Laporan Kasus

“Neurogenic Shock
ec Spinal Cord Injury”
Stase Emergensi
Pembimbing: dr. Ranti Waluyan
Co-ass: Akbar Taufik
NIM: I4061162042
Definition of Neurogenic Shock
• Neurogenic shock results in the loss of vasomotor tone and
sympathetic innervation to the heart.
Pathophysiology and Clinical manifestation of
neurogenic shock
• Injury to the cervical or upper thoracic spinal cord (T6 and above) can
cause impairment of the descending sympathetic pathways.
• The resultant loss of vasomotor tone causes vasodilation of visceral
and peripheral blood vessels, pooling of blood, and, consequently,
hypotension.
• Loss of sympathetic innervation to the heart can cause bradycardia or
at least the inability to mount a tachycardic response to hypovolemia.
• However, when shock is present, it is still necessary to rule out other
sources because hypovolemic (hemorrhagic) shock is the most
common type of shock in trauma patients and can be present in
addition to neurogenic shock.
Principal of the treatment in Neurogenic
Shock
• massive resuscitation can result in fluid overload and/or pulmonary
edema.
• Judicious use of vasopressors may be required after moderate volume
replacement, and atropine may be used to counteract
hemodynamically significant bradycardia.
Type of spinal cord injury
•• Incomplete or complete paraplegia (thoracic injury)
•• Incomplete or complete quadriplegia/tetraplegia (cervical injury)
Simple Pneumothorax
• Causing the lung on that side to collapse as pressure continues to
build up in the pleural cavity
Where is the pneumothorax?
•Pencil-thin white line
running parallel to chest
wall
•No lung markings lateral
to the line

Blade of right scapula

Types of Pneumothorax
• Spontaneous Pneumothorax (Closed) • Open Pneumothorax
• Primary Spontaneous Pneumothorax • Sucking chest wound
• Secondary Spontaneous Pneumothorax • Closed Pneumothorax
• Traumatic Pneumothorax
• Penetrating
• Iatrogenic (e.g. needle aspiration,
thoracentesis, insertion of CVC)
• Non-iatrogenic (e.g. gun shot, knife stab)
• Non-penetrating
• Ribs fracture
Where is the pneumothorax?
 Visceral
pleural line
(zoomed
view on next
slide)

Small pleural
No mediastinal shift effusion
(common
finding)
Clinical Features
• Inspection
• Tracheal deviation (-)
• Unequal chest rise (+) / (-)
• Dyspnea
• JVP (normal)
• Palpation
• Decreased or absence of tactile fremitus
• Percussion
• Hypersonor on the affected side
• Auscultation
• Decreased / absence of breath sounds on the affected side
• Traumatic pneumothorax 86% - 96% positive predictive value for diagnosis
• Others
• Pleuritic Chest Pain
Treatment?
Tension Pneumothorax
• Life-threatening condition!
• Results from CONTINUED AIR ACCUMULATION within the
interpleural space  due to ONE-WAY VALVE!!!
• Air enter the pleural space from:
• Open thoracic injury
• Injury to the lung parenchyma due to blunt trauma (most common)
• Barotrauma (PPV)
• Tracheobronchial injuries due to shearing forces
Tension Pneumothorax
• Results from CONTINUED AIR
ACCUMULATION within the interpleural
space
• ONE-WAY VALVE  Go inside, but can’t
get out!  GROWING Pressure 
compresses involved lung  diminishing
pulmonary circulation  shifting
mediastinum to the unaffected side 
compression of the heart and vena cava
 reduced preload gradually  shock!
Tension Pneumothorax - Sign
• Inspection
• Tracheal deviation
• Unequal chest rise
• Dyspnea
• JVP ↑
• Percussion
• Hypersonor on the affected side
• Auscultation
• Absence of breath sounds on the affected side
• Others:
• Pulsus Paradoxus
• Tachycardia
• Shock
Tension Pneumothorax - CXR
Tension Pneumothorax - CXR
Tension Pneumothorax - Treatment
• Sign of TP:
• High-flow supplemental oxygen (12 – 15 L/min) via NRB mask
• Cover open wounds
• Needle decompression (needle thoracentesis/pleural decompression)
• 14-16 G cannula
• 2nd ICS in the midclavicular line
Kasus
• Pasien datang dengan keluhan sesak nafas sejak 2 hari SMRS. Pasien
merupakan rujukan dari RS Harapan Bersama.
Primary Survey
• Airway:
• Obstruction [-]:
• Snoring (-)
• Gurgling (-)
• Stridor (-)
• Choking (-)
Primary Survey
• Breathing:
• SPO2 : 96% dgn O2 4 LPM
• Respiratory:
• Spontan (+), simetris
• RR: 28 x/min
• Bantuan otot asesoris (+)
• Deviasi Trakea (x), leher edema (+)
• Thorax: SND ves (-/+), rh (-/-), wh (-/-)
Primary Survey
• Circulation:
• Akral dingin
• CRT < 2
• PR: kuat angkat, 100 x/min
• BP: 140/100 mmHg
• JVP (x)
Primary Survey
• Disability
• GCS: E4M6V5
• Pupil: isokor | diameter OD/OS: 3 mm/3 mm | RCL (+/+) | RCTL (+\+)
Primary Survey
• Exposure
• Temp: 37.2˚C
• Expose and cover (if needed)
• Jejas ban mobil (a/r thorax anterior)
• Hematoma (a/r thorax anterior D & S)
• Bekas WSD (punggung ICS 6 D)
Secondary Survey
Identitas Pasien
• Nama : Tn. B.
• Umur : 51 thn
• Jenis kelamin : Laki-laki
• BB : 60 kg
• Alamat : Dsn. Semparuk Lorong RT. 019/ RW 007 Ds.
Semparuk Kec. Semparuk Kab. Sambas
 Secondary Survey (AMPLE)
Keluhan Utama :
• Pasien datang dengan keluhan sesak nafas sejak 2 hari SMRS. Pasien
merupakan rujukan dari RS Harapan Bersama.

• A (Alergy) : Tidak ada

• M (Medication) : Tidak ada

• P (Past Medical History): Hipertensi (-), Diabetes Melitus (-)

Secondary Survey
• L (Last Oral Intake)

• E (Event) : MOI  Mobil Isuzu yang dikendarai pasien mengalami

maslaah pada mesin. Pasien kemudian melakukan pengecekan
terhadap bagian bawah/kolong mobil. Namun tiba-tiba mobiil
tersebut bergerak sendiri ke arah depan sehingga melindas badan
pasien.
Secondary Survey
• Pemeriksaan Tanda Vital:
• KU: TSB
• Kesadaran: CM
• GCS E4V5M6
• BB: 60 kg
• Tensi: 140/100
• Nadi: 100 x/min
• Suhu: 37,2
• RR: 28 x/min
• SPO2: 96% dgn NK 4 LPM
Secondary Survey
• Head to Toe (To make sure no other injuries have higher priority for
treatment.)
• Kepala: Normocephal
• Mata: CA (-/-), SI (-/-)
• Leher: Perbesaran KGB (-/-), edema (+), JVP (x), deviasi trakea (x)
• Thorax: RR spontan, otot asesoris (+), jejas ban mobil D + S (+)
• Paru: SND ves (-/+), Rh (-/-), Wh (-/-)
• Cor: S1S2 reg, m (-/-), g (-/-)
• Abd: soepl (+), BU (+) n, NT (-)
• Ekstremitas: Akral hangat, CRT < 2,
• Combustio grade III a/r vertebra – lumbal dan brachii + antebrachia D
Secondary Survey
• Focused on Injury (a/r thorax)
• Hematome D + S
• Vulnus Ekskoriatum (bentuk
permukaan ban mobil)
Pemeriksaan Penunjang
• H2TL • Hb : 10,3
• Diff Count • Leukosit : 20.200
• HbsAG • Trombosit : 212.000
• HIV • Hematokrit: 30,9
• GDS • Eritrosit : 3,81
• Foto thorax • Ureum : 192 (N: 10-50)
• Ureum • Creatinine : 10,62 (N: 0.62 – 1.10)
• Creatinine
• EKG
EKG
Foto Thorax – 14/6/18
Foto Thorax – 16/6/18
Foto Thorax – 19/6/18
Foto Thorax – 22/6/18
Diagnosis
• Hemato-Pneumothorax

• DD:
• Efusi pleura
• Tension pneumothorax
Treatment
• IVFD NaCL 0,9% 15 tpm
• O2 3 L/M
• Inj. Ranitidine 1 amp / 12 jam
• Inj. Ceftriaxone 1 amp / 12 jam
• Inj. Dexketoprofen drip PBNS 1 x / 8 jam
• Nebu Farbivent + NS 1 cc / 6 jam
• Pro ICU
TERIMA KASIH