Manajemen akut abdomen by dr. djoko, sp b
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Manajemen Akut
Abdomen
Oleh
dr. Joko Judojoko Sp. B
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Penyebab Akut Abdomen
1. Infeksi (Peritonitis)
Lumen GI Tract
Wanita tubafallopi
2. Gangguan passase usus
Obstruksi mekanik
Obstruksi fungsional
3. Peritonitis kimiawi
Pancreatitis
Perporasi gaster
4. Gangguan vasculer
Aneurisma aorta
Thrombosis mesentrika
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Pendekatannya
Surgical diagnostic making
Latih dan gunakan maksimal kemampuan fisik
dan diagnostic
Imaging hanya untuk konfirmasi
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pada 20 detik pertama tentukan
Very ILL (mengancam jiwa)
ILL (kondisi akut)
Reasonable ILL (Terencana)
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Very ILL
Tidak bisa diselesaikan dua tangan
Panggil teman
Terapi resusitasi dan diagnostik bersamaan
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ILL
Stabil dalam beberapa jam
Investigasi lebih teliti
Inisial managemen terapi (A.B.C)
Definitive Theraphi
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Reasonable ILL
Investigasi dan diagnostik lebih teliti
Terapi konsisten dengan diagnostik
Konsul spesialis ke poliklinik
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Perhatikan Faktor Usia
Gunakan insiden penyakit
tertentu pada usia tertentu
Usia Tua :
kelainan Vaskuler
keganasan
Usia Muda :
Infeksi
Obstruksi
Veritonitis kimiawi
Trauma
Usia Anak:
Apendicitis
invaginasi
Newbound
Kelainan kongenital
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Yang sering dilupakan
Hernia vermoraris pada wanita tua yang kurus
Pada veritonitis umum selalu periksa amilasa /
lipase untuk pankreatitis
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Studi Kasus
OS laki-laki 38 thn supir Truk, KLL di Jalan
Tol kecepatan 80 km/jam menabrak mobil dari
belakang dengan keluhan sakit perut dan sesak
nafas.
Kesan pertama ?
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Studi Kasus
ILL
A: Bersih
B: Nafas Pendek RR 28 /menit
C: Tensi 100/70, Nadi 120, Suhu 36,3
OS kesakitan akral dingin
Apa yang dilakukan ?
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Studi Kasus
IV Line :
Kristaloid / Koloid (Guyur 500cc NHCl)
Periksa laboratorium sample darah bersama
sama dengan pemasangan IV Line
Diberikan Oksigen 8 L/menit
Periksa Thorak pergerakan simetris jejas –
ronchi – vesiculer
Diberikan analgetik
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Studi Kasus
Abdomen:
Jejas + abdomen atas
Nyeri tekan +
Bising usus + lemah
Ektrimitas tidak ada kelainan
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Studi Kasus
Hasil Laboratorium datang
Hb 12 gr %
HT 36
Leukosit 11.000
Troumbosit 200.000
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Studi Kasus
30 menit kemudian OS gelisah dan kesakitan
lagi.
Apa yang dilakukan?
Reevaluasi tensi 90/60, nadi 120, RR 28, Suhu
36,3 C,
A dan B, baik
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Studi Kasus
Abdomen:
Destended
Nyeri tekan +
Nyeri ketok +
Defance muskuler +
Bising usus + lemah
Akral dingin
Kesan apa ? Dilakukan apa?
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Studi Kasus
Kesan Peritonitis dan shock
IV diguyur 1000 cc koloid
Oksigen 8 L
Pasang kateter
Dilakukan apa ?
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Studi Kasus
Hasil Evaluasi
Tensi naik menjadi 100/70
Nadi 100
RR tetap 28
Suhu 36,3
A dan B baik
Kesan apa?
Kesan repid respon
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Studi Kasus
30 menit kemudian
Tensi 80 pervalpasi
Nadi 120
RR 28
Suhu 37,2
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Studi Kasus
Hasil Hb 8 gr%
Kesan on going Bleeding (Transient Respon)
Apa yang dilakukan ?
Awasi tensi nadi
RR suhu dan kesadaran
Infus diguyur coloid 1.000 cc
Sedia darah PRC 2000 cc
Konsul bedah dan OK disiapkan
Selanjutnya apa yang dilakukan ?
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Studi Kasus
IV NaCl 500 dan 2 unit PRC
Tensi menjadi 100/60, Nadi 100 RR 28 gr%
suhu 37,0, kateter urin 40 cc/jam akral hangat
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OS dilakukan explorasi laparotomi ditemukan
Ruptur lien pada hilus
Dilakukan spleenektomi
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Catatan
Pada kasus trauma dan bleeding masif, shock
sangat cepat
Jangan biarkan shock berlama lama
Perfusi O2 sampai ke cel harus senantiasa
dijaga
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Hal baru
Kasus dengan masif bleeding acut
Ingat trias of deed
Coagulopatia
Hipotermi
Asidosis
Jangan biarkan shock berkelamaan
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PATHOPHYSIOLOGI OF
LETHAL TRIAD OF DEATH
Coagulopati
Asidosis
Hypothermia
Tissue HypoxiaBleeding
SevereTrauma
Coloid andCrystaloid infusion
Massive RBCTranfution
Delution ofCoagulation Vaktor
and platelets
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Hipopelemi shock:
Type repid respon
Type transiant respon
Type norespon
Infus kristanoid dan koloid 2000 cc
PRBC O Noncrossmacth
Segera mungkin ganti PRBC crossmacth
FFP, PLT, F VII a Crossmacth
Protokol ATLS
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TissueHypoperfusion
Volume Infusion Diagnostic Studiesas Indicated
OperatingRoom
Nonresponder
TransientResponder
Operating Room
Diagnostic LaporotomyAnd / or thoracotomy
Rapid Diagnostoc Evaluation
Responder
HemorrhagicConsider Operative Tx
Hemorrhagic,Traumatic
Supportive Care
NeurogenicSupportive CareTx spinal injury
ObstuctiveChest tube
Decompress pericardiumTreat cardiac injury
SepticSupportive Care
Tx Primary Infection
Yes No
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Studi Kasus II
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Studi Kasus
Wanita 54 Thn pos os appendictomy hari ke 14
perut kembung dan nyeri, muntah 1 X
Apa yang dipikirkan ?
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Studi Kasus
Keadaan umum ILL (kondisi akut) yang perlu
ditanyakan
Muntah warnanya hijau,
flatus (–) 3 hari
BAB (-) 3 hari
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Studi Kasus
Pemeriksaan:
Keadaan umum lemah, CM
Tensi 120/80 nadi 98 RR 20 Suhu 37,7
Cor dan pulmo TAK
Abdomen distanded
Bissing usus meningkat
Nyeri tekan (+)
Defance (+)
Nyeri ketok (+)
Peka hepar (+)
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Studi Kasus
Colok dubur
TSA baik
Mukosa licin
Ampula kolaf
Sarung tangan
Faeces (-)
Kesannya apa?
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Studi Kasus
Peritonitis
Obstruksi
Apa yang ingin diketahui
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Studi Kasus
Laboratorium
Hb 10,6 gr%
HT 42
Leukosit 11.000
Trombosit 180.000
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Studi Kasus
Apakah perlu pemeriksaan lain ?
Abdomen tiga posisi
Lumen usus dilatasi
R fluid level (+)
Udara bebas (-)
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Studi Kasus
Apa diagnosanya ?
DD obstruksi dan peritonitis
Status A.B baik C dehidrasi ringan (kompensited)
Tindakan IV line infus RL 28 gtt/mnt
Puasa
Pasang NGT
Kateter
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Studi Kasus
Konsul bedah dengan diagnosa
Ileus obstruksi e.c
-strengt ilius DD c.a colon
OS dilakukan eksplorasi laparotomy
diagnosanya ileus obstruksi e.c CA colon
flexura lienalis
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Studi Kasus
Tanda tanda yang mendukung diagnosa
Muntah hijau
Abdomen distanded
Nyeri tekan (+)
Peristaltik meningkat
RT ampula kolaf
ST Faeces (-)
Darah dan lendir (-)
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