NIGHT SHIFT DUTY

SPV ADVISOR :
dr. Liana Karliasari, Sp. Rad (K)

SPV INCHARGE :
dr. Agung Setyawan, Sp.Rad (K)

RESIDENT INCHARGE :
FAD AMA IKE
 VISI DAN MISI PS PDS RADIOLOGI FK UB/ RSSA

• VISI :
“MENJADI INSTITUSI PENDIDIKAN DOKTER SPESIALIS RADIOLOGI, PELOPOR, DAN PEMBAHARU, DENGAN REPUTASI
INTERNASIONAL UNTUK MENGHASILKAN LULUSAN UNGGUL DI BIDANG DETEKSI DINI PENYAKIT DAN KOMPLIKASINYA”

•
MISI:
1. MENYELENGGARAKAN PENDIDIKAN, PENELITIAN, PENGABDIAN KEPADA MASYARAKAT DI BIDANG RADIOLOGI TERGINTEGRASI
BERSTANDAR INTERNASIONAL YANG MENGHASILKAN LULUSAN YANG BERIMAN DAN BERTAKWA KEPADA TUHAN YANG MAHA
ESA, SERTA MEMILIKI MORAL DAN BUDI PEKERTI YANG LUHUR, MANDIRI, PROFESIONAL, DAN INOVATIF.
2. MENYELENGGARAKAN PROGRAM STUDI SEBAGAI AGEN PENGEMBANG DAN PENYEBAR ILMU RADIOLOGI DENGAN BERDASAR
NILAI KEARIFAN LOKAL YANG LUHUR UNTUK PERBAIKAN KUALITAS HIDUP
3. MENYELENGGARAKAN TATA KELOLA PROGRAM STUDI DI PERGURUAN TINGGI YANG UNGGUL, BERKEADILAN, DAN
BERKELANJUTAN.
4. MERINTIS DAN MENJADI PIONER PENDIDIKAN, PENELITIAN, DAN PENGABDIAN MASYARAKAT DI BIDANG RADIOLOGI TERKINI
DAN BERMUTU DENGAN KEUNGGULAN BIDANG DETEKSI DINI PENYAKIT DAN KOMPLIKASINYA
 RESUME

FNK : 59 USG: 1

CT Scan: 9 Uretrografi: 0
 IDENTITAS PASIEN

CKR, Blunt chest

Tn.C/ 23 Th/ trauma, emfisema CT Cervico
11587848 subkutis regio thoracal + K
Cervical
 ANAMNESA
• Pasien datang dibawa keluhan dengan keluhan sesak dan nyeri pada leher serta lengan kanan setelah mengalami
kecelakaan tunggal menabrak pohonTidak ada yang tau mekanisme kejadian berlangsungRiwayat penurunan
kesadaran (-)Pasien tidak ingat kejadian
• KU TAMPAK SAKIT SEDANG

• TD : 106/61MM, NADI :120X/MENIT, RR : 26X/M, SPO2 98%

• PEMERIKSAAN FISIK :

KEPALA LEHER : BLOODY RINORRHEA (-/-)BLOODY OTORRHEA (-/-)HEMATOMA PERIORBITA (-/-)DENTAL AVULSI
INCISIVUS I S

JEJAS PADA LEHER (+)E MFISEMA SUBCUTIS REGIO COLLI (+)

THORAX :JEJAS (+) COR: S1-S2 NORMAL PARU: VESIKULER (+/+), RHONKI (-/-), WHEEZING (-/-) EMFISEMA SUBCUTIS
HEMITHORAX D(+)
● Kesan tampak deformitas tracheal ring disertai defek pada trachea sisi kanan setinggi level T1-T2 selebar ±4 mm, kesan berhubungan
dengan lesi densitas udara pada paratrachea kanan
● Tampak lesi densitas udara luas pada paratrachea kanan kiri, retrotrachea, paracardia kanan kiri dan sisi anterior, paraesofagus,
● meluas ke visceral space cervical kanan kiri, carotid space kanan kiri, perivertebral kanan kiri, posterior cervical space kanan kiri, submandibular space kanan kiri, masticator
space kanan kiri, hingga subcutis regio hemithorax kanan kiri, colli kanan kiri, submandibula kanan kiri, supra-infraclavicula kanan kiri, dan facialis kanan kiri
● Tampak penebalan soft tissue regio laring melibatkan supraglottis- glottis- infraglottis (true
dan false vocal cord) dengan terpasang ETT dengan ujung distal ±4,7 cm di atas carina
(setinggi T2) dengan panjang cuff 3,7 cm dan lebar 2,1 cm.
● Tampak defek soft tissue multiple pada regio hemithorax kanan kiri
● Cavum hemithorax D/S: Simetris.
● Tampak lesi densitas cairan (±25 HU) pada cavum hemithorax kanan kiri
● Aorta: Kaliber normal, tidak tampak kalsifikasi.
● Jantung: Ukuran, bentuk dan posisi normal.
● Paru Dextra: Corakan vascular normal, tidak tampak ground glass opacity/cavitas/nodul. Main bronchus kanan terbuka. Tampak atelektasis kompresif pada segmen 6, 7, 10 paru
kanan
● Paru Sinistra: Corakan vascular normal, tidak tampak ground glass opacity/cavitas/nodul. Main bronchus kiri terbuka. Tampak atelektasis kompresif pada segmen 1/2, 6, 8, 9, 10
paru kiri
● Thyroid D/S: Ukuran normal, permukaan reguler, densitas normal, tidak tampak
lesi patologis.
● Hepar yang tervisualisasi: Ukuran normal, permukaan reguler, tidak tampak nodul
maupun kista.
● Gall bladder: Ukuran normal, tidak tampak batu/sludge.
● Lien: Ukuran normal, sudut lancip, permukaan rata, densitas parenkim homogen,
vena lienalis tidak melebar, tidak tampak nodul/massa.
● Pankreas: Ukuran normal, tidak tampak lesi patologis.
● Ren D/S yang tervisualisasi: Ukuran normal, tidak tampak lesi patologis.
● Tulang-tulang yang tervisualisasi: Tidak tampak lesi osteolisis maupun
osteoblastik.
KESIMPULAN
● DEFORMITAS TRACHEAL RING DISERTAI DEFEK PADA TRACHEA SISI KANAN SETINGGI T1-T2
SELEBAR ±4 MM, KESAN BERHUBUNGAN DENGAN LESI DENSITAS UDARA PADA PARATRACHEA
KANAN MENGESANKAN GAMBARAN TRACHEAL INJURY, YANG MENYEBABKAN :
○ PNEUMOMEDIASTINUM
○ EMFISEMA SUBCUTIS REGIO HEMITHORAX BILATERAL, COLLI BILATERAL,
SUBMANDIBULA BILATERAL, SUPRA-INFRACLAVICULAR BILATERAL DAN FACIALIS
BILATERAL
● EDEMA SOFT TISSUE REGIO LARING MELIBATKAN SUPRAGLOTTIS-GLOTTIS-INFRAGLOTTIS
● DEFEK SOFT TISSUE MULTIPLE PADA REGIO HEMITHORAX BILATERAL
● EFUSI PLEURA BILATERAL DENGAN ATELEKTASIS KOMPRESIF
 FOLLOW UP

• STATUS GENERAL :
• GCS : ON SEDASI TD : 110/78 MMHG N : 88 X/MNT R : 24 X/MNT TAX : 36,6 SPO2: 99 %
ON VENTILATOR

• RENCANA TINDAKAN :- MELANJUTKAN PERAWATAN ICU- CXR DAN BGA

EVALUASI BERKALA
TEORI
NORMAL TRACHEA ANATOMY
 TRACHEOBRONCHIAL INJURY

• TRACHEOBRONCHIAL INJURY IS A SERIOUS BUT UNCOMMON MANIFESTATION OF

CHEST TRAUMA. IT IS USUALLY A FATAL INJURY WITH ONLY A SMALL PERCENTAGE
OF PATIENTS MAKING IT TO HOSPITAL. GIVEN THE MAGNITUDE OF FORCE
REQUIRED TO INJURE THE MAJOR AIRWAYS, THERE ARE OFTEN MULTIPLE CHEST
INJURIES AND OTHER BODY REGIONS AFFECTED.
• PLAIN RADIOGRAPH

• SUBCUTANEOUS EMPHYSEMA IN THE CHEST AND/OR NECK

• PNEUMOTHORAX

• PNEUMOMEDIASTINUM

• ENDOTRACHEAL TUBE BALLOON

• OVERINFLATION
• ABNORMAL SHAPE
• HERNIATION INTO THE AIRWAY DEFECT

• CT
• FEATURES INCLUDE 6:
• DISRUPTION OF THE TRACHEAL OR BRONCHIAL CARTILAGE RINGS
• IRREGULARITY OF THE AIRWAY WALL
• FOCAL THICKENING OF THE TRACHEAL OR BRONCHIAL WALL
• LARYNGEAL DISRUPTION
• MASSIVE PNEUMOMEDIASTINUM (SOMETIMES DESPITE APPROPRIATE PLEURAL SPACE DECOMPRESSION WITH INTERCOSTAL
CATHETERS)

• FALLEN LUNG SIGN (FIRST DESCRIBED IN 1970 1): RARE

 MECHANISM OF INJURY
A. PENETRATING INJURY
• PENETRATING TRACHEOBRONCHIAL INJURIES MOST COMMONLY RESULT FROM STABBING OR
GUNSHOT INJURIES. MANY PENETRATING INJURIES SEEN BY RADIOLOGISTS INVOLVE THE
ANTERIOR CERVICAL TRACHEA AND MOSTLY OCCUR IN INSTANCES OF STABBING
 MECHANISM OF INJURY
B. IATROGENIC INJURY
• MANY INVASIVE AIRWAY AND THORACIC PROCEDURES CAN BE COMPLICATED BY IATROGENIC
TRACHEOBRONCHIAL INJURIES, INCLUDING ENDOTRACHEAL INTUBATION, BRONCHOSCOPY,
STENT PLACEMENT, AND MEDIASTINOSCOPY.
• INTUBATION-RELATED TRACHEAL LACERATIONS CAN CAUSE SIGNIFICANT PNEUMOTHORAX OR
PNEUMOMEDIASTINUM. IF A PATIENT UNDERGOES IMAGING WHILE INTUBATED, EXTRALUMINAL
PLACEMENT OF THE TUBE IMPLICATING THE SITE OF INJURY MAY BE DEPICTED
 MECHANISM OF INJURY
C. BLUNT FORCE INJURY
• BLUNT FORCE TRACHEOBRONCHIAL INJURIES USUALLY RESULT FROM A HIGH-IMPACT MECHANISM,
MOST COMMONLY IN THE SETTING OF ROAD TRAFFIC ACCIDENTS. THEY RESULT FROM SHEARING
FORCE ALONE OR IN COMBINATION WITH INCREASED INTRATHORACIC PRESSURE. BLUNT FORCE
TRACHEOBRONCHIAL INJURIES OCCUR MOST FREQUENTLY IN THE DISTAL TRACHEA, CARINA, AND
PROXIMAL MAIN BRONCHI, MORE SO ON THE RIGHT COMPARED WITH THE LEFT
• THE LARYNGOTRACHEA IS A FURTHER SITE OF VULNERABILITY IN BLUNT FORCE TRAUMA, INCLUDING
SEAT BELT INJURIES AND HANGINGS, MAINLY BECAUSE OF THE WEAKNESS OF THE CRICOTRACHEAL
MEMBRANE. SEVERE INJURIES HERE CAN MANIFEST WITH LARYNGOTRACHEAL SEPARATION (FIG 11).
IMAGING FINDINGS INCLUDE DISCONTINUATION OF THE LARYNGOTRACHEA WITH DEEP CERVICAL
AND PREVERTEBRAL EMPHYSEMA, PNEUMOMEDIASTINUM, AND PNEUMOTHORAX
 GOLD STANDARD

• BRONCHOSCOPY REMAINS THE GOLD STANDARD FOR IMAGING TRACHEO-

BRONCHIAL INJURY. DIAGNOSTIC IMAGING IS USUALLY PERFORMED WITH CT
AT AN EARLIER STAGE IN THE ACUTE SETTING, AND IT IS OFTEN USED TO HELP
SELECT PATIENTS FOR BRONCHOSCOPIC EVALUATION.
• CT HAS THE ADVANTAGE OF BE-ING FAST AND NONINVASIVE, AND IT
DEMONSTRATES EXTRATRACHEAL INJURIES IN THE CONTEXT OF MAJOR
TRAUMA, INCLUDING MAJOR VESSELS AND PULMONARY AND
MUSCULOSKELETAL DAMAGE
 KEYPOINT

• THE PRECISE SITE OF INJURY IS FREQUENTLY SUBTLE OR OCCULT AT IMAGING, EVEN IN

THE PRESENCE OF OTHER SUGGESTIVE IMAGING FEATURES SUCH AS
PNEUMOMEDIASTINUM, PNEUMOTHORAX, OR DEEP CERVICAL SUBCUTANEOUS
EMPHYSEMA.
• HIGH-IMPACT BLUNT FORCE INJURIES TEND TO INVOLVE THE INTRATHORACIC DISTAL
TRACHEA NEAR THE CARINA, WITH A SLIGHT PREPONDERANCE OF RIGHT-SIDED
INVOLVEMENT
 SURGERY INDICATION

• SURGERY IS USUALLY PERFORMED IN LACERATIONS GREATER THAN 2–4 CM, ESPECIALLY WHEN
THERE IS INVOLVEMENT OF THE CARTILAGE. SURGERY MAY ALSO BE PERFORMED IN PATIENTS
WITH WORSENING PNEUMOMEDIASTINUM, SUBCUTANEOUS EMPHYSEMA, OR PNEUMOTHORAX
OR WITH A LUNG THAT FAILS TO RE-EXPAND DESPITE DRAIN PLACEMENT.
• MEDIASTINAL SEPSIS AND PROXIMITY OF THE INJURY TO THE CARINA HAVE ALSO BEEN
PROPOSED AS INDICATIONS FOR SURGERY.
• EMERGENCY SURGERY IS REQUIRED WHERE THERE IS FAILURE TO VENTILATE OR IF THERE IS
ESOPHAGEAL HERNIATION THROUGH THE TRACHEAL DEFECT, WHICH MAY BE VISUALIZED AT
CT.
 NON SURGERY TREATMENT

• IN MORE BORDERLINE CASES WITH LACERATIONS MEASURING 1.5–2 CM OR LESS, THERE

IS INCREASING MOMENTUM BEHIND NONSURGICAL MANAGEMENT OPTIONS. THESE
INCLUDE RIGID AND FLEXIBLE BRONCHOSCOPIC APPLICATION OF SYNTHETIC ADHESIVES
(FIBRIN- OR CYANOACRYLATE-BASED), WHICH MAY BE CONSIDERED IN INJURIES
SMALLER THAN 5 MM, AND COVERED METALLIC OR SILICONE STENT PLACEMENT, BOTH
OF WHICH HAVE SHOWN PROMISING RESULTS IN SPECIALIST UNITS.
NECK INJURY
THE NECK HAS TRADITIONALLY BEEN DIVIDED INTO THREE ANATOMIC ZONES WHEN DESCRIBING PENETRATING NECK
TRAUMA, WHICH GUIDES CLINICAL MANAGEMENT

zone 1 from the level of the important structures include the aortic arch, proximal common carotid
clavicles and sternal arteries, vertebral arteries, subclavian vessels, innominate vessels, lung
notch to the cricoid apices, esophagus, trachea, brachial plexus and thoracic duct
cartilage

Zone 2 from the cricoid important structures include the common, internal and external carotid
cartilage to the angle arteries, internal and external jugular veins, larynx, hypopharynx and
of the mandible proximal esophagus

Zone 3 from the angle of the important structures include the internal carotid artery, vertebral artery,
mandible to base of external carotid artery, jugular veins, prevertebral venous plexus and
skull facial nerve trunk
THANK YOU