MODULE 3

Emergency hemodynamic
CHAPTER I. THE THIRD WEEK LEARNING OBJECTIVES
1. Explains emergency obstetrics and gynecology
2. Understanding the signs and symptoms of shock (hypoperfusion)
3. Able to calculate the fluid in the shock and bleeding
4. Explains emergency abdominal surgery and treatment
5. Explain the cardiac emergency
6. Understanding and assessing burns and principles of treatment of burns
7. Know and be able to perform stabilization actions with strict monitoring on burns
8. Explain and capable of handling emergencies on the skin

Expert lecture:
1. Obstetrics and Gynecology
Lecture 1 by dr. Taufiqurrahman R, Sp. OG
a. Emergency Obstetrics and Gynecology (100 minutes)
2. Heart
Lecture 1 dr. Asrizal T, Sp. JP
a. Emergency heart (100 minutes)
3. Surgery
Lecture 5 by dr. Yuzar Harun, Sp. B
a. burns, treatment principles, and criteria for inpatient stabilization
and reference (10 0 minutes)
Lecture 6 by dr. Pirma Hutauruk, Sp. B
a. aspect of emergency abdominal surgery and treatment (100 minutes)
4. Anesthesia
lecture 6 by dr. Undang Komarudin, Sp. An
a. Understanding the signs and symptoms of shock (hypoperfusion) (50 minutes)
b. Being able to calculate the infusion of fluids in shock and bleeding (50 minutes)




5. Skin and Genital
Lecture 1 by dr. M. Syafei Hamzah, Sp. K K
emergency Skin (100 minutes)

Tutorial
Scenario 3

Skill lab
ETT (Endo tracheal tube)




CHAPTER II. SCENARIO 3
STOVE EXPLODES

A woman of 35 years, 8 months pregnant during the antenatal care (ANC) has done regular to a gynecologist.
During the ANC obtained blood pressure 180/100 mmHg, the second leg swelling.
One day he was taken to the Emergency Unit with burns along his chest and abdomen caused by the explosion
of a stove when she was cooking. Patients are aware of pain in the chest and abdomen which caught fire.
Slightly hoarse voice, his eyebrows on fire. The patient complained of breathlessness and coughing, black
sputum. Blisters were found in the chest and abdomen, but the patient still feels pain.
At the time of the patient's sudden seizure and tension obtained 200/110 mmHg and a weak but rapid pulse. On
examination DJJ 160 x per minute ..
Laboratory results obtained: proteinuri +3.









CHAPTER III. REVIEW REFERENCES
S CENARIO 3: STOVE EXPLODES
1. The principle of treatment of burns and their classification
Burn patients should be evaluated systematically. The main priority is to maintain the airway remains
patent, effective ventilation and support the systemic circulation. Endotracheal intubation performed in
patients suffering from severe burns or suspicion of inhalation injury or burns to the upper airway.
Intubation can not be done if there has been a burn edema or fluid resuscitation is too much. In burn
patients, intubation and nasotrakea orotrakea preferred over tracheostomy.
Treatment of burns resuscitation
a. Management of airway resuscitation :
1. Intubation
Intubation action done before the manifestation of mucosal edema causing obstruction. Purpose
of intubation to maintain airway and the airway pemelliharaan facilities.
2. Cricothyroidotomy
Aiming with intubation only be considered too aggressive and lead to greater morbidity than
intubation. Cricothyroidotomy minimize dead space, tidal volume increase, it is easier to do
bronchoalveolar rinses and the patient can talk, if compared with intubation.
3. Oxygen administration 100%
Aims to provide the oxygen requirements when there is blocking the airway pathology of
oxygen supply. Be careful in giving large doses of oxygen as it can cause oxidative stress, so it
will form free radicals that are vasodilator and modulator of sepsis.
4. Airway care
5. Suction secretions (periodic)
6. Inhalation therapy
Aims to seek a better air atmosphere in the airway lumen and liquefy thick secretions so easily
removed. Inhalation therapy generally uses liquid sodium chloride 0.9% base plus
bronchodilator when necessary. Additionally bias added substances with specific properties
such as atropine sulfate (lowering the production of secretions), sodium bicarbonate (to
overcome cellular acidosis) and steroids (still controversial)
7. Rinse bronchoalveolar
8. Rehabilitative care for respiration
9. Escharotomy on the wall of the piston which aims to improve lung compliance
b. Management of fluid resuscitation
Fluid resuscitation is done by giving replacement fluids. There are several ways to calculate the fluid
requirements of this :
The way Evans
1. Extensive burns (%) x weight (kg) into mL NaCl per 24 hours
2. Extensive burns (%) x weight (kg) to 24 mL plasma per hour
3. 2,000 cc glucose 5% per 24 hours
Half of 1 +2 +3 is given in the first 8 hours. The rest are given in the next 16 hours. On the second
day given half the amount of fluid the first day. On the third day be half the amount of fluid the
second day.
Baxter Formula
Extensive burns (%) x weight (kg) x 4 mL
Half of the amount of fluid given in the first 8 hours. The rest are given in the next 16 hours. On the
second day given half the amount of fluid the first day. On the third day be half the amount of fluid
the second day.
c. Nutritional resuscitation
In burn patients, the enteral feeding should be done early and the patient does not need to be fasted. If
the patient is unconscious, then feeding through naso-gastric can tube (NGT). Nutrition provided
should contain 10-15% protein, 50-60% carbohydrates and 25-30% fat. Early nutrition can enhance
immune function and prevent the atrophy of intestinal villi. It is expected early nutrition can help
prevent the occurrence of SIRS and MODS.
Treatment of burns
Generally to relieve pain from burns used a small dose of morphine intravenously (initial adult dose:
0.1 to 0.2 mg / kg and the 'maintenance' 5-20 mg/70 kg every 4 hours, whereas a dose of children
0.05 to 0.2 mg / kg every 4 hours). But there is also a provision stating methadone (5-10 mg adult
dose) every 8 hours is the treatment of chronic pain is good for all adult burn patients. If the patient
still feels pain despite the administration of morphine or methadone, benzodiazepines may also be
given in addition.


2. Inhalation trauma
Trauma can be defined as the inhalation of acute damage to the respiratory system caused by the inhalation
of combustion products or vapor where the patient is in a closed room. Region are usually exposed to
inhalation trauma is oropharings, tracheobronchial tree or lung parenchyma.
Some literature mentions inhalation trauma was found in 3-15% of patients who present with severe burns.
The incidence of burns increases with age. With the highest incidence is found in over 59 years and the
lowest incidence below the age group 5-14 years. The prevalence of men and women are equal, namely 1:
1.
TRAUMA MECHANISM
There are two mechanisms of occurrence of inhalation injury, namely carbon monoxide and smoke
inhalation. Smoke is divided into two, namely the direct trauma and smoke poisoning. Direct trauma to the
respiratory system the most rare cases, some experts conclude that carbon monoxide poisoning is a major
cause of inhalation trauma.
Carbon monoxide
Carbon monoxide gas is a gas that is odorless, colorless and does not cause irritation resulting from
incomplete combustion of carbon. Effect of this gas in the tissues causing hypoxia due to carbon monoxide
binds to hemoglobin and oxygen and compete with binding to hemoglobin. Affinity for carbon monoxide
binds to hemoglobin 200 times more than the oxygen concentration karboksihemoglobin high enough so
that even if the concentration of carbon monoxide in the air only 5%. Toxicity of carbon monoxide
depends on the concentration in the air and how much exposure to carbon monoxide.

Direct trauma
Inhalation of hot, dry air (300
o
F or more) caused damage to the tissue in the upper respiratory tract and
laryngs. In the edema can arise laryngs laryng, spasm laryngs, and shortness of breath. If there is hot steam
vapor will cause damage to the distal part of the respiratory tract.

Toxicity of smoke
In addition there are also noxious carbon monoxide gas that is the result of degradation of man-made
material, while the nature of the material produced oxidation of sulfur and nitrogen, and aldehydes. One of
the aldehyde, acrolein showed irritation of the respiratory tract of the upper and pulmonary edema.



Pathophysiology
Direct effects of smoke inhalation on the loss of cilia function and severe mucosal edema. Within a few
seconds then it will decrease surfakatan work which will be seen as micro and macro atelectasis. If
inhalation trauma severe enough, it will cause damage to the alveoli and the bronchial epithelium which
will also spread to the capillary. Which in minutes will be detected as bronchial edema and perivasculer,
which will lead to the onset of wheezing due to bronchial obstruction. Ekspetorasi black sputum usually
occurs at this time. After several hours, the mucosa of trakeobronkial will begin to form membrane
peeling and mucopurulent. At this time the patient will spend sputum and bronchial mucosa contain. Once
established it will be followed by pseudomembranous necrotizing bronchiolitis, hyaline membrane
formation, intraalveolar perdarhan, fibrin-thrombus formation, and the latter no pulmonary edema.

DIAGNOSIS
Diagnosis of inhalation injury on the basis that:
1) Anamnesis
Obtained from the anamnesis causes burns and whether the patient is stuck in the house that tebakar
or not. If the patient is stuck in the house then it will increase the likelihood of inhalation trauma.
Meanwhile, when the cause of burns due to flames in the room that opens the possibility for the
occurrence of inhalation injury is reduced.
2) Examination
Examination reveals a black-colored sputum, colored laryngs hita (by examination laryngoskop) is a
significant sign of inhalation trauma. As for some additional symptoms, among others, eyebrows and
nose hair on fire, a hoarse voice, cough and difficulty breathing.
3) Investigations
Several investigations can be done to establish the diagnosis of inhalation injury :
a) Chest x-rays
b) Blood Gas Analysis
c) Bronchoscopy
Bronchoscopy is the gold standard examination to confirm the presence of inhalation trauma.
At bronchoscopy examination found :
Black
Hyperemia, bronkorhea
Petechial
Pink-gray areas of necrosis
White area is flat but sometimes concave

MANAGEMENT
Treatment for patients with inhalation trauma, namely;
1) Make sure the airway remains free to make endotracheal intubation. If there is a deep burn on the
neck and the body then quickly made incisions to relieve the neck and body.
2) Make sure the ventilation and adequate oxygenation to peripheral regions
3) Fluid resuscitation
4) Pulmonary toilet and bronchodilators
5) Analgosedasi
6) Specific Antidotum

3. Management of shock (hemodynamic)
Shock Response
Reduction of shock begins with general measures aimed at improving tissue perfusion; improve
oxygenation of the body; and maintain body temperature. This action does not depend on the cause of
shock. Diagnosis should be established so that it can be a causal treatment.
Immediately provide first aid in accordance with the principles of resuscitation ABC.
Airway (A = water way) should be free if necessary with the installation of an endotracheal tube.
Respiration (B = breathing) should be ensured, if necessary, to provide artificial ventilation and
administration of oxygen 100% .
Circulatory volume deficit (C = circulation) in true hypovolemic shock or relative hypovolemia (septic
shock, neurogenic shock, and anaphylactic shock) should be treated with intravenous fluids and if
necessary the provision of inotropic drugs to maintain cardiac function or vasoconstrictor drugs to cope
peripheral vasodilatation.
Maintain Respiration
1. Clear the airway. Perform exploitation, if any secretions or vomit.
2. Tilted-head prop his chin, if necessary, attach a walker breath (Gudel / oropharingeal airway).
3. Give oxygen 6 liters / minute
4. If breathing / ventilation is inadequate, give oxygen to the pump lid (Ambu bag) or ETT.

Maintain Circulation
Immediately attach an intravenous infusion. Can more than one infusion. Monitor pulse, blood pressure,
skin color, the contents of the vein, urine production, and (CVP).
Find and Overcome Cause
Bleeding is a common cause of shock in trauma patients, either because of bleeding or bleeding that looks
invisible. Visible bleeding, bleeding from wounds, or hematemesis from gastric ulcer. Bleeding is not
visible, such as bleeding from the gastrointestinal tract, such as duodenal ulcers, splenic injury,
pregnancy outside the uterus, pelvic fractures, and large or multiple fractures.

4. Emergency obstetric
A. Abortion
Abortion is spending the products of conception are age less than 20 weeks of pregnancy. The
diagnosis is based on the presence of amenorrhea, signs of pregnancy, vaginal bleeding, placental
tissue and the possibility of spending fetal death. On septic abortion, vaginal bleeding a lot or
moderate fever (chills), possible symptoms of peritoneal irritation, and possible shock.
2. Ekstrauteri pregnancy (ectopic)
The cause of this disorder is the ovum transport delays due to mechanical obstruction of the road that
passes through the uterine tubes. Especially in the ampulla of tubal pregnancy, ovarian pregnancy is
rare. The diagnosis is confirmed by the presence of amenorrhea 3-10 weeks, rarely longer, irregular
vaginal bleeding (not always).
3. Placenta previa
Placenta previa is the implantation of the placenta into the lower uterine segment. The cause of this
disorder is the phase shift occurs / over the placenta overlaps internum cervix which causes the
release of the placenta.
4. Solusio (abruption) Placenta
Placental abruption is a normal placenta detaching embedded in the wall of the uterus either partial
mauppun complete, at the age of 20 weeks or more. The cause is retroplasenta hematoma due to
bleeding from the uterus (changes in blood vessel walls), increased pressure in the room intervillus
enhanced by hypertension or toxemia. The diagnosis is confirmed through the findings of pain (due to
contraction peralinan often exist as a continuous pain, tetanik uterus), bleeding per vagina (rare and in
severe cases, external bleeding varies), to weigh fluctuating heart sounds (almost always exceeds the
limits of the norm, it is generally not there are in severe cases), shock (weak pulse, rapid, low blood
pressure, pallor, cold sweats, cold extremities, blue nails). is dead or can not live.
5. Retained placenta (Placenta Incompletus)
The cause of this disorder is retained (born less powerful pain or pathology equipment) and
incarceration (spasm in the isthmus region of the cervix, often caused by an overdose of painkillers).
Diagnosis is made by the placenta is not born spontaneously and was not sure if the placenta is
complete.
6. Ruptured uteri
The cause of uterine rupture include obstetric measures (version), fetopelvik imbalance, where the
latitude is negligible for a drug overdose or labor induction of labor pain, scarring of the uterus (the
state after cesarean section, meomenukleasi, Strassman operation, wedge excision suetu tuba),
accidents ( traffic accidents), are very rare.
7. Septic shock (Bacteria, Endotoxin)
The cause of this disorder is the inclusion of gram negative bacterial endotoxin (coli, proteus,
pseudomonas, aerobakter, enterococcus). Gram-positive bacterial toxin (streptococci, Clostridium
welchii) is less common.
8. Weight preeclampsia
The term eclampsia comes from the Greek word for "thunder". The word is used because it seems
eclampsia symptoms occur suddenly without any prior signs of another. Eclampsia in women who
suffer from seizures occur, followed by a comma. Dependent on the onset, divided into eclampsia
eclampsia gravidarum, eclampsia parturientum, and puerperal eclampsia.
If either one of the following signs or symptoms are found in pregnant women, mothers predictably
suffered severe preeclampsia.
1. Blood pressure was 160/110 mmHg.
2. Oliguria, the urine is less than 400 cc / 24 hours.
3. Proteinuria, more than 3g / liter.
4. Subjective complaints (epigastric pain, visual disturbances, headache, pulmonary edema, cyanosis,
impaired consciousness).
5. On examination, found increased levels of liver enzymes with jaundice, bleeding in the retina, and
platelets less than 100,000 / mm.
Diagnosis of eclampsia should be distinguished from epilepsy, seizures due to drug anesthesia, or
coma due to other causes such as diabetes. The hardest complication is maternal and fetal mortality.




2. Treatment of hypertension of pregnancy
a. Control of Hypertension
Methyldopa
Clonidine [-adrenergic agonist]
Calcium channel blockers
Hydralazine
Beta blockers
b. Provision of the antihypertensive effect of breast feeding
o Knowledge about the pharmacokinetics of anti-HT drugs in breast milk is minimal.
o Giving a thiazide diuretic should be sad indarkan therefore can cause a decrease in milk
production.
o Methyldopa estimated safe for nursing mothers.
o Except for propranolol, another beta blocker type found in breast milk with high levels.
o Captopril Clonidine and levels in breast milk is minimal.
c. Obstetric Management of Public
On my first visit to ask:
o Old hypertensive and type of drug used
o And a history of kidney disease or heart
o Outcome of last delivery
Physical examination:
o Fundus examination occuli
o Renal artery auscultation
o Dorsalis pedis artery pulse examination (coarctatio aorta)
o Examination of TD in a sitting position
Laboratory tests at the first antenatal visit:
o Complete blood and urine examination
o Renal physiology
o Hepatic physiology
o Serum electrolyte
o ECG
o 24-hour urine creatinine clearance to see
o Thorax X-ray
o Ultrasound examination: to determine the gestational age
Diet advice : Retriksi regular food without salt The frequency
of antenatal antenatal care more often than
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