ofvisualizingtheinsideof
theairwaysfordiagnostic
andtherapeuticpurposes.
 ManualAssistedVentilation

Applyfacemask
Oro/nasopharyngeal
airwayadjuncts
Mouthopening
Handpositioning
Elevatemandibleandchin
Resuscitationbag
compression volumeand
frequency
 SingleHandMethodofFacemask
Application

Base ofmaskplaced
overchinandmouth
opened
Apex ofmaskover
nose
Mandible elevated,
neckhyperextend(no
cervicalinjury),and
downwardpressureby
maskhand
TwoHandMethodofFacemask
Application
 InadequateMasktoFaceSeal

Identifyleak
Repositionfacemask
Improve sealalong
cheeks
Slightly increase
downwardpressureover
faceorneckextensionif
nocervicalinjury
Usetwo handtechnique
TemporoMandibularJointDislocation
(LockedJaw)

Type:
Anterior
Posterior
Superior

Unilateral/
Bilateral
Thepatientisunabletoclosethemouthandmayhavegarbledspeech,
droolingandinpain.
Adepressionmaybenotedinthepreauriculararea.PalpationoftheTMJ
revealsoneorbothofthecondylestrappedinfrontofthearticulareminence
andspasmofthemusclesofmastication.
Inaddition,thecoronoidprocessofthemandiblebecomesprominentand
palpablejustbelowthemaxilla

Treatmentdependson
patientstatusandvaries
fromsimplereductionto
surgicalintervention.
ManualclosedReduction(Classic)
Bartonbandage
ApplicationofaBartonbandage
afterreduction.
ApplywarmcompressestotheTMJ
areafor24hours
Avoidextremeopeningofthejaw
forthreeweeks.Insomepatients,
placementofapaddedrigidcervical
collar.
Supportthelowerjawwhen
yawning.
Maintainasoftdietforoneweek.
Takenonsteroidalantiinflammatory
agents(eg ibuprofen10 mg/kg orally
everysixhoursasneeded,maximum
singledose:800mg)asneededfor
painandswelling.
BrainDeath
 Shock Definition
A physiological state characterized by a
significant, systemic reduction in tissue
perfusion, resulting in decreased tissue oxygen
delivery and insufficient removal of cellular
metabolic products, resulting in tissue injury.
ClassificationofShock

Hypovolemic Cardiogenic

Obstructive Distributive
 Pathophysiology
Preload
Afterload Stroke Volume x Heart Rate
Contractility

O2 Content Cardiac
Resistance
Output
x x

O2 Delivery Arterial Blood

Pressure
 Pathophysiology
BP=COxR
CO=SVxHR
SVcomponents=Preload,Afterload,
Contractility

DO2=COxCaO2
CaO2=(Hb xsatx1.34)+(PaO2 x0.003)
 Pathophysiology
Shock CO SVR

Hipovolemik (preloaddan sebagai

(termasukperdarahan) afterload) kompensasi
Kardiogenik (kontraktilitas) sebagai
kompensasi
Distributif sebagai
(termasukanafilaktik, kompensasi
septik,neurogenik/
spinal)
 CharacteristicsofShock

Endorgan Metabolic
dysfunction: dysfunction:
reducedurine
output acidosis
alteredmental
status
alteredmetabolic
poorperipheral demands
perfusion
 Therapy
Goal: pengangkutan O2&kebutuhan O2
Cara: O2,cairan,kontrol suhu, antibiotik, koreksi kelainan
metabolik,Inotropik
Airway:intubasi &kontrol ventilasi
Breathing:
Awal :O2100%,monitor saturasi
Sirkulasi
Akses IV scr cepat.
Intraosseus:anak4 6th
Kateter venasentral
HYPOVOLEMICSHOCK
 PerkiraanKehilanganDarah
KelasI KelasII KelasIII KelasIV
Kehilangandarah <750 7501500 15002000 >2000
(mL)*
Kehilangandarah <15% 1530% 3040% >40%
(%volumedarah)
Nadi <100 >100 >120 >140
Tekanandarah Normal Normal Menurun Menurun
Tekanannadi Normalataunaik Menurun Menurun Menurun
Frekuensinafas 1420 2030 3040 >35
Produksiurin >30 2030 515 Tidakberarti
(ml/jam)
Statusmental Sedikitcemas Agakcemas Cemas,bingung Bingung,letargis
Penggantian Kristaloid Kristaloid Kristaloiddan Kristaloiddan
cairan darah darah
*)untuklakilakidenganberatbadan70kg
 EstimatedBloodVolume(EBV)
Lakilaki=75 cc/kgBB (7075cc/KgBB)
Perempuan=65 cc/kgBB
Infant=80 cc/kgBB
Neonatus=85 cc/kgBB
Prematureneonatus=96 cc/kgBB
 Therapy Hypovolemic
PRINSIPTERAPI:CAIRAN

TUJUAN
VOL.INTRAVASKULERTERCUKUPI
KOREKSIASIDOSISMETABOLIK
OBATIPENYEBAB
REASSESPERFUSI,UO, TANDAVITAL

PILIHAN:
KRISTALOIDISOTONIK:20CC/KGSCRCEPATBILAFUNGSI
JANTUNGNORMAL
NSDAPAT MENYEBABKANASIDOSISHIPERCHLOREMIK
 IVfluids
Crystalloidsolutions (isotonic)
Both 0.9% saline and RL are equally effective
RL may be preferred in hemorrhagic shock because it
somewhat minimizes acidosis and will not cause
hyperchloremia.
For patients with acute brain injury, 0.9% saline is preferred.

Colloidsolutions (eg,HES,albumin,dextrans)
also effective for volume replacement during major
hemorrhage.
offer NO major advantage over crystalloid solutions, and
albumin has been associated with poorer outcomes in patients
with traumatic brain injury.
Sumber:MerckManuals
IVFluidsComposition
 nd
E point and Monitoring
Theactualendpointoffluidtherapyinshockisnormalization
ofDO2

Adequateendorganperfusionisbestindicatedbyurine
outputof > 0.5to1mL/kg/h

CentralVenousPressure

isthepressureinthesuperiorvenacava,reflectingrightventricularend
diastolicpressureorpreload.
NormalCVP:2to7mmHg(3to9cmH2O)
CVP > 12to15mmHg:fluidadministrationrisksfluidoverload
CARDIOGENICSHOCK
 Therapy Cardiogenic
Terapi Inisial Dg.Pemberian Cairan

Bila Tak Ada Perbaikan memburuk susp.

Syok Kardiogenik Inotropik
zdvnk
Anaphylactic Septic Neurogenic

DISTRIBUTIVESHOCK
 DistributiveShock
Inflammatory mediators disruptionofcellular
metabolism peripheralvasodilation
decreasedPVR
Etiology
Anaphylaxis
Septic
Neurogenic
Sign&symptoms
Febrile,tachycardia,clearlungs,warmextremities,
flatneckveins,oliguria
 AnaphylacticShock
Anaphylacticshock
atypeofdistributiveshock,whichinvolvestheimmunesystem
(Hurst,2008)

Type1hypersensitivity
antigenbindstoIgE antibodiesonmastcells,whichleadsto
degranulation ofthemastcells

Sign&symptoms
itching,hives,andswelling
circulatorycollapse (vasodilatation)
suffocation (bronchialandtrachealswelling)
Hipersensitivity reactions

Figure122
 Management
AnaphylacticShock
1. Administeroxygen.
2. Maintainanadequateairway.
3. Removetheallergenthatcausedthereaction.
4. Administerepinephrine(0.3to0.5mL ofa1:1.000solution
IM/SC or0.3to0.5mL ofa1:10.000solutionIV).
5. Initiale fluidtherapyearlywithnormalsalinetomaintainan
MAP70mmHgorasystolicbloodpressure90mmHg.
6. Administervasopressor agentsifcrystalloidtherapyis
inadequateformaintainingCO.
7. Considerotherpharmacologictreatments:antihistamines,
bronchodilators,andcorticosteroidsareotheroptions.
8. Performcardiacmonitoring.
9. Observeforapossiblesecondphasereaction.
Epinephrine inAnaphylactic
 NeurogenicShock

Neurogenic shockistherarestformofshock.

Itiscausedbytrauma tothe spinalcord suddenloss

of autonomic andmotor reflexesbelowtheinjurylevel

Stimulation by sympatheticnervoussystem () thevessel

wallsrelaxuncontrollably suddendecreasein peripheral
vascularresistance vasodilation and hypotension
Gambar4.Patofisiologispinalshock
 SepticShockTx
O2
Antibiotics
Fluids
Vasopressor
Indication: persistenthypotension* once
adequateintravascularvolumeexpansionhas
beenachieved
DOC:NOREPINEPHRINE

*systolicbloodpressure<90mmHgorMAP<65mmHg
OBSTRUCTIVESHOCK
 ObstructiveShock
COakibat OBSTRUKSIFISIKterhadapALIRANDARAH

KOMPENSASISVR

PENYEBAB:
TAMPONADEPERIKARD
TENSIONPNEUMOTHORAX
CRITICALCOARCTASIOAORTA
STENOSISAORTA

TERAPI
CAIRAN
ATASIPENYEBAB
 START
SimpleTriageandRapidTreatment
TRIASE
prosespemilihanpasienberdasarkanberatnyakondisi
pasien
Terdiri dari 4prioritas penanganan:
Merah immediatecare/lifethreatening
Kuning urgentcare/candelayupto1hour
Hijau delayedcare/candelayupto3hours
Hitam dead/nocarerequired
 RPM
respirasi,perfusi,mental
Semua proses evaluasi
dalam STARTharus
dilakukan dalam waktu
kurang dari 60detik.
AcidBaseRegulation
 Keterangan: angka normal analisis gas darah (arteri): pH: 7,35-7,45 ; PCO2: 35-45 mmHg ; HCO3: 22-26 mmol/L.

GangguanAsamBasa
Gangguanasam pH PCO2 HCO3 Penyebabumum
basa
Asidosisrespiratorik jika PPOK,asma,ARDS
terkompensasi
Alkalosisrespiratorik jika Hiperventilasi,
terkompensasi sepsis
Asidosismetabolik jika Dehidrasiberat,
terkompensasi DM,gagalginjal,
starving,Diare
Alkalosismetabolik jika Muntah
terkompensasi
 Tanda
Terkompensasi
(sebagian/sepe
nuhnya)
ditandaidgn
ARAHpanah
yangSAMA
AntaraPaCO2
denganHCO3
COPoisoning
 CyanidePoisoning
Sources

Naturally infoods(somefruits,limabeans,SINGKONG)
Cyanidesaltsusedinindustry
Producedinsmokeofburningplastics/synthetics,electroplating,
metal polishing

Mechanism

Inhibitscellularrespiration
TissuecannotutilizeO2
Arterializationofvenousblood

Characteristics

Smellslikealmonds
Cyanide inhibitcellularrespiration
ClinicalEffectsofCyanide
Headache Hypertension,
Dizziness bradycardia
Seizures Hypotension,laterin
Coma course
Cardiovascular
collapse

CNS Cardiovascular

Dyspnea Nausea,vomiting
Tachypnea Causticeffects
Pulmonaryedema
Apnea

Pulmonary Gastrointestinal
 CyanideDiagnosis
Clinicalpicture:sweetalmondbreath
Lacticacidosis
ABG:
metabolicacidosis

ABGsample
Treatment
Removefromsource
Oxygen
Cyanideantidotekit:
Amylnitriteperle untilIVestablished
SodiumNitrite(300mgIV)
Peds:0.33ml/kgof10%solution)
SodiumThiosulfate (12.5gmIV)
Peds:1.65ml/kgof25%solution
 DjengkolicAcidPoisoning
Sources

JENGKOLbean

Mechanism

poorsolubilityunderacidicconditions
the aminoacidprecipitatesintocrystals
mechanicalirritationoftherenaltubulesandurinarytract

Characteristics

abdominaldiscomfort,loinpains,severecolic,nausea,
vomiting,dysuria,grosshematuria,andoliguria,occurring2to
6hoursafterthebeanswereingested.
 DjengkolicAcidPoisoning
Supportingexamination

Urineanalysis erythrocytes,epithelial
cells,protein,andtheneedlelikecrystalsof
djenkolic acid.

Treatment

Hydrationtoincreaseurineflow
Alkalinizationofurinebysodium
bicarbonate.
 OrganophosphatePoisoning
Sources

Insecticides,herbicides

Mechanism

Inhibitacethylcholinesterase
ACh accumulatesthroughoutthenervoussystem
Overstimulation ofmuscarinic andnicotinicreceptors

Characteristics

SLUD+GEM
OrganophosphatePoisoning
SignandSymptom

+GEM
G:Gastrointestinal
E:Emesis
M:Miosis
 Atropine
Competitiveinhibitoratautonomicpostganglioniccholinergicreceptors (GI&
pulmonarysmoothmuscle,exocrineglands,heart,andeye)

Dosis awal dewasa:2mg IM.Dosisdapatdigandakan setiap 10menit

sampai teratropinisasi.

ThemainconcernwithOPtoxicityisrespiratoryfailurefrom
excessiveairwaysecretions.Theendpointforatropinization
isdriedpulmonarysecretionsandadequateoxygenation.
Tachycardiaandmydriasis mustnotbeusedtolimitortostop
subsequentdosesofatropine.
OpiatesIntoxication
 AntidoteforOpiateIntoxication:
NALOXONE
Dosage
Adult:Ashydrochloride:0.42mgrepeatedifnecessaryat23minintervals.Ifthereisno
responseafteratotalof10mghasbeengiven,considerthepossibilityofoverdosage with
otherdrugs.Reducedoseforopioiddependentpatients:0.10.2mg.IM/SCroutesmaybe
used(atIVdoses)ifIVadminisnotfeasible.
Child:Ashydrochloride:Initially10mcg/kgIVfollowedby100mcg/kgIVifnecessary.
Alternatively,0.40.8mgIMorSC,repeatedasnecessary,ifIVadminisnotfeasible.
Parenteral
AmphetamineIntoxication
 Management
AirwayManagement
Gastrointestinaldecontamination :activated
charcoalandgastriclavage
Psychomotoragitation:lorazepam2mgIVor
Diazepam2mgIV
Hyperthermia :icepacksandevaporativecooling
Hypertension :AntiHTsuchasnitroprusside
Seizure:diazepamIV
ArsenicToxicity
 Management
Decontamination
SkinDecontamination
Gastrointestinaldecontamination:nasogastric
suction,andadministeractivatedcharcoal
Fluids Administerintravenousfluidstomaintain
adequateurineflow.
Monitoring Patientsshouldhavecontinuous
cardiacmonitoring.Additionally,fluidand
electrolytebalanceshouldbemonitored.
Chelation DimercaprolandDMSA
 MethanolToxicity
Methanol
woodalcohol
organicsolventthat,becauseofitstoxicity,can
causemetabolicacidosis,neurologicsequelae,
andevendeath,wheningested
Complication
Visualloss(opticnervedamage)
Metabolicacidosis
Movementdisorder(damageinputamen>>)
Therapy
 Therapy
Hemodialysis caneasilyremovemethanoland
formicacid.
MercuryPoisoning
Sensorydisturbance
peripheralneuropathy paresthesia,itching,
burning
Visualfieldconstriction
Ataxia
Cognitivedecline
Bizarrebehavior
excessive shynessoraggression
Tremor
Gingivitis
Acrodynia
Neuropsychiatric
emotionallabilityorsubtleperformance
decline
Death
MercuryPoisoning

CongenitalMinamataDisease:
CP,MR,seizure
 Management
Chelatingagent
Penicillamine isgivenatdosesof500mgPOeverysix
hoursforfivedays,oftenincombinationwith
pyridoxine(vitaminB6)indosesof10to25 mg/day.
DMPS isadministeredaccordingtothefollowing
regimen:250mgintramuscular(IM)orintravenous
(IV)everyfourhoursonday1,250mgIMorIVevery
sixhoursonday2,and250mgIMorIVeverysixto
eighthoursfordays3to5.DMPSisnotapprovedfor
useintheUnitedStates.
DMSA isgivenatadoseof10 mg/kg POeveryeight
hoursforfivedays.
Botulinum Toxin
AlcoholWithdrawalSyndrome
 Management
BenzodiazepinesIVareusedtocontrolpsychomotoragitation,seizure,DTand
preventprogressiontomoreseverewithdrawal.
(DOC:Diazepam,lorazepam,orchlordiazepoxide)

Volumedeficitsreplacement,isotonicintravenousfluidcanbeinfusedrapidlyuntil
patientsareclinicallyeuvolemic

Deficienciesofglucose,potassium,magnesium,andphosphateshouldbe
correctedasneeded.

Patientsbeingtreatedformoderateorseverealcoholwithdrawalmustbeclosely
monitored(vitalsigns,pulseoximetry,fluidstatus,andneurologicalfunction)and
mayrequireadmissiontoanintensivecareunit(ICU).
 BEDAH
Surgery
BIMBELUKDIMANTAP
NEURO SURGERY
 EpiduralHemorrhage

>>a.meningeamedia,temporoparietal,
biconvex/lenticular,lucidinterval
 EpiduralHemorrhage
Signs and Symptoms :

Most patients are unconscious

when first seen. A lucid
interval of several minutes to
hours before coma supervenes
is most characteristic of
epidural hemorrhage
Deterioration of consciousness
Unilateral dilated pupil on side
of injury
Hemiparesis or hemiplegia on
side of body opposite injury

Biconvex/lenticular
SubduralHemorrhage

Bridgingvein,semilunar
 Subarachnoidhemorrhage

Aneurisma,AVM
Thunderclapheadache,Muntah,stiffneck,meningeal
irritation, confusion / penkes
 Intracerebral hemorrhage

Parenkimotak
Braintrauma atau spontan pada hemorrhagic stroke.
CTScan
MRI
Specificfor
SoftTissue
BrainHerniation
 BrainHerniation
Supratentorialherniation
Subfalcine(Cingulate)herniation
Centralherniation
Transtentoriallateral(Uncal)herniation
Transcalvarialherniation

Infratentorialherniation
Upwardcerebellarherniation
Downwardcerebellar(Tonsillar)herniation
 Uncal herniation
Herniationofthemedialtemporallobeinferiorlythrough
thetentorialnotch

Clinicaltriadassociatedwithuncalherniation :
Dilatedpupilipsilateral
Hemiplegiacontralateral
Coma

compressedipsilateraltoherniation:hemiplegiawillbeon
thecontralateralsideofthebody(axonsdecussateat
pyramidaldecussation)
compressedcontralateraltoherniation:Iftheherniationis
verysevere,thecontralateralcerebralpedunclemaybe
compressedbytheoppositesideofthetentorialnotch
leadingtoanipsilateral(totheherniation)hemiplegia
(Kernohan'sphenomenon).
GlasgowCommaScore
 Motorresponse2

Motorresponse3
CEDERA KEPALA

ATLS

Klasifikasi klinis cedera kepala

berdasarkan GCS :

Cedera Kepala Ringan (CKR)

GCS 13-15
Cedera Kepala Sedang (CKS)
GCS 9-12
Cedera Kepala Berat (CKB)
GCS 3-8
BasisCranii
 CLASSIFICATION

AnteriorSkull Posteriorfrontalsinus,roofofethmoid,
cribriform,andorbitalroof,sphenoid
BaseFracture bone

MiddleSkull Temporalbone
BaseFracture

PosteriorSkull Clivusoccipital,condylaroccipital
BaseFracture
 Clinical sign :
Presentationwithanteriorcranialfossafractures iswithCSFrhinorrhea
andbruisingaroundtheeyes "raccooneyes."

Patientswithfracturesofthepetroustemporalbone presentwithCSF
otorrheaandbruisingoverthemastoids Battlesign.

Longitudinaltemporalbonefracturesresultinossicularchaindisruption
andconductivedeafnessofgreaterthan30dBthatlastslongerthan67
weeks.
TransversetemporalbonefracturesinvolvetheVIIIcranialnerveandthe
labyrinth,resultinginnystagmus,ataxia,andpermanentneuralhearing
loss.

Occipitalcondylarfracture isaveryrareandseriousinjury. Mostofthe

patientsareinacomaandhaveotherassociatedcervicalspinalinjuries.
Thesepatientsmayalsopresentwithotherlowercranialnerveinjuries
andquadriplegia.
 HaloSign
(Ringsign/Targetsign)

TandaCSFleak:
Glucose(+)
Halosign(+)
Beta2transferrin(+) highlyspecifictoCSF,notpresent
inplasma,nasalsecretion,tear,saliva,orotherfluid.
THORAX AND CARDIOVASCULAR
SURGERY
TraumaAlgorythm
 TraumaThorax
PRIMARYSURVEY MengancamJiwa

Airway Gangguan jalan nafas

Pneumotoraks terbuka
Breathing Pneumotoraks tension
FlailChest

Hematoraks masif
Circulation Tamponade kordis
Hematothorax
Definition:
accumulationofblood
inpleuralcavity
Simple
Massive:
>1.5litresbloodon
chestdrainageor>
200ccblood/houron
drainage
 Etiology
Trauma:ruptur arteri didinding thorax
ataupun internalorgandithorax
A.thoracica interna anditsbranches
A.intercostalis
A.bronchialis
 PhysicalExam
Sign:dyspneu

I:Jejas(+),ketingalan gerak (+)

P:Fremitustaktilmenurun
P:Redup(+)
A:Vesikulerturun,normalheartsound
TubeThoracostomy /ChestTube
WaterSealedDrainage
CardiacTamponade
Etiology:bluntor
penetratingtrauma
inmidchest
Nomal breathsound
SignTrias Beck
1. IncreaseJVP
2. Hypotension
3. MuffledHeart
sound
Tx :
pericardiocentesis
Pericardiocentesis
Pneumothorax

Definition:
accumulationofair
orgasinpleural
cavity
 Classification
Spontan (primerdan sekunder)andTrauma
OpenandClosed
SimpleandTension
 PhysicalExam
Sign:Dyspneu,subcutis emfisem

I:Jejas(+),ketingalan gerak (+)

P:Fremitustaktilmenurun
P:Hipersonor
A:Vesikulerturun/hilang,normalheartsound
 OpenPneumothorax
Etiology:PenetratingTrauma lubang dinding
dada (ukuran mendekati diametertrakea)
MediastinalFlutter
SuckingChestWound
 Treatment
Occlusivedressingtapein3
sides.
thedressingpreventsatmospheric
airfromenteringthechestwall
duringinspirationbutallowsany
intrapleuralairoutduring
expiration
ClosedPneumothorax

Etiology:blunttrauma,
spontaneousruptureof
pleurae airleakageto
pleural cavity
Candevelopedinto
TensionPneumothorax
Tx :ChestTube
TensionPneumothorax
Clinicalsign:
Himpitan venacava
Shock
JVP
Himpitan paru
kontra lateral
distressnafas
deviasitrakhea
Tx :
Neddle
thoracostomy
(decompression)
Chesttube
TensionPneumothorax
NeedleThoracostomy

Location:
SICII/IIILinea
Midclavicula
 FlailChest
Fraktur costae segmental,multipel,
berurutan
Severerespiratorydistress
Paradoxal movement
Asymmetricalanduncoordinatedchestwall
movement
Crepitationonpalpation
Pain>>>>
FlailChest
 Management
ABCDE
Adequateventilation,oxygenation,
analgesia
ChestXRay
PenyakitOklusiArteriPerifer
Namalain:PeripheralArtery
OcclusiveDisease(PAOD),
PeripheralArteryDisease
(PAD),PeripheralVascular
Disease(PVD)
Definisi:gangguanaliran
darahakibatpenyempitan
ataukerusakanpembuluh
darahperifer(selain
pembuluhdarahkoroner dan
pembuluhdarahotak)
Etiologi:aterosklerosis(>>>),
nonaterosklerosis
 PenyakitOklusiArteriPerifer
PenyebabAterosklerosis
Faktorrisikoyangtidakdapatdimodifikasi
Usiatua
Lakilaki
Faktorgenetik
Faktorrisikoyangdapatdimodifikasi
Mayor:merokok,hipertensi,diabetesmellitus,
dislipidemia
Minor:obesitas,hiperhomosisteinemia,hiperkoagulasi,
gayahidupdankepribadian,kurangolahraga
 PenyakitOklusiArteriPerifer
PenyebabNonaterosklerosis
Raynaudssyndrome
Buergersdisease(ThromboangiitisObliterans)
Vasculitis
Largevesselvasculitis=GiantCellArteritis(Temporal
Arteritis),TakayasusDisease
Mediumvesselvasculitis=PolyarteritisNodosa,
KawasakisDisease,BehcetsDisease,CogansSyndrome,
Smallvesselvasculitis=AntineutrophilCytoplasmic
AntibodyassociatedVasculitidies,VasculitisAssociated
withConnectiveTissueDiseases
 PenyakitOklusiArteriPerifer
PenyebabNonaterosklerosis(cont)
Heritablearteriopathies
CysticMedialNecrosis
PseudoxanthomaElasticum
ArteriaMagnaSyndrome
CongenitalConditionsAffectingtheArteries
PersistentSciaticArtery
PoplitealEntrapmentSyndromes
AdventitialCysticDisease
PeripheralArteryAneurysms
FemoralArteryAneurysms
PoplitealArteryAneursyms
Claudicatio Intermitten
Definition:painin
calfregionduring
exercise(walking)
causenarrowingof
vesseldueto
atherosclerotic
plaque(e.c Peripheral
ArteryDisease)
PenyakitOklusiArteriPerifer
 PenyakitOklusiArteriPerifer
AnkleBrachialIndex(ABI)
Membandingkantekanansistolikarteridorsalis
pedisdanarteritibialisposterior(dipilihnilaiyang
tertinggi)dengantekanansistolikarteribrachialis
NilainormaiABI=0,9 1,3
NilaiABI<0,9 gangguanalirandarah
ABI<0,9 risikomortalitascardiovascularmeningkat
36kali
NilaiABI>1,3 pengerasan(kalsifikasi)
pembuluhdarah
 PenyakitOklusiArteriPerifer
Sumbatanarteripadaekstremitasbawahapabila
terusdanprogresif criticallimbischemia(CLI)
TandadangejalaCLI=
Nyerihebatdanmenetapsaatistirahat(restpain)
Pucat saatekstremitasbawahdielevasikan
Gangguantrofik dingin,kulitkeringdanmudah
lepas,hiperkeratosisplantar,atrofiujungjari,kuku
menebal
Ulkus
Iskemiayangmeluashinggakeseluruhekstremitas
bawah
CriticalLimbIschemia
 TatalaksanaPAD Revaskularisasi
Prosedurendovaskular(angioplasti,stenting),
Pembedahan(bypass,profundoplasty),
simpatektomi
AcuteLimbIschemia
5P Pain,Pallor,Pulseless,
Paresthesia,Paralysis
ChronicLimbischemia ada
kolateralisasi,AcuteLimb
ischemia tidakada/sedikit
kolateralisasi,kurangbisa
menoleririskemia
Etiologi tromboembolism
(atrialfibrilasi,valvular
leaflets,riwayatbypassatau
stentplacement)
AcuteLimbIschemia
 AcuteLimbIschemia

I,IIA revaskularisasidengantrombolitik
IIB revaskularisasidenganintervensioperatif
 Thromboangitis Obliterans
AlsocalledasBuerger Disease
Male,2040y.o
Anacuteinflammationandtrombosis of
vesselonperipeheral region(footandhand)
thatassociatewithsmoking.
Symptom :claudicatio intermitten
 RaynaudPhenomenon
Mayappearasacomponentofother
conditions.
Causes:
connectivetissuediseases(scleroderma&SLE)
arterialocclusivedisorders.
carpaltunnelsyndrome,
thermalorvibrationinjury.
Pale>Cyanosis>Redness
Aggrevated withcold
 Raynauds
Phenomenonvs
Syndrome
Vasospastic disordercausing
discolorationofthefingers,toes,
andoccasionallyotherareas.
Raynaud'sdisease("Primary
Raynaud'sphenomenon")
idiopathic
Raynaud'ssyndrome
(secondaryRaynaud's),
commonlyconnectivetissue
disorderssuchasSystemic
lupuserythematosus
Takayashu
DeepVeinThrombosis
(TriasVirchow)
 DeepVeinThrombosis

Sign and Symptoms :

Leg swelling
Pain of the affected leg
Erythema or discolored skin of
the affected leg
Warmth of the affected leg skin
Leg fatigue

Commonly affects leg veins

popliteal, femoral, pelvic

(Half of all DVT cases cause no symptoms)

PLASTIC SURGERY
 BurnInjury

TheDepthof
Etiology
skinburn

Sizeandextentof
theburnwound
 BurnInjury

pricktest(+)
 SuperficialPartial
ThicknessBurn(IIa)
 DeepPartial
ThicknessBurn(IIb)
FullThicknessBurn
(III)
 TotalBody
SurfaceArea

Toestimatescatteredburns:patient's
palmsurface=1%totalbodysurface
Parklandformula=baxter formula area
 IndikasiRawatInap

Menurut American Burn Association, seorang

pasien diindikasikan untuk dirawat inap bila:
Luka bakar derajat III
Luka bakar derajat II > 10%
Luka bakar derajat II atau III yang melibatkan area kritis (wajah,
tangan, kaki, genitalia, perineum, kulit di atas sendi
utama) dan risiko signifikan untuk masalah kosmetik dan kecacatan
fungsi
Luka bakar sirkumferensial di thoraks atau ekstremitas
Luka bakar signifikan akibat bahan kimia, listrik, petir, adanya
trauma mayor lainnya, atau adanya kondisi medis signifikan yang
telah ada sebelumnya
Adanya trauma inhalasi
Indikasiklinisadanyatraumainhalasi
Lukabakaryangmengenaiwajahdan/atauleher

Alismatadanbuluhidunghangus

Adanyatimbunankarbondantandaperadanganakutorofaring

Sputumyangmengandungkarbon/arang

Suaraserak

Riwayatgangguanmengunyahdan/atauterkurungdalamapi

Lukabakarkepaladanbadanakibatledakan

Secureairway(pembebasanjalannafas)
LabioGnatoPalato Schisis
 TheNeonatalPeriod
SurgicalRepair
CleftLip
InUS theruleoftens 10wks,10lbs,Hgb 10
Lipadhesionvs babyplates
CleftPalate
Variesfrom618months mostaround10mo
Earlyrepairmayleadtomidface retrusion
Earlyrepairimprovesspeech
PEDIATRIC SURGERY
Urachal Abnormalities
Urachalanomalies
areduetofailureofcompleteobliterationofthelumenduringgestation.

Presentingsymptoms:

Umbilicaldrainageoramassand/orpainduetoinfection. Theumbilical
drainagemaybeclear,serous,purulent,orbloody.
Urachalabnormalitiesareafrequentconcerninnewbornswithumbilical
drainagethatpersistsbeyondafewweeks.

Apatenturachusorurachalsinuscanappearasadimpleorindentationin
thebaseoftheumbilicus.

Ingeneral,symptomaticurachalremnantsshouldbetreatedwithsurgical
excision. Thisshouldincludecompleteexcisionoftheurachusfromthe
umbilicustothedomeofthebladder.
Iftheurachaldisorderpresentswithaninfection,theinfectionistreated
first. Thisrequiresantibiotics,possibleadmissionforintravenousantibiotics,
andoccasionalsurgicaldrainageofanyinfectedcystorpoorlydrainingcavity.
HirschprungDisease
Kelainankongenitalakibatkegagalan
migrasikristaneuraliskecolon.
Tidakterbentukselganglionikpd
plexusmyentericus(Auerbach)dan
plexussubmucosal(Meissner)
80% rectosigmoid
Klinis:
Delayedmeconium(>24h)
Abdominaldistention
Bilousvomiting
Severediarrheaalternatingwith
constipation
Dx:
Bariumenema
Rectalbiopsy
Anorectalmanometry
SignandSymptoms

Symptomsmayrecurafterpreviously
resolvingwithlaxatives,orfeeding
changes.

DigitalRectalexaminationmay
demonstrateatightanalsphincter
andexplosivedischargeofstooland
gas.
Froglikeabdomen
Darmcontour
Darmsteifung
Metallicsound
 RadiographicFeatures
Imagingcanhelpdiagnose Contrastbariumenemaradiographs,
Hirschsprungsdisease.Aplain Afterthedilationprocessbegins,the
abdominalradiographmayshow diseasedportionofthecolonwill
adilatedsmallbowelorproximal appearnormalandthemoreproximal
colon(noairintherectum) colonwillbedilated.Atransitionzone
(thepointwherethenormalbowel
becomesaganglionic)maybevisibleon
acontrastenemaradiograph
 AtresiaEsophageal

Thefirstsignofesophagealatresiainthefetusmaybepolyhydramniosin
themother.
Prematurityhasalsobeenassociatedwithesophagealatresia.
Classically,presentswithcopious,fine,white,frothybubblesofmucusin
themouthand,sometimes,thenose.
Theinfantmayhaverattlingrespirationsandepisodesofcoughing,choking
andcyanosis,maybeexaggeratedduringfeeding.
Diagnosis

(A)Diagnosisofesophagealatresiaisconfirmedwhena10gauge
(French)cathetercannotbepassedbeyond10cmfromthegums.

(B)Asmallercalibertubeisnotusedbecauseitmaycurlupintheupper
esophagealsegment,givingafalseimpressionofesophagealcontinuity.

Thenormaldistance toaninfant'sgastriccardiaisapproximately17cm
chestradiographsshouldbeobtainedtoconfirmthepositionofthetube.The
radiographshouldincludetheentireabdomen.Inpatientswithesophageal
atresia,airinthestomachconfirmsthepresenceofadistalfistula,andthe
presenceofbowelgasrulesoutduodenalatresia

TheGaslessAbdomen
Absenceofgasinthe
abdomensuggeststhat
thepatienthaseither
atresiawithoutafistula
oratresiawitha
proximalfistulaonly
 HypertrophyPyloricStenosis
Hipertrofim.sphincterpylorus
Stenosis>canalispyloricus

Klinis:
Muntahproyektil,bilefree,
bolus+gastricjuice
Babylookshungry
Palpablemass (olive)
Dx :
Plainphoto (Singlebubblesign)
Bariummeal/OMD (Umbrellasign)
Komplikasi :dehidrasi&aspirasi
Tx :
Nonsurgery:resusitasicairan
Surgery:pyloromyotomy
 HPS
Typicalpresentationisonsetofnonbiliousvomitingat112weeksofage
(34weeks),becomesmorepredictable,occurringatnearlyeveryfeeding.
Vomitingintensityalsoincreasesuntilpathognomonicprojectilevomiting
ensues
Slighthematemesisofeitherbrightredflecksoracoffeeground
appearanceissometimesobserved.
Persistenthunger,weightloss,dehydration,lethargy,andinfrequentor
absentbowelmovementsmaybeseen.Stomachwallperistalsismaybe
visible.

Anenlargedpylorus,classicallydescribedasan"olive,"canbepalpatedin
therightupperquadrantorepigastrium oftheabdomenin6080%of
infants
Preoperativemanagementisdirectedatcorrectingthefluiddeficiency
andelectrolyteimbalance.
 RadiographicFeatures
SingleBubblesign Umbrellasign/StringSign
(PlainPhoto) (BariumMeal)
 Atresia/StenosisDuodeni
Atresia:complete
obstruction;stenosis:
partialobstruction
Lokasiterseringdi
duodenumpars
horizontal
Symptom:regurgitasi&
vomit(bilousvomit)
Dx:(doublebubble)
Plainphoto In approximately 80% of affected
neonates, the site of duodenal atresia is
Bariummeal/OMD postampullary, so that the patient may
present with bilious vomiting.
DoublebubbleSign

Plainfilmradiograph
DoublebubbleSign Bariummeal/OMD
(gasfilledstomachandduodenum
dilatationwithnodistalgas)
Withoutabdominaldistension
IntestinalObstruction
(jejunoilealobstruction)
Classicsignsofpatientswithjejunoilealatresia:

Biliousvomit
Abdominaldistention(indistalatresia)
Jaundice(32%) whichischaracteristicallyduetoindirect
hyperbilirubinemia
Failuretopassmeconiuminthefirst24hours(ruleoutHirschsprung
disease;passageofmeconiumdoesnotruleoutintestinalatresia)
Abdominaldistentionismostevidentincasesofilealatresias,inwhichit
isdiffuse,asopposedtoproximaljejunalatresias,inwhichtheupper
abdomenisdistendedandthelowerabdomenisscaphoid.
Intestinalloopsandtheirperistalsismaybeseenthroughthethin
abdominalwallofnewborns.
AtresiaJejunum

Triplebubblesign
Withabdominal
distension
Nogasinpelvic
cavity
 Anorectal
Malformations
Theresultingmalformationsrangefrom
isolatedimperforateanustopersistentcloaca.

Atresiaani(imperforateanus)isacongenitalabnormalitycharacterizedby
persistenceoftheanalmembraneresultinginathinmembranecovering
thenormalanalcanaloristhefailureoftheanalmembranetobreak
down(NodenandLahunta1985)

If,after24hours,thereisnomeconiumontheperineum,werecommend
performingacrosstablelateralxraywiththebabyinkneechest(prone)
position.

usefulindeterminingthe
levelofatresia
 Klasifikasi
MenurutBerdon,membagiatresiaaniberdasarkantinggirendahnya
kelainan,yakni:
~Atresiaaniletaktinggi:bagiandistalrectumberakhirdiatasmuskulus
levatorani(jarak>1,5cmdengankulitluar)
~Atresiaaniletakrendah:bagiandistalrectummelewatimusculus
levatorani(jarak<1,5cmdarikulitluar)

MenurutStephen, membagiatresiaani
berdasarkanpadagaris pubococcygeal :
~Atresiaaniletaktinggi:bagiandistalrectum
terletakdiatasgarispubococcygeal.
~Atresiaaniletakrendah:bagiandistalrectum
terletakdibawahgarispubococcygeal.

highsupralevatorlesionsaretypicallyassociated
withfistulas
 Intussusception
(Invagination)
Invaginationofaproximalportionofintestine(intussusceptum)intoa
moredistalportion(intussuscipiens),isoneofthemostcommoncauses
ofbowelobstructionin infants andtoddlers.
>80%involvestheileocecalregion.

Occurinchildrenlessthanoneyearofage,withapeakincidence
ofbetween610months.(>>9months)

TRIAS :
Colicky&Crampingabdominalpain
Biliousvomiting
Mucousredcurrantjellystools

PhysicalExam:
Palpableabdominalmass
(SausageAppearance)
Dancessign
 RadiographicFeaturesIntussusception
USG:
Targetor doughnutsign (Transversecrosssection)
Sandwichsign, pseudokidneysign (Longitudinal
section)

Pseudokidneysign
BariumEnema:Cuppingsign
(asadiagnostic)ortherapeutic (non
operativereduction)
 Volvulus

Volvulusoftheintestine,thetwistingofasegmentofintestineonits
mesentery,canbeaprimarypathologyorsecondarytomalrotationofthe
intestine.Clinicalpresentationsvaryfromacuteabdominalemergency
requiringimmediatesurgicalinterventiontoinsidioushistoryofcolicky
abdominalpain.

Volvulusofthesmallintestine iscommonlyassociatedwithabnormality
ofintestinalrotationandfixation.Thisisduetofailureoffixationand
narrowmesentericbasewhichallowvolvulustooccur.Midgutvolvulus
canleadtoirreversibleintestinalnecrosis,whichispotentiallyfatal.

Largebowelvolvulus ontheotherhandisrareinchildren;itusually
occursasaresultofredundantsigmoidcolonandaffectsmainlyadults.
 Upto80%ofpatientspresentinthefirstmonthoflife(20%ofpatients
presentafterthefirstyearoflife)andinthisagegroupthecardinal
symptomisbile(green)vomitingduetoduodenalobstructionthrough
midgutvolvulus.
Pain,irritability,andothernonspecificsymptoms(anorexiaornauseawas
noted)aremorecommonintoddlersandolderchildren.
 The coffeebeansign (alsoknownas bentinnertubesign)isasignonan
abdominalplainfilm.
Thisthick'innerwall'representsthedoublewallthicknessofopposed
loopsofbowel,withthinnerouterwallsduesinglethickness.
TERIMAKASIH