BEDAH 1

BIMBEL UKDI MANTAP

dr. Andreas W Wicaksono
dr. Anindya K Zahra
dr. Arius Suwondo
dr. M. Dzulfikar Lingga Q M
dr. Marika Suwondo
dr. Alexey Fernanda N
dr. Denise Utami Putri
dr. Aditya Wicaksana

Batch November 2016

 content

Thoracic and Cardiovascular Surgery

Neurosurgery

Pediatric Surgery

Plastic Surgery
Thoracic and Cardiovascular
Surgery
Trauma Algorythm
 Trauma Thorax
PRIMARY SURVEY EMERGENCY

Airway Gangguan jalan nafas

Pneumotoraks terbuka
Breathing Pneumotoraks tension
Flail Chest

Hematoraks masif
Circulation Tamponade kordis
Hematothorax
Definition :
accumulation of blood
in pleural cavity
Simple
Massive :
> 1.5litres blood on
chest drainage or >
200cc blood/ hour on
drainage
 Etiology
Trauma : ruptur arteri di dinding thorax
ataupun internal organ di thorax
A. thoracica interna and its branches
A. intercostalis
A. bronchialis
 Physical Exam
Sign : dyspneu

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

P : Fremitus taktil menurun
P : Redup (+)
A : Vesikuler turun, normal heart sound
Tube Thoracostomy / Chest Tube
Water Sealed Drainage
Pneumothorax

Definition :
accumulation of air
or gas in pleural
cavity
 Klasifikasi Pneumotoraks

Berdasarkan Artifial
Traumatika
terjadinya Spontan (primer dan sekunder)

Berdasarkan Terbuka/open
Tertutup/closed
fistulanya Tension

Berdasarkan Total
derajat kolaps Parsial
 Physical Exam
Sign : Dyspneu, subcutis emfisem

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

P : Fremitus taktil menurun
P : Hipersonor
A : Vesikuler turun/hilang, normal heart sound
 Open Pneumothorax
Etiology : Penetrating Trauma lubang dinding dada
(ukuran mendekati diameter trakea (>2/3 diameter
trakea))
Mediastinal Flutter
Sucking Chest Wound
 Treatment
Occlusive dressing tape in 3
sides.
the dressing prevents atmospheric
air from entering the chest wall
during inspiration but allows any
intrapleural air out during
expiration
Closed Pneumothorax

Etiology : blunt trauma,

spontaneous rupture of
pleurae air leakage to
pleural cavity
Can developed into
Tension Pneumothorax
Tx : Chest Tube
Tension Pneumothorax
Clinical sign :
Himpitan vena cava
Shock
JVP
Himpitan paru
kontra lateral
distress nafas
deviasi trakhea
Tx :
Neddle
thoracostomy
(decompression)
Chest tube
Tension Pneumothorax
 Needle Thoracostomy (Needle
Decompression / Needle Thoracocentesis)

Lokasi :
SIC II / III Linea
Midclavicula

Tindakan
emergensi untuk
mengubah tension
pneumothorax
menjadi simple
pneumothorax
Cardiac Tamponade
Etiology : blunt or
penetrating trauma
in mid-chest
Nomal breath sound
Sign Trias Beck
1. Increase JVP
2. Hypotension
3. Muffled Heart
sound
Tx :
pericardiocentesis
Pericardiocentesis
 Flail Chest
Fraktur costae segmental, multipel,
berurutan
Segmental fraktur komplit pada 2 tempat atau
lebih pada costa
Multipel berurutan terjadi pada 2 atau lebih
costa berurutan
Severe respiratory distress
Paradoxal movement
Asymmetrical and uncoordinated chest wall
movement
Crepitation on palpation
Pain>>>>
Flail Chest
 Management
ABCDE
Adequate ventilation, oxygenation, cairan,
analgesia
 Contusio Pulmonum
Cedera parenkim paru edema & akumulasi
darah dalam alveolus hilangnya fungsi paru
normal
Akibat cedera tumpul, sering pada usia muda
Dapat terjadi dengan atau tanpa adanya fraktur
iga
Klinis jejas thoraks, fraktur iga, flail chest,
crackles, hipoksia (bila terjadi bilateral dan luas)
Rontgen thorax tidak sensitif, patchy
consolidation
Tatalaksana pulse oxymetry, AGD, EKG,
ventilasi mekanik (SaO2 <90%)
 Contusio Pulmonum

Contusio pulmonum saat datang di UGD Contusio pulmonum 24 jam kemudian

Neurosurgery
 Epidural Hemorrhage

>>a. meningea media, temporo parietal,

biconvex/lenticular, lucid interval
 Epidural Hemorrhage
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
 Subdural Hemorrhage

Bridging vein, semilunar, countre-coup injury

 Subarachnoid hemorrhage

Aneurisma, AVM
Thunderclap headache, Muntah, stiff neck, meningeal
irritation, confusion / penkes
 Intracerebral hemorrhage

Parenkim otak
Brain trauma atau spontan pada hemorrhagic stroke.
CT-Scan
MRI
Specific for
Soft Tissue
 Cedera Otak
Cedera Otak Primer
Kepala diam dibentur oleh benda yang bergerak
Kepala yang bergerak membentur benda yang diam. (Proses
aselerasi & deselarasi)

Cedera Otak Sekunder

Terjadi sesudah lesi otak primer
Akibat dikeluarkannya zat-zat neurotoksis (interleukin, radikal
bebas, aspartat, dll)
Menyebabkan hipotensi, gangguan aliran darah, hipoksia,
peningkatan TIK, vasospasme,edema
Brain Herniation
 Brain Herniation
Supratentorial herniation
Subfalcine (Cingulate) herniation
Central herniation
Transtentorial lateral (Uncal) herniation
Transcalvarial herniation

Infratentorial herniation
Upward cerebellar herniation
Downward cerebellar (Tonsillar) herniation
 Uncal herniation
Herniation of the medial temporal lobe inferiorly through
the tentorial notch

Clinical triad associated with uncal herniation :

Dilated pupil ipsilateral
Hemiplegia contralateral
Coma

compressed ipsilateral to herniation: hemiplegia will be on

the contralateral side of the body (axons decussate at
pyramidal decussation)
compressed contralateral to herniation: If the herniation is
very severe, the contralateral cerebral peduncle may be
compressed by the opposite side of the tentorial notch
leading to an ipsilateral (to the herniation) hemiplegia
(Kernohan's phenomenon).
Cedera Kepala
ATLS

Klasifikasi klinis cedera kepala

berdasarkan GCS :

Cedera Kepala Ringan (CKR)

GCS 13-15
Kesadaran menurun 10 menit
Defisit neurologis (-)
CT SCAN normal
Cedera Kepala Sedang (CKS)
GCS 9-12
Kesadaran menurun >10 menit s/d <6 jam
Defisit neurologis (+)
CT SCAN abnormal
Cedera Kepala Berat (CKB)
GCS 3-8
Kesadaran menurun >6 jam
Defisit neurologis (+)
CT SCAN abnormal
 Primary Brain Injury
The damaged caused to the brain at the moment
of impact
Concussion
Temporary neuronal dysfunction after blunt head trauma
Head CT is normal, deficits resolve over minutes to hours
Contusion/laseration
Bruise of the brain
Breakdown of small vessels and extravasation of blood into the brain
Diffuse axonal injury
Damage to axons throughout the brain
Most frequent finding in patients who die from severe head injury
 Manajemen Cedera Kepala
Posisi tidur dengan leher lurus & head up 15-300
Meningkatkan venous return menurunkan TIK

Usahakan tekanan darah optimal

TD terlalu tinggi edema cerebri, TD terlalu rendah iskemia otak edema dan
meningkatkan TIK.
Jaga TDS>90, jaga euvolemia dengan NS 0,9%

Atasi kejang, nyeri, dan cemas

Meningkatkan demand metabolisme otak
Profilaksis kejang diindikasikan
Benzodiazepine, opioid
Menjaga suhu tubuh normal (<37,50C)

Hindari batuk, mengejan, dan suction jalan napas yang berlebihan

 Manajemen Cedera Kepala
Koreksi kelainan metabolik dan elektrolit
Hiperglikemia memperburuk outcome cedera kepala

Atasi hipoksia
PaCO2 dijaga pada level yang mendukung CBF (35 mmHg). Hiperkarbia menyebabkan
vasodilatasi meningkatkan TIK
Hiperventilasi terkontrol. Hiperventilasi berlebihan menyebabkan vasokonstriksi iskemia
edema cerebri meningkatkan TIK
Osmoterapi
Manitol 20%/20g manitol per 100 ml pelarut dosis 0,25-1 g/kgBB (diulangi 2-6 jam
kemudian, osmolaritas dijaga 310-320 mOsm/L)
Furosemide (efek sinergis bila dikombinasikan dengan manitol, efek terbaik bila diberikan 15
menit setelah manitol)
Salin hipertonik (alternatif pengganti manitol pada kondisi tertentu seperti gangguan fungsi
ginjal
Antikonvulsan
Feniton 1 g IV kecepatan 50 mg/menit, maintenance 100 mg/8 jam
Indikasi CT SCAN pada Cedera Kepala
CKR (bila disaksikan mengalami hilang kesadaran,
amnesia yang jelas, atau disaksikan mengalami
disorientasi dengan skor GCS 13-15)
GCS<15 setelah 2 jam paska trauma
Dicurigai adanya fraktur impresi terbuka atau tertutup
Adanya tanda-tanda fraktur basis cranii
Muntah (>2 kali)
Usia >65 tahun
Hilang kesadaran >5 menit
Amnesia retrograde >30 menit
Basis Cranii
 Classification

Anterior Skull Posterior frontal sinus, roof of ethmoid,

cribriform, and orbital roof, sphenoid
Base Fracture bone

Middle Skull Temporal bone

Base Fracture

Posterior Skull Clivus occipital, condylus occipital

Base Fracture
 Clinical sign :
Presentation with anterior cranial fossa fractures is with CSF rhinorrhea
and bruising around the eyes "raccoon eyes."

Patients with fractures of the petrous temporal bone present with CSF
otorrhea and bruising over the mastoids Battle sign.

Longitudinal temporal bone fractures result in ossicular chain disruption

and conductive deafness of greater than 30 dB that lasts longer than 6-7
weeks.
Transverse temporal bone fractures involve the VIII cranial nerve and the
labyrinth, resulting in nystagmus, ataxia, and permanent neural hearing
loss.

Occipital condylar fracture is a very rare and serious injury. Most of the
patients are in a coma and have other associated cervical spinal injuries.
These patients may also present with other lower cranial nerve injuries
and quadriplegia.
 Halo Sign
(Ring sign/Target sign)

Tanda CSF leak:

Glucose (+)
Halo sign (+)
Beta-2-transferrin (+) highly specific to CSF, not present
in plasma, nasal secretion, tear, saliva, or other fluid.
Pediatric Surgery
Hirschprung Disease
Kelainan kongenital akibat kegagalan
migrasi krista neuralis ke colon.
Tidak terbentuk sel ganglionik pd
plexus myentericus (Auerbach) dan
plexus submucosal (Meissner)
80% rectosigmoid
Klinis :
Delayed meconium (>24h)
Abdominal distention
Bilous vomiting
Severe diarrhea alternating with
constipation
Dx :
Barium enema
Rectal biopsy
Anorectal manometry
Sign and Symptoms

Symptoms may recur after previously

resolving with laxatives, or feeding
changes.

Digital Rectal examination may

demonstrate a tight anal sphincter
and explosive discharge of stool and
gas.
- Frog-like abdomen
- Darm contour
- Darm steifung
- Metallic sound
 Radiographic Features
Imaging can help diagnose Contrast barium enema radiographs,
Hirschsprungs disease. A plain After the dilation process begins, the
abdominal radiograph may show diseased portion of the colon will
a dilated small bowel or proximal appear normal and the more proximal
colon (no air in the rectum) colon will be dilated. A transition zone
(the point where the normal bowel
becomes aganglionic) may be visible on
a contrast enema radiograph
 Atresia Esophageal

The first sign of esophageal atresia in the fetus may be polyhydramnios in

the mother.
Prematurity has also been associated with esophageal atresia.
Classically, presents with copious, fine, white, frothy bubbles of mucus in
the mouth and, sometimes, the nose.
The infant may have rattling respirations and episodes of coughing, choking
and cyanosis, may be exaggerated during feeding.
Diagnosis

(A) Diagnosis of esophageal atresia is confirmed when a 10-gauge

(French) catheter cannot be passed beyond 10 cm from the gums.

(B) A smaller-caliber tube is not used because it may curl up in the upper
esophageal segment, giving a false impression of esophageal continuity.

The normal distance to an infant's gastric cardia is approximately 17 cm

chest radiographs should be obtained to confirm the position of the tube. The
radiograph should include the entire abdomen. In patients with esophageal
atresia, air in the stomach confirms the presence of a distal fistula, and the
presence of bowel gas rules out duodenal atresia

The Gasless Abdomen

Absence of gas in the
abdomen suggests that
the patient has either
atresia without a fistula
or atresia with a
proximal fistula only
 Hypertrophy Pyloric Stenosis
Hipertrofi m.sphincter pylorus
Stenosis > canalis pyloricus

Klinis :
1-12 minggu, muntah proyektil, bile
free, bolus+gastric juice
Baby looks hungry, fluid deficiency
and electrolyte imbalance
Palpable mass (olive) in the RUQ
Dx :
Plain photo (Single bubble sign)
Barium meal / OMD (Umbrella sign)
Komplikasi : dehidrasi & aspirasi
Tx :
Non surgery : resusitasi cairan
Surgery : pyloromyotomy
 Radiographic Features
Single Bubble sign Umbrella / Mushroom / String sign
(Plain Photo) (Barium Meal)
 Atresia / Stenosis Duodeni
Atresia: complete
obstruction; stenosis:
partial obstruction
Lokasi tersering di
duodenum pars
horizontal
Symptom: regurgitasi &
vomit (bilous vomit)
Dx : (double bubble)
Plain photo In approximately 80% of affected
neonates, the site of duodenal atresia is
Barium meal / OMD postampullary, so that the patient may
present with bilious vomiting.
Double bubble Sign

Plain film radiograph

Double bubble Sign Barium meal / OMD
(gas-filled stomach and duodenum
dilatation with no distal gas)
Without abdominal distension
Intestinal Obstruction
(jejunoileal obstruction)
Classic signs of patients with jejunoileal atresia :

Bilious vomit
Abdominal distention (in distal atresia)
Jaundice (32%) which is characteristically due to indirect
hyperbilirubinemia
Failure to pass meconium in the first 24 hours (rule out Hirschsprung
disease; passage of meconium does not rule out intestinal atresia)
Abdominal distention is most evident in cases of ileal atresias, in which it
is diffuse, as opposed to proximal jejunal atresias, in which the upper
abdomen is distended and the lower abdomen is scaphoid.
Intestinal loops and their peristalsis may be seen through the thin
abdominal wall of newborns.
Atresia Jejunum

Triple bubble sign

With abdominal
distension
No gas in pelvic
cavity
 Anorectal
Malformations
The resulting malformations range from
isolated imperforate anus to persistent cloaca.

Atresia ani (imperforate anus) is a congenital abnormality characterized by

persistence of the anal membrane resulting in a thin membrane covering
the normal anal canal or is the failure of the anal membrane to break
down (Noden and Lahunta 1985)

If, after 24 hours, there is no meconium on the perineum, we recommend

performing a cross-table lateral x-ray with the baby in knee chest (prone)
position.

useful in determining the

level of atresia
 Klasifikasi Atresia Ani
Menurut Berdon, membagi atresia ani berdasarkan
tinggi rendahnya kelainan, yakni :
~ Atresia ani letak tinggi : bagian distal rectum
berakhir di atas muskulus levator ani (jarak > 1,5 cm
dengan kulit luar)
~ Atresia ani letak rendah : bagian distal rectum
melewati musculus levator ani (jarak < 1,5cm dari kulit
luar)

Menurut Stephen, membagi atresia ani

berdasarkan pada garis pubococcygeal :
~ Atresia ani letak tinggi : bagian distal rectum
terletak di atas garis pubococcygeal.
~ Atresia ani letak rendah: bagian distal rectum
terletak di bawah garis pubococcygeal.

high supralevator lesions are typically associated

with fistulas
Invertogram
PSARP = posterosagittal anorectoplasty
Bukti klinis atresia ani letak rendah = perineal fistula, bucket handle, midline raphe fistula, stenosis anal, anal
membrane
Bukti klinis atresia ani letak tinggi = flat bottom, fistula rectovesica
 Intussusception
(Invagination)
Invagination of a proximal portion of intestine (intussusceptum) into a
more distal portion (intussuscipiens), is one of the most common causes
of bowel obstruction in infants and toddlers.
> 80% involves the ileocecal region.

Occur in children less than one year of age, with a peak incidence
of between 6-10 months. (>> 9 months)

TRIAS :
Colicky & Cramping abdominal pain
Bilious vomiting
Mucous-red currant jelly stools

Physical Exam :
Palpable abdominal mass
(Sausage Appearance)
Dance s sign
 Radiographic Features Intussusception
USG :
Target or doughnut sign (Transverse cross section)
Sandwich sign, pseudokidney sign (Longitudinal
section)

Pseudokidney sign
Barium Enema : Cupping sign
(as a diagnostic) or therapeutic (non-
operative reduction)
 Volvulus

Volvulus of the intestine, the twisting of a segment of intestine on its

mesentery, can be a primary pathology or secondary to malrotation of the
intestine. Clinical presentations vary from acute abdominal emergency
requiring immediate surgical intervention to insidious history of colicky
abdominal pain.

Volvulus of the small intestine is commonly associated with abnormality

of intestinal rotation and fixation. This is due to failure of fixation and
narrow mesenteric base which allow volvulus to occur. Midgut volvulus
can lead to irreversible intestinal necrosis, which is potentially fatal.

Large bowel volvulus on the other hand is rare in children; it usually

occurs as a result of redundant sigmoid colon and affects mainly adults.
 Up to 80% of patients present in the first month of life (20% of patients
present after the first year of life) and in this age group the cardinal
symptom is bile (green) vomiting due to duodenal obstruction through
midgut volvulus.
Pain, irritability, and other non-specific symptoms (anorexia or nausea was
noted) are more common in toddlers and older children.
 The coffee-bean sign (also known as bent inner tube sign) is a sign on an
abdominal plain film.
This thick 'inner wall' represents the double wall thickness of opposed
loops of bowel, with thinner outer walls due single thickness.
Gastroschisis
Definition : defect
in development of
abdominal wall
results in
protrusion of
abdominal viscera
without a visceral
sac
Omphalocele
Definition : defect
in development of
abdominal wall
results in
protrusion of
abdominal viscera
in a visceral sac
Plastic Surgery
 Superficial Partial
Thickness Burn (IIa)
 Deep Partial
Thickness Burn (IIb)
Full Thickness Burn
(III)
 Total Body
Surface Area

To estimate scattered burns: patient's

palm surface = 1% total body surface
Parkland formula = Baxter formula area
 Indikasi Rawat Inap

Menurut American Burn Association, seorang

pasien diindikasikan untuk dirawat inap bila:
Luka bakar derajat II dan III > 10%
Luka bakar derajat III (ukuran berapapun)
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
 Indikasi klinis adanya trauma inhalasi
Luka bakar yang mengenai wajah dan/atau leher

Alis mata dan bulu hidung hangus

Adanya timbunan karbon dan tanda peradangan akut orofaring

Sputum yang mengandung karbon/arang

Suara serak

Riwayat gangguan mengunyah dan/atau terkurung dalam api

Luka bakar kepala dan badan akibat ledakan

Secure airway (pembebasan jalan nafas) segera dengan airway definitif (intubasi)
 Luka Bakar Sirkumferensial
Luka bakar ekstremitas
(terutama bila Cek tanda-tanda sindrom kompartemen (5P)

sirkumferensial)

Lepaskan semua perhiasan

yang menempel pada Menurunkan efek tekanan

ekstremitas

Nilai status sirkulasi distal Cyanosis, penurunan CRT, parestesia, nyeri jaringan dalam). Paling baik dengan
Doppler USG flowmetri
ekstremitas

Menurunkan tekanan intrakompartemen (sebaiknya konsul dengan dokter bedah

Escharotomy terlebih dahulu)

Walaupun jarang digunakan, fasciotomy dapat memperbaiki sirkulasi ekstremitas

Fasciotomy pada pasien dengan trauma skeletal, crush injury, LUKA BAKAR LISTRIK TEGANGAN
TINGGI, luka bakar yang melibatkan jaringan hingga fascia
 Luka Bakar Listrik
Akibat kontak sumber listrik dengan tubuh tubuh
berperan sebagai konduktor kerusakan jaringan
timbul akibat panas yang dihasilkan
Kulit tampak relatif normal namun jaringan otot
dibawahnya nekrosis
Arus listrik yang berjalan di dalam pembuluh darah dan
saraf trombosis dan cedera saraf
Rhabdomiolisis mioglobin meningkat AKI
Arus listrik dapat mengganggu sistem konduksi jantung
dan menyebabkan aritmia
Urin gelap menandakan hemokromogens
 Luka Bakar Listrik

Stabilisasi airway dan breathing

Jalur IV, monitor EKG, pemasangan kateter urin

Kerusakan otot luas sindrom kompartemen SERING

MEMBUTUHKAN FASCIOTOMY

Rhabdomyolisis pelepasan myoglobin myoglobinuria

gagal ginjal akut
Pencegahan: curigai adanya rhabdomyolisis bila urin pasien gelap
administrasikan cairan untuk membuat urine output 100 cc/jam (dewasa) atau
2 cc/kg/jam (anak < 30 kg)
Labio-Gnato-Palato Schisis
 The Neonatal Period
Surgical Repair
Cleft Lip
In US - the rule of tens - 10 wks, 10 pounds/lbs, Hgb
10 (+ leucocyte count 10,000u/L
Lip adhesion vs baby plates
Cleft Palate
Varies from 6-18 months - most around 10 mo
Early repair may lead to midface retrusion
Early repair improves speech
Le Fort fracture classification
TemporoMandibular Joint Dislocation
(Locked Jaw)

Type :
Anterior
Posterior
Superior

Unilateral /
Bilateral
The patient is unable to close the mouth and may have garbled speech,
drooling and in pain .
A depression may be noted in the preauricular area. Palpation of the TMJ
reveals one or both of the condyles trapped in front of the articular eminence
and spasm of the muscles of mastication.
In addition, the coronoid process of the mandible becomes prominent and
palpable just below the maxilla

Treatment depends on
patient status and varies
from simple reduction to
surgical intervention.
Manual closed Reduction (Classic)
Barton bandage
Application of a Barton bandage
after reduction (for 2-3 days)
Apply warm compresses to the TMJ
area for 24 hours
Avoid extreme opening of the jaw
for three weeks. In some patients,
placement of a padded rigid cervical
collar.
Support the lower jaw when
yawning.
Maintain a soft diet for one week.
Take nonsteroidal anti-
inflammatory agents (eg ibuprofen
10 mg/kg orally every six hours as
needed, maximum single dose : 800
mg) as needed for pain and swelling.
Penyakit Oklusi Arteri Perifer
Nama lain : Peripheral Artery
Occlusive Disease (PAOD),
Peripheral Artery Disease
(PAD), Peripheral Vascular
Disease (PVD)
Definisi : gangguan aliran
darah akibat penyempitan
atau kerusakan pembuluh
darah perifer (selain
pembuluh darah koroner dan
pembuluh darah otak)
Etiologi : aterosklerosis (>>>),
non-aterosklerosis
 Penyakit Oklusi Arteri Perifer
Penyebab Aterosklerosis
Faktor risiko yang tidak dapat dimodifikasi
Usia tua
Laki-laki
Faktor genetik
Faktor risiko yang dapat dimodifikasi
Mayor : merokok, hipertensi, diabetes mellitus,
dislipidemia
Minor : obesitas, hiperhomosisteinemia, hiperkoagulasi,
gaya hidup dan kepribadian, kurang olahraga
 Penyakit Oklusi Arteri Perifer
Penyebab Non-aterosklerosis
Raynauds syndrome
Buergers disease (Thromboangiitis Obliterans)
Vasculitis
Large-vessel vasculitis = Giant Cell Arteritis (Temporal
Arteritis), Takayasus Disease
Medium-vessel vasculitis = Polyarteritis Nodosa,
Kawasakis Disease, Behcets Disease, Cogans Syndrome,
Small-vessel vasculitis = Antineutrophil Cytoplasmic
Antibody-associated Vasculitidies, Vasculitis Associated
with Connective Tissue Diseases
 Penyakit Oklusi Arteri Perifer
Penyebab Non-aterosklerosis (cont)
Heritable arteriopathies
Cystic Medial Necrosis
Pseudoxanthoma Elasticum
Arteria Magna Syndrome
Congenital Conditions Affecting the Arteries
Persistent Sciatic Artery
Popliteal Entrapment Syndromes
Adventitial Cystic Disease
Peripheral Artery Aneurysms
Femoral Artery Aneurysms
Popliteal Artery Aneursyms
 Penyakit Oklusi Arteri Perifer

Claudicatio intermitten = pain in calf IIa claudicatio intermitten ketika

region during exercise (walking) cause berjalan >200 m
narrowing of vessel due to atherosclerotic Iib claudicatio intermitten ketika
plaque (e.c Peripheral Artery Disease) berjalan <200 m
 Penyakit Oklusi Arteri Perifer
Ankle Brachial Index (ABI)
Membandingkan tekanan sistolik arteri dorsalis
pedis dan arteri tibialis posterior (dipilih nilai yang
tertinggi) dengan tekanan sistolik arteri brachialis
Nilai normai ABI = 0,9 - 1,3
Nilai ABI < 0,9 gangguan aliran darah
ABI < 0,9 risiko mortalitas cardiovascular meningkat
3-6 kali
Nilai ABI > 1,3 pengerasan (kalsifikasi)
pembuluh darah
 Penyakit Oklusi Arteri Perifer
Sumbatan arteri pada ekstremitas bawah apabila
terus dan progresif critical limb ischemia (CLI)
Tanda dan gejala CLI =
Nyeri hebat dan menetap saat istirahat (rest pain)
Pucat saat ekstremitas bawah dielevasikan
Gangguan trofik dingin, kulit kering dan mudah
lepas, hiperkeratosis plantar, atrofi ujung jari, kuku
menebal
Ulkus
Iskemia yang meluas hingga ke seluruh ekstremitas
bawah
Critical Limb Ischemia
Acute Limb Ischemia
5 P Pain, Pallor, Pulseless,
Paresthesia, Paralysis
Chronic Limb ischemia ada
kolateralisasi, Acute Limb
ischemia tidak ada / sedikit
kolateralisasi, kurang bisa
menolerir iskemia
Etiologi tromboembolism
(atrial fibrilasi, valvular
leaflets, riwayat bypass atau
stent placement)
Acute Limb Ischemia
 Thromboangitis Obliterans
Also called as Buerger Disease
Male, 20-40 y.o
An acute inflammation and trombosis of
vessel on peripeheral region (foot and hand)
that associate with smoking.
Symptom : claudicatio intermitten
 Raynaud Phenomenon
May appear as a component of other
conditions.
Causes:
connective tissue diseases (scleroderma & SLE)
arterial occlusive disorders.
carpal tunnel syndrome,
thermal or vibration injury.
Pale > Cyanosis > Redness
Aggrevated with cold
 Raynauds
Phenomenon vs
Syndrome
Vasospastic disorder causing
discoloration of the fingers, toes,
and occasionally other areas.
Raynaud's disease ("Primary
Raynaud's phenomenon")
idiopathic
Raynaud's syndrome
(secondary Raynaud's),
commonly connective tissue
disorders such as Systemic
lupus erythematosus
Takayashu Arteritis
Arteriosclerosis Obliterans
The most common peripheral arterial
disease (PAD)
Distal ischemia, skin pallor, pain and
ulceration occur. The patients often
have diabetes and high blood
pressure as primary diseases.
Diagnosis of ASO was based on :
Clinical presentations,
Images of segmental irregular
narrowing of atheromatous plaque by
angiography,
The evidence of atheromatous plaque
at the arterial wall during the operation
Histopathology of atherosclerosis in
the arterial wall from amputated
specimens.
Gastroschisis
Definition : defect
in development of
abdominal wall
results in
protrusion of
abdominal viscera
without a visceral
sac
Omphalocele
Definition : defect
in development of
abdominal wall
results in
protrusion of
abdominal viscera
in a visceral sac
 Spinal Shock vs Neurogenic Shock

Spinal Shock Neurogenic Shock*

*Due to acute spinal cord *Hemodynamic phenomenon-
* Loss of vasomotor tone & Loss of sympathetic
injury nervous system tone > inpaired cellular
*Absence all voluntary metabolism

and reflex neurologic *Critical features-

Hypotension (due to massive vasodilation
activity below level of Bradycardia- due to unopposed paraynmpathetic
injury stimulation

Decreased reflexes Poikilothermia; *Unable to regulate temperature-

Loss of sensation Occurs

Within 30 min cord injury level T 5 or above; last up to 6
Flaccid paralysis below weeks; also due to effect some drugs that effect vasomotor
injury center of medulla as opioids, benzodiazedines

Lasts days to months Management (*Determine underlying cause)

Airway support
(Transient) Fluids as needed- Typically 0.9 NS , rate depends upon
*Spinal shock & need
Atropine for bradycardia
neurogenic shock can in Vasopressors as phenylelphrine (Neo-synephrine) for
same patient-BUT not BP support

same disorder (some sources

may group both together)