Bakul Patofisiologi Trauma
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Transcript of Bakul Patofisiologi Trauma
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Widjoseno GardjitoDepartment of UrologyMedical School Airlangga University - Dr. Soetomo HospitalSurabaya1
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PATOFISIOLOGI TRAUMADefinisi :
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.2
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TRAUMA pada JARINGAN/ORGAN KERUSAKAN PERDARAHAN NYERI3
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JENIS TRAUMALedakan benda berkecepatan tinggi, benda tajam (tusukan, irisan, sabetan), benda tumpulSuhu tinggi/rendah uap panas luka bakar frostbite (suhu dingin)Arus listrik tegangan tinggiBahan kimiaRadiasi, ionisasiGigitan, sengatan4
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KERUSAKAN AKIBAT TRAUMABentuk :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, memar5
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AKIBAT TRAUMA SEMBUH CACAT (anatomis + fisiologis + psikologis) MENINGGAL10
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TRAUMAHEBATRINGANTUNGGAL GANDAREAKSI TUBUH(Bagian dari proses Penyembuhan secara alami)LOKALSISTEMIKTANDA + GEJALA11
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INSULT HEBAT / BERAT
4 I - s
Injury Infection Inflammation IschemiaS I R S(Systemic Inflammatory Response Syndrome) 12
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SIRS can be identified by the presence of two or more of the following manifestations :
1. A body temperature greater than 38C or less than 36C.2. Heart rate greater than 90 beats per minute3. Tachypnea (respiratory rate > 20 breaths per minute or Pa CO2 < 32 mmHg4. 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).14
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SIRS and MODSInflammatory 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).Beal et al, JAMA, 1994;271;226-23315
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SEPSIS :
SIRS plus a documented infection site (documented by positive culture for organisms)18
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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. oliguria3. or an acute alteration in mental status
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Septic Shock :Sepsis-induced hypotension despite fluid resuscitation PLUS hypoperfusion abnormalities20
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MODSOrgan Dysfunction associated with Severe Sepsis and Septic Shock :
Lungs : early fall in arterial PaO2 , Acute Respiratory Distress Syndrome (ARDS):
Capillary-leakage into alveoli; tachypnea, hyperpneaKidney : (acute renal failure): oliguria, anuria, azotemia, proteinuria
Liver : elevated levels of serum bilirubin, alkaline phosphatase, cholestatic jaundice
Digestive tract : nausea, vomiting, diarrhea and ileus21
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MODSOrgan 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 : confusion22
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OSLERS DICTUM
Patients usually die of complications of their disease, rather than from the disease itself23
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SIRS MODSMOF
BUKAN PENYAKITBUKAN 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 BERKELANJUTAN24
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SIRSSystemic Inflammatory Response SyndromeMODSMultiple Organ Dysfunction SyndromeMOFMultiple Organ FailureMSOFMultiple-Sytem Organ FailureARDSAcute Respiratory Distress SyndromeDICDisseminated Intravascular Coagulation25
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DEAR SIRSWE ARE SORRY TO SAYTHAT WE DONT LIKE YOU26
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Sir Isaac Newton :To every action is always an equal reactionorThe mutual action of two bodies upon each other are always equal, and directed to contrary parts
Philosophiae Naturalis principia Mathematica1687Bone RC Crit. Cave Med, 1996;24:1125-112827
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BIOLOGICAL SYSTEMS, such as the human body, are more complicated than the simple physical systems Sir Isaac was describing28
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MACROPHAGE ( morfologi ) :Sel besarInti bulat/indentedGolgi apparatus developedVakuol endositotik >Lisosom + fagolisosomPlasma membrane diselubungi mikrovili/ruffles30
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MACROPHAGE ( fungsi ) :Nonspecific phagocytosis/pinocytosisSpecific phagocytosis opsomized microorganisms (Fc receptors + complement receptor)Killing ingested microorganimsDigestion + presentation of antigens to T + B lymphocyteSecretion of : enzymes : lysozyme, collagenases, elastase, acid hydrogenases complements + coagulation factors some prostaglandins and leukotrienes several regulatory molecules (interferon, Interleukin-1)31
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MACROPHAGE ( jenis ) :HistiositSel KupfferOsteoclastsMicroglial cellsSynovial type A cellsInterdigititating cellsLangerhans cell Langerhans, epitheloid cellsMultinucleated giant cellsInflamed tissues32
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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 content33
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MEDIATOR
Bahan yang dilepaskan oleh sel sebagai hasil interaksi antigen-antibodi atau antigen dengan sel limfosit yang sudah mengalami sensitisasi34
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CYTOKINE (SITOKIN) : (cyto + kinesis)
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, monokinesmovement35
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SITOKIN
Anggapan: sitokin ~patologi
Sitokin: Melindungi tubuh tapi juga bisaSIRS
Mulai ditemukan antogonis sitokin
Mencegah SIRS ?36
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Proses dilepasnya
Pro inflamatori sitokin + mediator-mediator merupakanMekanisme pertahanan tubuh
melokalisir + menetralisir kuman yang menyerang membersihkan sel yang mati / rusak memulihkan jaringan
NAMUNAktivasi yang berkelanjutan / berlebihan justruMERUGIKAN37
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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 harireda 7 10 hari38
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PATOGENESIS SIRS
4 - I (Injury Infection Ischemia Inflammation)
Stage ILokal: Sitokin
(penyembuhan luka merangsang sel mematikan organisme patogen)39
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SITOKIN
Circulating form (misal : IL-1 beta) (sistemik) Cell associated form (misal : IL-1 alpha) (lokal)
Asumsi : lokal prekursor sistemikBila produksi sitokin lokal melampui batasambang tumpahsistemik40
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Stage II
Sejumlah kecil sitokin masuk sirkulasi
merekrut : makrofag, trombosit
growth factor
Terjadi reaksi akut :
terkendalitidak terkendalipro inflamm, mediator endogenous antogonist (misal : IL-1 receptor antagonist) Stage IIIantibodi
Luka sembuhInfeksi teratasiHomeostasis pulih41
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Stage III
Homeostasis tak berhasil dipulihkan
SitokinDestruktif( semula protektif )
Sirkulasi penuh dengan mediator inflamasi
Intergritas dinding kapiler rusak
Sitokin masuk organ / jaringan
M O D42
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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 syndrome; MODS, multiple organ dysfunction syndrome.43
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Figure 2. Three stages of the systemic inflammatory response syndrome reactionCrit Care Med 1996 Vol. 24, No. 144
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TRAUMA
may be considered to be an inflammatory disease
KADAR :- berbagai mediator- indikator respons inflamasipada trauma berat.
MARKERS inflamasi dapat digunakan : menilai beratnya trauma meramalkan prognosis (outcome)45
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TRAUMA BERAT dan KEMATIANPOLA 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 trauma46
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TRAUMA BERAT dan KEMATIANPOLA SITRIBUSI TRI MODALTRAUMA BERAT47
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JALAN TOL menuju kematian
Trauma multipel Sumber infeksi Immunocompromised
SistemPenunjang berbagai organ(ICU)
SIRS
MODSARDS, DIC, ARF, KARDIOMIOPATI
Meninggal48
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CerraJAMA Vol. 271, 199449
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1991Concensus Conference
Dirintis konsistensi Memperhatikan aspek-aspek : Klinik (bedside) Laboratorium Literatur terkait50
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SIRSMODS/MOF MORTALITAS TINGGI
KEGAGALAN1 ORGAN: 30% - 40%2 ORGAN: 60%3 ORGAN: > 90%
USIA > 65 TAHUN: RISIKO20%
Beal & Cerra
PREVENTION IS THE BEST TREATMENT(prevention is the only good answer)Baue51
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Prognostic test
yang meramalkan terjadinya organ failure (OF)
tidak bermanfaat
bila gambaran klinik OF sudah manifes52
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