K15-Tetanus Dan Malaria (Anestesi)
K15-Tetanus Dan Malaria (Anestesi)
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Indikasi Umum Pasien dirawat di ICU
Berdasarkan Prioritas
Berdasarkan Diagnosis
Berdasarkan Nilai-nilai Parameter
Hasil Laboratorium
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Penyakit Tropik Berat (yang sering
di ICU :
Tetanus Berat (Severe Tetanus)
Malaria Berat (Severe Malaria)
DHF Grade III-IV (DSS)
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TETANUS BERAT
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TETANUS adalah
Gangguan neurologis yang ditandai dengan
meningkatnya tonus otot dan spasme yang
disebabkan oleh tetano spasmin, suatu
toksin B yang kuat, yang dihasilkan oleh
Clostridium Tetani
CLOSTRIDIUM TETANI
Bakteri gram (+)
Anaerob
Bentuk Batang
Bergerak dan menghasilkan spora
berbentuk oval menyerupai raket
tenis
Tahan bertahun-tahun pada
lingkungan tertentu dan tahan
terhadap sinar matahari
Mechanism of Action of
Tetanus Toxin
TETANUS GENERALISATA
Opistotonus
Trismus & Risus Sardonicus
The back muscles are more
powerful, thus creating the arc
backward
“Oposthotonus” by Sir
Charles Bell, 1809.
Derajat Keparahan
(Severity Grading)
Philip
Dakar
Udwadia Gambaran Klinis
Ablett
Blect
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Philips Score
Waktu Masuk Skor Selama Perawatan Skor
Masa Inkubasi Spasme
> 14 hari 1 Hanya trismus 1
> 10 hari 2 Kaku seluruh badan 2
5 – 10 hari 3 Kejang terbatas 3
2 – 5 hari 4 Kejang seluruh badan 4
< 48 jam 5 Optistotonus 5
Komplikasi Pernafasan
Tidak ada 1 Sedikit berubah 0
Ringan 2 Apnea saat kejang 2
Tidak membahayakan 4 Kadang apnea setelah kejang 4
Mengancam Nyawa (tidak langsung) 8 Selalu apnea setelah kejang 8
Mengancam nyawa 10 Perlu trakeostomi 10
Grade I (mild)
Mild trismus, general spasticity, no respiratory compromise, no
spasms, no dysphagia
Grade 2 (moderate)
Moderate trismus, rigidity, short spasms, mild dysphagia, moderate
respiratory involvement, ventilatory frequency > 30
Grade 3 (severe)
Severe trismus, generalized rigidity, prolonged spasms, severe
dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40
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Derajat Keparahan hendaknya tidak
dipakai sebagai pedoman “Kaku” untuk
indikasi rawat ICU
Secure Airway
Tracheostomy
Benzodiazepines2
Midazolam
Diazepam
Antitoxin2
HIG im/it
Equine antitoxin im
Antibiotics2
Metronidazole
Manage autonomic dysfunction
2 1
Magnesium Inotropes
2
Benzodiazepines Consider
2
Bupivacaine DVT Prophylaxis1
2 Control Muscle Spasms
Morphine
2
Clonidine Benzodiazepines2 Dantrolene1
NDNMBA’s1 Baclofen2
Magnesium2
Immunization
Wound debridement
Antibiotics
Control muscle spasm
Control Autonomic Disturbance
Other supportive therapy
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MANAGEMENT
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MANAGEMENT
2. Prevent further toxin release
- Early surgical debridement of
wounds
- Antibiotics : Metronidazole 500mg
8 hourly and Penicillin G 1 MU 6-8
hourly.
Heavily contaminated wound may
need additional antibiotics.
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MANAGEMENT
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Drug used to control spasm and
autonomic disturbance
Benzodiazepine
Morphine
Muscle relaxant: vecuronium, rocuronium,
pancuronium
Magnesium sulfate
Dantrolen
Baclofen
Bupivacain, atropine,
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Benzodiazepine
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SEVERE MALARIA
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Adult Anopheles
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Plasmodium falciparum
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What is severe malaria?
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Different clinical manifestation between adults and
children with severe malaria
Management
· Parenteral antimalarials.
· IV fluid administration.
· Vital signs monitoring every 4 hours.
· Blood check up for malaria parasite every
day until disappearance of parasitemia.
· Monitoring clinical signs and symptoms of
severe malaria that may occur later.
· Record conscious level every 4 hours and
urine output every 8 hours.
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Poor prognostic features in
severe malaria
Clinical findings
Deep Coma
Repeated convulsions
Respiratory distress (rapid, deep, laboured, stertorous,
breathing often with intercostals recession)
Significant bleeding
Laboratory findings
Biochemistry
Hypoglycemia < 2.2 mmol/l
Hyperlactatemia > 5 mmol/l
Acidosis arterial pH<7.3 venous plasma HCO3 < 15 mmol/l
Serum creatitine >265 µmol/l
Total bilirubin > 50 µmol/l
Liver enzymes SGOT (AST) x 3 upper limit of normal
SGPT (ALT) x 3 upper limit of normal
5 – Nucleotidase
Muscle enzymes CPK
Myoglobin
Urate > 600 µmol/l
Hematology
Leucocytosis >12.999/µl
Severe anemia PCV < 15 %
Coagulopathy Platelet < 50.000/µl
PT prolonged > 3 s
Prolonged PPT
Fibrinogen <200 mg/dl
Parasitology
Hyperparasitemia > 100.000/µl - increased mortality
> 500.00/µl - high mortality
>20% of parasites are pigment – containing trophozoites and schizonts
>5% of neutrophils contain visible malaria pigment