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Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa Purnawan Putra 2018 Margareth Gracia 2019

Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

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Page 1: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Emergencies Internal Medicine

and

Morning Report notesRizal Hafiz

Edited : Nusa Purnawan Putra 2018

Margareth Gracia 2019

Page 2: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Kegawatan Penyakit Dalam

1. Nefro2. Cardio

3. Gastro

4. Endokrin5. Pulmo6. Hema

7. Rheuma8. Tropik9. Geriatri

: CKD, ggg. Cairan & elektrolit, asam basa: SKA, aritmia, syok cardio, oedem pulmo akut: PSCBA, encephalopati hepar, pankreatitis akut: hipoglikemia, KAD, HONK, krisis tiroid: asma akut, hemoptoe, gagal nafas: febrile neutropeni, sindr lisis tumor, sindr paraneoplasia: SLE: DHF, sepsis: konfusio akut, hipertermi, stroke

Page 3: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

1. NEFROLOGI-HIPERTENSI

KEGAWATAN UREMIA(Tx utama = dyalisis)1. Asidosis metabolik :

koreksi bicnat bila pH<7 atau HCO3<12meq

0,5 x 0,3 x BE x BB (dalam 150cc D5% habis 4 jam) 1 flash bicnat 25meq

2. Hiperkalemi ringan-sedang (5,5-7,5) Ca polystirene 4 x 15 gr Berat (>7,5)

Ca Glukonas 0,5mg/KgBB Bicnat 45-90meq (BE x 0.5 x BB x 0.3)

HCO3 dalam D5% 1:1 -> 50 cc jalan 8-12 cc/jam 10-20 U insulin reguler dlm 25-50gr D40% habis 4 jam

kecepatan 12.5cc/jam

Page 4: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefrologi

3. Overhidrasi : O2 masker Furosemid bolus 40-80 mg IV s/d 250 mg, lanjut Sp inj

Furosemide 5mg/jam IV Morfin 2,5mg IV

4. Hipertensi Emergency : diturunkan sesuai target dlm 1 jam Nikardipin

5mg/jam dinaikkan 2,5mg/5menit max 30mg/jam, target 25% MABP atau diastolik 110

Urgency : dgn antihipertensi oral, diturunkan dlm 24jam

5. Kejang uremik : diazepam 5-10mg iv pelan6. Perdarahan : dialisis7. Infeksi : antibiotik

Page 5: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Hipertensi emergency

• Hipertensi emergensi : meningkatnya tekanan darah secara akut

dan cepat yang menyebabkan kerusakan organ target. Umumnya

tekanan diastolik > 120 mmHg. Penurunan tekanan darah 10% pada

1 jam pertama, dan tambahan 15% pada 12 jam selanjutnya.

• Hipertensi urgensi : tekanan diastolik > 120 mmHg tanpa disertai

kerusakan organ. Pengendalian tekanan darah diharapkan dalam 24 –

48 jam.

• Hipertensi berat : sistolik > 180 mmHg dan diastolik > 110 mmHg.

Page 6: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

End-Organ Damage Associated Hypertensive Emergencies

End-Organ Damage Type No of Cases (%)

Cerebral Infarction 26 (24.5)

Intracerebral or sub-arachnoid

hemorrhage5 (4.5)

Hypertensive encephalopathy 18 (16.3)

Acute pulmonary edema 24 (22.5)

Acute congestive heart failure 15 (14.3)

Acute myocardial infarction or unstable

angina pectoris13 (12.0)

Eclampsia 5 (4.5)

Aortic dissection 2 (2.0)

Zampaglione, et al. AHA ; 27 (1) : 144

Page 7: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

SIMPLE APPROACH TO HYPERTENSIVE CRISIS

BP > 220/120 mmHg

Neurological sign

(encephalopathy or stroke)

Retinopathy grade 3-4

Severe chest pain

(Ischemia or dissecting

aneurism)

Pulmonary edema

Eclampsia

Cathecolamine excess

Acute renal failure

Headache

No neurological signs

No target organ damage

EMERGENCY

URGENCY

Intravenous therapy

Identify the cause

In panic attacks or anxiety use

analgesic, anxiolytics

Otherwise use oral antihypertensive

agents

recheck in 6-24 hours

Captopril, clonidine, labetalol

Page 8: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

JNC 7 Recommendation for Hypertensive Emergency

Drugs Dosage Onset Duration

Sodium nitroprusside

0.25-10 ugr/kg/min Immediate 1-2 minutesafter infusion stopped

Nitroglycerin 5-500 ug/min 1-3 minutes 5-10 minutes

Labetolol HCl 20-80 mg every 10-15 min or 0.5-2mg/min

5-10 minutes 3-6 minutes

Fenoldopan HCl 0.1-0.3 ug/kg/min <5 minutes 30=60 minutes

Nicardipine HCl 5-15 mg/h 5-10 minutes 15-90 minutes

Esmolol HCl 250-500 ug/kg/min IV bolus, then 50-100 ug/kg/min by infusion; may repeat bolus after 5 minutes or increase infusion to 300 ug/min

1-2 minutes 10-30 minutes

Page 9: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

AHA 2007 Recommendation for

Hypertensive Emergency

Drug I.V. Bolus Dose Continous Infus Rate

Labetalol

Nicardipine

Esmolol

Enalapril

Hydralazine

Nipride

NTG

5 – 20 mg every 15’

NA

250 ug/kg IVP loading dose

1,25-5 mg IVP every 6 h

5 – 20 mg IVP every 30’

NA

NA

2 mg/min (max 300mg/d)

5-15 mg/h

25-300 ug/kg/m

NA

1,5-5 ug/kg/m

0,1-10 ug/kg/m

20-400 ug/m

Page 10: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

CHEST 2007 Recommendation for Hypertensive Emergency

Acute Pulmonary edema /Systolic dysfunction

Nicardipine, fenoldopam, or nitropruside combined withnitrogliceryn and loop diuretic

Acute Pulmonary edema/ Diastolic dysfunction

Esmolol, metoprolol, labetalol, verapamil, combined with low dose of nitrogliceryn and loop diuretics

Acute Ischemia Coroner Labetalol or esmolol combined with diuretics

Hypertensive encephalopaty Nicardipine, labetalol, fenoldopam

Acute Aorta Dissection Labetalol or combined Nicardipine and esmolol or combinenitropruside with esmolol or IV metoprolol

Preeclampsia, eclampsia Labetalol or nicardipine

Acute Renal failure / microangiopathic anemia

Nicardipine or fenoldopam

Sympathetic crises/ cocaineoveerdose

Verapamil, diltiazem, or nicardipine combined withbenzodiazepin

Acute postoperativehypertension

Esmolol, Nicardipine, Labetalol

Acute ischemic stroke/ intracerebral bleeding

Nicardipine, labetalol, fenoldopam

CHEST, 2007

Page 11: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Obat yang tidak direkomendasikan untuk hipertensi krisis

• Nifedipine : penurunan tekanan darah yang cepat, sulit dikendalikan, menyebabkan iskhemia organ target

• Nitroglycerine : venodilator kuat, ‘preload’ dan ‘cardiac output’ turun, iskhemik organ target

• Hydralazine ; vasodilator kuat, sulit diprediksi, efek lama

• Diuretika : kecuali pada keadaan ‘volume overload’

Varon J and Marik PE. Critical Care 2003

Page 12: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

eGFR

eGFR laki-laki

𝑒𝐺𝐹𝑅 =140 − 𝑢𝑚𝑢𝑟 𝑥 𝑏𝑒𝑟𝑎𝑡 𝑏𝑎𝑑𝑎𝑛 (𝑘𝑔)

𝑆𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛 𝑥 72

eGFR wanita

𝑒𝐺𝐹𝑅 =140 − 𝑢𝑚𝑢𝑟 𝑥 𝑏𝑒𝑟𝑎𝑡 𝑏𝑎𝑑𝑎𝑛 (𝑘𝑔)

𝑆𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛 𝑥 72× 0,85

Page 13: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefrologi

Gangguan keseimbangan cairan

1. Hipovolemik“air dan Na keluar dlm jumlah yg sama”

koreksi dgn RL/NaCl isotonik, jumlah dankecepatan disesuaikan dg klinis kehilangan cairan :

ringan (<20%)

sedang (20-40%) x6%xBB

berat (>40%)

Page 14: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefro….

2. Dehidrasi“kehilangan air > Na” hipernatremi koreksi dg D5% sesuai kebutuhan :FD : 0,4xBBx ((Na Plasma/140)-1)kecepatan koreksi tdk >0,5meq/jam

Ex : pria 60kg, dehidrasi dg Na160meq, IWL 40cc/jam, UO 1,5L/24jam

Answ : Δ Na = 20kec.koreksi 20/0,5 = 40 jamFD : 0,4x60x((160/140)-1) = 3,42LIWL : 24X40ccUO :

= 0,96L= 1,5L

5,89L dlm 40 jam = 0,15L/jam

Page 15: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefro…

Ggg keseimbangan elektrolit1. Natrium hipoNa :

Na>125 Na<125

: NaCl 3x500mg po: (135-X)x0,6xBB = … meq NaCl 3%

akut<48jam : 5meq dlm 1 jam I, selanjutnya 1meq/jam s/d Na 130meq

Kronik>48jam : perlahan 0,5meq/jam

Sediaan NaCl 3% = 500 ccKomposisi = Na 513 mEq/L, Cl 513 mEq/L, Tek Osm 1026

Rumus Osmolaritas:

Normal: 285-295

Osmolaritas = 2 x Na Serum +GDS

18+

BUN

2,8

Osmolaritas = 2 x Na Serum +GDS

18+

Ureum

6

Page 16: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

NefrologihiperNakoreksi dg D5% sesuai kebutuhan :FD : 0,4xBBx ((Na Plasma/140)-1) kecepatan koreksi tdk >0,5meq/jam

Ex : pria 60kg, dehidrasi dg Na160meq, IWL 40cc/jam, UO 1,5L/24jamAnsw : delta Na = 20kec.koreksi 20/0,5 = 40 jam

FD : 0,4x60x((160/140)-1) = 3,42LIWL : 24X40ccUO :

= 0,96L= 1,5L

5,89L dlm 40 jam = 0,15L/jam

Page 17: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefrologi

2. Kalium hipoK

K>3,5 : KSR 3x1tab PO K<3,5 : (4,5-X)x0,4xBB = ..Y.. mEq/Lsediaan : inj 7,46% KCl, K 25mEq/25ml : Cl 25 mEq/25 mlKoreksi kecepatan 2 meq/jam(SP -> Y/2=Z) Y mEq habis dlm Z jam

hiperK ringan-sedang (5,5-7,5) Ca polystirene 4x15gr Berat (>7,5)

Inj Ca Glukonas 10% 0,5mg/KgBB Bicnat 45-90meq (BE x 0.5 x BB x 0.3)

HCO3 dalam D5% 1:1 -> 50 cc jalan 8-12 cc/jam 10-20 U insulin reguler dlm 25-50gr D40% habis 4 jam kecepatan 12.5cc/jam

Page 18: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefrologi

3. MagnesiumHipoMg Ringan : renapar/aspar 3x1tab POhipoMg berat : inj MgSO4 40% @25cc Dosis 3gr (7.5cc) dlm D5% habis 3jam, dilanjut Dosis 6gr dlm 21jam (3-3-6-21)

4. CalciumHipoCa ringan : CaCO3 3x500mg POhipoCa berat :

Bolus Ca glukonas iv 10-30cc dlm D5% 150cc selama 10menit, dilanjut maintanace 0.5-2mg/kgBB/jam

hiperCa : hidrocortison 200-300mg iv selama 3-5 hari,furosemid, atasi volume defisit

Page 19: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefrologi

Ggg. Keseimbangan Asam-basa

1. Konfirm BGA :

24(pCO2/HCO3) tdk lebih dr 10% pH x fc koreksi (setiap kenaikan 0,1 pH dikali 0,8 dan setiap turun 0,1 dikali 1,25)

2. Tentukan ggg asam-basa dgn melihat pH, pCO2 dan HCO3

Page 20: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefrologi

3. Tentukan kompensasi :

Asidosis met : pCO2 : (1,5xHCO3)+8 ± 2

Asid resp : akut HCO3 1meq setiap pCO2 10

kronik HCO3 3,5meq setiap pCO2 10

Alk met : pCO2 : 40+0,7 (delta HCO3) ± 5

Alk resp : HCO3 2meq setiap pCO2 10 (akut)

: HCO3 5-7meq setiap pCO2 10 (kronik)

Page 21: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Nefrologi

4. Jika asid met hitung anion gap AG : Na-(HCO3+Cl) (N + 2) AG

: KAD, intox metanol/salisilat AG : 2,5meq setiap alb 1gr/dlAG (N) hitung AG urin (Na+K)-Cl dlm urinjika (+), maka asid met dari Renal (RTA) jika (-), maka asid met dari TGI (diare)

5. Koreksi :asid met : 0,5x0,3xBExBBbicnatalk met: 0,3xBBx(HCO3-24)HCl/asetazolamid

Page 22: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019
Page 23: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019
Page 24: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

2. KARDIOLOGI

Sindrom koroner akut UAP & NSTEMI Tx=STEMI kecuali reperfusi STEMI

- oksigen (target spo2 94%), infus, monitor- nitrat ISDN : 2,5-10mg s.l bila nyeri

cedocard : 1-5mg/jamnitrogliserin 10-20mcg/min

- morfin : 2,5-5mg iv bolus

- aspirin loading 160mg (sebaiknya dikunyah) dilanjutkan 1x80mg- clopidogrel loading 300mg dilanjut 1x75mg

- heparin UFH : 60 IU/KgBB lanjut 12 IU/KgBB (target PTTK 1,5-2,5)

LMWH : Fondaparinux 1 x 2.5 mg sc- B blocker : Bisoprolol 1x2.5 mg PO- Atorvastatin 1x40 mg PO- Captopril 3 x 6.25 mg PO

Page 25: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Cardio…

- reperfusi : Fibrinolitik : streptokinase 1,5 juta IU dlm D5% 100cc habis

dlm 1 jamDoor to needle<30min

Cath lab tdk ada/door to ballon>90min

Akses vaskuler sulit

Onset<3jam

Observasi PAHA (Perdarahan, Aritmia, Hipotensi, Alergi)

PCI :Door to ballon <90min

Killip 3-4

KI thd fibrinolitik

Onset>3jam

Page 26: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Infark vent. Kanan

• Pertahankan pre load

• Ivfd NaCl 1-2L (jam I)200cc/jam (target CVP>10mmHg)

• Hindari nitrat dan furosemid

• Atasi AV block & bradikardi

• Beri inotropik jika dgn cairan cardiac output tdk meningkat

• Turunkan afterload (vasodilator)

• Reperfusi

• Lain2 sama

Page 27: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Cardio..

Edema paru akut- O2 8-10 lpm masker rebreath- intubasi bila diperlukan- Posisi Semi fowler- morfin 2-5mg iv bolus pelan- inj furosemid 40 mg IV bolus

lanjut Sp Furosemide 0,5-1mg/KgBB/menit

- nitrogliserin 10-20mcg/min IV- nitropusside 0,5-5mcg/KgBB/min

- ACE i Captopril 3x6,25 mg PO- Laktulosa 3x1C PO- B bloker Kontra Indikasi

Page 28: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Cardio..

SYOK

- Volume perbaiki defisit cairan, vassopress

- Irama atasi aritmia

- Pompa inotropik

2-20mcg/KgBB/min IVTDS 70-100 syok (-) : Dobutamin

syok (+) : dopamin

TDS <70 Norepinefrin 0,5-30mcg/min IV

Page 29: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019
Page 30: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Cardio..

1. Edema Paru

2. Kardiomegali

3. PND / ortopnoe

4. S3 gallop

5. Rales

6. JVP meningkat

7. Distensi vena jugularis

CHF (Framingham Criteria)MAYOR MINOR

1. Hepatomegali

2. Efusi pleura

3. Edema tungkai

4. Batuk malam

5. DOE

6. Takikardia

Page 31: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Cardio..

CHF• O2 target saturasi > 94%• Posisi setengah duduk• IVFD RL 10 tpm• Diet rendah garam, retriksi cairan• inj. Furosemid 40 mg/24 jam iv

– Bisa dilanjutkan Sp Furosemid 5-40 mg/jam

• Captopril 3x6.25 mg PO titrasi bertahap• Candesartan 4 mg/24 jam PO (bila ada kontraindikasi ACE-i)• Bisoprolol 1x2.5mg PO (kontraindikasi pada NYHA III-IV)• Sprinolacton 25mg/24 jam PO (bila refrakter terhadap diuretika)• Bila pasien gelisah : Inj Morfin 2-4 mg IV

Page 32: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Cardio..

AritmiaTakiaritmia

- O,I,M

- stabil? (hipotensi? Kesadaran? Tanda syok? Nyeri dada? GJ akut?)

- stabil (-) sync cardioversion (AF 120-200J, SVT 50J, VT 100J)

- stabil (+) QRS lebar : amiodarone, adenosin

QRS sempit : vagal manuver, adenosin

*) adeosin hanya diberikan pd QRS teratur, reguler, monomorfik

dosis : 6mg-12mg-12mg bolus cepat diflush

*) amiodarone : 150mg dlm 100cc NaCl selama 10menit dilanjut 1mg/min dlm 6 jam0,5mg/min dlm 18jam

Page 33: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Cardio..

Bradiaritmia

- O,I,M

- stabilobservasi

- tdk stabil

a) TPM (AV blok derajat 2 tipe 2, TAVB)

b) SA 0,5mg diulang tiap 5 min s/d max 3mg

respon (-)

dopamin 2-10mcg/KgBB/min

respon (-)

epinefrin 2-10mcg/min

Page 34: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019
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RAH : P pulmonum (tinggi >2,5 mm). Biasanya di stenosis trikuspid dan pulmonary HT (makanya namanya P pulmonum)

LAH : P mitral (lebar >2,5 kotak kecil/>0,10 ms dan bifida). Biasanya di mitral stenosis (makanya namanya P mitral)

RVH : R/S >1 di V1. Ada jg gambaran RAD dan S persisten di V6.

LVH : R di V6+S di V1/V2 >35 mm. Bisa jg R di V5/V6>25 mm.

Page 36: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

3. GASTROENTEROHEPATOLOGI

PSCBA• Etilogi tersering di INA : hipertensi portal, gastrtitis erosif, ulkus peptikum

Pengelolaan dasar

- Ass cepat status kegawatan (KU,GCS,TV, UO, syok?)

- Px Lab (DR, gol darah, cross match, studi koagulasi)

- Resusitasi Hemodinamik : kristaloid?Koloid? Tranfusi PRC? WB? Trombo? FFP?

Hatihati : pemberian cairan berlebihan dapat meningkatkan tekanan intraporta

Respirasi : jalan nafas? O2? Intubasi? NGT?

Monitoring ketat

- Pemeriksaan data dasar lengkap (Ax+PF+lab)

- obat anti sekresi asam, sitoproteksi

CHILD PUGH : ABAPE (Ascites Bilirubin Albumin Protrombintime Ensefalopati)

Page 37: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

Child Pugh Classification for severity in cirrhosis

Page 38: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

APRI Score

𝐴𝑃𝑅𝐼 =

𝐾𝑎𝑑𝑎𝑟 𝑆𝐺𝑂𝑇𝐵𝑎𝑡𝑎𝑠 𝑎𝑡𝑎𝑠 𝑘𝑎𝑑𝑎𝑟 𝑛𝑜𝑟𝑚𝑎𝑙 𝑆𝐺𝑂𝑇𝐽𝑢𝑚𝑙𝑎ℎ 𝑇𝑟𝑜𝑚𝑏𝑜𝑠𝑖𝑡 (109/𝐿)

× 100

Interpretasi:<0,5 menyingkirkan adanya kemungkinan fibrosis>1,5 terjadi fibrosis signifikan>2,0 kemungkinan sudah terjadi sirosis

Page 39: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

BCLC Score

Page 40: Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning Report notes Rizal Hafiz Edited : Nusa PurnawanPutra 2018 Margareth Gracia 2019

TANDA PHK

1. Gangguan Faal Hati– Sinstesis : Hipoalbumin (gama globulin), faktor

koagulasi (PPT, INR)– Metabolisme : Estrogen (hiperestrogenisme)– Ekskresi : Peningkatan bilirubin

2. Hipertensi Porta– Varises esophagus– Splenomegali– Ascites– Venektasi– Hemoroid

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Gastro.. Pengelolaan intensif/kontrol perdarahan Variceal

= VARISES VASOACTIV1.vasopressin : 0,5 U/min selama 20-60min2.somatostatin : 250mcg bolus250mcg/jam3.octreotid : 100mcg bolus 25-50mcg/jam hingga 2-5 hari atau sampai

perdarahan berhenti. CATATAN: 8 jam sebelum distop, berikan Propanolol 10mg/12 jam PO (target HR 55-70 x/menit)

ANTIBIOTIK1.Inj Cefotaxime 1gr/8jam IV2.Inj Ceftriaxone 1gr/24 jam IV

RESUSITASI : Fluid chalange kristaloid, lanjut D5% : Aminofusin 1:1 8-10 tpmINTAKE : Diet rendah garam 5gr/hariSPRINOLAKTON : Sprinolakton 100mg/24 jam, diberikan jika transudate

1.Cara pertama: dinaikkan bertahap per 4 hari jadi 200mg/24 jam, selanjutnya 300mg/24 jam

2. Cara kedua: tambahan dengan Inj Furosemide 40mg/24 jam ENDOSKOPI : Indikasi pada varises grade III, -Endoskopi cito STE/LVE SALVAGE : Bedah citoTIPS

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Gastro.. Pengelolaan definitive cari causa Transfusi PRC jika Hb < 8, target 8 atau lebih Antibiotik sesuai indikasi : Inj Ceftriaxone 2gr/24 jam IV Puasa 8 jam bebas perdarahan NON VARICEAL:

Inj Omeprazole 80 mg IV bolus, lanjut Inj 40mg/12 jam atau sp 8 mg/jam sampai 8 jam bebas perdarahan

Sukralfat 4x1C

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Gastro..

Encephalopati hepatikumPencetus : GI bleeding, elektrolit, metabolik,

infeksi, konstipasi, azotemi, drug (sedatif), diet tinggi prot

Patfis :- Peningkatan permeabilitas sawar darah otak

- Adanya substansi neurotoksin

- Ggg. Fx neurotransmiter

- Ggg. Suplai energi otak

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Gastro..

Klinis :

- derajat I : perubahan pola tidur

II : apatis/somnolen

III : sopor

IV : koma

- flapping tremor

- foetor hepatikum

Lab : studi koagulasi, DR, GDS, elektrolit, Ur, Cr, amoniak

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Gastro..

Management:

- Supportif : cairan, elektrolit, AB

- Spesifik• Menurunkan prod amoniak :

– Diet : prot 0,7gr/KgBB/hari, 45kal/BB/hari

– Infus AARC (Asam amino rantai cabang) 0.2-1.2gr/kgBB/hari

– Sterilisasi usus : laktulosa 30ml/8 jam PO,

– Antibiotik : neomisin 250mg/6jam PO

– Bisa digunakan metronidazole 500mg/8jam IV

• Terapi ggg transport as.amino : levodopa, bromokriptin

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Gastro..

HEPATORENAL SYNDROME

Peningkatan kreatinin 1.5 kali dari nilai normal

USG Ginjal normal

Pasien tidak mengalami syok

TATALAKSANA (VASA)Vasoaktif

Norepinepfrin

Antibiotik

StopStop diuretik,

propranolol, evaluasi 3 hari

Albumin Dikoreksi 20-60

gram per hari

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Gastro..

Pankreatitis akut Etiologi

- struktural ( batu empedu, spasm singter oddi)- toxin (alkohol, azatriopin, furosemid)- infeksi- metabolik (hiperTG, hiperCa)- vaskuler (atherosklerosis)- kongenital, idiopatik

Patfis :- fase inflamasi : fc pencetusaktivasi dini zimogen autodigesti pankreas- fase SIRSsepsis- fase MODS

Berdasar PA :1. pankreatitis akut intertitial2. pankreatitis akut nekrotik hemoragik

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Gastro..

Klinis : nyeri perut hebat mendadak, tdk berkurang dg analgetik biasa, mual, muntah, obstipasi, demam

Grey Turner : ekimosis besar di pinggang dan pungung, Cullen sign : ekimosis besar di umbilicus-> perdarahan dari pancreas

Lab : amilase darah & urn, lipase serum, CRP, DR, albumin, LDH, elektrolit, BGA

Imaging : USG abd, CT scan abd, ERCP

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Gastro..Management :1. Supportif- Resusitasi cairan (bisa sampai dengan 10L/hari)- Nutrisi (puasakan pasien -> TPN), elektrolit- Analgetik kuat : pethidin, KI : morfin (spasm sfi.oddi)- AB (quinolon, imipenem)- Bantuan respirasi- Monitoring (Pro HCU)- PPI: Inj Omeprazole 80mg/IV bolus lanjut Sp 8mg/jam IV- Antiemetik : Metoklopramide 10mg/8 jam IV2. Menekan prod. Enz. Pankreas- NGT : dekompresi, menurunkan gastrin- Menurunkan as lambung- Glukagon, kalsitonin, approtinin : menurunkan enz pankreas- Somatostatin: ocreotid 50mcg/8 jam SC- Memutus rantai SIRS

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Gastro..

Causatif :

- ERCP

- sfingterektomi

- stop alkohol

indikasi bedah :

1. perburukan dlm 72 jam tx intensif

2. sepsis

3. peritonitis

4. obst. sal,. Empedu

5. perdarahan intestinal >500cc/24jam

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Kadar Albumin Darah

Kadar Protein Darah=Kadar Albumin Ascites

Kadar Protein Ascites

Serum Albumin Ascites Gradient

SAAG < 1,1 Non PortalSAAG > 1,1 Portal

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LABORATORIUM KAD HONK

Glukosa plasma (mg/dl) > 250 > 600

pH < 7.3 > 7.3

HCO3 serum (mEq/L) < 15 > 20

Keton urine 3+ 1+

Keton serum (+) pengenceran 1:2 (-) pada pengenceran 1:2

Osmolalitas serum (mOsm/Kg) Bervariasi 330

Natrium serum (mEq/L) 130 – 140 145 – 155

Kalium serum (mEq/L) 5 – 6 4 – 5

BUN (mg/dl) 18 - 25 20 - 40

Panduan klinik praktis untuk membedakan KAD & HONK

Dengan pengertian sekitar 30% penderita KAD dapat

Tampil dalam kondisi HONK

4. ENDOKRINOLOGI METABOLIK

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Endo..

Tujuan terapi :

- menurunkan glukosa darah

- koreksi cairan dan elektrolit

- menghilangkan fc pencetus

• Infeksi

• Penghentian insulin

• New onset DM

- menghilangkan keton dari darahKAD

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Endo..Rehidrasi

NaCl1 jam I : 2L

1 jam II : 1L

Insulin (short/rapid acting)- Cepat menurunkan glukosa

- Tdk menyebabkan hipoglikemi

Bolus Insulin 0.1 U/kgBB IV, dilanjut Sp insulin0,1U/kgBB/jam,

Bila GDS tdk turun 50-75mg/dldosis naik 2x s/d100U/jam

bila GDS turun<250, dosis turun ½, infus ganti D5%(mencegah hipoglikemi + menghilangkan ketonemia)

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Endo..sliding scale :GDS < 100 :

Insulin 0 unit (D5%)GDS 101 – 150 : Insulin 0,5 unit (nacl )GDS 151 – 200 : Insulin 1 unit (nacl)GDS 201 – 250 : Insulin 2 unit (nacl)GDS 251 – 300 : Insulin 3 unit (nacl)GDS 301 – 350 : Insulin 4 unit (nacl)GDS >350 : Insulin 5 unit (nacl)

Antibiotik

Supportif : elektrolit, asam basa, nutrisi

Koreksi asid met : 0,5x0,3xBExBBbicnat

Kalium : drip dimulai bersamaan dengan

drip insulin, dosis 25 mEq/6 jam.

Setelah pemeriksaan elektrolit selanjutnya :

pH Koreksi HCO3 (mEq)

< 7 100

7 – 7.1 50

> 7.1 0 K+ Koreksi K+

< 3.0 Drip KCl 50 mEq/6 jam

3.0 – 4.5 Drip KCl 25 mEq/6 jam

4.5 – 5.5 Drip KCl 25 mEq/12 jam

> 5.5 Drip distop

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Endo..

Krisis tiroid

Trias klinis :

1. menghebatnya tanda hipertiroid

2. penurunan kesadaran

3. hiperpireksia

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Endo..

Supportif : cairan, elektrolit, nutrisi, oksigenasi

Koreksi hipertiroid

- blok sintesis PTU 600-1000mg, dilanjut 200mg/4jam, max 1000-1500mg

- mencegah sekresi tiroid lugol 8 tetes/6jam

- hambat konversi T4-T3 propranolol 20-40mg/6jam PO

Insuf adrenal relatifhidrokortison 100mg/12jam

AntipiretikParasetamol 500mg/8jam

KI : aspirin, kompetitif tiroksin thd prot binding

Bila AF Digoxin 0.25mg/8jam PO

Atasi pencetus

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Endo..

Koma miksedemKlinis : riwayat hipotiroid ditambah :

-penurunan kesadaran

- hipoventilasi

- hipotermi

- bradikardi

- hipoglikemi

- hiponatremi

Pencetus : infeksi, post OP, obat narkotik/hipnotik

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Endo..

Management :

Supportif

- Levotiroksin (T4) 300-500mcg bolus iv50mcg/hari atau

T3 25mcg/8jam12,5mcg/8jam

- Hidrokortison 100mg/12jam

- atasi fc pencetus

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Klasifikasi Diabetic Foot Ulcer – Wagner Classification

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5. PULMONOLOGI

Hemoptisis Ekspektorasi dahak yg mengandung bercak darah

dan berasal dari sal nafas bag bawah Hemoptisis masif :

- batuk darah >600cc/24jam- <600cc/24jam tp Hb<10gr%- >250cc/24jam, Hb>10gr tp tdk berhenti dlm obs selama 48 jam

Etiologi : 95% berasal dari a. bronkialis-TB paru- aspergilosis- bronkhiektase- abses paru- pneumonia-Ca paru

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Pulmo..

Asma BronkhialO2 max 8lpm Inhalasi B2 agonis dosis tinggi

- salbutamol 5mg/inhalasi- terbutalin 10mg

Steroid IV dosis tinggi- prednison 60mg/hidrokortison 200mg- maintanance : hidrokortison 200mg/6jam

Bronkodilator- aminofilin 250mg dlm 30 menit- salbutamol 200mcg/terbutalin 250mcg

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Pulmo..

Dampingi pasien sampai ada respon

Bila respon baiknebulasi/6jam

Bila respon buruk ulangi nebulasi + ipaproprium bromid 0,5mg dan Injmetilprednisolon 62.5mg/12 jam IV

Bila msh belum respon jg pertimbangkan :

-bolus aminofilin 5mg/kgBB dalam 30 menit,

dilanjut drips aminofilin 0,5mg/kgBB/jam

-salbu/terbutalin 2-30mcg/min

Evaluasi

- APE dipanttau 4x/hari sampai kondisi stabil

- BGA/6jam

- kadar aminofilin serum, kalium, GDS

Kontraindikasi : SEDATIF!!

Antibiotik diberikan sesuai indikasi

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Pulmo..

Indikasi ICU :PO2<60mmHg dg O2 60%

PCO2>50mmHg menetap dlm 6 jam

Tanda kelelahan

Penurunan kesadaran

Henti nafas

Indikasi pulang :APE>75% prediksi

Variasi diurnal <25%

Sesak malam hari (-)

Obat pulang:1. Inhalasi B2 agonis2. Salbutamol 3x2 mg PO3. Metilprednisolon 2x 4 mg

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Family Practice Management -AAFP

CURB 65 Pneumonia Severity Index

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Tanda / Gejala Ringan Sedang Berat AncamanGagal Nafas

Sesak nafas BerjalanDapat terlentang

BerbicaraLebih suka duduk

IstirahatMembungkuk

Berbicara Membuat kalimat Membuat frase Membuat kata

Kesadaran Mungkin gelisah Selalu gelisah Selalu gelisah Mengantuk ataubingung

Laju pernafasan Meningkat Meningkat > 30/menit

Otot tambahan retraksisuprasternal

Tidak Biasa ada Biasa ada Pergerakan poradok torako abdominal

Wheezing Sedang sering padasaat ekspirasi

keras Sangat keras Tidak ada wheezing.

Nadi/menit < 100 100 - 120 > 120 Bradikardi

Pulsus paradoksus < 10 mmHg 10 – 25 mmHg > 25 mmHg Tidak adaDicurigai adanyakelelahan

otot nafas.

APE > 80% 60 – 80 % < 60 %

PaO2 Normal > 60 mmHg < 60 mmHg

PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg

SaO2% > 95 % 91 – 95 % <90 %

Klasifikasi beratnya asma eksaserbasi

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Karakteristik TERKENDALITERKENDALI

SEBAGIAN

TIDAK

TERKENDALI

Gejala siang hari Tidak ada (2x /

< per minggu)

> 2 x perminggu Tiga atau lebih

gambaran dari asma

terkendali sebagian

muncul beberapa

minggu

Pembatasan aktivitas Tidak ada Ada

Gejala malam hari

/terbangun

Tidak ada Ada

Perlu reliever Tidak ada (2x /

< per minggu)

> 2 x perminggu

Fungsi paru PEF/ VEF1 normal < 80% prediksi

Eksaserbasi Tidak ada Satu / > per tahun Beberapa kali dalam

beberapa minggu

BERDASAR TINGKAT PENGENDALIAN ASMA

Istilah terkendali mengindikasikan pencegahan bahkan pengobatan

KLASIFIKASI ASMA

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TUJUAN Mencapai dan mempertahankan kontrol klinis

OBAT-OBATAN

GOL RELIEVERS GOL CONTROLLERS

rapid acting β2 agonist

inhalasi

Glukokortikosteroid inhalasi

dan sistemik

Antikolinergik inhalasi Leukotriene modifiers

Teophiline short acting Long acting β2 agonist +

glukokortikosteroid inhalasi

rapid acting β2 agonist oral Teophiline SR

Steroid sparing sistemik

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GLUKOKORTIKOSTEROID INHALASI

OBATDosis harian

rendah (μg)

Dosis harian

sedang (μg)

Dosis harian tinggi

(μg)

Beclomethasone

dipropionat

200 – 500 > 500 – 1000 > 1000 – 2000

Budesonide 200 – 400 > 400 – 800 > 800 -1600

Ciclesonide 80 – 160 > 160 – 320 > 320 – 1280

Flunisolide 500 – 1000 > 1000 – 2000 > 2000

Fluticasone 100 – 250 > 250 – 500 > 500 - 1000

Mometasone furoate 100 – 250 > 400 – 800 > 800 - 1200

Triamcinolone

acetonide

200 - 400 > 1000 – 2000 > 2000

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Pulmo..

Gagal Nafas Etiologi :

1. hipoventilasi

2. ventilasi/perfusi missmatch

3. shunt

4. kombinasi 1-3

GN tipe I (hipoksemi)

- paru gagal memenuhi keb O2, eliminasi CO2 msh normal- etiologi : kelainan intrapulmoner (V/Q missmatch,

shunting, ggg difusi/alveolar block)

- PaO2 <50 ; PCO2 normal/turun

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Pulmo..

GN tipe II

- etiologi : kelainan extraparu (hipoventilasi), V/Q missmatch, kombinasi

- PaO2 turun; PCO2>50

ARDS (acute Respiratory distress syndrome)

sindrom yg ditandai peningkatan permeabilitas

membran alveo-kapiler disertai kerusakan difus dan akumulasi cairan yg mengandung protein dlm parenkim paru

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Pulmo..

Fase eksudatif : edema intertitial & alveolar, nekrosis pneumosittipe I

Fase proliferatif : proliferasi pneumosit tipe II Fase fibrosis : pembentukan kolagen, fibrotisasi parenkim paru

Kriteria Diagnosis:1. Riwayat pencetus.2. Hipoksemia refrakter dengan terapi oksigen

PaO2/FiO2 <200 .3. X Foto thorak : infiltrat bilateral difus.4. Tidak ada gejala edema paru kardiogenik dan tekanan baji ≤ 18 mmHg.

Pada ARDS nilai AaDO2 >300.

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PATOGENESIS• Pada keadaan normal terdapat keseimbangan

antara tekanan onkotik dan hidrostatik antarakapiler paru dan alveolar.

• Teraktivasinya kaskade inflamasi yang berasal dari suatu fokus kerusakan jaringan tubuh. Neutrofil yang teraktivasi akan melepaskan toksin / sitokin.Sebagai hasilnya: kerusakan endotel → Peningkatan permeabilitas kapiler alveoli.

• Alveoli penuh eksudat kaya protein, banyak neutrofil dan sel inflamasi → membran hialin

• Pada tahap awal terjadi peningkatan kandungan cairan jaringan interstisial antara kapiler dan alveoli

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Penatalaksanaan

1.Mengobati penyakit dasarnya

2.Penatalaksanaan suportifA. Continuous positive airways pressure (CPAP).

Tidak boleh terlalu tinggi→ trauma. Diberikan dengan tidal volume 8-9ml/kgbb.

B. Management cairan dan hemodinamik Restriksi cairan: ↓ edema pulmo. Keseimbangan antara tata laksana ARDS dan volumeintravaskuler.

C. Terapi surfaktanD. Vasodilator pulmonal : NO inhalasiE. Glukokortikoidfase akut.

Belum dilakukan secara rutin/jangka lama: karena peningkatan resikoinfeksi.

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RESEP TB

SEDIAAN

100, 300

450, 600

500

400, 500

1000

Vitamin B6 = 10mg, 25mg, 100mg per 12/24 jam

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6. REUMATOLOGI

SLE

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6. REUMATOLOGI

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2

1

0

0

0

0

3

1

2

2

2

1

2

2

12

1

2

2

2

1

2

2

12

Total = 29

This score consists of an evaluation of patient’s skin thickness rated by

clinical palpation using a 0–3 scale (0=normal skin; 1=mild thickness;

2=moderate thickness; 3=severe thickness with inability to pinch the skin

into a fold) for each of 17 surface anatomic areas of the body: face,

anterior chest, abdomen, (right and left separately) fingers, forearms,

upper arms, tights, lower legs, dorsum of hands and feet. These individual

values are added and the sum is defined as the total skin score

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7. TROPIK INFEKSI

SEPSIS

1. ABC

2. Q-Sofa

3. Cairan 30cc/jam dalam 24 jam

4. Kultur sebelum pemberian AB

5. Inj Antibiotik broad spectrum

6. Prokalsitonin, laktat

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7. TROPIK INFEKSI

DENGUE SHOCK SYNDROME

INDIKASI RAWAT INAP

1. Peningkatan hematocrit atau

2. Trombosit < 100.000

3. Alarm sign (+)– Nyeri perut

– Muntah berkepanjangan

– Akumulasi cairan

– Perdarahan mukosa

– Letargi/lemah

– Hepatomegali > 2 cm

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MALARIA BERAT

• Penurunan kesadaran

• Tidak bisa makan

• Muntah profuse

• Anemia Hb < 5

• Hipoglikemia

• Asidosis metabolik

7. TROPIK INFEKSI

TATALAKSANA1. Inj Artesunat 2.4mg/kgBB

(jam ke 0, 12, 24), selanjutnya tiap 24 jam sampai pasien dapat minum obat.

2. DHP 3 tab/ hari -> lanjut 7 hari pemberian

3. Primakuin1. Falsi : 0.75 mg/kgBB/hari

(hari pertama saja)

2. Vivax : 0.25 mg/kgBB/hari

(selama 14 hari)

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TIFOID TOKSIKDemam tifoid disertai gangguan kesadaran dengan atau tanpa kelainanneurologis lainnya, dan hasil pemeriksaan LCS normal.

TATALAKSANA

1. Kloramfenikol 4 x 500mg IV

2. Ampisilin 4 x 1 gr IV

3. Prednison 1 x 40 mg IV

Jika delirium, koma, syok:

Inj Deksametason 3mg/kgBB IV, dilanjut 1mg/kgBB per 6 jam

7. TROPIK INFEKSI

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FEBRILE NEUTROPENIA

7. TROPIK INFEKSI

3x1 gr IV

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8. GERIATRI

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>18 Low Risk18-14 Medium risk14-10 High Risk<10 Very High Risk

Skala Norton – Resiko Dekubitus

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9. HEMATOLOGI

SINDROM LISIS TUMOR 1. Hiperurisemia2. Hiperkalemia3. Hiperfosfatemia4. Hipokalsemia

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9. HEMATOLOGI

TrombosisTrombofilia atau Hiperkoagulabilitas adalah merupakan suatu kondisi dimana terdapat peningkatan risiko untuk terjadinya trombosis.

Diturunkan

DidapatVirchow’s Triad (1856)

Venous stasis Vascular injury Hypercoagulability

Acquired Inherited

ARTERIAL VENOUS

Abnormalities of

blood vessels

(atherosclerosis)

Abnormalities of

blood flow

Hypercoagulability

Risk factors:

Hypertension,

Diabetes,

Hyperlipidemia

Risk factors:

immobility, surgery,

age, cancer, etc.

PATHOGENESIS

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PLATELET

BLEEDINGTHROMBOSIS

COAGULATION

INHIBITOR

FIBRINOLYSIS

INHIBITOR

VESSELS

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CLINICAL FEATURES

RISK FACTORS

CLINICAL FEATURES

ALTERNATIVE DIAGNOSIS

++

DVT MORE LIKELY DVT LESS LIKELY

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MODIFIED PRETEST PROBABILITY FOR DVT

• Tenderness along entire deep vein 1.0

• Swelling of the entire leg 1.0

• >3cm difference in calf circumference 1.0

• Pitting edema 1.0

• Collateral superficial veins 1.0

• Active cancer 1.0

• Prolonged immobility or paralysis 1.0

• Recent surgery or major medical illness 1.0

• Alternative diagnosis -2.0

Score>2: high, 1-2: moderate, <1: low probability

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Pulmonary Embolism

Dyspnoea, chest pain

Syncope

Hemoptysis

RR >20/m, tachycardia

Wheezing

Pulmonary hypertension

Right heart failure

Signs of DVT

DVT

PE

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DIAGNOSIS OF PULMONARY EMBOLISM

Pulmonary angiography

Helical CT

Ventilation-perfusion scan

Diagnostic test positive for DVT

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CLINICAL PROBABILITY FOR PE

DVT suspected

Clinical features of DVT 3

Recent prolonged immobility or surgery 1.5

Active Cancer 1

History for DVT or PE 1.5

Hemoptysis 1

Resting heart rate > 100 beat/min 1.5

No alternative explanation for acute

breathlessness or pleuritic chest pain

3

>6 high (60%); 2-6 moderate (20%); <1.5 low (3-4%) Turpie AGG, 2002

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Hema..

DIC

• DIC is an acquired syndrome, characterized by intravascular activation of coagulation and deposition of fibrin within the micovasculature

• DIC leads to organ ischaemia and infarction

The consumption of clotting factors and plateletsin the diffusely distributed thrombi may lead to ahemorrhagic diathesis and clinical bleeding.

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CAUSES DICINFECTIONS:• Gram-negative or Gram-positive septicemia (endotoxin)• Viruses(e.g. Epstein-Barr virus, cytomegalovirus, human

immunodeficiency virus)• Miliary tuberculosis• Fungi• Parasites (malaria, Toxoplasma spp.)

RELEASE OF TISSUE FACTOR• Malignancy, especially if disseminated• Obstetric complications:

abruptio placentae amniotic fluid embolism eclampsia and pre-eclampsia retained dead fetus

• Extensive trauma, burn, surgery• Large aortic aneurysm• Snake, spider venoms• Acute hemolytic transfusion reactions

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CLINICAL PRESENTATION: ACUTE DIC

• Acute DIC occurs with endotoxemia, extensive tissue trauma, preeclampsia, placental abruption or amniotic fluid embolism.

• Also in patients experiencing hypotension or shock for any reason: difficult surgical procedure, massive stroke, heart attack

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SCORE GLOBAL COAGULATION TEST RESULTS:

Platelet count

>100.000=0, <100.000=1, <50.000=2

D-Dimer

no increase (<500)=0, moderate (500-1000)=2, strong

(>1000)=3

Prolonged prothrombin time (PT)

<3sec.=0, 4-6sec.=1, >6sec=2

Fibrinogen level

<100mg/dl=1, >100mg/dl=0

Calculate score

If ≥5: overt DIC; If <5: suggestive for non-overtDIC: repeat next 1-2 days

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MANAGEMENT OF DIC

• Treatment of underlying disease (sepsis)

• Blood component (cryoprecipitate and platelet) substitution therapy

• Anticoagulants (chronic DIC)

• Restoration of anticoagulant pathways:

ATIII, PCa

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Anemia Mikrositik Hipokromik

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Anemia Normositik Normokromik

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DOSIS OBAT EMERGENCY

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NOREPINEPRIN 4 MGKg/mi

kro 0,01 0,02 0,03 0,04 0,05 0,06 0,07 0,08 0,09 0,1 0,11 0,12 0,13 0,14 0,15

40 0,3 0,6 0,9 1,2 1,5 1,8 2,1 2,4 2,7 3 3,3 3,6 3,9 4,2 4,5

45 0,338 0,675 1,013 1,35 1,688 2,025 2,363 2,7 3,038 3,375 3,713 4,05 4,388 4,725 5,063

50 0,375 0,75 1,125 1,5 1,875 2,25 2,625 3 3,375 3,75 4,125 4,5 4,875 5,25 5,625

55 0,413 0,825 1,238 1,65 2,063 2,475 2,888 3,3 3,713 4,125 4,538 4,95 5,363 5,775 6,188

60 0,45 0,9 1,35 1,8 2,25 2,7 3,15 3,6 4,05 4,5 4,95 5,4 5,85 6,3 6,75

65 0,488 0,975 1,463 1,95 2,438 2,925 3,413 3,9 4,388 4,875 5,363 5,85 6,338 6,825 7,313

70 0,525 1,05 1,575 2,1 2,625 3,15 3,675 4,2 4,725 5,25 5,775 6,3 6,825 7,35 7,875

75 0,563 1,125 1,688 2,25 2,813 3,375 3.938 4,5 5,063 5,625 6,188 6,75 7,313 7,875 8,438

80 0,6 1,2 1,8 2,4 3 3,6 4,2 4,8 5,4 6 6,6 7,2 7,8 8,4 9

85 0,638 1,275 1,913 2,55 3,188 3,825 4,463 5,1 5,738 6,375 7,013 7,65 8,288 8,925 9,563

90 0,675 1,35 2,025 2,7 3,375 4,05 4,725 5,4 6,075 6,75 7,425 8,1 8,775 9,45 10,13

NOREPINEPRIN 8 MGKg/mi

kro 0,01 0,02 0,03 0,04 0,05 0,06 0,07 0,08 0,09 0,1 0,11 0,12 0,13 0,14 0,15

40 0,15 0,3 0,45 0,6 0,75 0,9 1,05 1,2 1,35 1,5 1,65 1,8 1,95 2,1 2,2545 0,169 0,338 0,506 0,675 0,844 1,013 1,181 1,35 1,519 1,688 1,856 2,025 2,194 2,363 2,53150 0,188 0,375 0,563 0,75 0,938 1,125 1,313 1,5 1,688 1,875 2,063 2,25 2,438 2,625 2,81355 0,206 0,413 0,619 0,825 1,031 1,238 1,444 1,65 1,856 2,063 2,269 2,475 2,681 2,888 3,09460 0,225 0,45 0,675 0,9 1,125 1,35 1,575 1,8 2,025 2,25 2,475 2,7 2,681 2,925 3,16965 0,244 0,488 0,731 0,975 1,219 1,463 1,706 1,95 2,194 2,438 2,681 2,925 3,169 3,413 3,65870 0,263 0,525 0,788 1,05 1,313 1,575 1,838 2,1 2,363 2,625 2,888 3,15 3,413 3,675 3,93875 0,281 0,563 0,844 1,125 1,406 1,688 1,969 2,25 2,531 2,813 3,094 3,375 3,656 3,938 4,21980 0,3 0,6 0,9 1,2 1,5 1,8 2,1 2,4 2,7 3 3,3 3,6 3,9 4,2 4,585 0,319 0,638 0,956 1,275 1,594 1,913 2,231 2,55 2,869 3,188 3,506 3,825 4,144 4,463 4,78190 0,338 0,675 1,013 1,35 1,688 2,025 2,363 2,7 3,038 3,375 3,713 4,05 4,388 4,725 5,063

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DOPAMINKg/Mikro 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1540 0,6 1,2 1,8 2,4 3 3,6 4,2 4,8 5,4 6 6,6 7,2 7,8 8,4 9

45 0,675 1,35 2.025 2,7 3.375 4,05 4.725 5,4 6.075 6,75 7.425 8,1 8.775 9,45 10,13

50 0,75 1,5 2,25 3 3,75 4,5 5,25 6 6,75 7,5 8,25 9 9,75 10,5 11,25

55 0,825 1,65 2.475 3,3 4.125 4,95 5.775 6,6 7.425 8,25 9.075 9,9 10,73 11,55 12,36

60 0,9 1,8 2,7 3,6 4,5 5,4 6,3 7,2 8,1 9 9,9 10,8 11,7 12,6 13,5

65 0,975 1,95 2.925 3,9 4.875 5,85 6.825 7,8 8.775 9,75 10,73 11,7 12,68 13,65 14,63

70 1,05 2,1 3,15 4,2 5,25 6,3 7,35 8,4 9,45 10,5 11,55 12,6 13,65 14,7 15,75

75 1.125 2,25 3.375 4,5 5.625 6,75 7.875 9 10,13 11,25 12,38 13,5 14,63 15,75 16,88

80 1,2 2,4 3,6 4,8 6 7,2 8,4 9,6 10,8 12 13,2 14,4 15,6 16,8 18

85 1.275 2,55 3.825 5,1 6.375 7,65 8.925 10,2 11,48 12,75 14,03 15,3 16,58 17,85 19,13

90 1,35 2,7 4,05 5,4 6,75 8,1 9,45 10,8 12,15 13,5 14,85 16,2 17,55 18,9 20,25

DOBUTAMINKg/Mi

kro 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

40 0,48 0,96 1,44 1,92 2,4 2,88 3,36 3,84 4,32 4,8 5,28 5,76 6,24 6,72 7,2

45 0,54 1,08 1,62 2,16 2,7 3,24 3,78 4,32 4,86 5,4 5,94 6,48 7,02 7,56 8,1

50 0,6 1,2 1,8 2,4 3 3,6 4,2 4,8 5,4 6 6,6 7,2 7,8 8,4 9

55 0,66 1,32 1,98 2,64 3,3 3,96 4,62 5,28 5,94 6,6 7,26 7,92 8,58 9,24 9,9

60 0,72 1,44 2,16 2,88 3,6 4,32 5,04 5,76 6,48 7,2 7,92 8,64 9,36 10,08 10,8

65 0,78 1,56 2,34 3,12 3,9 4,68 5,46 6,24 7,02 7,8 8,58 9,36 10,14 10,92 11,7

70 0,84 1,68 2,52 3,36 4,2 5,04 5,88 6,72 7,56 8,4 9,24 10,08 10,92 11,76 12,6

75 0,9 1,8 2,7 3,6 4,5 5,4 6,3 7,2 8,1 9 9,9 10,8 11,7 12,6 13,5

80 0,96 1,92 2,88 3,84 4,8 5,76 6,72 7,68 8,64 9,6 10,56 11,52 12,48 13,44 14,4

85 1,02 2,04 3,06 4,08 5,1 6,12 7,14 8,16 9,18 10,2 11,22 12,24 13,26 14,28 15,3

90 1,08 2,16 3,24 4,32 5,4 6,48 7,56 8,64 9,72 10,8 11,88 12,96 14,04 15,12 16,2

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NICARDIPINKg/mikro 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5

40 1,2 2,4 3,6 4,8 6 7,2 8,4 9,6 10,8 12 13,2 14,4 15,6 16,8 1845 1,35 2,7 4,05 5,4 6,75 8,1 9,45 10,8 12,15 13,5 14,85 16,2 17,55 18,9 20,2550 1,5 3 4,5 6 7,5 9 10,5 12 13,5 15 16,5 18 19,5 21 22,555 1,65 3,3 4,95 6,6 8,25 9,9 11,55 13,2 14,85 16,5 18,15 19,8 21,45 23,1 24,7560 1,8 3,6 5,4 7,2 9 10,8 12,6 14,4 16,2 18 19,8 21,6 23,4 25,2 2765 1,95 3,9 5,85 7,8 9,75 11,7 13,65 15,6 17,55 19,5 21,45 23,4 25,35 27,3 29,2570 2,1 4,2 6,3 8,4 10,5 12,6 14,7 16,8 18,9 21 23,1 25,2 27,3 29,4 31,575 2,25 4,5 6,75 9 11,25 13,5 15,75 18 20,25 22,5 24,75 27 29,25 31,5 33,7580 2,4 4,8 7,2 9,6 12 14,4 16,8 19,2 21,6 24 26,4 28,8 31,2 33,6 3685 2,55 5,1 7,65 10,2 12,75 15,3 17,85 20,4 22,95 25,5 28,05 30,6 33,15 35,7 38,2590 2,7 5,4 8,1 10,8 13,5 16,2 18,9 21,6 24,3 27 29,7 32,4 35,1 37,8 40,5

NTGAmp/Mikro 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

1 1,5 3 4,5 6 7,5 9 10,5 12 13,5 15 16,5 18 19,5 21 22,5 24 25,5 27 28,5 302 0,75 1,5 2,25 3 3,75 4,5 5,25 6 6,75 7,5 8,25 9 9,75 10,5 11,3 12 12,8 13,5 14,3 153 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 5,5 6 6,5 7 7,5 8 8,5 9 9,5 104 0,38 0,75 1,13 1,5 1,88 2,25 2,63 3 3,38 3,75 4,13 4,5 4,88 5,25 5,63 6 6,38 6,75 7,13 7,55 0,3 0,6 0,9 1,2 1,5 1,8 2,1 2,4 2,7 3 3,3 3,6 3,9 4,2 4,5 4,8 5,1 5,4 5,7 6

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