Widjoseno Gardjito

Department of Urology
Medical School Airlangga University - Dr. Soetomo Hospital
Surabaya
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 PATOFISIOLOGI TRAUMA
Definisi :

TRAUMA adalah semua jenis kekerasan yang menimpa

tubuh sehingga terjadi kerusakan/gangguan pada struktur
dan fungsi jaringan/organ tubuh yang terkena, bahkan
secara sistemik dapat berdampak pada aspek fisiologis,
kejiwaan dan kondisi sosial insan yang bersangkutan.

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TRAUMA pada JARINGAN/ORGAN

 KERUSAKAN
 PERDARAHAN
 NYERI
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JENIS TRAUMA
• Ledakan benda berkecepatan tinggi, benda
tajam (tusukan, irisan, sabetan), benda tumpul
• Suhu tinggi/rendah
 uap panas
 luka bakar
 frostbite (suhu dingin)
• Arus listrik tegangan tinggi
• Bahan kimia
• Radiasi, ionisasi
• Gigitan, sengatan
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KERUSAKAN AKIBAT TRAUMA
Bentuk :
Diastase (kerobekan), memar, erosi, lecet, hancur
(crush injury), jaringan hilang

Lokalisasi :
• Jaringan lunak + kulit : - luka terbuka
- luka tertutup

• Tulang / sendi : fraktura / dislokasi

• Organ berongga (lambung, usus) : perforasi
• Organ Padat (hati, limpaa,
ginjal, otak : ruptur, memar
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AKIBAT TRAUMA
 SEMBUH
 CACAT
(anatomis + fisiologis + psikologis)
 MENINGGAL

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 HEBAT TUNGGAL
TRAUMA
RINGAN GANDA

LOKAL
TANDA + GEJALA
REAKSI TUBUH
(Bagian dari proses SISTEMIK
Penyembuhan secara alami)

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INSULT HEBAT / BERAT

4 I-s

Injury – Infection – Inflammation – Ischemia


SIRS
(Systemic Inflammatory Response Syndrome)

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 Bacteremia

Other
Fungemia

INFECTION SEPSIS SIRS Trauma

Parasitemia

Viremia BURNS

Other

Pancreatitis

Beal et al, JAMA, 1994;271;226-233 13

SIRS can be identified by the presence of two or more of
the following manifestations :

1. A body temperature greater than 38C or less than 36C.

2. Heart rate greater than 90 beats per minute
3. Tachypnea (respiratory rate > 20 breaths per minute or
Pa CO2 < 32 mmHg
4. White blood cell count greater than 12.0 x 109/L or less than
4.0 x 109/L or the presence of more than 10% immature
neutrophils (bands).

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 SIRS and MODS

Inflammatory and organ dysfunction responses to injury. Normal response to an injury or insult may
decrease after 3 to 5 days or be reactivated by a complication. A continuous inflammatory response is
seen with systemic inflammatory response syndrome (SIRS) and can eventually progress to organ
dysfunction (reprinted from 4). 15
Beal et al, JAMA, 1994;271;226-233
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SEPSIS :

SIRS plus a documented infection

site (documented by positive culture
for organisms)

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Severe Sepsis :
Sepsis associated with organ dysfunction,
hypoperfusion abnormalities, or hypotension.
Hypoperfusion abnormalities include but are not
limited to :
1. lactic acidosis,
2. oliguria
3. or an acute alteration in mental status

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Septic Shock :
Sepsis-induced hypotension despite
fluid resuscitation PLUS hypoperfusion
abnormalities

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MODS
Organ Dysfunction associated with Severe Sepsis and
Septic Shock :

Lungs : early fall in arterial PaO2 , Acute Respiratory Distress

Syndrome (ARDS):

Capillary-leakage into alveoli; tachypnea, hyperpnea

Kidney : (acute renal failure): oliguria, anuria, azotemia,
proteinuria

Liver : elevated levels of serum bilirubin, alkaline

phosphatase, cholestatic jaundice

Digestive tract : nausea, vomiting, diarrhea and ileus

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MODS
Organ Dysfunction associated with Severe Sepsis and
Septic Shock :

Skin : ecthyma gangrenosum (think Pseudomonas

aeruginosa in neutropenic patients), Petechia or purpura
(think Neisseria meningitidis or Rickettsia rickettsia (if
evidence of tick bite)), Hemorrhage or bullous lesions in
patient who has eaten raw oysters (Vibrio vulnificus),
generalized erythroderma (Toxic Shock Syndrome=
Staphylococcus aureus or Streptococcus pyogenes)

Heart : cardiac output is initially normal or elevated,

Brain : confusion 22
OSLER’S DICTUM

Patients usually die of complications of

their disease, rather than from the
disease itself

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SIRS MODS MOF

BUKAN PENYAKIT
BUKAN SINDROMA

MERUPAKAN PERUBAHAN BERKELANJUTAN DARI FUNGSI

ORGAN YANG MENYANGKUT ASPEK FISIOLOGIS DAN METABOLIK
SEBAGAI RESPONS TERHADAP SUATU “INSULT” YANG SERIUS.
HUBUNGAN ANTARA RESPONS-RESPONS SERIAL DAN FUNGSI
ORGAN BERSIFAT DINAMIS DAN BERKELANJUTAN

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SIRS Systemic Inflammatory Response Syndrome

MODS Multiple Organ Dysfunction Syndrome

MOF Multiple Organ Failure

MSOF Multiple-Sytem Organ Failure

ARDS Acute Respiratory Distress Syndrome

DIC Disseminated Intravascular Coagulation

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DEAR SIRS
WE ARE SORRY TO SAY
THAT
WE DON’T LIKE YOU

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Sir Isaac Newton :
To every action is always an equal reaction
or
The mutual action of two bodies upon each other
are always equal, and directed to contrary parts

Philosophiae Naturalis principia Mathematica1687

Bone RC Crit. Cave Med, 1996;24:1125-1128

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BIOLOGICAL SYSTEMS, such as the
human body, are more complicated
than the simple physical systems Sir
Isaac was describing

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MACROPHAGE ( morfologi ) :
 Sel besar

 Inti bulat/indented

 Golgi apparatus developed

 Vakuol endositotik >

 Lisosom + fagolisosom

 Plasma membrane diselubungi mikrovili/ruffles

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MACROPHAGE ( fungsi ) :
• Nonspecific phagocytosis/pinocytosis
• Specific phagocytosis opsomized microorganisms
(Fc receptors + complement receptor)
• Killing ingested microorganims
• Digestion + presentation of antigens to T + B lymphocyte
• Secretion of :
 enzymes : lysozyme, collagenases, elastase, acid hydrogenases
 complements + coagulation factors
 some prostaglandins and leukotrienes
 several regulatory molecules (interferon, Interleukin-1)
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MACROPHAGE ( jenis ) :
 Histiosit
 Sel Kupffer
 Osteoclasts
 Microglial cells
 Synovial type A cells
 Interdigititating cells
 Langerhans cell
 Langerhans, epitheloid cells
Inflamed tissues
 Multinucleated giant cells

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MACROPHAGE

Mononuclear phagocytes di dalam jaringan :

Bone marrow : STEM CELL

monoblast

promocyte

Blood (40 hours): MONOCYT

Tissue : MACOPHAGES : - size

- phagocytic activity
- lysosomal enzym content
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MEDIATOR

Bahan yang dilepaskan oleh sel sebagai

hasil interaksi antigen-antibodi atau antigen
dengan sel limfosit yang sudah mengalami
sensitisasi

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CYTOKINE (SITOKIN) : (cyto + kinesis)
movement

Nonantibody protein released by one cell population

(eg. Primed T-lymphocytes) on contact with specific
antigen, which act as intercellular mediators, as in the
generations of immune response.
Examples include : Lymphokines, monokines

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SITOKIN

Anggapan : sitokin ~ patologi

Sitokin : Melindungi tubuh

tapi juga bisa SIRS

Mulai ditemukan antogonis sitokin

Mencegah SIRS ?
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Proses dilepasnya

Pro inflamatori sitokin + mediator-mediator

merupakan
Mekanisme pertahanan tubuh

 melokalisir + menetralisir kuman yang menyerang

 membersihkan sel yang mati / rusak
 memulihkan jaringan

NAMUN
Aktivasi yang berkelanjutan / berlebihan justru
MERUGIKAN
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NORMAL STRESS RESPONSE

• PERUBAHAN KARDIOVASKULER
takikardi, kontraktilitas, curah jantung (CO), konsumsi oksigen

• RESPONSE SISTEM NEUROENDOKRIN

Dilepasnya katekolamin, kortisol, ADH, Growth Hormone,
glukagon, insulin.

• “CASCADE” : - koagulasi
- komplemen
- sistem fibrinolitik

Puncak reaksi : 3 – 5 hari

reda 7 – 10 hari
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PATOGENESIS SIRS

4 - I (Injury – Infection – Ischemia – Inflammation)

Stage I
Lokal : Sitokin 

(penyembuhan luka – merangsang sel –

mematikan organisme patogen)

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SITOKIN

• Circulating form (misal : IL-1 beta)

(sistemik)
• Cell associated form (misal : IL-1 alpha)
(lokal)

• Asumsi : lokal prekursor sistemik

Bila produksi sitokin lokal melampui batas
ambang tumpah sistemik

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Stage II
- Sejumlah kecil sitokin masuk sirkulasi

merekrut : makrofag, trombosit

growth factor

Terjadi reaksi akut :

terkendali tidak terkendali

- pro inflamm, mediator 
- endogenous antogonist 
(misal : IL-1 receptor antagonist) Stage III
- antibodi 

Luka sembuh
Infeksi teratasi
Homeostasis pulih 41
Stage III

Homeostasis tak berhasil dipulihkan

Sitokin Destruktif
( semula protektif )

Sirkulasi penuh dengan mediator inflamasi

Intergritas dinding kapiler rusak

Sitokin masuk organ / jaringan

MOD
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Figure 1. First hit, second hit, and sustained hit that can occur with systemic
inflammatory response syndrome (SIRS). ARDS, adult respiratory distress
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syndrome; MODS, multiple organ dysfunction syndrome.
Figure 2. Three stages of the systemic inflammatory
response syndrome reaction 44
Crit Care Med 1996 Vol. 24,
TRAUMA

may be considered to be an inflammatory disease

KADAR : - berbagai mediator

- indikator respons inflamasi
pada trauma berat.

“MARKERS” inflamasi dapat digunakan :

- menilai beratnya trauma
- meramalkan prognosis (“outcome”)

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TRAUMA BERAT dan KEMATIAN
POLA DISTRIBUSI “TRI MODAL”

• Kematian Sesaat (Immediate Deaths)

Segera setelah trauma

• Kematian Dini (Early Deaths)

Beberapa jam setelah trauma

• Kematian Lambat (Late Deaths)

Berhari-hari hingga berminggu-minggu
setelah trauma
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 TRAUMA BERAT dan KEMATIAN
POLA SITRIBUSI “TRI MODAL”

1 2 3

Immediate Early Late

TRAUMA BERAT 47
JALAN TOL menuju kematian

 Trauma multipel
 Sumber infeksi
 Immunocompromised

Sistem
Penunjang berbagai organ
(ICU)

SIRS

MODS
ARDS, DIC, ARF, KARDIOMIOPATI

Meninggal
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Cerra
JAMA Vol. 271, 1994 49
1991 Concensus Conference

 Dirintis konsistensi
 Memperhatikan aspek-aspek :
 Klinik (bedside)
 Laboratorium
 Literatur terkait

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SIRS MODS/MOF
MORTALITAS TINGGI

KEGAGALAN 1 ORGAN : 30% - 40%

2 ORGAN : 60%
3 ORGAN : > 90%

USIA > 65 TAHUN : RISIKO 20%

Beal & Cerra

PREVENTION IS THE BEST TREATMENT

(prevention is the only good answer)
Baue
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 Prognostic test

yang meramalkan terjadinya “organ failure” (OF)

tidak bermanfaat

bila gambaran klinik OF sudah manifes

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