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By Koas EM periode 17 Des – 6 Jan 2013

Tennyson Kwan

E
MERGENCY MEDICINE
17 Desember 2012 – 6 January 2013 (dr. Dwiwardoyo Trituliarto, SpEM)
1.

Pendekatan dx pada abdominal pain
Buku PAPDI Kegawatdarutan PD PG 443 2011
Anamnesis
Onset nyeri
Lokasi nyeri
Perjalanan waktu/duration
Intensitas dan deskripsi nyeri/characteristik pain
Faktor yang memperberat dan memperingan nyeri/agrivating factor
radiating
Pemeriksaan Fisik
Inspeksi Abd
Auskultasi Abd, auskultation is perform first before percussion or palpation
Perkusi Abd
Palpasi Abd
Tanda2 : Murphy, Uji Carnett, Tanda iliopsoas, Tanda Obturator
Laboratorium
DL, SE, Ur/Cr, OP/PT, Amylase, Urinalisis
Plano test (Perempuan usia reproduktif)
BGA
Pencitraan (Imaging)
Foto Torak
Foto polos abdomen
Foto Toraks posisi tegak (deteksi udara bebas di bawah diafragma)
Foto BNO 3 posisi (Foto KUB + Foto Decubitis + Foto posisi setengah duduk)

2.

Cervical injury Cedera Leher.

A. Patologi/kelainan pd cedera cervical

Deviation Trachea, Distress nafas, Jejas pada bagian leher? Prove?
Buku hitam Shirley
Vital sign: Neurogenic shock (Hypotension with bradycardia)
Neurogenic shock is more likely cushing respons in increased initracranial pressure
patients. Clinical manifestation of cushing respons are bradikardi, hipotensi and
patologcal changes in breathing.

By Koas EM periode 17 Des – 6 Jan 2013
Tennyson Kwan

On Inspection:
i.
Diaphragmatic breathing
ii.
Flexed posture of upper limbs suggests a high cervical cord injury
iii.
Spontaneous muscle fasciculations
iv.
Priapism
On testing:
i.
Myotomic pattern of power loss
ii.
Dermatomic pattern of sensory loss
iii.
Complete spinal cord lesion
iv.
Incomplete cord lesion (Central cord syndrome, Brown Sequard syndrome,
Anterior cord syndrome)

B. MOI yang dapat menyebabkan cedera cervical

Buku hitam Shirley
i.
Penetrating injury
ii.
Blunt trauma with disruption of vertebral column causing transaction or
compression of neural elements
iii.
Primary vascular damage to spinal cord, eg. Compression by extradural
hematoma

C. Tanda2 spinal syok

Ebook – A comprehensive EM approach
Only seen in complete spinal cord lesion, occur more common above T6
Transient physiological reflex depression of cord function below the level of injury (Last for
several hours to days, rarely weeks)
 Loss of all sensorimotor functions
 Flaccid paralysis
 Bowel incontinence & Urinary retention
 Sustained priapism
D. Prinsip manajemen.

Buku hitam shirley
i.
Minimizing movement of the spinal column
ii.
Immobilize the spine in neutral position
iii.
Document neurological deficits
iv.
Radiological
 C-spine X-ray (AP/Lateral view-patient’s shoulder may have to be pulled
down during lateral view to ensure adequate visualization of C7/T1 junction),
Swimmer’s view(if C7/T1 junction not seen on lateral view), Open mouth
odontoid view(C1/2 injury suspected)
 Thoracic and lumbar spine X-ray (AP/Lateral view)

By Koas EM periode 17 Des – 6 Jan 2013
Tennyson Kwan

v.

vi.

vii.

3.

CT Scan (Good visualization of the lower C-spine not obtained on X-ray)
 MRI (Most accurate data in the presence of neurological deficits)
IV fluids
 Avoid overzealous fluid> may precipitate pulmonary oedema
 Insert urinary catheter to monitor urinary output
 For neurogenic shock, consider vasopressors if the BP does not improve
IV Methyprednisolone
 Indication : Proven non penetrating spinal cord injury, within 8 h postinjury
 30 mg/kg over 15 min followed by 5.4 mg/kg/h for the next 23 h
 Contraindication
Paediatric <13 yo
Pregnancy
Mild injury limited to cauda equine/nerve root
Presence of abdominal trauma
Major life-threatening morbidity
Disposition
 Refer to Orthopaedic Surgeon and/or Neurosurgeon depending on local
practice

A. Sistem triage yg anda ketahui dan manfaatnya.
Slide Presentasi Teori Triage dan ABC
Triage adalah suatu proses mengkategorikan pasien menurut tipe dan tingkat kegawatan
kondisinya
Tujuan utama: Identifikasi kondisi yang mengancam jiwa
Tujuan kedua: Memprioritaskan pasien menurut keakutannya
Pengkategorikan mungkin ditentukan sewaktu2
Jika ragu, pilih prioritas yang lebih tinggi
Kegunaan triage bukan untuk mendiagnosa tetapi memeriksa dan rencana intervensi

B. Beda triage igd n bencana.
IGD Triage
Kode warna internasional
Warna merah P1 Emergency
Kondisi yang mengancam jiwa, ruang resusitasi, gangguan salah satu A/B/C
Cth: Perdarahan berat, Syok, Luka bakar >30%, Trauma kepada, Crush injury, cedera
pada maxilla
Warna kuning P2 Urgent
Penyakit akut, hemodinamik stabil, Butuh trolley, kursi roda, atau jalan kaki
Cth: Luka bakar <30%, Cedera jaringan lunak, Fr. Tertutup tualng panjang

By Koas EM periode 17 Des – 6 Jan 2013
Tennyson Kwan

Warna hijau P3 Non-Urgent
Masalah medis minimal/luka lama/kondisi lama, Tidak ada gangguan ABC
Cth: Trauma minor, kasus rawat jalan
Warna hitam P4 Meninggal
Tidak ada respon pada segala rangsangan
Tidak ada respirasi spontan
Tidak ada bukti aktivitas jantung
Hilangnya respon pupil terhadap cahaya

PDF. Disaster Medical Services Planning by Paulo J. Reyes, 2006
2 on-site triage system typically used for disaster scenarios.
i.
START (Simple triage and rapid treatment)
- Use the vital signs and level of mentation to determine the acuity of the patient and
priority in transfer.
- Patients breathing well, with good pulses, and able to follow commands are lower
priority transfers, while patients with difficulty breathing, not able to follow commands
well or with weak pulses are priority.
- This allows paramedic and other personnel to quickly assess victims, prioritize
transfers, and disposition those patients with minor injuries and medical conditions.
ii.
SAVE (Secondary assessment of victim endpoint)
- The second triage system is used to address circumstances when there are mass

-

casualties and there is potential for delay in care because hospitals are either
overwhelmed or lack ambulance transport systems.
This system divides victims into 3 categories
1) those individuals that will expire regardless of the medical care they receive
2) those that will do well whether they receive medical care or not,
3) those patients that will benefit most from immediate medical care.
This system serves to prioritize patients who will receive medical care.

4. Kasus (COPD) 60 Wanita, riwayat penurunan kesadaran dan pasif, sesak nafas 1
mggzyll, sering sesak nafas, hilang timbul, panas-, rokok +, Batuk +, DM-, HipertensiBuku PAPDI Kegawatdarutan PD PG 393 2011
A. Pmasalahan apa saja yg dialami px.
- Dispnea
- Cough
- Post AMS/DOC
B. Pemeriksaan yg dperlukan
i.
Anamnesis
ii.
Pemeriksaan fisik

By Koas EM periode 17 Des – 6 Jan 2013
Tennyson Kwan
iii.
-

Keadaan umum dan tanda2 vital
Pemeriksaan toraks
Pemeriksaan jantung
Pemeriksaan abdomen
Pemeriksaan extremitas
Pemeriksaan penunjang
Lab (LED, DL, OT/PT, Ur/Cr. SE, GDs, BGA)
EKG
Imaging (Foto toraks PA, CT scan, Ekokardiografi)
Tes fungsi paru
Brain Natriuretic Peptide (BNP) – Meningkat pd sesak nafas kardiak, tidak meningkat
pd sesak nafas Pulmonal

C. Apakah diagnosis anda
- Dispnea dt COPD ec perokok

D. Tx dan manajemen

Sarawak handbook COPD 2.13
i.
Non medikamentosa
- Reduce smoking?
- Hindari paparan yang akan merusakan paru2?
- Chest physiotherapy
ii.
Medikamentosa
- O2 10 lpm NRBM if Pa O2 < 55 or SaO2 <89%
- Bronchodilator (First line therapy)
(B2 agonist, Salbutamol 2.5-5mg +/- Anticholinergic agents, Ipratropium bromide 0.250.5 mg)
- Corticosteroids (inhaled)
(Prednisolon 30 mg/day or IV 200 mg hydrocortisone, 7-14 days)
- Antibiotics prophylaxis in presence of signs of bacterial infection
- Consider non-invasive mechanical ventilation
iii.
Monitor
- Monitor fluid balance and nutrition
- Treat associated conditions
GCS 234, trauma, muntah +, rhinorhoe +, hematom frontal, gurgling, snoring. Abratio
Antebrachii S/D.
A. Apakah Sikap kamu pada pasien ini?
Stlh 1 jam, RR 24-->16, N 100-->80, CRT >2  >2, TD 130/80 > 170/90
B. Apa yg kamu lakukn slanjtnya?
5.

6. Typical chest pain, Unstable angina. Nyeri dada, bru ptama kali, tjadi saat aktivitas,
slama 30 menit, menjalar dari dada kiri ke rahang kiri, seperti ditindih.
A. Tx awal? Apakah sikap kamu

By Koas EM periode 17 Des – 6 Jan 2013
Tennyson Kwan

B. Kalo px ingin rwat jalan, gmana?

7.

Pasien 30 Female datang dengan berdebar2, TD: 128/85, Nadi irregular, Resp 24x/m,
akral dingin. Gambar pvc.

Assesment n manajemen?

By Koas EM periode 17 Des – 6 Jan 2013
Tennyson Kwan

UJIAN EM YANG LALU
1. pasien ketelan ayam KFC
2. kurva disosiasi
3. kolik abdomen,
a) Anamnesis
b) Pemeriksaan fisik
c) Penunjang
d) Ddx
e) Life treatening pada kondisi apa
4. keringat dada tidak enak
a) Anamnesis
b) Pemeriksaan fisik
c) Penunjang
d) Ddx
e) Life treatening pada kondisi apa
5. kecelakaan aspek trauma. Sistematis penanganan sampai initial terapi, pemeriksaan
penunjang, alasan?