RUPTUR LIMPA

Oleh : dr. Fyra Zahara

DPJP : dr. Tamsil, Sp.B
RS BUDIKEMULIAAN KOTA BATAM
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TINJAUAN PUSTAKA
-RUPTUR LIMPA-
ETIOLOGI

Trauma Tajam Trauma Tumpul

Trauma Iatrogenik Ruptur Spontan

ETIOLOGI

RUPTUR LIMPA

Pecahnya limpa
ANATOMI
TRAUMA

 150,000 kematian per tahun

 50% karena KLL

 Mayoritas  trauma tumpul abdomen

 Trauma hepar  mortalitas paling sering

 Kecelakaan paling sering terjadi

 motorcycle
TRAUMA

The key to saving lives in abdominal trauma is NOT to make an accurat

e diagnosis, but rather to RECOGNIZE that there is an abdominal inju
ry
MEKANISME TRAUMA ABDOMEN

TRAUMA ABDOMEN

BLUNT TRAUMA
PENETRATING TRAUMA
(non- penetrating trauma)

Trauma Kompresi

Trauma Seat Belt (Sheared Injury)

Trauma Akselerasi/Deselerasi
MEKANISME TRAUMA ABDOMEN

PENETRATING TRAUMA

• Adanya benda tajam yang menimbulkan luka di abdomen

• Jika peritoneum parietale rusak  trauma tembus (penetrating)
• Pisau, kayu/bambu, obeng, peluru, dll
• KHUSUS:
o Impalement injury
o Evisceration
MEKANISME TRAUMA ABDOMEN

PENETRATING TRAUMA

Impalement Injury Evisceration

DO NOT REMOVE OBJECT OR EXERT ANY FORCE UPON IT! Extrusion of abdominal contents secondary to penetrating
abdominal trauma
MEKANISME TRAUMA ABDOMEN

BLUNT TRAUMA Trauma Kompresi (Crushed Injury)

 Bagian depan badan berhenti bergerak, sedangkan bagian belakang dan bagian dalam tetap bergerak ke depan.

 Organ-organ terjepit dari belakang oleh bagian belakang thorakoabdominal dan kolumna vetebralis dan di depan
oleh struktur yang terjepit.

 Pada tabrakan penderita refleks menarik napas dan menahannya. Kompresi abdominal mengakibatkan peningkatan
tekanan intrabdominal dan dapat menyebabkan ruptur diafragma dan translokasi organ-organ abdomen ke dalam
rongga thorax. Transient hepatic kongestion dengan darah sebagai akibat tindakan valsava mendadak diikuti
kompresi abdomen ini dapat menyebabkan pecahnya hepar. Keadaan serupa dapat terjadi pada usus halus bila ada
usus halus yang closed loop terjepit antra tulang belakang dan sabuk pengaman yang salah memakainya.

 Biasanya terjadi oleh karena benturan secara langsung yang mengakibatkan bagian depan dari badan ber
henti bergerak, sedangkan struktur bagian dalam masih tetap bergerak ke depan. Sehingga menyebabkan
kerusakan struktur-struktur baik organ yang padat dan berongga di tengah-tengahnya. Misalnya pada trau
MEKANISME TRAUMA ABDOMEN

BLUNT TRAUMA Trauma Seat Belt (Sheared Injury)

• Sabuk pengaman tiga titik jika digunakan dengan baik, mengurangi

kematian 65%-70% dan mengurangi trauma berat sampai 10 kali.
• Agar berfungsi dengan baik, sabuk pengaman harus dipakai di bawah
SIAS, dan di atas femur, tidak boleh mengendur saat tabrakan dan
harus mengikat penumpang dengan baik.
• Bila dipakai terlalu tinggi (di atas SIAS) maka hepar, lien, pankreas,
usus halus, diodenum, dan ginjal akan terjepit di antara sabuk
pengaman dan tulang belakang.
• Hiperfleksi vetebra lumbalis akibat sabuk yang terlalu tinggi
mengakibatkan fraktur kompresi anterior dan vertebra lumbal.
• Merupakan bentuk trauma yang terjadi bila komponen alat pena
han (sabuk pengaman) dipakai dengan cara yang salah.
MEKANISME TRAUMA ABDOMEN

BLUNT TRAUMA Trauma Seat Belt (Sheared Injury)

MEKANISME TRAUMA ABDOMEN

BLUNT TRAUMA Trauma Akselerasi/Deselerasi

Trauma deselerasi terjadi bila bagian yang menstabilasi organ, seperti pedikel ginjal, ligamentum teres berhenti,
sedangkan organ yang distabilisasi tetap bergerak. Shear force terjadi bila pergerakan ini terus berlanjut, contoh p
ada ginjal dan limpa denga pedikelnya, pada hati terjadi laserasi hati bagian sentral, terjadi jika deselerasi lobus ka
nan dan kiri sekitar ligamentum teres.

Merupakan bentuk trauma yang terjadi oleh karena gerakan yang berbeda dari bagian badan yan
g bergerak dan yang tidak bergerak, misalnya sering terjadi pada hepar dan lien.
KLASIFIKASI

Berdasaran jenis organ yang cedera dapat dibagi dua :

1. Organ padat (hepar dan limpa)  gejala utama perdarahan
2. Organ berongga (usus dan saluran empedu ) gejala utama peritonitis

Berdasarkan daerah organ yang cedera dapat dibagi dua :

1. Organ Intraperitoneal : Ruptur hepar, ruptur limpa, ruptur usus halus
2. Organ Retroperitoneal. : Retroperitoneal abdomen terdiri dari ginjal, ureter, pancreas, aorta, dan vena cava.
Trauma pada struktur ini sulit ditegakkan diagnosis berdasarkan pemeriksaan fisik. Evaluasi regio ini memerlukan
CT scan, angiografi, dan intravenous pyelogram. Trauma pada daerah ini menyebabkan ruptur ginjal, ruptur
pankreas, ruptur ureter
ANATOMI ABDOMEN
ANATOMI ABDOMEN
ANATOMI ABDOMEN
ANATOMI ABDOMEN
ANATOMI ABDOMEN
ANATOMI ABDOMEN
ANATOMI ABDOMEN
ANATOMI HEPAR
ANATOMI HEPAR
ANATOMI SPLEEN
ANATOMI SPLEEN
ANATOMI SPLEEN
PEMERIKSAAN PENUNJANG

Foto Polos Laboratorium USG FAST

DPL CT Scan Abdomen

PEMERIKSAAN PENUNJANG
Foto Polos

• Abdomen x-ray : tidak terlalu diandalkan

• Chest x-ray :
o Mandatory procedure
o Dapat menemukan pneumoperitoneum
o Untuk evaluasi masalah2 di paru & pleura
PEMERIKSAAN PENUNJANG
Laboratorium

• Serial Hb/Hct – untuk monitoring perdarahan : tidak sensitif / perlu waktu

rapid hemorrhage - false negative

crystalloid hemodilution - false positive

• Digunakan untuk baseline follow-up

PEMERIKSAAN PENUNJANG
USG FAST (Focused Abdominal Sonography for Trauma)

• Tujuan :

Identifikasi adanya hemoperitonium pada pasien dengan kecurigaan cidera

intra-abdomen

• Indikasi :

pasien yang secara hemodinamik unstable dengan kecurigaan cedera abdomen dan

pasien-pasien serupa yang juga mengalami cedera ekstra-abdominal signifikan

(ortopedi, spinal, thorax, dll.) yang memerlukan bedah non-abdomen emergensi.

PEMERIKSAAN PENUNJANG
USG FAST (Focused Abdominal Sonography for Trauma)
PEMERIKSAAN PENUNJANG
USG FAST (Focused Abdominal Sonography for Trauma)
PEMERIKSAAN PENUNJANG
DPL (Diagnostic Peritoneal Lavage)

• suatu prosedur invasif


perdarahan intraperitoneum
• Akurasi diagnostik 98-100%
• Sensitivitas 98-100%
• Spesifikasi 90-96%
PEMERIKSAAN PENUNJANG
DPL (Diagnostic Peritoneal Lavage)

INDIKASI KONTRAINDIKASI
Pemeriksaan fisik yang meragukan Mutlak :
indikasi untuk laparotomi eksplorasi sudah jelas
Syok atau hipotensi yang tidak dapat dijelaskan Relatif :
Penurunan kesadaran (cedera kepala tertutup, obat-obatan) riwayat laparotomi eksplorasi sebelumnya, kehamilan,
Penderita dalam narkose umum untuk prosedur ekstra morbid obesity ,sirrhosis yang lanjut ,dan adanya
abdominal koagulopati sebelumnya .
Cedera medula spinalis
PEMERIKSAAN PENUNJANG
DPL (Diagnostic Peritoneal Lavage)
• Darah bebas tampak jelas
• Analisis cairan lavage :
RBC > 100,000 cells/mm3
Bile, bacteria, vegetable fib
ers, fecal material
Amylase, alkaline phosphat
ase
PEMERIKSAAN PENUNJANG
CT Scan Abdomen

• Very specific (95-100%)

• Good sensitivity (85-99%)
• Can evaluate the retroperitoneum
• Allows staging of blunt organ injuries
• Most major injuries are operator (reader) independent

Dx modality of choice for hemodynamically stable patients with suspected blunt abdominal injury
PEMERIKSAAN PENUNJANG
CT Scan Abdomen

Disadvantages

• Requires time and patient transport

• May miss blunt intestinal injuries

• Highly dangerous for unstable or equivocal pts

PEMERIKSAAN PENUNJANG

DPL USG CT-Scan

Indikasi Menentukan adanya perdar Menentukan adanya cairan, Menentukan organ-organ
ahan, dilakukan bila dilakukan bila tekanan yang cedera, dilakukan bila
tekanan darah menurun. darah menurun. tekanan darah normal.
Keuntungan Diagnosis cepat dan sensitif Diagnosis cepat dan tidak Paling spesifik untuk cedera
(akurasi 98 %). invasif dan dapat diulang (akurasi 92 – 98 %).
(akurasi 86 – 97 %).
Kerugian Invasif, tidak bisa Tergantung operator, dapat Biaya mahal, waktu lama,
mengetahui cedera pada terdistorsi oleh gas usus tidak bisa mengetahui
diafragma atau pada dan udara di bawah kulit, cedera pada diafragma,
retroperitoneal. selain itu tidak bisa usus, dan pankreas.
mendeteksi jejas diafragma
, usus, dan páncreas.
PENATALAKSANAAN

PRIMARY SURVEY SECONDARY SURVEY

PENATALAKSANAAN

PRIMARY SURVEY
PENATALAKSANAAN

PRIMARY SURVEY

• Paten ?

• Jaw thrust maneuver

• Sadar  nasopharingeal airway

• Tidak sadar  oropharingeal airway

PENATALAKSANAAN

PRIMARY SURVEY

• Inspeksi  gerakan dinding dada

• Auskultasi  suara nafas ?

• Perkusi  udara atau cairan cavum pleura

• Palpasi  getaran ddg dada & krepitasi

• Pasang pulse oximetry

PENATALAKSANAAN

PRIMARY SURVEY

1. Volume Darah
• Hipotensi  hipovolemia
2. Tingkat Kesadaran
• Penurunan kesadaran
 Hipovolemia
 Intoksikasi
3. Warna Kulit
• Akral pucat dan dingin  hipovolemia
4. Nadi
• Cepat & kecil  hipovolemia
PENATALAKSANAAN

PRIMARY SURVEY
Pasang 2 IV line untuk
resusitasi cairan kristaloid
(ringer laktat / RL) 2-3 liter

Koloid

Tranfusi darah segolongan

PENATALAKSANAAN

PRIMARY SURVEY

Pada tahap ini dilakukan penilaian neurologis secara cepat berupa tingkat kesadaran, ukuran dan reaksi pupil,
tanda-tanda lateralisasi dan tingkat cedera spinal.
PENATALAKSANAAN

PRIMARY SURVEY

Pada tahap ini, pakaian pasien dibuka keseluruhan kemudian dinilai kelainan yang tampak secara cepat.
Selanjutnya selimuti pasien agar tidak hipotermi.
PENATALAKSANAAN

SECONDARY SURVEY

1. Pemeriksaan “Head to toe”

• Kepala : konjungtiva anemis, tanda-tanda trauma kepala, luka dan kontusio pada kulit kepa
la, fraktur, edema palbebra, benda asing dalam mata, perdarahan konjungtiva, ukuran dan respon
pupil.
• Vertebre servicalis & leher : pemeriksaan neurologis untuk menilai defisit neurologis yang di
sesuaikan dengan penjalaran persarafan servikal. Maka dilakukan imobilisasi hingga verte
bra servikal diperiksa teliti dengan foto servikal.
PENATALAKSANAAN

SECONDARY SURVEY

1. Pemeriksaan “Head to toe”

• Thorax
 Inspeksi : flail chest atau open pneumothorax, hematom pada dinding dada, dist
ensi vena jugularis
 Palpasi pada setiap kosta dan klavikula untuk menilai adanya fraktur.
 Auskultasi bising napas pada atas toraks untuk menentukan pneumotoraks dan bagian poste
rior untuk menilai adanya hemotoraks.Bunyi jantung yang jauh disertai nadi yang kecil mung
kin disebabkan tamponade jantung.Suara napas yang menurun pada auskultasi dan hiperso
nor pada perkusi disertai syok mengarahkan pada pneumotoraks.
PENATALAKSANAAN

SECONDARY SURVEY

1. Pemeriksaan “Head to toe”

• Abdomen
 Inspeksi : Baju penderita harus dibuka semua. Amati adanya :
o Hematom, seat belt sign, vulnus ekskoriatum, vulnus laseratum, vulnus p
uctum, benda asing yang tertancap
o Keluarnya isi perut
o Distensi abdomen, yang biasanya berhubungan dengan pneumoperitone
um, dilatasi gaster, atau ileus akibat iritasi peritoneal.
o Kebiruan pada regio flank, punggung bagian bawah ( grey turner sign) me
nandakan adanya perdarahan retroperitoneal yang melibatkan ginjal, pa
nkreas, atau fraktur pelvis.
o Kebiruan disekitar umbilikus (cullen sign) menandakan adanya perdaraha
n pankreas.
PENATALAKSANAAN

SECONDARY SURVEY

1. Pemeriksaan “Head to toe”

• Abdomen
 Auskultasi : Penurunan peristaltik usus dapat berasal dari adanya peritonitis kimiawi k
arena perdarahan atau ruptur organ berongga.Cedera pada struktur yang berdekata
n seperti tulang iga, tulang belakang atau tulang panggul juga dapat mengakibatkan i
leus meskipun tidak ada cedera intraabdomen sehingga tidak ada peristaltik usus bu
kan berarti pasti ada cedera intraabdomen.Adanya peristaltik usus pada toraks mena
ndakan adanya cedera pada diafragma.
PENATALAKSANAAN

SECONDARY SURVEY

1. Pemeriksaan “Head to toe”

• Abdomen
 Perkusi : Perkusi pada dinding abdomen menyebabkan pergerakan peritoneum dan
dapat menunjukkan peritonitis. Perkusi timpani pada kuadran atas akibat dari dilatasi
lambung akut atau bunyi redup bila ada hemoperitoneum.
PENATALAKSANAAN

SECONDARY SURVEY

1. Pemeriksaan “Head to toe”

• Abdomen
 Palpasi : Kecenderungan mengeraskan dinding abdomen (voluntary guarding) dapat menyul
itkan pemeriksaan. Sebaliknya, defans muskular (voluntary guarding) merupakan tanda irita
si peritoneum.palpasi dilakukan selain menilai haltersebut juga untuk mengetahui adanya n
yeri tekan superfisial,nyeri tekan dalam. Nyeri tekan lepas menandakan peritonitis akibat da
rah atau isis usus. Pada kasus trauma tumpul ini, perlu curiga akan adanya fraktur pelvis. Ol
eh karena itu, untuk menilai stabilisasi pelvis dengan cara menekankan tangan pada tulang-t
ulang iliakauntuk membangkitkan gerakan abnormal atau nyeri tulang.
PENATALAKSANAAN

SECONDARY SURVEY

1. Pemeriksaan “Head to toe”

• Regio penis, perineum, rektum dan vagina
Adanya darah pada meatus uretra menyebabkan dugaan kuat robeknya uretra.Adanya ekimosis at
au hematom pada inspeksi skrotum dan perineum dapat diduga kuat robeknya uretra.
PENATALAKSANAAN
ALUR PENANGANAN SCR UMUM
Trauma Tumpul Abdomen
Tanda
peritonitis USG :
generalisata cairan
tidak
Hemodinamik stabil ya ada bebas jelas

tidak ya ya tidak

Perubahan
USG : Cairan Bebas ya laparotomi konservatif
kesadaran,
Makroskopis
hematuria,
Tidak jelas DPL tidak ya HCt < 35 %

CT-Scan ya tidak

USG ulang
(30 menit),
HCt ulang
(4 jam),
Observasi
(8 jam)
INDIKASI LAPAROTOMI

Berdasarkan Evaluasi Klinik :

1. Trauma tumpul dengan hasil DPL dan USG adanya internal bleeding
2. Trauma tumpul dengan hipotensi terus menerus walaupun dilakukan resusitasi adekuat
3. Adanya tanda-tanda peritonitis dini atau yang lanjut

Berdasarkan Evaluasi Radiologis (rontgen) :

1. Adanya udara bebas (air sickle) atau ruptura diafragma
2. CT-Scan dengan contrahaz memperlihatkan adanya ruptur organ – organ berongga intraabdo
minal.
SECONDARY SURVEY
SECONDARY SURVEY
SECONDARY SURVEY
PENATALAKSANAAN
PENATALAKSANAAN
Trauma Tumpul Abdomen

Tanda peritonitis tidak USG : cairan

Hemodinamik stabil ya
generalisata ada bebas jelas

tidak ya ya tidak

Perubahan
USG : Cairan Bebas ya laparotomi konservatif
kesadaran,

Makroskopis
Tidak jelas DPL tidak ya hematuria,

CT-Scan ya tidak

USG ulang (30

menit),

HCt ulang (4
jam),

Observasi (8
PENATALAKSANAAN
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colors, photos and Text
Columns Style
Your Text Here
You can simply impress your audience and add a unique zing and appeal to
your Presentations. Easy to change colors, photos and Text. I hope and I
believe that this Template will your Time, Money and Reputation. You can
simply impress your audience and add a unique zing and appeal to your
Presentations. Easy to change colors, photos and Text.

Easy to change colors, photos and Text. I hope and I believe that this
Template will your Time, Money and Reputation. You can simply impress
your audience and add a unique zing and appeal to your Presentations. You
can simply impress your audience and add a unique zing and appeal to your
Presentations. Easy to change colors, photos and Text.

You can simply impress your audience and add a unique zing and appeal to
your Presentations. Easy to change colors, photos and Text.
Columns Style
Your Text Here Your Text Here
You can simply impress your You can simply impress your
audience and add a unique zing and audience and add a unique zing and
appeal to your Presentations. Easy appeal to your Presentations. Easy
to change colors, photos and Text. to change colors, photos and Text.

You can simply impress your You can simply impress your
audience and add a unique zing and audience and add a unique zing and
appeal to your Presentations. Easy appeal to your Presentations. Easy
to change colors, photos and Text. I to change colors, photos and Text. I
hope and I believe that this Template hope and I believe that this Template
will your Time, Money and will your Time, Money and
Reputation. You can simply impress Reputation. You can simply impress
your audience and add a unique your audience and add a unique
zing and appeal to your zing and appeal to your
Presentations. Presentations.
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Fully Editable Shapes
 Fully Editable Icon Sets : A

You can Resize without

losing quality

You can Change Fill Color &

Line Color

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 Fully Editable Icon Sets : B

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com
 Fully Editable Icon Sets : C

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com