You are on page 1of 53

Widjoseno Gardjito

Department of Urology
Medical School Airlangga University - Dr. Soetomo Hospital
Surabaya
1

PATOFISIOLOGI TRAUMA
Definisi :
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

TRAUMA pada JARINGAN/ORGAN

KERUSAKAN
PERDARAHAN
NYERI
3

JENIS TRAUMA
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
4

KERUSAKAN AKIBAT TRAUMA


Bentuk :
Diastase (kerobekan), memar, erosi, lecet, hancur
(crush injury), jaringan hilang

Lokalisasi :
Jaringan lunak + kulit

Tulang / sendi
Organ berongga (lambung, usus)
Organ Padat (hati, limpaa,
ginjal, otak

: - luka terbuka
- luka tertutup
: fraktura / dislokasi
: perforasi
: ruptur, memar
5

AKIBAT TRAUMA
SEMBUH
CACAT
(anatomis + fisiologis + psikologis)
MENINGGAL

10

TRAUMA

HEBAT

TUNGGAL

RINGAN

GANDA

LOKAL

REAKSI TUBUH
(Bagian dari proses
Penyembuhan secara alami)

TANDA + GEJALA

SISTEMIK

11

INSULT

HEBAT / BERAT
4 I-s

Injury Infection Inflammation Ischemia

SIRS
(Systemic Inflammatory Response Syndrome)
12

Bacteremia

Other

Fungemia

INFECTION

Parasitemia

SEPSIS

SIRS

Viremia

Trauma

BURNS
Other
Pancreatitis

Beal et al, JAMA, 1994;271;226-233

13

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 minute
3. Tachypnea (respiratory rate > 20 breaths per minute or
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).
14

SIRS and MODS

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

15

16

17

SEPSIS :
SIRS plus a documented infection
site (documented by positive culture
for organisms)

18

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
19

Septic Shock :
Sepsis-induced

hypotension

despite

fluid resuscitation PLUS hypoperfusion


abnormalities

20

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

Digestive tract : nausea, vomiting, diarrhea and ileus


21

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,
Brain : confusion

22

OSLERS DICTUM
Patients usually die of complications of
their disease, rather than from the
disease itself

23

SIRS

MODS

MOF

BUKAN PENYAKIT
BUKAN 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 BERKELANJUTAN

24

SIRS

Systemic Inflammatory Response Syndrome

MODS

Multiple Organ Dysfunction Syndrome

MOF

Multiple Organ Failure

MSOF

Multiple-Sytem Organ Failure

ARDS

Acute Respiratory Distress Syndrome

DIC

Disseminated Intravascular Coagulation

25

DEAR SIRS
WE ARE SORRY TO SAY
THAT
WE DONT LIKE YOU

26

Sir Isaac Newton :


To every action is always an equal reaction
or
The mutual action of two bodies upon each other
are always equal, and directed to contrary parts
Philosophiae Naturalis principia Mathematica1687
Bone RC Crit. Cave Med, 1996;24:1125-1128
27

BIOLOGICAL SYSTEMS, such as the


human body, are more complicated
than the simple physical systems Sir
Isaac was describing

28

29

MACROPHAGE ( morfologi ) :

Sel besar

Inti bulat/indented

Golgi apparatus developed

Vakuol endositotik >

Lisosom + fagolisosom

Plasma membrane diselubungi mikrovili/ruffles

30

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 :

enzymes : lysozyme, collagenases, elastase, acid hydrogenases

complements + coagulation factors

some prostaglandins and leukotrienes

several regulatory molecules (interferon, Interleukin-1)


31

MACROPHAGE ( jenis ) :
Histiosit
Sel Kupffer
Osteoclasts
Microglial cells
Synovial type A cells
Interdigititating cells
Langerhans cell
Langerhans, epitheloid cells
Multinucleated giant cells

Inflamed tissues
32

MACROPHAGE
Mononuclear phagocytes di dalam jaringan :
Bone marrow : STEM CELL
monoblast
promocyte
Blood (40 hours): MONOCYT
Tissue

: MACOPHAGES : - size
- phagocytic activity
- lysosomal enzym content
33

MEDIATOR
Bahan yang dilepaskan oleh sel sebagai
hasil interaksi antigen-antibodi atau antigen
dengan sel limfosit yang sudah mengalami
sensitisasi

34

CYTOKINE (SITOKIN) : (cyto + kinesis)


movement

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

35

SITOKIN
Anggapan

: sitokin

patologi

Sitokin: Melindungi tubuh


tapi juga bisa

SIRS

Mulai ditemukan antogonis sitokin


Mencegah SIRS ?
36

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

37

NORMAL STRESS RESPONSE


PERUBAHAN KARDIOVASKULER
takikardi, kontraktilitas, curah jantung (CO), konsumsi oksigen
RESPONSE SISTEM NEUROENDOKRIN
Dilepasnya katekolamin, kortisol, ADH, Growth Hormone,
glukagon, insulin.
CASCADE

Puncak reaksi
reda

: - koagulasi
- komplemen
- sistem fibrinolitik
: 3 5 hari
7 10 hari

38

PATOGENESIS SIRS
4 - I (Injury Infection Ischemia Inflammation)
Stage I
Lokal

: Sitokin

(penyembuhan luka merangsang


mematikan organisme patogen)

sel

39

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
40

Stage II
- Sejumlah kecil sitokin masuk sirkulasi
merekrut

: makrofag, trombosit
growth factor

Terjadi reaksi akut :


terkendali
- pro inflamm, mediator
- endogenous antogonist
(misal : IL-1 receptor antagonist)
- antibodi
Luka sembuh
Infeksi teratasi
Homeostasis pulih

tidak terkendali
Stage III

41

Stage III
Homeostasis tak berhasil dipulihkan
Sitokin
Destruktif
( semula protektif )
Sirkulasi penuh dengan mediator inflamasi
Intergritas dinding kapiler rusak
Sitokin masuk organ / jaringan
MOD
42

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

43

Figure 2. Three stages of the systemic inflammatory


response syndrome reaction
Crit Care Med 1996 Vol.

44

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)
45

TRAUMA BERAT dan KEMATIAN


POLA 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 trauma
46

TRAUMA BERAT dan KEMATIAN


POLA SITRIBUSI TRI MODAL

Immediate

Early

Late

TRAUMA BERAT

47

JALAN TOL menuju kematian


Trauma multipel
Sumber infeksi
Immunocompromised
Sistem
Penunjang berbagai organ
(ICU)
SIRS
MODS
ARDS, DIC, ARF, KARDIOMIOPATI
Meninggal

48

Cerra
JAMA Vol. 271, 1994

49

1991

Concensus Conference
Dirintis konsistensi

Memperhatikan aspek-aspek :
Klinik (bedside)
Laboratorium
Literatur terkait
50

SIRS

MODS/MOF
MORTALITAS TINGGI

KEGAGALAN

USIA > 65 TAHUN

1 ORGAN
2 ORGAN

: 30% - 40%
:
60%

3 ORGAN

>

90%

: RISIKO

20%
Beal & Cerra

PREVENTION IS THE BEST TREATMENT


(prevention is the only good answer)
Baue
51

Prognostic test
yang meramalkan terjadinya organ failure (OF)
tidak bermanfaat
bila gambaran klinik OF sudah manifes

52

53