flail chest & ards
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flail chestTRANSCRIPT
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Flail Chest & ARDS
Heru KoesbijantoSurabaya
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Sejarah Flail Chest
1958 : Emergency War NATO Handbook1988 : Emergency War Surgery NATO Handbook
ARDS1821 : Laenec edema paru tanpa gagal jantung
1961 : Asbaugh Acute Respiratory Distress in Adult
1971 : Acute Respiratory Distress Syndrome
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Insiden Flail Chest :
10%-20% trauma tumpul toraks10%-35% MortalitasPria > Wanita
ARDS :150.000 – 200.000 kasus/tahun AS30%-60% Mortalitas
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Penyebab Flail Chest
Cedera : - langsung mengenai dada - tenaga kinetik besar
ARDS Langsung - aspirasi asam lambung- inhalasi gas toksik- trauma tumpul toraks
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Tidak langsung / sistemik- sepsis- trauma multipel- reaksi transfusi- pancreatitis- pemakaian mesin paru-jantung lamaMediator inflamasi sangat berperan.
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Trauma tumpul toraks- Flail chest- Kontusio paru 50%-60% ARDS
edema alveoli, perdara han & atelektasis
gangguan difusi O2&CO2
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ARDS- Akut- Infiltrat bilateral- Tekanan arteri Pulmonalis < 18 mmHg- PaO2 : FiO2 < 200 mg
Klinis : lemah, sesak, nafas cepat-dangkal, refrakter dengan pemberian O2
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Permasalahan Gangguan Ventilasi
- Gerakan dinding toraks paradoksal
- Nyeri Gangguan Difusi
- Edema alveoli- Perdarahan- Atelektasis
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Flail Chest + ARDS- Prioritas : A-B-C- Penanganan intensif pada pernafasan
Internal Pneumatic
Stabilization
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Intervensi Bedah - Penderita dengan cedera organ intratora kal yang perlu torakotomi- Penderita dengan ventilator :- nyeri hebat- fungsi paru turun - gagal disapih / weaning- Flail chest antero lateral luas late chest wall deformity
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Flail Chest + ARDS Keadaan yang serius Morbiditas & Mortalitas tinggi Penanganan multi disiplin :
- ahli bedah- ahli paru Team
- ahli anestesi/intensivist- ahli rehabilitasi medik
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Algoritme pengelolaan flail chest dengan kontusio pulmonum
Severe Flail Chest
Associated thoracic injuries requiring thoracotomy
Associated thoracic injuries not requiring thoracotomy
Surgical stabilization Respiratory failure No respiratory failure
Surgical stabilization Internal Pneumatic Stabilization
Pulmonary contusion present
Pulmonary contusion absent
Surgical stabilization Internal Pneumatic Stabilization
Prolonged ventilation Resolution
Surgical stabilization
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Intervensi Bedah Kontroversial : - konservatif
- operatifOperatif : - ventilasi mekanik singkat - tinggal di ICU singkat - komplikasi infeksi turun - disfungsi respirasi & deformi
tas dinding dada baik - nyeri berkurang / hilang
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Indikasi & waktu pembedahan - Kontroversial
- Prinsip : - tunda : - KU tidak stabil
- disfungsi pernafasan- dilakukan : - KU stabil
- resolusi parenchim paru
- pernafasan membaik
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Stabilisasi bedah- plate & screw- intramedullary devices- bridging- wiring
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Pengelolaan Kontusio paru
- timbul 24 – 48 jam setelah trauma- rontgen : kesuraman dengan sudut
paru-diafragma tajam- terapi tidak spesifik, oksigenasi, ventilasi
dan analgetika- pemberian cairan : euvolaemi- 50% ARDS
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ARDS - terapi penyebab
- langsung- tidak langsung
- ventilasi mekanik- low tidal volume 6 ml/kgBB- PEEP
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- Posisi penderita- prone / telungkup- membuka atelektasis- drainase postural
- Terapi cairan- euvolaemia- restriksi
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- Kortikosteroid- tidak banyak manfaat- NO- inhalasi : vasodilatasi vaskular paru- bermanfaat : ARDS+hipoksemia berat & hipertensi pulmonal- Surfaktan- tidak bermanfaat
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Ringkasan- Flail chest + kontusio paru / ARDS adalah suatu keadaan yang memerlukan penanganan serius yang melibatkan berbagai disiplin dalam ilmu kedokteran- Masih banyak yang belum tergali pada ARDS,sehingga perlu penelitian dan kajian yang lebih mendalam sehingga morbiditas dan mortalitas dapatditekan.
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