Beruflich Dokumente
Kultur Dokumente
first problem
A Bloody Situation
Thursday, 28 September 2017
Group 9
Name of Tutor : dr. Okta
- Kelvin Pangestu 405130095
- Paat Natalia D A 405130128
- Fenny Irawan 405130143
- Chairani 405140025
- Ivanny Lestari G 405140070
- Sheren Maharani 405140078
- Leonardo Bernard 405140089
- Kurnia Halim 405140128
- Marsella Epifania S 405140166
- Indriani 405140178
- Diajeng Fatimah 405140213
- Faza Ghani Y 405140214
A bloody Situation
A 65-year-old male is brought to an emergency department after he vomited 3 times,
500 cc – 1000 cc each time, containing fresh blood mixed with coffee colored blood
since an hour ago. In the last 5 days, he complained of stomachache and nausea which
got better after he ate and took antacids, but the symptoms still persist after some
time. He has a history of coronary artery disease and took aspirin daily. He also
consumed alcohol daily in his thirties and was once hospitalized because of alcoholic
liver disease. Before he was brought to the ED, he was given a traditional medicine
(Jamu) by his son to help him stop vomiting. Soon after he drank the medicine, he felt
itchy and his face is swelled all over.
From initial physical examinations, the patient’s blood pressure is 60/20 mmHg, heart
rate is 120 beats per minute, respiratory rate is 24 breaths per minute and
temperature is 39°C. Physical thorax examination results are unremarkable. On
physical abdomen examinations results, there are tenderness on the patient’s whole
abdomen when palpated, decreased and weak bowel sounds on auscultation.
Initial laboratory results showed that the patient’s Hemoglobin is 9.4 g/dL, leucocyte is
17.000/mm3 and thrombocyte is 300.000/mm3
Discuss the case, assess the patient’s condition and plan proper treatment while
considering all possibilities!
DD: Ruptur gaster, DD: Varices
Patient’s History: ulcer peptic esophagus
• CAD
• alkoholic liver
disease gastric mucosal Shock
Vomiting blood fresh
irritation relief by hypo-
• aspirin daily + coffee colored
antacids volemic
consumption
Physical exam:
• Hypotension
• tachycardi
• CT Scan
• tachypneu
• fever (Temp >39⁰C) ABC • endoscopy
• Resistence culture
• Blood gas analysis
DD:
-appendicitis
- Syok septic
- Acute abdomen
Learning issues
• MM SHOCK
• MM GI BLEEDING
• MM ACUTE ABDOMEN
Shock
• Clinical syndrome that results from
inadequate tissue perfusion
• Lack of blood flow means that the cells and
organs do not get enough oxygen and
nutrients to function properly.
• As a response of oxygen decrease, aerobic
metabolism change into anaerobic
metabolism. Our body can tolerate this
condition only for a while.
Resistensi vaskuler
Vasodilatasi
SVR ↓
Heart rate
Kontraksi
V preload
Preload Kontraksi ↓
volume ↓ ESV ↑
EDV ↓
Classification dan etiology
Rosen’s emergency medicine: concept and clinical practice, 8th ed.
Hypovolemic shock
• This most common form of shock results either from the loss
of red blood cell mass and plasma from hemorrhage or from
the loss of plasma volume alone due to extravascular fluid
sequestration or GI, urinary, and insensible losses
Longo D, Fauci AS, Kasper D, Hauser S, Jameson JL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 18th
edition.
Hemorrhagic Shock
• Hemorrhage is the most common cause of shock after injury, and virtually all
patients with multiple injuries have an element of hypovolemia.
• Hemorrhage is defined as an acute loss of circulating blood volume.
• Normal adult blood volume is approximately 7% of body weight.
Hemorrhagic Shock
Management
Cardiogenic shock
• Cardiogenic shock (CS) : characterized by
systemic hypoperfusion due to severe
depression of the cardiac index (<2.2
[L/min]/m2) and sustained systolic arterial
hypotension (<90 mmHg) despite an elevated
filling pressure (pulmonary capillary wedge
pressure [PCWP] >18 mmHg)
• Results when >40% of the myocardium
undergoes necrosis from ischaemia,
inflammation, toxins, or immune destruction
Etiology
• Circulatory failure based on
cardiac dysfunction may be
caused by primary
myocardial failure, most
commonly secondary to
acute myocardial infarction
(MI), and less frequently by
cardiomyopathy or
myocarditis, cardiac
tamponade, or critical
valvular heart disease
Longo D, Fauci AS, Kasper D, Hauser S, Jameson JL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 18th
edition.
Septic shock
• The harmful host response to infection;
systemic response to proven or suspected
infection plus some degree of organ
hypofunction sepsis (or severe sepsis)
• Septic shock: sepsis accompained by
hypotension that cannot be corrected by the
infusion of fluids
Longo D, Fauci AS, Kasper D, Hauser S, Jameson JL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 18th
edition.
Longo D, Fauci AS, Kasper D, Hauser S, Jameson JL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 18th
edition.
Etiology
• Most common (64%): respiratory infection
Longo D, Fauci AS, Kasper D, Hauser S, Jameson JL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 18th
edition.
Management
Rosen Emergency Medicine ed.7th
Anaphylactic shock
- acute, potentially fatal,
multi organ systemicrx
caused by released of
chemical mediators
from mast cell and
basophil by IgE.
Signs and Symptoms
http://www.privatehealth.co.uk/EasysiteWeb/getresource.axd?AssetID=2683&type=full&servicetype=inline&cus
Insidence & Epidemiology
• Approximately 100/100,000 person-years in
Europe and the Americans or about 11 cases
per 10,000 people annually
• Most commonly in 10 to 19 y.o
• Overall, 70% of patients are less than 30 y.o
and most are men
• ♂ : ♀ ratio is 1.4 : 1
• Approximately 20% of all patients have
evidence of perforation at presentation, but
percentage risk is much higher in patients
Fauci, Braunwald, Kasper, dkk. Harrison’s Principles of Internal Medicine. 19th edition. USA: Mc Graw Hill,
Appendicitis
• Etiology
– In approximately one third of cases, no direct
cause of obstruction
– In this cases, it is surmised that inflammation is
caused by viral, bacterial or parasitic infection
with subsequent mucosal ulceration or lymphoid
hyperplasia
Marx JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Practice, 8th edition. Philadelphia: Elsevier
Pathophysiology
• Afferent fibers that conduct visceral pain from the appendix accompany the
sympathetic nerves and enter the spinal cord at the level of the tenth thoracic
segment referral of pain to the umbilical area
• In majority of affected patients due to an acute obstruction of the appendiceal
lumen
• After acute obstruction, intraluminal pressures ↑ & mucosal secretions are unable
to drain
• The resulting distention stimulates visceral afferent pathways dull, poorly
localized pain
• Next, ulceration & ischemia develop as the intraluminal pressure exceeds the
venous pressure & bacteria & PMN cells begin to invade the appendiceal wall
• With time, appendix swollen & factors elaborated in the pathologic process
begin to irritate surrounding structures, including peritoneal wall (the pain now
become more localized to RLQ)
• If swelling does not abate, hypoxia leads to gangrene and ultimately, perforation
through the appendiceal serosal layer. (this can lead to abscess formation or
diffuse peritonitis
Marx JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Practice, 8th edition. Philadelphia: Elsevier
Appendicitis
• Sign and symptom
– Vague onset of dull periumbilical pain
– Anorexia
– Nausea & vomiting
– Pain migrates to RLQ
– If the appendix is retrocecal or retroiliac pain
may be blunted
– If the appendix is elongated pain may be
referred to the flank, pelvis or RUQ
– Marx
Other less typical symptoms increased urinary
JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Practice, 8th edition. Philadelphia: Elsevier
Appendicitis
• Physical examination
– Localized abdominal
tenderness RLQ
– Abdominal guarding
and rigidity to
palpation
– McBurney’s sign
– Rovsing’s sign
– Psoas sign
–MarxObturator sign
JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
th
Practice, 8 edition. Philadelphia: Elsevier
Appendicitis
• Physical examination
– Rebound tenderness to palpation is a late finding
in patients with appendicitis and usually is noted
only after the appendix is significantly inflamed or
ruptured
– The presence of peritoneal irritation also can be
elicited by other maneuvers that cause the
visceral and parietal peritonei to rub against each
other cough
Marx JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Practice, 8th edition. Philadelphia: Elsevier
Appendicitis
• Diagnostic
– Leukocyte count
• Approximately 80-90% of patients with acute
appendicitis have an elevated WBC count above
10.000/mm3
– Urinalysis
• Helpful in differentiating urinary tract disease from
acute appendicitis and is suggested in all patients
– Pregnancy test
• Should be performed in all women of child-bearing age
because a positive result broadly expands the scope of
Marx JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
the DD for RLQ pain th
Practice, 8 edition. Philadelphia: Elsevier
Appendicitis
• Imaging studies
– Plain radiography not useful (low sensitivity and specificity)
– Barium enema sensitivity approximately 80 to 90%, but a
normal appendiceal lumen often is not visualized with this
technique
– USG sensitivity and specificity (75-90% and 85-90%). USG
examination a non compressible appendix with a diameter >
6 to 7 mm is considered diagnostic for appendicitis
– CT-scan sensitivity and specificity (87-100% and 89-98%).
Enlarged appendix (diameter > 6 mm), pericecal inflammation,
presence of appendicolith and periappendical phlegmon or
abscess
– MRI sensitivity similar to that for CT-scan
– Laparoscopy for diagnosis or definitive treatment
Marx JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Practice, 8th edition. Philadelphia: Elsevier
Appendicitis
• Differential diagnosis
All patients Women Children
Nonspesific Ovarian cyst Henoch-Schonlein
abdominal pain purpura
Renal colic
Marx JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Practice, 8th edition. Philadelphia: Elsevier
Appendicitis
• Management
– Dehydrated patients IV crystalloid fluids
– Nausea or vomiting parenteral antiemetics
– Patients with more than mild discomfort pain
medication
– Once the decision to operate has been made,
prophylactic antibiotics should be given to provide
coverage for gram-negative and aerobic organisms
IV 2nd gen. cephalosporin (cefotetan or
cefoxitin
– Marx
In JA,cases with high likelihoodPractice, perforations
th
8 edition. Philadelphia: 2nd
Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Elsevier
Appendicitis
• Complications
– Infection
– Perforation
– Prolonged ileus
– Small bowel obstruction
– Urinary retention and infection
Marx JA, Hockberger RS, Walls RM, Biros MH, eds. 2014. Rosen’s Emergency Medicine: Concept and Clinical
Practice, 8th edition. Philadelphia: Elsevier
Acute Peritonitis
• Peritonitis is an inflammation of the
peritoneum
• It may be localized or diffuse in location, acute
or chronic in natural history, and infectious or
aseptic in pathogenesis.
• Primary or spontaneous peritonitis : no
intraabdominal source is identified
• Secondary peritonitis : usually related to a
perforated viscus
Have you had it before? Yes suggests recurrent problems such as ulcer disease,
gallstone colic, diverticulitis, or mittelschmerz
http://www.merckmanuals.com/professional/gastrointestinal_disorders/acute_abdomen_and_surgical_gastroenterol
ogy/acute_abdominal_pain.html#v890312
History in patients with acute abdomen
Question Potential responses and indication
Was the onset sudden? •Sudden: “Like a light switching on” (perforated ulcer, renal
stone, ruptured ectopic pregnancy, torsion of ovary or
testis, some ruptured aneurysms)
•Less sudden: Most other causes
How severe is the pain? •Severe pain (perforated viscus, kidney stone, peritonitis,
pancreatitis)
•Pain out of proportion to physical findings (mesenteric
ischemia)
Does the pain travel to •Right scapula (gallbladder pain)
any other part of the •Left shoulder region (ruptured spleen, pancreatitis)
body?
•Pubis or vagina (renal pain)
•Back (ruptured aortic aneurysm, pancreatitis, sometimes
perforated ulcer)
http://www.merckmanuals.com/professional/gastrointestinal_disorders/acute_abdomen_and_surgical_gastroenterol
ogy/acute_abdominal_pain.html#v890312
History in patients with acute abdomen
Question Potential responses and indication
What relieves the pain? •Antacids (peptic ulcer disease)
•Lying as quietly as possible (peritonitis)
What other symptoms •Vomiting precedes pain and is followed by diarrhea
occur with the pain? (gastroenteritis)
•Delayed vomiting, absent bowel movement and flatus
(acute intestinal obstruction; the delay increases with a
lower site of obstruction)
•Severe vomiting precedes intense epigastric, left chest, or
shoulder pain (emetic perforation of the intra-abdominal
esophagus)
http://www.merckmanuals.com/professional/gastrointestinal_disorders/acute_abdomen_and_surgical_gastroenterol
ogy/acute_abdominal_pain.html#v890312
65 yo, complained: Physical exam:
Vomited 3 times Tachycardi,
Hypovolemic hipotension,
containing fresh blood
shock tachypnea, febrile,
+ coffee colored blood
abdomen tenderness,
decreased bowel
The last 5 days, he sound, lab :
complained: leukocytosis, << HB
Stomachache and Acute abdomen
nause better after pain
antacids
Septic shock
History :
Coronary artery • BASED ON THE DISCUSSION WE
disease aspirin, HAVE LEARNED :
Consumed alcohol UGI bleeding
- MM SHOCK
alcoholic liver disease
- MM GI BLEEDING
- MM ACUTE ABDOMEN