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Crush syndroma

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ASKEP CRUSH SYNDROMA CAUSES CRUSH INJURY Ns. M. Shodikin, M.Kep, Sp.Kep.MB
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Page 1: Crush syndroma

ASKEP CRUSH SYNDROMA

CAUSES CRUSH INJURY

Ns. M. Shodikin, M.Kep, Sp.Kep.MB

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DEFINISI

Crush syndrome = traumatic rhabdomyolysis =  Bywaters' syndrome) is a medical condition characterized by major shock and renal failure after a crushing injury to skeletal muscle.

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CRUSH INJURY

Compression of body part causing localyzed muscle and nerve damage.

Crush injury sering ditemukan pada kejadian alam ( gempa bumi, badai tornado,sunami ) dan juga buatan manusia ( kecelakaan industri, bom dll)

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CRUSH SYNDROME

“CRUSH SYNDROME” pertama kali dilaporkan saat bombing di london pada saat perang dunia ke dua.

5 orang mengalami shock, bengkak pada extremitas dan urinnya berwarna gelap.

Semua pasien meninggal karena gagal ginjal.

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Crush injury lokal dapat menunjukkan adanya manifestasi sistemik.

Efek/manifestasi sistemik terjadi disebabkan adanya trauma/kerusakan otot dan pelepasan komponen toksis dari sel otot dan elektrolit ke dalam sistem peredaran sistemik.

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CRUSH SYNDROME COMMON IN EARTHQUAKES

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Insiden crush injury akibat erathquakes 2-15 %

50% korban mengalami gagal ginjal 50 % korban memerlukan hemodialisis > 50 % membutuhkan tindakan fasiotomi

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Incidence berdasarkan lokasi crush injury.

Lower extremity : 74 % Upper extermity : 10 % Trunk : 9 %

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Component of crush syndrome

Local tissue injury Organs of dysfungsion Metabolic ab-normalites

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PATHOFISIOLOGI

CRUSH INJURYMuscle ischemia and nicrosis

from prolonged pressure

CRUSH SYNDROME(systemic Effects)

Fluid retention

in extremity

Myoglobinuria

Metabolic abnormalities (electrolytes)

acidocis,hyperkalemia,hypocalc

emia

Secondary complicatio

n

Hypotension Renal Failure Cardiac Arrhythmia

Compartement syndrome

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MANAGEMENT CRUSH SYNDROME

A. PRINSIP UTAMA: Adequate fluid resuscitation is

critical in treating victime of crush injury.

Ideal resuscitation fluid : Normal Saline

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B. SECONDARY TREATMENT MODALITIES :

Bicarbonate Manitol ( no proven benefits but no

significant deleterious effects )

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GOAL FLUID THERAPY

Preven tubular precipitation of myoglobin

Decrease risk of hyperkalemia Correct acidemia

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Early Mortality in Crush Syndrome

Hipovolemia Hiperkalemia

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Late Mortality in Crush Syndrome

Sepsis Multiple Organ Failure

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Factor Impacting Mortality and Morbidity

Severity of the crush injury Timing of the treatment Initial treatment provided to the

victim

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INITIAL MANAGEMENT

Assessment of 'Airway, Breathing and Circulation.

Perhatikan adanya cedera yang mengancam jiwa.

Venous access harus diperoleh sedini mungkin.

Pada orang dewasa infus dengan normal saline 1,500 ml/jam.

Pasang kateter Because of the very high risk of acute kidney injury.

Bila diperlukan cari vena sentral.

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TINDAKAN LANJUT

Urin harus dipertahankan pada 300 ml / jam sampai myoglobinuria telah berhenti.

Diuresis manitol untuk melindungi kerusakan ginjal dari mioglobin dan dapat mengurangi risiko hiperkalemia, mannitol melindungi ginjal dengan meningkatkan perfusi ginjal dan juga dapat mengurangi cedera otot .

Natrium bikarbonat dapat membantu mencegah gagal ginjal akut.

Dialisis ginjal mungkin diperlukan. Plasma dan trombosit segar untuk mencegah

terjadinya Koagulasi intravaskular diseminata (DIC) .

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PEMBEDAHAN

Amputasi anggota gerak yang mengalami crush injury berat dapat menjadi tindakan pilihan, sebab  Amputation at an early stage may prevent crush syndrome.

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Contoh penatalaksanaan/Pembedahan crush injury.

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COMPLICATIONS

Hyperkalaemia. Infection . Acute kidney injury.. Compartment syndrome. Disseminated intravascular

coagulation (DIC)

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PREHOSPITAL THE MANAGEMENT OF VICTIMS WITH CRUSH INJURY

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PENATALAKSANAAN SECARA UMUM

Rehidrasi 1 -2 liters normal saline before releasing crush jika memungkinkan.

Jika tidak memungkinkan, pertimbangkan untuk memasang tourniquet pada ekstremitas yang cedera dengan memberikan terapi cairan IV sebagai pertolongan pertama.

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METABOLIC ABNORMALITIES :Acidosis : IV Sodium

Bicarbonate to prevent myoglobin deposites in kidneys

Hyperkalemia : calcium, natrium bicarbonate, insulin/D5W

Hypocalcemia : calciumDelays of hydration for longer than

12 hours increase the incidence of renal failure

Late treatment : Dialysis

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COMPARTEMENT SYNDROMA Pasca traumatic injury organ – organ dalam

compartement (nerves.vascular and muscle) dapat mengalami bengkak, tertekan, ischemia yang bersifat irreversible.

Compartement syndrome adalah kondisi emergency.

Pertimbangkan kemungkinan compartement syndrome dapat terjadi dalam waktu kurang dari 1 jam.

Keadaan fraktur tidak selalu akan terjadi compartement syndrome.

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Upper extremity compartement syndrome

Forearm and hand are at highest risk.

Lower extremity compartement syndrome

Anterior and lateral compartements of the lower leg (calf) are at highest risk.

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FASCIOTOMY

Keputusan untuk melakukan fasiotomy harus dibuat berdasarkan indek atau kecurigaan yang tinggi dari sindrom compartemen pada pasien dengan cedera ekstremitas yang kompleks.

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Fasiotomi

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Figure  apparatus for measuring compartment pressure.

WHITESIDES

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Tekanan Intra-compartement Tekanan normal

0-4 mm Hg 8-10 mmHg setelah excercise

Tekanan absolut secara teoritis 30 mm Hg - Mubarak 45 mm Hg - Matsen

Perkiraan tekanan secara teoritis < 20 mm Hg of diastolic pressure –

Whitesides (McQueen, et al)

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Kemampuan adaptasi dari jaringan

Otot 3-4 hours - reversible changes 6 hours - variable damage 8 hours - irreversible changes

Saraf 2 hours - looses nerve conduction 4 hours - neuropraxia 8 hours - irreversible changes

Kematian jaringan

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Mechanism and local pathology

Compartment syndrome is due to a vicious circle.

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diagnosa

Tanda klasik "5 P“ : 1. Pain :

▪ Severe/berat, deep/dalam, konstant dan sukar melokalisir tempatnya (diffuse)

▪ >> stretching dari kelompok otot yang ada didalam kompartemen yg terkena

▪ Analgetik (ec. Morphin) tidak berpengaruh

2. Paraesteshia3. Pallor4. Paralysis5. Pulselessness6. Poikilothermia (akral dingin) dan kulit

tampak tegang serta mengkilat

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TERIMAKASIH


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