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PROGRAM CO-ASSISTEN STASE

BEDAH TKV

Sub Bagian Bedah Thoraks Kardio


Vaskuler
RSUD Dr Muwardi Fakultas Kedokteran UNS
Surakarta

3 Day Program
1st day
Diskusi materi dasar BTKV & Emergency
Mencari kasus yg menarik di ruangan lapor
residen/konsulen & buat status

2nd
Melanjutkan diskusi
Diskusi kasus / kalo tidak ada kasus, pakai metode
phantom
Visite (bed side teaching)

3rd
Melanjutkan diskusi utk menambah nilai jika diperlukan
Membahas kasus BTKV yang menarik (bahan dari
konsultan, residen atau co ass)

Penilaian
Selama diskusi penilaian
kemampuan kognitif & sikap, sesuai
formulir mini
Visite (bed side teaching)
penilaian ketrampilan & sikap,
sesuai formulir mini
Keaktifan dalam diskusi
Penulisan laporan kasus (kelompok)

Materi Dasar Bedah TKV


Pemeriksaan fisik
Pemeriksaan khusus BTKV (varices &
arterial injury)
Awal resusitasi & BLS
Chest XR
WSD
Penyakit Jantung Koroner
Penyakit Jantung Bawaan
Tumor regio Thoraks

Kaidah Dalam Emergency


1.
2.
3.
4.

ABC
LLF
Diagnostic cepat & tepat
Penatalaksanaan tepat
1.
2.
3.
4.

Life saving
Definitive
Pemeriksaan penunjang
Merujuk

5. Observasi & evaluasi

Look Listen - Feel


1. Airway
L: gerakan dada,
L: suara nafas & ST,
F: hembusan nafas

2. Breathing
L: tanda2 sesak, DVJ, gerakan dada paradoksal &
tertinggal
L: SD, ST
F: Perkusi !!

3. Circulation
L: anemis, cyanosis, DVJ
L: SJ, SJ menjauh
F: akral dingin, CRT, nadi, tekanan darah

Materi dasar Emergency


Airway obstruction & management
Tension pneumothorax & sucking
chest wound
Massive hemothorax
Tracheobronchial injury
Flail chest
Pericardial tamponade
Laceration of vascular structure

CARDIO THORACIC VASCULAR


SURGERY
(Basic Knowledge & Skill)

For Internship Program


UNS Medical Faculty Dr Moewardi
Hospital
Surakarta

Pathophysiology of Trauma

Blunt Trauma
Results from kinetic energy forces
Subdivision Mechanisms
Blast

Pressure wave causes tissue disruption


Tear blood vessels & disrupt alveolar tissue
Disruption of tracheobronchial tree
Traumatic diaphragm rupture

Crush (Compression)

Body is compressed between an object and a hard surface


Direct injury of chest wall and internal structures

Deceleration

Body in motion strikes a fixed object


Blunt trauma to chest wall
Internal structures continue in motion
Ligamentum Arteriosum shears aorta

Age Factors

Pediatric Thorax: More cartilage = Absorbs forces


Geriatric Thorax: Calcification & osteoporosis = More fractures

Pathophysiology of Trauma
Penetrating Trauma
Low Energy
Arrows, knives, handguns
Injury caused by direct contact and cavitation

High Energy
Military, hunting rifles & high powered hand guns
Extensive injury due to high pressure cavitation

Injuries Associated with


Cardio Thoracic Vascular Trauma
Airway obstruction
Closed pneumothorax
Open pneumothorax
(sucking chest wound)
Tension
pneumothorax
Pneumomediastinum
Hemothorax
(massive)
Hemopneumothorax
Rib fracture (flail
chest)

Tracheobronchial
tree lacerations
(rupture)
Esophageal
lacerations
Penetrating cardiac
injuries
Pericardial
tamponade
Spinal cord injuries
Diaphragm trauma
Intra-abdominal
trauma associated
organ injury

Airway obstruction
Clinical finding
Shortness of breath (dyspnea)
Stridor
Apnea

Management
Chin lift
Jaw thrust
Triple finger manuever
Evacuate foreign body
Hemlich manuver
ET insertion
Cricothyroidostomy
Tracheostomy

DONT FORGET

CERVICAL SPINE
CONTROL !!!!

Tension Pneumothorax
Build up of air under
pressure in the
thorax.
Excessive pressure
reduces effectiveness
of respiration
Air is unable to
escape from inside
the pleural space
Progression of Simple
or Open
Pneumothorax

Tension Pneumothorax

(simplify)

Anx: Progressive shortness of breath


PE :
Pneumothorax percution: hypersonor
Neck vein distension (severe case)

Treatment :
Needle thoracocentesis
Consult : chest tube insertion

SUCKING CHEST WOUND


Upon exhaling, air
in the chest
escapes through
the flutter-type
valve created by
taping 3 sides only
With inhaling, the
patch should suck
against the skin,
preventing air
entry

Hemothorax
Hemothorax
Accumulation of blood in the pleural space
Serious hemorrhage may accumulate 1,500 mL
of blood
Mortality rate of 75%
Each side of thorax may hold up to 3,000 mL
MASSIVE (criteria)

Blood loss in thorax causes a decrease in tidal


volume
Ventilation/Perfusion Mismatch & Shock

Typically accompanies pneumothorax


Hemopneumothorax

Hemothorax
Blunt or penetrating
chest trauma
Shock

Dyspnea
Tachycardia
Tachypnea
Diaphoresis
Hypotension

Dull to percussion over


injured side
Treatment
Chest tube insertion &
consult

(simplify)

Flail chest
Multiple rib fractures produce a mobile
fragment which moves paradoxically
with respiration
Significant force required
Usually diagnosed clinically
Treatment
ABC
Analgesia
Fixation : internal &/ external

Tracheobronchial Injury
MOI
Blunt trauma
Penetrating trauma

50% of patients with injury die within 1 hr of injury


Disruption can occur anywhere in tracheobronchial tree
Signs & Symptoms

Dyspnea
Cyanosis
Hemoptysis
Massive subcutaneous emphysema
Suspect/Evaluate for other closed chest trauma

Tracheobronchial Injury
Observe for development of
Subcutaneus emphysema &
tension pneumothorax (deadly)
Treatment
Keep airway clear
Administer high flow O2
Consider intubation if unable to
maintain patient airway
If tension needle
thoracocentesis
Consult : tracheal repair or
tracheostomy

Pericardial Tamponade
Restriction to cardiac filling caused by blood or
other fluid within the pericardium
Occurs in <2% of all serious chest trauma
However, very high mortality

Results from tear in the coronary artery or


penetration of myocardium
Blood seeps into pericardium and is unable to escape
200-300 ml of blood can restrict effectiveness of
cardiac contractions
Removing as little as 20 ml can provide relief

Pericardial Tamponade
Dyspnea
Possible cyanosis
Becks Triad

DVJ
Distant heart tones
Hypotension or
narrowing pulse
pressure
Weak, thready pulse
Shock

(simplify)

Kussmauls sign
Decrease or
absence of JVD
during inspiration
Pulsus Paradoxus
Drop in SBP >10
during inspiration
Due to increase in
CO2 during
inspiration
Electrical Alterans
P, QRS, & T
amplitude changes
in every other

Pericardial Tamponade
(ilustrasi)

Laceration of vascular
structures
General sign
Hypovolemia & shock
Penetrating trauma

Internal bleeding
Thoracic Chest XR
Abdominal FAST or CT
Pelvicum CXR
Femur expanding hematoma + XR

External bleeding thorough examination


& suturing

Laceration of vascular
structures
Internal bleeding consult
External bleeding