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8/16/2019 Acute Limb Ischemia.pptx
http://slidepdf.com/reader/full/acute-limb-ischemiapptx 1/49
Presentator : dr. Dedi Irwansyah
Pimpinan Sidang : dr. Dairion Gatot, Sp.PD,KHOM
DEPAREME! PE!"AKI DA#AM $K %S%&RS%PHAM
'ase Pro()em *
RA 1(WANITA )RSUP HAM
8/16/2019 Acute Limb Ischemia.pptx
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IDE!IAS PASIE!!ama : KS%m+r : - tah+n
enis Ke)amin : Peremp+an
angga) )ahir : **/-0/1233A)amat : D%S%! III 4 #.KO!GSI GG S"%K%R
Pe5er6aan : IR
Stat+s : Meni5ah
Pendidi5an : amat S#PS+5+ : 4ata5
Agama : Kristen Protestan
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8/16/2019 Acute Limb Ischemia.pptx
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Gizi BB : 48 kg 4: 1-'mIMT : 18,755g/m7 8 normoweight9
Kesadaran Compos Mentis Deskripsi: Dalam batasnormal
Nadi Frekuensi : 84 x/menit Reguler, t/v: ukup
!ekanan dara" #erbaring:$engan kanan: %&&/'&mm(g$engan kiri : %&&/'&
mm(g
Duduk:$engan kanan:%&&/'&mm(g$engan kiri :%&&/'&
mm(g
!emperatur )ksila: *',+ C Rektal : tdp
-erna.asan Frekuensi : & x /menit Deskripsi: Regular
8/16/2019 Acute Limb Ischemia.pptx
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Kepa)a◦ Mata: 'on6. pa)pe(ra inerior p+;at 8&/&9,s5)era i5teri5 8&/&9
#eher : < R&* ;mH*O, tra;hea media), str+ma tida5 mem(esar,
KG4 tida5 tera(a
ora5s
JANTUNG
4atas ant+ng Re)ati: Atas : I'R III sinistra
Kanan : #inea Sterna)is De=tra
Kiri : 1 ;m )atera) #M'S I'R < sinistra
ant+ng : HR : >- =/menit, irreg+)er, M1?M* ,A*?A1 ,P*?P1 ,A*?P*, desah8&9
Depan Belakang
Inspeksi 0imetris .usi.ormis,
spider nevi 123
0imetris .usi.ormis
Palpasi 0F ka ki, kesan normal 0F ka ki, kesan normal
Perkusi 0onor 0onor
Auskultasi 0- : 5ersikuler0!: 2
0- : 5ersikuler0!: 2
Pemeri5saan @si5
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A(domen: soepe), H/#/R tt(
Pinggang : tapping pain &/& Ing+ina) : Pem(esaran K4G 8&9
E5stremitas :
S+perior : hematom 8&9/89
Inerior :
de=tra : oedem89 dors+m pedis dan preti(ia de=tra , hematom89, sensasi men+r+n, dingin, (+)a 89 (ir+.Sinistra : oedem 8&9 hematom 89 p+)sasi a.emora)is 8/9p+)sasi a. dors+m pedis : /sdn
Ke)amin : dp
Pemeri5saan @si5
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Hasi) #a( IGD 1-/11/*-13Dara r!"i#H(: 1B, gC, #e+5osit: 1*,*/mmB, Ht: * C, rom(osit: *>B.---/mmB,M'<: 1-* #, M'H: B*,3 g, M'H': B*, gC!/#/M/E/4 3/1>/1B/*,3/-,*
Uri#a$i%a:Farna: 5+ning 6ernih, g)+5osa 8&9, (i)ir+(in 8&9, 5eton 8&9, (erat 6enis 1,-1-,pH .-, protein 8&9, %ro(i)inogen 8&9, !itrit 8&9, Darah 8&9,
Sedimen: Eritrosit -&1 #P4, #e+5osit -&1 #P4, Epite) -&1 #P4, 'asts 8&9,Krista) 8&9
&GD A'Ra#'*: > mg/d#,
Gi#+a$
%re+m: *0,1- mg/d# Kreatinin:1,2 mg/d# 'r.') : 0B ;;/mnt
$-k"r$i" :!atri+m : 1.5 mE/), Ka)i+m: ,1 mE/), K)orida : 20 mE/)
A#a$i%a ga% 'ara
pH 0,1>, p'O* *,B mmHg, pO* 12*,2 mmHg, (i5a(onat 1, mmo)/#, tota) 'O* 10, mmo)/#, 5e)e(ihan (asa &,3 mmo)/#, sat+rasi O* 22,C
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Dara r!"i#H(: 1B, gC, #e+5osit : 1.1*-/mmB, rom(osit: *-B.---/mmB,
M'<: 1-1.>- #, M'H: B3.*- pg, M'H': B.- gC
Hit+ng 6enis : !e+tro@) 0*.2-C, #imosit 10.-C, Monosit2.B-C, Eosino@) -.*-C, 4aso@) -,*--C
Gi#+a$%re+m: 1BB.*- mg/d), 5reatinin:1.* mg/d)
$-k"r$i"
!a: 1B2 me/#, K: ,* me/#, '): 1- me/#
Osmo)aritas *>B.->3
/aa$ H-*%"a%i%
P rasio 3,3, I!R 3,2, AP rasio 1,2B, rasio -,23,@(rinogen >, D&dimer B1B
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Ha"i
A)(+min B.0 g/d)
KGD random 1-.3- mg/d#
roponin -.1- g/#
A#a$i%a Ga% DarapH: 0.2, p'O*: 12.-, pO*: *-*.-,
4i5ar(onat 8H'OB9: 1.B, ota) 'O*: 1.2,Ke)e(ihan 4asa 84E9: &.1, Sat+rasi O*: 2>.-
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$OO ORAKS
$oto thora= PA ra5ea media)
+)ang inta5
'R J3-C
S+d+t 5ostoreni5+s
)an;ip
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&G (110110215):
Atria) $i(ri)asi, a=isnorma), PR intera)tida5 (isa dini)ai,
ge)om(ang P s+)itdini)ai, LRS rate >-=/i, LRS d+r -,-> s, inerse II, III, A<$,#<H 8&9, R<H 8&9,<ES 8&9.
Kesimp+)an: Atria)$i(ri)asi!ormoentri5+)arRespon 8A$ !<R9.
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&A;+te #im( Is;hemi; denganhaematoma& Stat+s Hipo5oag+)asi&'H$ $; I e; MS seere&A$ !<R
&AKI stadi+m Ris5
Assessment
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& irah (aring&Diet ant+ng III&I<$D !a') -.2C 1- gtt/i 8mi5ro& In6. Ketoro)a; B- mg/> 6am&In6. <it K 1 amp/* 6am& In6. Koa5 *3 +nit/5g44*3 = -N 13-- N * ;&Spirono)a;ton 1 = *3 mg
& ISD! 3 mg 8S#9 (i)a nyeri dada& $+rosemide 1 = - mg& rans+si $$P 1- ;;/5g44
erapi
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Ren;ana :
Darah #eng5apHS
D&dimer$i(rinogen4)eeding imeA)(+minE)e5tro)itEKG seria)
$oto thora5sE5o5ardiogra@Pro@) )ipid%SG Dopp)erArteriogra@
Panta+ %OP * 6am%rina)isa/ 5+)t+r +rin/S%SG Gin6a) dan Sa)+ran 5emih
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$o))ow +p angga) 11 no *-13S : Ke(as pada 5a5i 5anan 89, )e(am 89
O : Sens: 'ompos Mentis D : 11-/- mmHg!adi: 0- =/mnt, reg+)er, t/: ;+5+pRR : *- =/mnt emp: B,Q'PD : Mata : s;)era i5teri5 8/9,#eher: t6 R&* ;mH*-, tra5ea media)Par+: Sp : esi5+)er
ant+ng : S1 S* ireg+)er, m+rm+r 89E5stremitas :S+perior : hematoma 8&9/89Inerior: de=tra : oedem 89 dors+m pedis dan Preti(ia de=tra, hematom 89,Sensasmen+r+n, dingin, (+)a 89 4ir+.
Sinistra: oedem 8&9, hematom 89, P+)sasi a. emora)is: 8/9P+)sasi a. dors+m
pedis: /s+)it dini)ai. Diisi HOM:S: #e(am 89O: Sens: 'M D: 11-/- mmHgHR: 0- =/I RR: *- =/i
emp: B.'
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awa(an Kons+) Kardio)ogi: erima 5asih atas 5ons+)nya. "ang ditem+5an pada pemeri5saanperemp+an, - tah+n, 5e)+han +tama 5e(as pada 5a5i 5anan,
)e(am 89, riwayat nyeri 89, pasien meng5ons+msi Simar; 1 = *mg 5arena menderita penya5it 6ant+ng se6a5 * tah+n tera5hir.Riwayat sesa5 napas (i)a (era5tiitas sedang, P!D 8&9, DOE 8&9,riwayat nyeri dada 5has angina pe;toris 89, riwayat DM 8&9,Hipertensi 8&9, 5o)estero) tinggi 89, asam +rat tinggi 89.<ita) Sign: Sens: 'M D: 11-/- mmHg!adi: 0- =/I RR: *- =/I emp: B. 'Kepa)a : Mata: Anemis 8&/&9, i5teri5 8&/&9#eher: <P S&* ;m H*O hora5s: SP: <esi5+)er S: 8&/&9 ant+ng: S1 S* ireg+)er, m+rm+r 89A(domen: Soepe), H/#/R: tida5 tera(a, perista)ti5 89 !orma).E5stremitas:E5stremitas :S+perior : hematoma 8&9/89Inerior: de=tra : oedem 89 dors+m pedis dan Preti(ia de=tra,hematom 89, Sensasi men+r+n, dingin, (+)a 894ir+.
Sinistra: oedem 8&9, hematom 89, P+)sasi a. emora)is: 8/9P+)sasi a. dors+m pedis: /s+)it dini)ai
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6K7: )trial Fibrilasi, axis normal, -R interval tidak bisa dinilai, gelombang -sulit dinilai, R0 rate 8& x/i, R0 dur &,&8 s, ! inverse 99, 999, )5F, $5( 123,R5( 123, 560 123Foto !"oraks: C!R ; <&= 1.oto sedang dibaakan di Radiologi3
7e>ala )$9: -arastesia 1?3, -oikilotermi 1?3, pulselessness 1?3, pain 1?3, 14/'3 std 99 )/#Dx: C(F F 9 e M0 severe ? )$9 dengan (ematom ? )F N5R ? 0tatus(ipokoagulasi!x: 2!ira" #aring
2Captopril * x ',< mg 20pironolakton % x < mg 2#isoprolol % x ,< mg 20imvastatin % x & mg 290DN < mg 10$3 bila n@eri dada 29n> 5it K % amp/4 >am
2(entikan 0imar
)n>uran: ek lipid pro.il dan uri aid
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&A;+te #im( Is;hemi; denganhaematoma& Stat+s Hipo5oag+)asi&'H$ $; I e; MS seere
&A$ !<R&AKI stadi+m Ris5
Assessment
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irah (aringDiet ant+ng III
I<$D !a') -.2C 1- gtt/i8mi5roIn6. Ketoro)a; B- mg/>
6amIn6. <it K 1 amp/* 6am
Spirono)a;ton 1 = *3 mgISD! 3 mg 8S#9 (i)a nyeridada$+rosemide 1 = - mg
rans+si $$P 1- ;;/5g44
erapi
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$o))ow +p angga) 1* no *-13S : !yeri pada 5a5i 5anan 89, )e(am 89O : Sens: 'ompos Mentis D : 1--/- mmHg!adi: 0- =/mnt, ireg+)er, t/: ;+5+pRR : *- =/mnt emp: B,Q'PD : Mata : s;)era i5teri5 8/9,#eher: t6 R&* ;mH*-, tra5ea media)
Par+: Sp : esi5+)er ant+ng : S1 S* ireg+)er, m+rm+r 89E5stremitas :S+perior : hematoma 8&9/89Inerior: de=tra : oedem 89 dors+m pedis dan Preti(ia de=tra,hematom 89, Sensasi men+r+n, dingin, (+)a 89 4ir+.
Sinistra: oedem 8&9, hematom 89, P+)sasi a. emora)is: 8/9P+)sasi a. dors+m pedis: /s+)it dini)ai
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$aa) Hemostasis:P: R: *,1* I!R: *,1 AP: R: 1,--3 : R:
-,2A)(+min: B.* g/D)Pro@) #ipid:Ko). ota)/rig)iserida/HD#/#D#:
1-*/1B/B*/33Asam +rat: 2.* mg/d)
Hasi) #a( 1*/11/*-13
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FolloA up divisi Kardiologi:0: 0esak 1?3B: 0ens: CM !D: %&/8& mm(g (R: +& x/9 irregular -edis 1R3: -ulselessness 1?3, a dorsalis pedis tidak teraba, pain1?3, poikilotomi 1?3, bulla 1?3): C(F F 9 e M0 severe )F N5R 0tatus (ipokoagulasi
)$9 dengan "ematom-: !ira" #aring Captopril * x ',< mg 0pironolakton % x < mg #isoprolol % x ,< mg 0imvastatin % x &
90DN < mg 1k/p3 9n> 5it K % amp/4 >am 19M3R: 6"oardiogra.i, 07 Doppler
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Hasi) %SG Dopp)er81*/11/*-139:
&Arteri: Di6+mpai ge)om(ang 4ipasi5 padaarteri emora)is 5anan, arteri emora)is 5iri,
arteri pop)itea 5iri dan arteri ti(ia)isposterior 5iri.Di6+mpai ge)om(ang monophasi5 padaarteri pop)itea 5anan.
Di6+mpai no ow pada arteri ti(ia)isposterior 5anan dan arteri dorsa)is pedis5anan.&<ena: D< 8&9.&Kesimp+)an: Gangg+an ow m+)ai a.
pop)itea 5anan hingga TUno owUU pada a.
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H i) E5 5 di @
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Hasi) E5o5ardiogra@ 81*/11/*-139:
Kesimp+)an: MS seere, MR mi)d, AS seere,AR moderate, R seere, PR mi)d e; RHD.
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aAaban Konsul Divisi Ne.rologi:0: lebamB: 0ens: CM !D: %&/8& mm(g ): Emg/dl): )K9 stad Risk 0tatus (ipokoagulasi C(F F 9 e C)D )F N5R -: perbaiki .ungsi renal dengan meningkatkan
pompa >antung
)n>uran: rinalisa, 07 7in>al dan 0aluranKemi"
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&A;+te #im( Is;hemi;dengan haematoma& Stat+s Hipo5oag+)asi&'H$ $; I e; MS seere&A$ !<R&AKI stadi+m Ris5
Assessment
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irah (aring'aptopri) B = ,*3
mgSpirono)a;ton 1 =*3 mg
4isopro)o) 1 = *,3mgSimastatin 1 = *-
mgISD! 3 mg 8S#9(i)a nyeri dadaIn6. <it K 1 amp/*am
erapi
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(asil 07 7in>al
dan 0aluranKemi"
1%*/%%/&%<3:
)ute
aute tubula
ne.ritis)n>uran: (indari
obat ne.rotoksik,
urinalisa, kultur
urin
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(asil rinalisa 1%*/%%/&%<3:arna: kuning >erni", protein 123, bilirubin 123,glukosa 123, nitrit 123, sedimen epitel: %&2&/ $-#
(asil $ab 1%*/%%/&%<3 :
Dara" $engkap :(b : %%,4&(t : *4,%& =$eukosit : %'8&&/mm*
!rombosit : %<%&&&/mm*
Faal 7in>al :reum : 4,4& mg/dlKreatinin : &,+8 mg/dl
asam urat : ',8 mg/dl
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E)e5tro)it!atri+m : 130 mE/#Ka)i+m : B, mE/#K)orida : 1-0 mE/#
$aa) HemostasisP : rasio : 1,0*I!R : 1,0-
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FolloA up divisi Kardiologi:0: N@eri kaki 1?3
B: 0ens: CMG!D: %&&/'& mm(gG !emp: *', HC-edis 1R3: ' - 1?3): )$9 C(F F 9 e M0 severe )F N5R 0tatus (ipokoagulasi
-: !ira" #aring Captopril * x ',< mg 0pironolakton % x < mg #isoprolol % x ,< mg 0imvastatin % x & mg 1malam3 90DN < mg 1k/p3
R: ek (0! )rteriogra.i
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FolloA up !im aga :0: $ebam pada lengan dan tanganB: 0ens: CMG !D: %%&/'& mm(gG (R: 84 x/9G RR: & x/9G !emp: *+ HC6kstremitas: (ematoma 1?3 pada lengan dan tangan): 20tatus (ipokoagulasi 2C(F F 9 e M0 severe 2)ute $imb 9s"emi dengan "aematoma 2)F N5R
2)K9 stadium Risk -:!ira" baring& Diet antung 999
& 95FD NaCl &E= %& gtt/i 1mikro& 9n> Ketorola *& mg/8 >am& 9n> 5it K % amp/4 >am& 0pironolaton % x < mg& 90DN < mg 10$3 bila n@eri dada& Furosemide % x 4& mgRenana: masuk 9n> $ovenox &,4 /% >am/9M
)dvis dari stase kardiologi, an>uran: Kon.irmasi stase (BM, >aAaban stase(BM: ek ulang (0!, D2dimer, Fibrinogen)dvis dr Iainal 0a.ri, 0p-D viatelepon untuk diberikan 9n> $ovenox &,4 / % >am/9M selan>utn@a advis dr0avita (, 0p-D untuk diberikan FF- %& 9/kg## 1meli"at status koagulasi %,+3dan setela" diberikan FF- dilan>utkan dengan pemeriksaan (0!, D2dimer,Fibrinogen Dan bila "asil suda" keluar diberikan $ovenox &,4 /% >am/9M
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Assesment
&A;+te #im( Is;hemi; dengan
haematoma & Stat+s Hipo5oag+)asi
&'H$ $; I e; MS seere
&A$ !<R
&AKI stadi+m Ris5
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irah (aring'aptopri) B = ,*3 mgSpirono)a;ton 1 = *3 mg
4isopro)o) 1 = *,3 mgSimastatin 1 = *- mgISD! 3 mg 8S#9 (i)a nyeri dadaIn6. <it K 1 amp/* 6am
erapi
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$o))ow +p angga) 1&1 !o *-13S : !yeri pada 5a5i 5anan 89, s+)it digera55an 89, )e(am 89, sesa5napas 8&9
O : Sens: 'ompos Mentis D : 11-/- mmHg!adi: >* =/mnt, reg+)er, t/: ;+5+pRR : *- =/mnt emp: B,BQ'%OP: -- ;;/* 6am <AS : 1&*PD : Mata : s;)era i5teri5 8/9,#eher: t6 R&* ;mH*-, tra5ea media)
Par+: Sp : esi5+)er ant+ng : S1 S* ireg+)er, m+rm+r 89E5stremitas :S+perior : hematoma 8&9/89Inerior: de=tra : oedem 89 dors+m pedis dan Preti(ia de=tra,hematom 89,Sensasi men+r+n, dingin, (+)a 89 4ir+.
Sinistra: oedem 8&9, hematom 89, P+)sasi a. emora)is: 8/9P+)sasi a. dors+m pedis: /s+)it dini)ai. anda ita) : Sens: 'ompos Mentis, D :11-&1B-/>-&2- mmHgPo)s : >&>> =/mnt, reg+)er, t/: ;+5+p , RR : 1>&*-=/mnt, emp: B0,*&B>,3Q '%OP:2--&1---;;/*6am.
<AS /3
H i) # ( 8 i
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Hasi) #a( 8senin,1/11/*-139
Eritrosit : *,23 = 1- /mmB
#e+5osit : 1,1 =1-B/mmB
rom(osit : 1B2= 1-B/mmB
P : rasio : 1,*0 deti5aP : rasio : 1,-1 deti5
rom(in : -,>1 deti5
$i(rinogen : 1>-.- mg/d)
D&dimer : *B0 ng/d)
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Hasi) Arteriography 8se)asa, 10/11/*-139
Ren;ana Arteriography 8 senin,1/11/*-139
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Assesment
&A;+te #im( Is;hemi; dengan
haematoma & Stat+s Hipo5oag+)asi
&'H$ $; I e; MS seere
&A$ !<R
&AKI stadi+m Ris5
8/16/2019 Acute Limb Ischemia.pptx
http://slidepdf.com/reader/full/acute-limb-ischemiapptx 47/49
irah (aring'aptopri) B = ,*3 mgSpirono)a;ton 1 = *3 mg4isopro)o) 1 = *,3 mgSimastatin 1 = *- mgISD! 3 mg 8S#9 (i)a nyeri dadaIn6. <it K 1 amp/* 6am
erapi
8/16/2019 Acute Limb Ischemia.pptx
http://slidepdf.com/reader/full/acute-limb-ischemiapptx 48/49
Nama Penderita : Klara BR SiraitNo. RM. : 65.9.!9
6 " 9 # 6
No
.
$anggalDitemuka
nM A S A % A &
Masala'
Selesai($anggal $erkontrol( $anggal $etap
) %%/%%/&%< 0tatus (ipokoagulasi J 1%*2%%2&%<3
! %%/%%/&%< C(F F 9 e M0 severe J 1%*2%%2&%<3
* %%/%%/&%< )ute $imb 9s"emi dengan"aematoma
J 1%*2%%2&%<3
" %%/%%/&%< )F N5R J 1%*2%%2&%<3
5 %%/%%/&%< )K9 stadium Risk J 1%*2%%2&%<3
Ad Vitam : Dubia ad bonam
Ad Functionam : Dubia ad bonam
Ad Sanationam : Dubia ad bonam
8/16/2019 Acute Limb Ischemia.pptx
http://slidepdf.com/reader/full/acute-limb-ischemiapptx 49/49
Ta#k !