EMERGENCY

A. PHLEGMON

Cellulitis  Acute inflammation of epidermis yang meluas ke dermis dan subkutan. Disebabkan oleh
bacteria.

 Facial Cellulitis
o Selulitis Sirkumskripta Serous Akut
o Selulitis Sirkumskripta Supuratif Akut
 Selulitis Difus Akut
 Ludwig’s Angina / Phlegmon / Ludovici’s Angina : Mengenai 3 space
(submandibular, submental, dan sublingual) bilaterally.
 Selulitis Kronis

Predispose :

- Bad oral hygiene

Etiology :

- Odontogenic infection :
Periapical
Impaksi M3
Kista odontogenic
Fraktur akar gigi (biasanya karena gigitan)
Jaringan periodontal (held teeth pada tempatnya di dalam socket)
- Non odontogenic infection :
Submandibular gland infection
Tonsillar infection
Mandibular osteomyelitis

Pathogenesis : Infeksi peripaikal rahang bawah. Infeksi odontogenic terjadi pada M1, M2, dana tau M3
(akar terletak di bawah mylohyoid sehingga infeksi di bawah mylohyoid menyebabkan penyebaran ke
space2 lainnya)
 Sm : Sub mandibula space | Ms : Maxillary sinus | Bm : Buccinator muscle |
Mh : Mylohyoid muscle | PI : Platysma muscle | V : Vestibule | Bs : Buccal space |
P : Palate | SI : Sublingual space | 1 : Lateral | 2 : Submasseteric space |
3 : Buccal spac | P : parotid gland | M : Masseter muscle | Mp : Medial pterygoid

Clinical manifestation :

- Tanda-tanda inflamasi akut : ↑RR, ↑HR, ↑Temperature, ↑TD, menggigil

- Respiratory distress
- Inflamasi kelenjar limfe
- Inflamasi leher depan dan jaringannya
- Extra oral syms : Pembengkakan yg kaku dan keras seperti papan, intense pain
- Intraoral syms : Lidah terangkat dan terdorong ke belakang, hipersalivasi, drooling, susah
menelan, susah menutup mulut/mulut tampak penuh, trismus (lockjaw), leukocytosis

!Tidak fluktuatif

Differential diagnosis :

1. Abses bilateral submandibular  Pembengkakan pada angle of mandible hingga leher.

Fluktuatif. Sublingual space not affected. Pernapasan normal. Bisa disebabkan baik oleh molar
ataupun premolar infection
2. Kista odontoma pada mandibular  Sublingual space not affected. Pada rontgen ditemukan
radiolucent mass yang berbatas jelas pada ramus mandibular

3. Pseudophlegmon  Unilateral. Baru mengenai < 3 space (yang paling awal submandibula).
Tidak fluktuatif. Lidah tidak terangkat / terangkat sebagian

Complication :

- Glossitis
- Mediastinisis
- Thrombophlebitis of jugularis vein
- Thrombophlebitis of cavernous sinus
- Meningitis
-
Management :

- Perbaikan kondisi umum : Kontrol jalan napas dan cairan

- Kultur bakteri + Antibiotik broad spectrum dosis tinggi 
Penicillin G 2000.000 unit/8 jam atau Clindamycin 300mg / 8 jam
Metronidazole IV lewat infus
- Antiinflamasi, antipiretik, analgesic 
Steroid : Dexamethasone inj 1amp/12 hr
Nonsteroid : Ketoprofen inj 1amp/12 hr
- Insisi dan drainage (setelah pasien stabil) + pencabutan gigi penyebab (semua fokal infeksi
dibersihkan)
- Kontrol nutrisi, cairan, vitamin  Kontrol pernapasan dengan tracheostomy jika diperlukan;
Karbohidrat dan protein ↑

RAWAT INAP (wajib pada phlegmon dan pseudophlegmon)

- Progressive cellulitis
- Dyspnea
- Dysphagia
- Dehidrasi
- Trismus moderat – berat (<20mm interinsisal)
- Demam >38oC
- Meluas sampai facial space yang dalam
- Malaise berat dan “toxic appearance”
- Butuh general anesthesia dalam pearawatannya
B. ANTEPARTUM BLEEDING

Menentukan usia kehamilan

- HPHT  Tahun +1, bulan -3, hari +7 [KALO MENSTRUASI TERATUR]
- USG  Akurat pada umur kehamilan <12 minggu. >12 minggu false 1-3 weeks

Antepartum hemorrhage = Perdarahan pervaginam pada usia kehamilan ≥20 minggu

Kalo <20 minggu  Abortus

 Obstetric
- Solusio placenta : Separation of placenta from uterine lining before second stage of labor
causing blood to accumulate, pushing placenta and uterine wall apart. Bisa mengakibatkan
external bleeding ataupun concealed hemorrhage (darah gak merembes). Terjadi pada usia
kehamilan ≥20 minggu atau berat janin ≥1000 gram.
Risk factors :
a. Peningkatan umur dan paritas
b. Hipertensi kronis dana tau pre-eklampsia
c. Ketuban pecah premature  Sudden decompression of uterus atau inflammation
d. Smoking  Berkaitan dengan decidual necrosis, chorionic villous hemorrhage,
intervillous thrombosis
e. Pemakaian cocaine dan vasoconstrictive drugs  mempengaruhi uteroplacental
blood flow dan decidual integrity
f. Trauma atau uterine manipulation kayak external cephalic version
g. Riwayat solusio placenta
h. Thrombophlebitis
i. Myoma uteri
Grading :
a. GRADE 0 : Asymptomatic. Ada small blood clots pada maternal side of placenta
(retroplacental) after placental delivery. Diagnosis dibuat retrospectively
b. GRADE 1 (MILD) : No sign – small amount of vaginal bleeding. Maternal BP and HR
normal. Slight uterine tenderness. No sign of fetal distress

GRADE 0 – 1 BIASANYA MARGINAL ATAU PARTIAL SEPARATION

c. GRADE 2 (MODERATE) : No sign – moderate vaginal bleeding. Significant uterine

tenderness with uterine contaction. Change in vital sign (maternal tachycardia,
orthostatic changes in BP). Evidence of fetal distress. Hypofibrinogenemia (karena
fibrinogen and other clotting factors dipake di site of separation, sehingga darah yg
masuk ke systemic circulation melalui uterine venous system mengandung serum
dengan reduced coagulation factors, no fibrinogen, and red cells)
d. GRADE 3 (SEVERE) : No sign – heavy vaginal bleeding. Tetanic-uterus (board-like
consistency pada palpation). Maternal shock. Clotting profile alteration
(hypofibrinogenemia and coagulopathy). Fetal death

GRADE 2 – 3 BIASANYA COMPLETE ATAU CENTRAL SEPARATION

 Umumnya uterine contraction >>>frequency, <<<amplitude (>5x/10 minutes, saw-
tooth pattern). Elevated baseline tone may occur.

!Perilisan prostaglandin (inflammatory mediator) lead to uterine

contraction/spasm  penurunan placental perfusion. Gangguan perfusi juga
terjadi akibat clot forming a barrier between placental bed & villi. Nyeri timbul
akibat perilisan prostaglandin, extravasation of blood into myometrium,
overdistensi uterus akibat retroplacental bleeding.

Activation of clotting cascade  Rapid consumption of coagulation factors &

platelets, fibrin deposition di microcirculation, juga thrombus formation pada
maternal surface of placenta leading to defibrination, thrombocytopaenia,
hemostatic failure  Consumption coagulopathy  DIC stimulates fibrinolysis 
Fibrin degradation products (FDP) interfere with fibrin clot formation 
Exacerbating hemorrhage  Negative effect on cardiac and myometrial function

Histopathological finding : Presence of a retroplacental clot after placenta delivery.

Blood extravasation into the myometrium, resulting in purple discoloration of the serosa
of the uterus.
Evaluation :
DIAGNOSIS CLINICALLY MADE
Cervix ditigal examination baru boleh dilakukan kalau letak plasenta sudah diketahui
dan placenta previa sudah dirule out dengan sonogram (ultrasound).
a. PE  Takikardi dan hipotensi merupakan indicator concealed haemmorhage.
Evaluasi uterine tenderness (kaku seperti papan), consistency, and frequency +
duration of uterine contractions pada palpasi. Vaginal area is inspected for the
presence of bleeding. Keluhan nyeri yang tajam dan mendadak
b. Ultrasound  To eliminate Placenta Previa. Susah dipakai untuk mengamati
placenta abruption karena pada acute phase hemmorhagenya isoechoic dengan
surrounding placental tissue. Sulit memvisualisasi dan membedakan concealed
hemorrhage dari tissue sekitar.
c. Cek darah  CBC, clotting (fibrin dan PT/PTT), BUN to evaluate beratnya
perdarahan
d. Evaluasi fetus  Denyut jantung janin, penurunan pergerakan, apa ada recent
changes in activity pattern?
e. Kleihauer-Betke test  To determine the amount of FMH (Fetomaternal
Hemmorhage) sehingga dosis RhIg untuk isoimmunization pada ibu dengan Rh- dan
fetus Rh+ bisa diperkirakan
Management :
Depends on gestational age, serta kondisi maternal & fetus
a. Stabilisasi kondisi umum Ibu dan Janin
b. Mild Solutio Placenta with no signs of maternal or fetal distress dan usia gestasi <37
weeks  Treratment konservatif. Close monitoring of maternal and fetal status
sampai ada change in condition atau fetal maturity is reached
c. Moderate and Severe abruptio dan fetusnya viable and alive  Delivery
 Kematian janin dalam rahim  Amniotomi, drip oxytocin, persalinan
harus terjadi dalam 6 jam

Komplikasi :
a. Maternal : Hemmorhagic shock, DIC, rupture uteri, gagal ginjal
 b. Fetal : Hypoxia, Anemia, Intra Uterine Growth Restriction, Kehamilan Janin Dalam
Kehamilan

- Placenta previa : Partial or complete covering of cervical internal os by placenta

 Total
 Partial
 Marginal
 Letak rendah ≤2cm from margin of internal os (>2 cm = normal)

Risk factors :
a. Advanced maternal age (>35 tahun), relating to altered hormonal and implantation
environment
b. Multiparitas
c. Smoking (nikotin dan karbonomonoksida act as potent vasoconstrictors of placental
vessels  compromises the placental blood flow  leading to abnormal placentation)
d. Cocaine use
e. Prior suction
f. Curettage
g. Assisted reproductive technology
h. History of cesarian section (common source of scarring in myometrium and
endometrium)
i. Prior placenta previa

! Zygote implantation requires environment rich in oxygen and collagen. Prior uterine scars
provide environment rich in oxygen and collagen. Thropoblast (yg form placenta dan fetal
membrane) can adhere to uterine scar, leading to placenta covering the cervical os atau
placenta invading dinding myometrium.
Evaluation :
a. Routine sonography pada first and second trimester (transabdominal dan transvaginal
sonogram before digital examination. Digital examination performed AFTER placenta
previa ruled out)
!Transvaginal ultrasound superior to transabdominal (lebih akurat dan safe)

Clinical findings :
a. Painless bleeding  Placenta can easily detached from decidua basalis with slight
uterine contraction and cervical effacement (thinning)
 b. Soft and non-tender uterus
c. Maternal hypotension
d. Maternal tachycardia
e. DJJ umumnya normal
f. Bagian terendah janin masih tinggi (belum masuk Pintu Atas Pangul)
Management :

- Vasa previa
- Rupture sinus
 Non obstetric
- Malignancy
- Robekan

C. POSTPARTUM BLEEDING

Blood loss ≥500 cc pada persalinan pervaginam atau blood loss ≥1000 cc pada persalinan SC

 Primary (Early) : Excessive bleeding pada third stage of labour, atau within 24 hours of
delivery
 Secondary (Late) : Excessive bleeding pada 24 hours after delivery – 6 weeks postpartum

Klasifikasi lainnya : Third stage PPH  Before placenta delivery; Fourth stage PPH  After
placenta delivery

Etiologi :

- Tone
Uterine Atony (most common)
 Perdarahan primer
 Uterus tidak berkontraksi dan lembek
- Tissue
Sisa plasenta / bekuan
 - Trauma
Laserasi
a. Perlukaan vulva
b. Perlukaan vagina
c. Robekan serviks
Rupture
a. Ruptur uteri spontan
b. Ruptur traumatic
c. Ruptur uteri pada parut uterus
Inversio
- Thrombin
Koagulopati

D. EMERGENCY TOXICOLOGY & POISONING

Toxicology  Ilmu mengenai adverse effect chemical, physical, and biological agent on living
organism dan ekosistemnya (termasuk pencegahan dan perbaikan adverse effect tersebut)
Poisoning  Condition / physical state akibat exposure terhadap deleterious agent

Prinsnip Toxicology :
 Toxicokinetics : Study of toxicant movement around the body (absorbsi, distribusi,
metabolism, eliminasi)
 Toxicodynamics : Proses dan perubahan yang terjadi pada toxicant at the target tissue
(termasuk metabolism and binding yang results in an adverse effect)

Exposure and response :

 Acute exposure or high dose  Clinically manifest
 Chronic exposure or low dose  Manifestasinya subtle or long term (cancer,
neurodegenerative disease, reproductive effects, immunologic susceptibility)

GENERAL MANAGEMENT for ANY EPISODE of poisoning

 What type of agent
 When (time of exposure)
 Who (children / adult / geriatric / pregnant ?)
 Why (reason of exposure: suicide attempt / occupational /
ANAMNESIS
accident ?)
 How much (mg or kg)
 What else
  Route of exposure (inhalation / ingestion / skin and mucous contact ?)
 Search environment for pill bottles, suicide note, chemical container

 Assess and manage ABCDE (Dekontaminasi dan Eliminasi)

 BP
PHYSICAL  HR
EXAM :  RR  Rate : Tachypnea (salicylates) / Bradypnea (opioids)
VITAL SIGN  Depth : Hyperpnea (salicylates) / Shallow respiration (opioids)
 Temperature
!DEFG  DON’T EVER FORGET THE GLUCOSE

 Size
- Large : Anticholinergic or sympathomimetic
- SmallPHYSICAL
: Cholinergic
- Pinpoint : Opioid
EXAM :
 PUPILS
Nystagmus
- Horizontal
- Vertical
- Rotary

 Look : Track marks, pupil size, oral cavity

 Feel PHYSICAL
: Temperature, sweating?
 Smell EXAM
: Alcohol,
: organophosphate
LOOK, FEEL,
SMELL

TREATMENT OF ACUTE POISONING

GOAL :
- Keep concentration as low as possible (prevent absorption/decontamination, ↑ elimination)
- Counteract toxicological effect at effector site (antidote)  Jika bahan racun sudah berikatan
dengan target organ

SPECIFIC MANAGEMENT
 Prevent absorption (decontamination) :
- Emesis
- Gastric lavage (kumbah lambung)
- Activated charcoal  Menyerap bahan yang sudah masuk usus
- Cathartic (agent yang ↑defekasi, mempercepat transit bahan di usus sehingga
penyerapan dan bahan yg didistribusikan minimal)
  Increase elimination
- pH alteration dan diuresis paksa
- Activated charcoal
- Haemodyalisis  Tanpa menunggu hasil AGD
- Peritoneal dialysis  Jarang. Hemodyalisis more common
- Haemoperfusion
- Plasmapharesis dan plasma exchange

 Counter effect (antidote)

SPECIFIC POISON
 Organophosphate
 Caustic agent
 Opioid
 Metanol

CARDIOVASCULAR

Cardiac muscle characteristics :

 Rythmicity
 Conductivity
 Contractility
 Excitability

Conduction system :

 SA Node  pacemaker. [80 beats/min]

 AV Node  [60 beats/min]
 Bundle of His [40 beats/min]
 Cardiac muscle [20 beats/min]