Sesak Nafas Setelah Dipukul....

Step 1
step 2
1. Mengapa penderita kesadarannya menurun ?
2. Mengapa penderita tampak sesak nafas dan sianosis ?
3. Kenapa didapatkan RR 40x/mnt dangkal tekanan darah 90/60
nadi 120X/mnt teraba lemah dan kecil ?
4. Kenapa didapatkan kepalanya hematom didaerah temporal kanan
?
5. Kenapa didapatkan dada asimetris dan ada luka tusuk
dihemithoraks kanan setinggi ICS 5 pada garis axilaris anterior
kanan
6. Kenapa suara nafas hemithoraks kanan menghilang ?
7. Mengapa kondisi penderita semakin menurun setelah diberikan
oksigen dengan face mask ?
8. Penanganan masalah dari skenario ?
9. DD ?
10.
Apa interpretasi GCS 11?
11. Mengapa dilakukan pemeriksaan abdomen ?
12.
Pemeriksaan penunjang ?

step 3

1. Mengapa penderita kesadarannya menurun ?

Pusat kesadaran :

2. Mengapa penderita tampak sesak nafas dan sianosis ?

3. Kenapa didapatkan RR 40x/mnt dangkal tekanan darah 90/60

4. Kenapa didapatkan kepalanya hematom didaerah temporal kanan?

The importance of cerebral vasoactivity and its relationship to systemic

PCO2 and partial pressure of oxygen (PaO) has been known for some
time. This relationship acts as the foundation for the use of
hyperventilation in the acute setting to control presumed increased ICP
after severe head injury. Because PCO2 decreases with hyperventilation,
cerebral vasoconstriction usually occurs. This vasoconstriction results in
decreased parenchymal blood volume, which, in turn, may buffer the
effects of increasing edema or an expanding hematoma within the rigid
cranial vault; however, a significant reduction in systemic PCO2 levels
caused by prolonged
hyperventilation can result in severe vasoconstriction at the adjacent or
penumbra regions of injured brain tissue, causing brain ischemia and cell
death [1214]. For these reasons and because of the risk for reperfusion
injury, the use of prophylactic hyperventilation and prolonged
hyperventilation in the ICU is not recommended (Fig. 4) [14].

ICP is related directly to the volume of intracranial contents, including

blood, cerebrospinal fluid (CSF), and brain parenchyma. This relationship
is explained by the Monro-Kellie doctrine [15,16]. In the United States,
the use of ICP monitoring and control has become standard in cases of
moderate and severe TBI, despite the lack of prospective controlled
research studies showing clear efficacy as an individual patient treatment
modality. The role of ICP monitoring in the initial emergency department
(ED)

Fig. 4. Neurologic effects of hypocapnia. Systemic hypocapnia results in

cerebrospinal fluid alkalosis, which decreases CBF, cerebral oxygen delivery,
and, to a lesser extent, cerebral blood volume. The reduction in ICP may be
lifesaving in patients in whom the pressure is severely elevated; however,
hypocapnia-induced brain ischemia may occur because of vasoconstriction
(impairing cerebral perfusion), reduced oxygen release from hemoglobin, and
increased neuronal excitability, with the possible release of excitotoxins, such
as glutamate. Over time, cerebrospinal fluid pH and, hence, CBF, gradually
return to normal. Subsequent normalization of the partial pressure of arterial
carbon dioxide can result in cerebral hyperemia, causing reperfusion injury to
previously ischemic brain regions. (From Laffey JG, Kavanagh BP. Hypocapnia.
N Engl J Med 2002;347:44; with permission. Copyright 2002, Massachusetts
Medical Society

5. Kenapa didapatkan dada asimetris ada luka tusuk dihemithoraks

PATHO-PHYSIOLOGY IN PENETRATING WOUNDS OF THE CHEST
Penetrating injuries of the chest produce ill-effects as a
result of the following factors:
1. Blood-loss and shock.
2. Impairment of pulmonary ventilation owing to:
(a) presence of air and blood in the pleural space,
causing partial or complete collapse of lung,
(b) injury to pulmonary parenchyma, diaphragm
and chest wall,
(c) pain with fixation of the hemithorax, and
(d) phenomenon of 'pendelluft'.
3. Reduced cardiac output owing to:
(a) reduced venous return, due to loss of negative
pressure within the thoracic cage, loss of circulating
blood volume by internal or external
haemorrhage or kinking of large veins due to
mediastinal shift, and
(b) cardiac tamponade.
The collapse of the lung may have to its credit a
beneficial effect, in that it causes a reduction of the
volume of circulating blood and air within it, and so
lessens the loss of blood and air from the injured lung.
This is why progressive increase of a haemothorax or
pneumothorax is uncommon. When it does occur, it is

usually due to involvement of a major bronchus or vessel

such as hilar, intercostal or internal mammary vessels.
These are the cases that frequently die within a few hours
of injury or fail to respond to adequate resuscitative
measures.

6. Kenapa suara nafas hemithoraks kanan menghilang ?

Primary survey
Physical examination
Physical examination is the primary tool for diagnosis of acute trauma to
the chest (Figure 2), but it may be very difficult to do in a noisy Accident
and Emergency department. Signs of sig-nificant thoracic injury may be
subtle or even absent even under ideal conditions. The process of physical
examination should be concise and done simultaneously with
resuscitation: time must not be wasted.
The position of the patient will affect the clinical findings on
examination (Figure 3). A haemothorax will be dull to percussion
with absent breath sounds at the bases in the erect patient; signs
will be posterior in the supine patient.

7. Mengapa kondisi penderita semakin menurun setelah diberikan

oksigen dengan face mask ?

8. Apa interpretasi GCS 11?

9. Pemeriksaan penunjang ?
Radiologi :
Px lab :
10.
Penanganan masalah dari skenario ?
11. DD ?

OPEN PNEUMOTHORAX

Penetrating chest wound

A sucking or hissing sound with inhaling
Difficulty breathing
Impaled object in chest
Froth or bubbles around injury
Coughing up blood or blood-tinged sputum

Pain in chest or shoulder

CLOSSED PNEUMOTHORAX

TENSION PNEUMOTHORAX

Difficulty breathing
Chest pain
Unilateral decreased/absent breath sounds
Anxiety or agitation
Increased pulse
Tracheal deviation
Jugular venous distention (JVD)
Cyanosis

HEMOTHORAX

12.
Kenapa dilakukan pemeriksaan abdomen ?
Untuk menyingkirkan diagnosis banding
Step 4
Multiple
trauma

Trauma kapitis

Trauma
thoraks