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
TraumaMaksilofasial

ProblemAirway

PasienBerbicaraLancar>
airwaybaik
Adakahpatensijalan
nafas?

TraumaLeher

TraumaLaryngeal

Look:Agitasi,penkes,
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
curigaCspineterganggu>dipertahankandengan
nasofaringealairwayatauorofaringealairway
Dapatteroksigenasi
Assessairwayanatomy>
LEMON
Intubation drug assistance
Cricoidpressure

unsuccesfull
Consideradjunct>GEB/LMA/LTA

Definitifarway
surgical

NO

OPA

Definitifairway
surgical

Difficult

Callassistance
orAwake
intubation

Intubation

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.

Airwaydefinitif
KebutuhanUntuk PERLINDUNGAN
AIRWAY

OrotrachealTube
NasotrachealTube
Airwaysurgical:
Krikotiroidotomi
Trakheostomi
Kebutuhan UntukVENTILASI

Penurunan Kesadaran(GCS<9)

Apneu:
Paralisis neuromuscular
Tidaksadar

FrakturMaxilofacialberat

UsahaNafastidakadekuat
Takipneu
Hipoksia
Hiperkarbia
Sianosis

ResikoAspirasi :Perdarahan,muntah
muntah

Cederakpalatertutupberatyang
membutuhkanhiperventilasi

ResikoSumbatan:Hematomaleher,
cedera laring,trachea,stridor

Kehilangandarahyangmasifdan
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
Contractility

Stroke Volume x Heart Rate

O2 Content

x
O2 Delivery

Cardiac
Output

Resistance

Arterial Blood
Pressure

Pathophysiology
BP=COxR
CO=SVxHR
SVcomponents=Preload,Afterload,
Contractility
DO2=COxCaO2
CaO2=(Hb xsatx1.34)+(PaO2 x0.003)

Pathophysiology
Shock

CO

Hipovolemik
(preloaddan
(termasukperdarahan) afterload)
Kardiogenik
(kontraktilitas)
Distributif
(termasukanafilaktik,
septik,neurogenik/
spinal)

sebagai
kompensasi

SVR
sebagai
kompensasi
sebagai
kompensasi

CharacteristicsofShock
Endorgan
dysfunction:

Metabolic
dysfunction:

reducedurine
output

acidosis

alteredmental
status
poorperipheral
perfusion

alteredmetabolic
demands

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
Kehilangandarah <750
(mL)*
Kehilangandarah <15%
(%volumedarah)
Nadi
<100
Tekanandarah

KelasII

KelasIII

KelasIV

7501500

15002000

>2000

1530%

3040%

>40%

>100

>120

>140

Normal

Normal

Menurun

Menurun

Tekanannadi

Normalataunaik

Menurun

Menurun

Menurun

Frekuensinafas

1420

2030

3040

>35

Produksiurin
(ml/jam)
Statusmental

>30

2030

515

Tidakberarti

Sedikitcemas

Agakcemas

Cemas,bingung

Bingung,letargis

Kristaloid

Kristaloid

Kristaloiddan
darah

Kristaloiddan
darah

Penggantian
cairan

*)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.
2.
3.
4.
5.
6.
7.
8.
9.

Administeroxygen.
Maintainanadequateairway.
Removetheallergenthatcausedthereaction.
Administerepinephrine(0.3to0.5mL ofa1:1.000solution
IM/SC or0.3to0.5mL ofa1:10.000solutionIV).
Initiale fluidtherapyearlywithnormalsalinetomaintainan
MAP70mmHgorasystolicbloodpressure90mmHg.
Administervasopressor agentsifcrystalloidtherapyis
inadequateformaintainingCO.
Considerotherpharmacologictreatments:antihistamines,
bronchodilators,andcorticosteroidsareotheroptions.
Performcardiacmonitoring.
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
basa
Asidosisrespiratorik

pH

PCO2

HCO3
jika

Penyebabumum
PPOK,asma,ARDS

terkompensasi

Alkalosisrespiratorik

jika
terkompensasi

Asidosismetabolik

jika

terkompensasi

Alkalosismetabolik

jika
terkompensasi

Hiperventilasi,
sepsis
Dehidrasiberat,
DM,gagalginjal,
starving,Diare
Muntah

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
Dizziness
Seizures
Coma

Hypertension,
bradycardia
Hypotension,laterin
course
Cardiovascular
collapse

CNS

Cardiovascular

Dyspnea
Tachypnea
Pulmonaryedema
Apnea

Nausea,vomiting
Causticeffects

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
BaseFracture

Posteriorfrontalsinus,roofofethmoid,
cribriform,andorbitalroof,sphenoid
bone

MiddleSkull
BaseFracture

Temporalbone

PosteriorSkull
BaseFracture

Clivusoccipital,condylaroccipital

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

Breathing

Pneumotoraks terbuka
Pneumotoraks tension
FlailChest

Circulation

Hematoraks masif
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
skinburn

Etiology

Sizeandextentof
theburnwound

BurnInjury

pricktest(+)

SuperficialPartial
ThicknessBurn(IIa)

DeepPartial
ThicknessBurn(IIb)

FullThicknessBurn
(III)

TotalBody
SurfaceArea

Parklandformula=baxter formula

Toestimatescatteredburns:patient's
palmsurface=1%totalbodysurface
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
Hirschsprungsdisease.Aplain
abdominalradiographmayshow
adilatedsmallbowelorproximal
colon(noairintherectum)

Contrastbariumenemaradiographs,
Afterthedilationprocessbegins,the
diseasedportionofthecolonwill
appearnormalandthemoreproximal
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
(PlainPhoto)

Umbrellasign/StringSign
(BariumMeal)

Atresia/StenosisDuodeni
Atresia:complete
obstruction;stenosis:
partialobstruction
Lokasiterseringdi
duodenumpars
horizontal
Symptom:regurgitasi&
vomit(bilousvomit)
Dx:(doublebubble)
Plainphoto
Bariummeal/OMD

In approximately 80% of affected

neonates, the site of duodenal atresia is
postampullary, so that the patient may
present with bilious vomiting.

DoublebubbleSign

Plainfilmradiograph
DoublebubbleSign
(gasfilledstomachandduodenum
dilatationwithnodistalgas)
Withoutabdominaldistension

Bariummeal/OMD

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