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Definisi :
TRAUMA adalah semua jenis kekerasan yang menimpa tubuh sehingga terjadi kerusakan/gangguan pada struktur dan fungsi jaringan/organ tubuh yang terkena, bahkan Widjoseno Gardjito
Department of Urology Medical School Airlangga University - Dr. Soetomo Hospital Surabaya
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secara sistemik dapat berdampak pada aspek fisiologis, kejiwaan dan kondisi sosial insan yang bersangkutan.
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JENIS TRAUMA
TRAUMA pada JARINGAN/ORGAN
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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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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INSULT
HEBAT TUNGGAL GANDA
TRAUMA
RINGAN
LOKAL
REAKSI TUBUH
(Bagian dari proses Penyembuhan secara alami)
SISTEMIK
SIRS
(Systemic Inflammatory Response Syndrome)
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Bacteremia
SIRS can be identified by the presence of two or more of the following manifestations :
Other
1. A body temperature greater than 38C or less than 36C. 2. Heart rate greater than 90 beats per minute 3. Tachypnea (respiratory rate > 20 breaths per minute or
Fungemia
INFECTION
Parasitemia
SEPSIS
Viremia Other
SIRS
Trauma
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).
BURNS
Pancreatitis
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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). 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 phosphatase, cholestatic jaundice bilirubin, alkaline
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,
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Brain : confusion
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OSLERS DICTUM
Patients usually die of complications of their disease, rather than from the disease itself
SIRS
MODS
MOF
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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Multiple Organ Failure Multiple-Sytem Organ Failure Acute Respiratory Distress Syndrome Disseminated Intravascular Coagulation
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BIOLOGICAL SYSTEMS, such as the human body, are more complicated than the simple physical systems Sir Isaac was describing
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 :
MACROPHAGE ( jenis ) :
Histiosit Sel Kupffer Osteoclasts Microglial cells Synovial type A cells Interdigititating cells Langerhans cell Langerhans, epitheloid cells Multinucleated giant cells
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enzymes : lysozyme, collagenases, elastase, acid hydrogenases complements + coagulation factors some prostaglandins and leukotrienes several regulatory molecules (interferon, Interleukin-1)
Inflamed tissues
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MACROPHAGE
MEDIATOR
Mononuclear phagocytes di dalam jaringan : Bone marrow : STEM CELL
hasil interaksi antigen-antibodi atau antigen dengan sel limfosit yang sudah mengalami sensitisasi
Anggapan 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 Sitokin
: sitokin
patologi
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
Growth
Hormone,
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PATOGENESIS SIRS
4 - I (Injury Infection Ischemia Inflammation) Stage I Lokal
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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: Sitokin sel
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Stage II
- Sejumlah kecil sitokin masuk sirkulasi merekrut : makrofag, trombosit growth factor Terjadi reaksi akut :
Stage III
Homeostasis tak berhasil dipulihkan Sitokin ( semula protektif ) Destruktif
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.
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Figure 2. Three stages of the systemic inflammatory response syndrome reaction Crit Care Med 1996 Vol. 24, No. 1
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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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Immediate
Early
Late
TRAUMA BERAT
1991
Concensus Conference
Dirintis konsistensi
SIRS
MORTALITAS TINGGI KEGAGALAN 1 ORGAN 2 ORGAN 3 ORGAN USIA > 65 TAHUN
MODS/MOF
Prognostic test
: 30% - 40% : 60% :
>
90% 20%
Beal & Cerra
yang meramalkan terjadinya organ failure (OF) tidak bermanfaat bila gambaran klinik OF sudah manifes
Baue
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: RISIKO
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