Farmakoterapi pada Kasus

Bedah Trauma
Henderi Saputra
1950913310001
Contoh Kasus Bedah Trauma
 Mr. Beriyan/Male/16 yo/1 44 75 07
Admitted December 15th 2019,at 03.30 PM

Chief Complain: Open wound at perioral

History taking:
He complained open wound at perioral after got slashed by someone unknown with a machete in last 30
minutes before admission. He fell nothing after got that slashed, and then the blood flow from his mouth. He
was brought to Emergency department immediately.

History of Past Illness : (-)

History of Family Illness : (-)
Primary Survey
• Airway :
• Snoring (-), gurgling (-), stridor (-), Patient can speak clearly,
• Without C-Spine restriction
• Breathing :
• Lesion (-), symmetrical movement, RR : 20x/minute (reg), vesicular breath sound Rh (-/-) Wh (-/-).
• SpO2 : 98% without O2 supplement
• Circulation :
• HR : 90x/minute (regular, strong pulse), BP : 110/80 mmHg, warm extremities.
• Active Bleeding (+) pressure bandage  ligation
• Disability :
• GCS E4V5M6, pupil equal 3 mm/3 mm, direct light reflex (+/+), lateralization (-)
• Exposure :
• Open wound at the perioral region
 Secondary Survey
• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : 10.00 PM
• Environment : Kayu Tangi
 • Open wound at perioral  look at local state
• pale conjungtiva (-/-), sclera icteric (-/-), pupil 3mm/3mm. Light reflex (+/+),
Head/Neck • BH (-), BR (-), BO (-/+), BS (-)
• Neck swelling (-), enlargement lymph node (-), increased jugular vein pressure (-)

• I : symmetric respiratory movement, retraction (-), bruise (-)

• P : symmetric vocal fremitus
Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : Lesion (-) Distension (-)

• A : Bowel sound (+) 4-6x/minute
Abdomen • P : Soft (+), defence muscular (-), tenderness (-)
• P : thympani (+)

• Male, Bloody discharge (-)

Genital/Pelvic
• Stable in AP, Lateral, Vertical Compression

Extremities • warm extremities in all regio, parase (-), edem (-)

 Local State At Left Leg
Inspection
• Open Wound (+) size
10cmx23cmx1,5cm, penetrating
to intraoral, active bleeding (+)
 Ligation, necrotic tissue (-),
regular border, clear wound,
fracture alveolar bone

Palpation
• Crepitation (+), Tenderness (+) at
wound, malocclusion (+)
Skull AP/Lat
Clinical Pictures
 Thorax X-Ray
December 15th 2019, Ulin Hospital
 Laboratory Finding (December, 15th 2019)
Examination Result Normal Value
Hemoglobin 14.3 14,00-18,00 g/dl
Leukosit 9.0 4,0-10,5 thousand/ul
Eritrosit 5.32 3,90-5,50 million/ul
Hematokrit 42.3 37,00-47,00 vol%
Trombosit 210 150-450 thousand/ul
RDW-CV 12.7 11,5-14,7 %
MCV 79.5 80,0-97,0 fl
MCH 26.9 27,0-32,0 pg
MCHC 33.8 32,0- 38,0 %
Neutrofil% 83.8 50,0-81,0 %
Limfosit% 14.4 20,0-40,0 %
MID% 1.8 %
Neutrofil# 7.50 2.50-7.00 ribu/uL
Limfosit# 1.30 1.25-4.00 ribu/uL
MID# 0.2
Laboratory Finding (December, 15th 2019)
Examination Result Normal Value

Hasil PT 12.2 detik

Hasil APTT 23.5 detik

GDS 116 <200mg/dl

SGOT 20 0-46 U/l

SGPT 11 0-45 U/l

Ureum 19 10-50 mg/dl

Creatinin 0.63 0,7-1,4 mg/dl

Natrium 140 136-145 Meq/L

Kalium 3.7 3.5-5.1 Meq/L

Chlorida 107 98-107 Meq/L

 Diagnosis
Open Fracture Superior alveolar bone displaced + Vulnus laceratum
a/r oris superior + laceration alveolus oris
 Management
Treatment On ER Consult to Plastic Surgery
•IVFD NS 20 dpm
• Debridement + Primary Suturing in OK
• Inj. Ceftriaxone 2x1 gr
• Inj. Ketorolac 3x30 mg
• Inj. Tetagam 250 iu
• Debridement
Diskusi Masalah
• Apa yang terjadi pada trauma ?
• Obat-obatan apa saja yang diberikan pada pasien trauma untuk
menunjang kesembuhan dan kenyamanan pasien?
• Tepatkan pemberian obat yang telah diberikan ke pasien tersebut?
…….
• Farmakoterapi  penatalaksanaan medis dengan obat-obatan.
• Trauma  luka yang diakibatkan oleh kekerasan atau kecelakaan
• Luka  kerusakan jaringan
• Kulit merupakan jaringan yang berfungsi untuk melindungi organ di
bawahnya, ketika kulit mengalami kerusakan, resiko infeksi akibat2
kuman kuman pathogen dan komensal di permukaan kulit dapat
menginfeksi tubuh.
 Apa yang Terjadi
Saat Kerusakan Jaringan?
Cell wall Releases
Membrane phospholipids
injury

Phospholipase A2

Arachidonic Acid

COX-1 & COX-2 that is induced with injury

and inflammation, cancer

PGH2 (Prostaglandin H2)

PGD2 PGI2 PGE2 PGF2 TXA2

Prostaglandins- PGE2 as the most significant Thromboxane

 Arachidonic Acid Cascade
Phospholipid from cell membrane

Arachidonic Acid

Cyclo-oxygenase Lipoxygenase

PGH2 5-HPETE

Thromboxane Prostaglandins Leukotrienes

These inflammatory mediators activate the nociceptors on the Aδ and c

fibres and result in pain and sensitization
Analgesic
Tools yang digunakan untuk menentukan
tingkat keparahan nyeri yang dirasakan
pasien
 Arachidonic Acid Cascade
Phospholipid from cell membrane

NSAIDs / COX-2 Arachidonic Acid

inhibitors

Cyclo-oxygenase Lipoxygenase

PGH2 5-HPETE

Thromboxane Prostaglandins Leukotrienes

Reduce Prostaglandins and Thromboxane, resulting in

reduced pain
NSAID yang biasa digunakan
• Paracetamol
• Asam Mefenamat
• Meloxicam
• Ibuprofen
• Ketoprofen
• Dexketoprofen
• Ketorolac
• Metamizol
• dll
Opioids
 Opioids
• Opium alkaloids derived from the opium
poppy has been used for pain relief for centuries
• Morphine was isolated by Sertuner in 1813
• The glass syringe was introduced in 1844
• Since then morphine has been the mainstay in the management of severe pain
• The term “opioid” is referred to any drug, either natural, semi-synthetic or fully
synthetic, which has actions similar to morphine
 Available Opioids
Natural Semi-Synthetic Fully Synthetic
• Morphine • Hydromorphone • Pethidine
• Codeine • Oxycodone (meperidine)
• Diacetylmorphine • Tramadol
(heroin) • Nalbuphine
• Naloxone • Methadone
(antagonist) • Pentazocine
• Fentanyl
• Alfentanil
• Sufentanil
• Remifentanil

• Opioids on the WHO essential drug list

• Morphine
• Codeine
• Tramadol
 Opioids can be classified as:
• Strong opioids used for severe pain
– Morphine, Oxycodone, Pethidine, Fentanyl

• Weak Opioids used for moderate pain

– Codeine, Tramadol
The analgesic ladder for acute pain management
Strong opioids

Weak opioids
 Mechanism of Action
• Opioids act by binding to opioid receptors
(complex proteins embedded within the cell
membrane of neurons)

There are three different

opioid receptors - µ, δ, κ

µ - most relevant as all

clinically used opioids exert
their action via the
µ -opioid receptor

Opioid receptors are found in the brain

and in the dorsal horn of the spinal cord
 Mechanism of Action
• Opioids bind to opioid receptors
• Activate intracellular signaling events
• Leading to reduction in excitability of neurons and inhibition of pain signals
• Resulting in reduction of pain perception
 Opioids can be administered via several routes

Opioids produce potent analgesia when administered:

• Systemically – oral, Intravenous, intramuscular, subcutaneous, transcutaneous, per rectal

• Spinally – epidural, intrathecal, intraventricular

Time to peak action and duration of action depends on the route and dose of the drug
Antibiotic
Antibiotik
Profilaksis Tetanus
Anti Tetanus
Terima Kasih