p1 KGD - Putri

First Problem
PUTRI AYUNINGTYAS
405130019
EMERGENCY MEDICINE BLOCK 2017
LI 1
• SHOCK:
- Klasifikasi (etiologi, tanda dan gejala, PF & PP,
tatalaksana)
- Algoritma
CLASSIFICATION OF SHOCK
HYPOVOLEMIC
CARDIOGENIC
SHOCK
DISTRIBUTIVE
OBSTRUCTIVE
Current Diagnosis & Treatment Emergency Medicine. 7th Ed.

Hypovolemic Shock
• Causes:

Hypovolemic Shock
• Sign and symptoms
Harrison's principles of internal medicine, 18th

Hypovolemic Shock
• Treatment
– Volume resuscitation  isotonic saline / Ringer's lactate
• 2–3 L of salt solution over 20–30 min
• severe traumatic brain injury (TBI)  small volumes of hypertonic
saline
– Continuing acute blood loss + Hb <= 10 g/dL  blood transf
– Administration of fresh-frozen plasma (FFP) and platelets,
packed red blood cells (PRBCs)
– Extreme emergencies  type-specific or O-negative packed red
cells
– norepinephrine, vasopressin, or dopamine may be required
• ONLY IF blood volume has been restored
– Supplemental oxygen + intubation
Harrison's principles of internal medicine,

18th
Cardiogenic Shock
• Causes:

Cardiogenic Shock
• Clinical findings
– Continuing chest pain & – Tachypnea, Cheyne-Stokes
dyspnea respirations
– Pale, apprehensive, – jugular venous distention
diaphoretic – S1 is usually soft, and an S3
– Altered consciousness gallop may be audible
– weak and rapid pulse – Acute, severe MR and VSR
• 90–110 beats/min  systolic murmurs
– Systolic BP <90 mmHg + – LV failure causing CS 
narrow pulse pressure (<30 rales
mmHg) – Oliguria
– quiet precordium + weak • urine output < 30 mL/h
apical pulse
18th
Cardiogenic Shock
• Laboratory findings • ECG
– WBC count > with left – acute MI with LV failure
shift • Q waves and/or >2-mm
– BUN & creatinin >> ST elevation in multiple
leads
– Hepatic transaminase >> • LBBB
– Lactic acid > – 1,5 of infarct  anterior
– Arterial blood gases – severe left main stenosis
• hypoxemia and metabolic  global ischemia
acidosis
• severe (e.g., >3 mm) ST
– creatine phosphokinase, depressions in multiple
troponin I & T > leads

18th
Cardiogenic Shock
• Chest X ray • Echocardiogram
– pulmonary vascular – left-to-right shunt in
congestion patients with VSR
– pulmonary edema – Pulmonary embolism 
– CS results from a first MI Proximal aortic
 heart’s size is normal dissection with aortic
regurgitation or
tamponade

18th
Cardiogenic Shock

18th
Distributive Shock
• Causes:

1. Anaphylactic Shock
• Etiology
– antibiotics
• penicillins, cephalosporins, amphotericin B, nitrofurantoin,
quinolones
– pollen extracts
• ragweed, grass, trees
– nonpollen allergen extracts
• dust mites, dander of cats, dogs, horses, and laboratory animals
– Food
• peanuts, milk, eggs, seafood, nuts, grains, beans, gelatin in
capsules
– occupation-related products (latex rubber products)

18th
Anaphylactic Shock
• Pathophysiology & manifestations
– differ in the time of appearance of symptoms and signs
• hallmark of the anaphylactic reaction is the onset of some
manifestation within seconds to minutes after introduction
– Laryngeal edema
• "lump" in the throat, hoarseness, or stridor
• feeling of tightness in the chest and/or audible wheezing
(bronchial obstruction)
• Secretions >, peribronchial congestion, submucosal edema, and
eosinophilic infiltration, and the acute emphysema (severe cases)
– diffuse erythema and a feeling of warmth
– Urticarial eruption + pruritus

18th
Anaphylactic Shock
• Treatment
– 0.3 to 0.5 mL of 1:1000 (1 mg/mL) epinephrine SC or IM
• repeated doses as required at 5- to 20-min intervals for a severe
reaction
– if intractable hypotension occurs
• 2.5 mL epinephrine, diluted 1:10,000, at 5- to 10-min intervals IV
infusion + normal saline + vasopressor agents (dopamine)
– If hypoxia develops
• Oxygen alone via a nasal catheter or with nebulized albuterol +
endotracheal intubation or a tracheostomy
– Ancillary agents
• antihistamine diphenhydramine, 50-100 mg IM or IV
• aminophylline, 0.25-0.5 g IV

18th
2. Septic Shock

18th
Septic Shock
• Etiology

18th
Septic Shock
• Clinical manifestations
– Hyperventilation
– Disorientation, confusion, and other manifestations of
encephalopathy
• in the elderly and in individuals with preexisting neurologic
impairment
– Cellulitis, pustules, bullae, or hemorrhagic lesions
• develop when hematogenous bacteria or fungi seed the skin or
underlying soft tissue/the effect of bacterial toxins
– Hypotension and DIC predispose to acrocyanosis and
ischemic necrosis of peripheral tissues
– nausea, vomiting, diarrhea, and ileus  acute
gastroenteritis

18th
Septic Shock
• Laboratory findings
– Blood lactate levels > early
•  accumulation of lactate  metabolic acidosis (with increased anion
gap)
• increased glycolysis
• impaired clearance of the resulting lactate and pyruvate by the liver
and kidneys
– blood glucose concentration >
• Patients with DM
– Hypoglicemia
• impaired gluconeogenesis
• excessive insulin release on occasion
– Cytokine acute phase response
• inhibits the synthesis of transthyretin
• C-reactive protein, fibrinogen, and complement components >

18th
Septic Shock
– leukocytosis with a left shift, thrombocytopenia,
hyperbilirubinemia, and proteinuria
– thrombocytopenia worsens
• prolongation of the thrombin time, decreased
fibrinogen, and the presence of d-dimers  suggesting
DIC
– levels of aminotransferases >, azotemia and
hyperbilirubinemia become more prominent
– Hyperventilation  respiratory alkalosis

18th
Septic Shock
• Other examinations
– Chest radiograph
• normal or may show evidence of underlying
pneumonia, volume overload, or the diffuse infiltrates
of ARDS
– ECG
• Tachycardia & nonspecific ST–T-wave abnormalities

18th
Algoritma
Rosen
LI 2
• PERDARAHAN SALURAN CERNA:
- Perbedaan perdarahan saluran cerna atas dan
bawah
- Penyebab perdarahan (patfis)
- Penanganan/tatalaksana
LI 3
• AKUT ABDOMEN:
- Etiologi, PF, PP
- Tanda-tanda akut abdomen
- Tatalaksana
Peritonitis
• Peritonitis is an inflammation of the
peritoneum, the tissue that lines the inner
wall of the abdomen and covers and supports
most of your abdominal organs.
http://www.webmd.com/digestive-disorders/peritonitis-symptoms-causes-treatments
Etiology
• primary spontaneous peritonitis
An infection that develops in the peritoneum
• secondary peritonitis
usually develops when an injury or infection in
the abdominal cavity allows infectious
organisms into the peritoneum.
The most common risk factors for primary
spontaneous peritonitis include:
• Liver disease with cirrhosis
Such disease often causes a buildup of abdominal
fluid (ascites) that can become infected.
• Kidney failure getting peritoneal dialysis
The implantation of a catheter into the peritoneum,
is used to remove waste products in the blood of
people with kidney failure. It's linked to a higher risk
of peritonitis due to accidental contamination of
the peritoneum by way of the catheter.
Common causes of secondary peritonitis
include:
• A ruptured appendix, diverticulum, or stomach ulcer
• Digestive diseases such as Crohn's disease
and diverticulitis
• Pancreatitis
• Pelvic inflammatory disease
• Perforations of the stomach, intestine, gallbladder, or
appendix
• Surgery
• Trauma to the abdomen, such as an injury from a knife
or gunshot wound
Harrison_s - Medicina Interna - 16th_Edition
• Aseptic peritonitis may be due to peritoneal
irritation by abnormal presence of physiologic
fluids (gastric juice, bile, pancreatic enzymes,
blood, urine) or sterile foreign bodies (surgical
sponge, starch from surgical gloves)

Pathophysiology
Pathophysiology peritonitis
from appendicitis
perforation
Sign & symptoms
• The first symptoms of peritonitis are typically poor
appetite and nausea and a dull abdominal ache that
quickly turns into persistent, severe abdominal pain,
which is worsened by any movement.
• Abdominal tenderness or distention
• Chills
• Fever
• Fluid in the abdomen
• Extreme thirst
• Not passing any urine, or passing significantly less urine
than usual
• Difficulty passing gas or having a bowel movement
• Vomiting
Test & Diagnosis
• Blood tests. A sample of your blood may be drawn and sent to a lab
to check for a high white blood cell count. A blood culture also may
be performed to determine if there are bacteria in your blood.
• Imaging tests. Your doctor may want to use an X-ray to check for
holes or other perforations in your gastrointestinal tract. Ultrasound
may also be used. In some cases, your doctor may use a
computerized tomography (CT) scan instead of an X-ray.
• Peritoneal fluid analysis. Using a thin needle, your doctor may take
a sample of the fluid in your peritoneum (paracentesis), especially if
you receive peritoneal dialysis or have fluid in your abdomen from
liver disease. If you have peritonitis, examination of this fluid may
show an increased white blood cell count, which typically indicates
an infection or inflammation. A culture of the fluid may also reveal
the presence of bacteria.
http://www.mayoclinic.org/diseases-conditions/peritonitis/basics/tests-diagnosis/con-20032165
Acute Appendicitis
• Appendicitis is a very common cause of
emergency surgery. The problem most often
occurs when the appendix becomes blocked
by feces, a foreign object, or rarely, a tumor
https://www.nlm.nih.gov/medlineplus/ency/article/000256.htm
Etiology
• Tumor
• Calculus (often called a stone, is a concretion of
material, usually mineral salts, that forms in an
organ or duct of the body)
• Parasite
• Bacteria
• Viral infection
• Enlarged lymph node
• Foreign objects
Rosen’s Emergency Medicine Conceps and Clinical Practice
https://www.nlm.nih.gov/medlineplus/ency/article/000256.htm
Pathophysiology
• Obstruction of the appendiceal lumen 
intraluminal pressure rise and mucosal
secretions are unable to drain  ulceration
and ischemia  bacteria and PMN cells begin
to invade the appendiceal wall  swollen
irritate surrounding structures  hypoxia
 gangrene perforation

Sign & Symptoms
• Abdominal pain (right lower quadrant)
• Anorexia
• Nausea
• Vomiting
• Diarrhea
• Temperature normal or slightly elevated 370C-380C
• Temperature >380C  should suggest perforation
• Leukocytosis (10.000 – 18.000 cells/microL)
• Leukocytosis (>20.000 cells/microL)  suggests
probable perforation
Diagnosis
• Physical examination • Diagnostic score
– Rovsing’s sign – Alvarado score
– McBurney’s sign • Imaging
– Blumberg’s sign – Plain radiography
– Psoas sign – Barium Enema
– Obturator sign – USG
• Lab – CT
– Leukocytosis – MRI
– CRP – Laparoscopy
– Urinalysis

Hernia
• Hernia is defined as an abnormal protrusion of an
organ or tissue through a defect in its surrounding
walls
• Abdominal wall hernias occur only at sites at which the
aponeurosis and fascia are not covered by striated
muscle
Townsend CM, Beauchamp RD,

Evers BM, Mattox KL. Sabiston
textbook of surgery. 19th Ed.
Philadelphia : Elsevier
Saunders; 2012
Incarcerated Hernia
• A hernia is reducible when its contents can be replaced within the
surrounding musculature, and it is irreducible or incarcerated when
it cannot be reduced
• If the omentum or a loop of intestine becomes trapped in the weak
point in the abdominal wall, it can obstruct the bowel
• Clinical presentation :
– Severe pain
– Nausea
– Vomiting
– Inability to have a bowel movement or pass gas
– The overlying skin should appear to be normal
– The contents should not be tense
– Bowel sounds can sometimes be heard
Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery. 19th Ed. Philadelphia :
Elsevier Saunders; 2012
Strangulated Hernia
Strangulation occurs more often in large hernias
that have small orifices  entraps the hernia
contents  obstructs arterial blood flow, venous
drainage, or both to the contents of the hernia
sac
Strangulated Hernia
• This can lead to the death of the affected bowel
tissue
• Femoral hernias have the highest rate of
strangulation
• Clinical presentation :
Hernia associated with
– Vomiting
– Blood in excrement
– Constipation
– Malaise with or without fever
– A burning or hot sensation around the hernia
http://www.drugs.com/health-guide/images/205087.jpg
Incarcerated
Hernia
http://radiopaedia.o
rg/cases/incarcerate
d-ventral-hernia-1
Strangulated Hernia
http://www.bjui.o
rg/ContentFullIte
m.aspx?id=660
Management
• Preperitoneal repair
• The hernia sac contents can be directly visualized
and their viability assessed through a single
incision
• The constricting ring is identified and can be
incised to reduce the entrapped viscus with
minimal danger to the surrounding organs, blood
vessels, and nerves
• If it is necessary to resect strangulated intestine,
the peritoneum can be opened and resection
done without the need for a second incision.
• Complication
– If strangulation is not recognized,
gangrenous bowel can be reduced, which
leads to peritonitis and sepsis
– Recurrent Hernia
• Prevention
Hernia should be repaired at the time of
discovery
Intussusception
• Invagination of one
portion of the bowel into
an immediately adjacent
portion
• The proximal segment,
or intussusceptum, is
carried by progressive
smooth muscle
contractions into the
distal segment, or
intussuscipiens
Source: Sands DR. Intestinal intussusception [Internet]. Clin Colon Rectal Surg. 2008 May; 21(2): 106–113. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780199/
Etiology (pediatric)
Source: Sands DR. Intestinal intussusception [Internet]. Clin Colon

Rectal Surg. 2008 May; 21(2): 106–113. Available from:
Etiology (adult)
Source: Sands DR. Intestinal

intussusception [Internet]. Clin
Colon Rectal Surg. 2008 May;
21(2): 106–113. Available from:
http://www.ncbi.nlm.nih.gov/p
mc/articles/PMC2780199/
Clinical Presentation (pediatric)
• Sudden onset of abdominal pain exhibited by the
drawing up of the knees, screaming, and lethargy
between painful bouts
• The onset of pain is shortly followed by
obstructive symptoms such as bilious vomiting
and abdominal distension
• Half of cases progress to bloody, mucoid “currant
jelly” stools within 12 hours
• Depending on timing of presentation they may or
may not have fever and leukocytosis
• Physical exam  Dance's sign
Source: Sands DR. Intestinal intussusception [Internet]. Clin Colon Rectal Surg. 2008 May; 21(2): 106–113. Available from:
Clinical Presentation (adult)
• Abdominal pain
• Nausea/vomiting
• Diarrhea/constipation
• Rectal bleeding
• Common physical findings  distension,
hypoactive bowels, abdominal tenderness,
and guaiac positive stools
• Abdominal mass is identified infrequently
Source: Sands DR. Intestinal intussusception [Internet]. Clin Colon Rectal Surg. 2008 May; 21(2):
106–113. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780199/
Patient evaluation (Adult)
• CT scan  to evaluate the location and the cause
of the obstruction  reveal the signs of
obstruction including the target sign or sausage-
shaped mass
• When chronic intermittent small bowel
obstruction is the initial presenting sign and adult
enteroenteric intussusception is suspected 
Barium small bowel follow through  a spiral,
“coil spring” or “stacked coin” appearance with
narrowed central canal
Patient evaluation (Adult)
• Colonic obstruction  barium enema and
colonoscopy
• Laparoscopy  identification of the location,
the nature of the lead point, and the presence
of compromised bowel
Treatment
• For all patients who present with signs of
perforation, shock, or peritonitis, immediate
laparotomy is necessary
• In the absence of these signs, the therapeutic
approach to pediatric and adult
intussusception is different
Treatment (adult)
• Definitive surgical intervention is mandatory and
preoperative reduction with barium or air is not
recommended as a part of definitive treatment
• Resect the intussusception en bloc and reduce
the intussusception
• En bloc resection of all colonic lesions, due to the
higher rate of malignancy, but a more limited
resection of small bowel, where malignancy is
less common

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First Problem

Current Diagnosis & Treatment Emergency Medicine. 7th Ed.

Current Diagnosis & Treatment Emergency Medicine. 7th Ed.

Harrison's principles of internal medicine, 18th

Harrison's principles of internal medicine,

Current Diagnosis & Treatment Emergency Medicine. 7th Ed.

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Current Diagnosis & Treatment Emergency Medicine. 7th Ed.

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison's principles of internal medicine,

Harrison_s - Medicina Interna - 16th_Edition

Rosen’s Emergency Medicine Conceps and Clinical Practice

Rosen’s Emergency Medicine Conceps and Clinical Practice

Townsend CM, Beauchamp RD,

Source: Sands DR. Intestinal intussusception [Internet]. Clin Colon

Source: Sands DR. Intestinal

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