CASE REPORT By : Nizar Abdullah (09.04.0.0164)Aqidatul Izzah201410401011033

Supervisor : Dr. dr. Bambang Arianto, Sp. B*SMF ILMU BEDAH FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG 2015

Trauma disorders Tension pneumothorax Open pneumothorax Massive hematothorax Flail chest Cardiac tamponade Contusio pulmonum with or without flail chest Rupture aorta thorakalis Injury of trachea and bronchi Esophageal perforation Rupture diaphragm Contusio miocard Subcutaneus emfisemaClassification of thoracic disorders

Non-trauma disorders Spontaneous pneumothorax Pleural effusion Pleural empiema*

TRAUMA DISORDERTension pneumothoraxA pneumothorax is one emergency at a chest injury. This situation occurs due to damage caused air into the pleural cavity and the air can not get out, this state is called the phenomenon ventiles ( one way-valve)*

*Open pneumothorax (sucking chest wound)Defects or large wounds that remain open in the walls of the thorax and lungs causing "Sucking chest wound around" so that there is a balance between intra-thoracic pressure with the atmospheric air pressure. If a defect in the chest wall approaching 2/3 of the diameter of the trachea, the air will tend to flow melalul defect because prisoners have less or smaller than the trachea. As a result, impaired ventilation, causing hypoxia and hypercapnia.

*Massive hematothoraxHematothorax classified on the amount of blood coming out, namely:- Minimal / lightweight 350 ml- Medium 350 ml - 1500 ml- Massive occurs when bleeding above 1,500 ml.

Diagnose :- Shock hemorrhagic.- The absence or weakness of unilateral lung sounds.- Percussion dimmed on the affected side- The veins of the neck to be flat- Photo illustration shows radioopaque unilateral thorax.

*Management- Put intubation in patients with shock or difficulty breathing.- Attach the large size of the infusion and provide blood for transfusion prior to decompression.- If available, attach it to the autotransfusion chest tube collector system.- Perform thoracostomy catheter tube with a large size (36F or 40F) in the fourth intercostal gapThe second chest tube at any time needed to dry a large hemothorax

Indication thoracotomy:- Hemodynamic decompensation or irritability which is still ongoing due to bleeding chest.- Bleeding 1000 mL from the beginning.- Bleeding> 200ml / h which still lasted 4 hours.- Hemothorax drainage that did not succeed in completely, although it has been used 2 functioning chest tube and positioned correctly.- Consider Video Assisted Thoracoscopy (VATS) early for hemothorax incomplete in drainage or hemothorax clot

*Flail ChestFlail chest occurs when a segment of the chest wall no longer have continuity with the entire chest wall. That situation occurred due to multiple rib fractures on two or more ribs with two or more fracture lines. The presence of flail chest segment (segment floating) cause interference with the movement of the chest wall. If damage to the underlying lung parenchyma occurs in accordance with the damage to the bone, it will cause serious hypoxiaThe main difficulty in disorders namely Flail Chest trauma to the lung parenchyma that may occur (lung contusion).

*DiagnoseOccurs hypoxia, hypoventilation, ipsilateral thorax time percussion dullness, loss of or decrease in breath sounds, hypotension, increased neck veins. At X chest x-ray looks great effusion

Management1. Immediately do intubation if any shock or symptoms of respiratory depression such as:a. Difficult breathing that requires the use of additional respiratory muscles.b. Respiratory rate> 35x / min or

*Cardiac TemponadeCardiac tamponade is often caused by penetrating wounds. However, blunt trauma can also cause pericardial blood filled both of the heart, great vessels and from pericardial blood vessels. Human pericardium consists of connective tissue structures are rigid and despite the relatively small amount of blood collected, but was able to inhibit the activity of the heart and disrupt cardiac filling. Bleeding or pericardial fluid, often only 15 ml to 20 ml, through perikardiosintesis will soon improve hemodynamics.

Diagnose Persistent hypertension, acidosis and alkaline levels are low. The classic signs are composed of an increase in venous pressure, reduced arterial pressure and heart sounds away, pulsus paradoxus, Kussmaul sign.

*Management Pericardiocentesis Thoracotomy anterolateral sinistra Sternotomy Pericardial window

*Kontusio pulmonumLung contusion is a bruise or inflammation of the lungs that can occur in blunt chest injuries due to vehicle accidents or crushed by heavy objects. The etiology may be due to trauma to the thorax, traffic accidents, occurring mainly after blunt thoracic trauma can also occur in sharp trauma to the mechanisms of parenchymal hemorrhage and edema.Clinical manifestations may arise or worsen in 24-72 hours after trauma, dyspnea, PO artery, localized infiltrates on chest radiographs, in severe conditions may be accompanied: tracheobronchial secretions are many, hemoptysis, and pulmonary edema.

*Clinical manifestations may arise or worsen in 24-72 hours after trauma, dyspnea, PO artery, localized infiltrates on chest radiographs, in severe conditions may be accompanied: tracheobronchial secretions are many, hemoptysis, and pulmonary edema.

Management analgesic Toilet pulmonalis intubation and ventilation

*Kontusio miocard The term of blunt trauma to the heart usually depict different levels of trauma to the heart. This can be from bruising to the heart muscle are asymptomatic, up to disaritmia with significant clinical symptoms, acute heart failure, valvular trauma or cardiac rupture. Although rare, cardiac trauma can cause hemodynamic instabilityComplication of blunt trauma to the heart muscle is disaritmia such as tachycardia, atrial premature contractions, atrial fibrillation and premature ventricular contractions. ECG changes that may be visible is Right Bundle Branch Block or acute trauma with ST elevation and T wave flat.

NON-TRAUMA DISORDERSpontaneous pneumothoraxPrimary spontaneous pneumothoraxSecondary spontaneous pneumothorax

Spontaneous pneumothorax occurs due to the weakness of the alveolar wall and visceral pleura, while at an elevation of pressure occurs when the airway by some cause so that the alveolar and pleural covering rupture.Clinical symptoms of spontaneous pneumothorax in which patients spontaneously complained of pain and shortness of breath that appear suddenly. On physical examination, chest may seem asymmetrical, fremitus decreased or disappeared. If there pneumothoraks insisted, would arise cyanosis, tachypnea and signs of other hypoxia.*

*Management Thorax tube with WSD Bullectomy

*Pleural effusionAccumulation of fluid in the pleural cavity called pleural effusion. can be distinguished on the effusion of fluid transudation and exudationThe disorder is caused by impaired balance between production and absorption, for example, the hyperemia as a result of inflammation, changes in osmotic pressure (hypoalbuminemia), and increased venous pressure (heart failure).

PATIENT IDENTITYName: Mr. LDPAge: 21 years oldGender: BoyReligion: ChristianAdresss: Dukuh Kupang Utara II B / 23Nasionality: JavaneseWork: Not WorkingMarriage Statue : SingleExamination date: 7 Oktober 2015Medical Record Number: 750182

INTERVIEW

RIWAYAT PENYAKIT SEKARANG

HISTORY OF PAST ILNESS

HISTORY OF FAMILY ILNESS

TREATMENT HISTORY

SOCIAL HISTORY

PHYSICAL EXAMINATIONGeneral conditions: high illnessAwareness / GCS: Compos mentis / 4-5-6Vital sign: Tension: 120/70mmHgRR: 28 x/minutePulse: bpmTemp. axilla: 37,1 0CWeight: 65 kgHeight : 170 cmBMI 22,49 kg/m2

PHYSICAL EXAMINATIONGenerality Status:Head / face: symmetricAnemia / jaundice / cyanosis / dyspnea: - / - / - / -Neck : enlarged lymph nodes (-) / (-) , thyroid gland (-), trachea deviation (-)Thorax:Pulmo:I: asimetric chest, retraction (-)P: Chest Expansion = left behind / normal Stem fremitus = / normalP:

A: vesicular / normal, rhonchi -/-, wheezing -/-Cor:I: ictus cordis not seemP: ictus cordis not palpable, thrill (-)P: normal cor borderA: S1 S2 single, murmur (-), gallop (-)

PHYSICAL EXAMINATIONAbdomen: I: flat, symmetricA: bowel sound (+), normalP: soepel, hepar, lien not palpable, tenderness (-)Pr: thympaniExtremity : warm acral (+), oedema (-)

LOCAL STATUEREGIO : Pulmo

I: asimetric chest, retraction (-)P: Chest Expansion = left behind / normal Stem fremitus = / normalP:

A: vesicular / normal, rhonchi -/-, wheezing -/-

LABORATORYComplete Blood CountHaemoglobin = 13,2 g/dlWhite blood cell = 11990/mm3Haematocrit = 37,6%Platelet = 209000/mm3Clinical ChemicalBlood Glucose Stick = 85 mg/dlBUN = 8Creatinin Serum = 0,7SGOT = 11SGPT = 6Albumin = 4,7

*Electrolyte Serum Kalium = 3,6 mmol/l Natrium = 140 mmol/l Chlorida = 103 mmol/l

CHEST X-RAY

PLANNING THERAPYO2 nasal 3 lpmInfusion of RL 14 tpmInjection of Ceftriaxon 2x1 grInjection of antrain 3x1 grChest tube and WSD

PlanningDiagnosis = Complete Blood Count, LED, Faal Hemostasis, ICT TB.Monitoring = Patient Complaint, vital sign, blood production in WSD.*

OPERATION REPORT1. Informed consent and antibiotic prophylaxis. 2. The half-sitting position with a local anesthetic. 3. Disinfection visual field, fenestrated drape. 4. The incision above costae 7, anterior axillary line, deepened layer by layer. 5. Chest Tube Insertion in ICS VI No. 28 found that aerial spraying, blackish blood of approximately 400 cc. 6. Fixed with 1/0 side *

CHEST X-RAY POST CHEST TUBE INSERTION (7-10-2015)

*

*

SOAP*

*

TanggalSOAP8-10-2015Nafas sedikit sesak, nyeri pada luka operasi jika bergerak.KU = cukupTTV = tensi 130/90 mmHg, nadi 84x/menit, RR 25x/menit, Suhu aksila 37,0C.K/L : a/i/c/d = -/-/-/-Thorax Inspeksi = normochest, pergerakan kanan kiri simetris, retraksi ICS (-) , retraksi suprasternal (-), dan retraksi subkostal (-).Palpasi = fremitus suara simetris, ekspansi dinding dada simetrisPerkusi = sonor pada kedua lapang paru.Auskultasi = vesikuler/ vesikulerAbdomen : dbnExtremitas : dbn Status lokalis = terpasang insersi chest tube di ICS VI hemithorax dextra. Produksi darah 150 cc.Pemeriksaan penunjang: Darah lengkap :Hb = 11,1 g/dlLekosit = 8130/mm3Hematokrit = 32,8%Trombosit = 170000/mm3FH :PPT = 10,5APTT = 25,8LEDLED I = 10 mm/jam APTT = 25,8LED II = 32 mm/jamICT TB = negatifHematoPneumothorax dextra post insersi chest tube hari ke-1Planning diagnosis : Foto thorax AP, DL.

Planning terapi :Infus RL 1500 cc/ 24 jam.O2 4 lpmInj Kalnex 3x500 mg.Inj Vit. K 3x1Inj Terfacef 2x1 grSanmol drip 3x1WSD 18 cm H2OFisioterapi nafas

*

TanggalSOAP9-10-2015Sesak berkurang, nyeri luka bekas operasi (-)KU = cukupTTV = tensi 110/70 mmHg, nadi 72x/menit, RR 18x/menit, Suhu aksila 37,0C.K/L : a/i/c/d = -/-/-/-Thorax Inspeksi = normochest, pergerakan kanan kiri simetris, retraksi ICS (-) , retraksi suprasternal (-), dan retraksi subkostal (-).Palpasi = fremitus suara simetris, ekspansi dinding dada simetrisPerkusi = sonor/sonorAuskultasi = vesikuler/vesikulerAbdomen : dbnExtremitas : dbn Status lokalis = terpasang insersi chest tube di ICS VI hemithorax dextra. Produksi darah 40 cc.Pemeriksaan Penunjang: Darah LengkapHb = 11,9 g/dlLekosit = 5850/mm3Hematokrit = 35,4%Trombosit = 190000/mm3HematoPneumothorax dextra post insersi chest tube hari ke-2Planning diagnosis : Foto thorax AP

Planning terapi :Infus RL 1500 cc/ 24 jam.O2 4 lpmInj Kalnex 3x500 mg.Inj Vit. K 3x1Inj Terfacef 2x1 grSanmol drip 3x1WSD 18 cm H2OFisioterapi nafas

*

*

TanggalSOAP10-10-2015Sesak (-), nyeri luka bekas operasi (-)KU = cukupTTV = tensi 110/70 mmHg, nadi 80x/menit, RR 20x/menit, Suhu aksila 36,8C.K/L : a/i/c/d = -/-/-/-Thorax Inspeksi = normochest, pergerakan kanan kiri simetris, retraksi ICS (-) , retraksi suprasternal (-), dan retraksi subkostal (-).Palpasi = fremitus suara simetris, ekspansi dinding dada simetrisPerkusi = sonor/sonor.Auskultasi= vesikuler/vesikulerAbdomen : dbnExtremitas : dbn Status lokalis = terpasang insersi chest tube di ICS VI hemithorax dextra. Produksi darah 30 cc.HematoPneumothorax dextra post insersi chest tube hari ke-3Planning diagnosis : DL, Foto thorax AP

Planning terapi :Infus RL : D5 = 1000 : 500 cc/ 24 jam.Inj Terfacef 2x1 grSanmol drip 3x1WSD 18 cm H2OFisioterapi nafas

*

*

TanggalSOAP11-10-2015Sesak berkurang, nyeri luka bekas operasi (-).KU = cukupTTV = tensi 110/70 mmHg, nadi 84x/menit, RR 22x/menit, Suhu aksila 37,0C.K/L : a/i/c/d = -/-/-/-Thorax Inspeksi = normochest, pergerakan kanan kiri simetris, retraksi ICS (-) , retraksi suprasternal (-), dan retraksi subkostal (-).Palpasi = fremitus suara simetris, ekspansi dinding dada simetrisPerkusi = sonor/sonor.Auskultasi = vesikuler/vesikulerAbdomen : dbnExtremitas : dbn Status lokalis = terpasang insersi chest tube di ICS VI hemithorax dextra. Produksi darah 40 cc.Pemeriksaan Penunjang: Darah LengkapHb = 11,1 g/dlLekosit = 5300/mm3Hematokrit = 31,9%Trombosit = 173000/mm3HematoPneumothorax dextra post insersi chest tube hari ke-4Planning diagnosis : Foto thorax AP

Planning terapi :Infus RL 1500 cc/ 24 jam.O2 4 lpmInj Kalnex 3x500 mg.Inj Vit. K 3x1Inj Terfacef 2x1 grSanmol drip 3x1WSD 18 cm H2O

*

*

TanggalSOAP12-10-2015Sesak (-), nyeri luka bekas operasi (-).KU = cukupTTV = tensi 120/70 mmHg, nadi 78x/menit, RR 20x/menit, Suhu aksila 36,5C.K/L : a/i/c/d = -/-/-/-Thorax Inspeksi = normochest, pergerakan kanan kiri simetris, retraksi ICS (-) , retraksi suprasternal (-), dan retraksi subkostal (-).Palpasi = fremitus suara simetris, ekspansi dinding dada simetrisPerkusi = sonor/sonorAuskultasi= vesikuler/vesikuler.Abdomen : dbnExtremitas : dbn Status lokalis = terpasang insersi chest tube di ICS VI hemithorax dextra. Produksi darah = minimal.HematoPneumothorax dextra post insersi chest tube hari ke-5Planning diagnosis : Foto thorax AP

Planning terapi :Klem WSDInfus RL : D5 = 1000 : 500 cc/ 24 jam.Inj Terfacef 2x1 grSanmol drip 3x1Onj Ketorolac 3x1Aff WSD

*

TanggalSOAP13-10-2015Sesak (-), nyeri dada kanan (-)KU = cukupTTV = tensi 120/80 mmHg, nadi 80x/menit, RR 20x/menit, Suhu aksila 36,0C.K/L : a/i/c/d = -/-/-/-Thorax Inspeksi = normochest, pergerakan kanan kiri simetris, retraksi ICS (-) , retraksi suprasternal (-), dan retraksi subkostal (-).Palpasi = fremitus suara simetris, ekspansi dinding dada simetrisPerkusi = sonor/sonorAuskultasi= vesikuler/vesikuler.Abdomen : dbnExtremitas : dbn Status lokalis = post aff chest tubeHematoPneumothorax dextra post insersi chest tube hari ke-6Planning terapi :Cefixime 2x400 mgIbuprofen 3x400 mg

Kontrol Poli Bedah Umum RSU Haji Surabaya

*

*

TERIMA KASIH*

*********