SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,

HAIKAL, YOGIK, GRACE,EVIT

Lecture 13 : Cardiac Arrest and Cardiopulmonar Resuscitation

dr. Pontisomaya Parami, SpAn MARS

SCENARIO 1
As on duty doctor at hospital, you are received emergency call from 2nd floor
hospital. The nurse said that there is a 70 yo male patient, diagnose as stable
angina, suddenly suffered SOB after eating, getting worse shortly, but still
conscious. After 10 minute, the patient became unconscious.

LEARNING TASK :
1. Describe briefly the immediate act of first aid that should be done to
overcome the emergency and what is the next step/therapy?
- cek respon, liat nafas, cek nadi
- RJP ➔ 30:2 dan AED
- C, A, B ➔ bisa kasih epinephrine setelah 25 shockable
- MONA
- tanda chocking ➔ heimlich maneuver
2. What happen to her?
- sudden cardiac arrest
3. Can we prevent this patient became unconscious?
- yes

SCENARIO 2
A 30 year old woman attends your clinic with asthma attack. She has a long
history of asthma, with severe attacks requiring hospitalisation. Despite
continuous nebulised salbutamol, she rapidly gets worse over about ten
minutes with severe respiratory distress, she is unable to talk and is becoming
increasingly confused and unconcious. From the monitor you already attach,
the ECG shown takikardi and became bradikardia and continue to asystole.

LEARNING TASK :
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
1. Based on immediate observation, what is the patient going through and
what actions should be done ?
- suspek heart attack
- CAB, RJP dan AED
2. Based on your analysis what would have caused this emergency and
explain its pathogenesis and pathophysiology.
- respiratory distress
- salbutamol ➔ menyebabkan aritmia
3. Can you prevent this patient from asystole? Explain it.
- yes, penanganan yang sesuai
4. Explain the management of asystole
- CPR, AED
- epinephrine 1 mgIV setiap 3-5 detik
- karena di RS bisa advanced airway (intubasi)

SCENARIO 3
85 year old man is delivered by car to your clinic. He was found collapsed 10
minute ago by his family in the garden. At Physical examination, no pulse at
a.jugularis, no heart sound. A monitor is attached and the rhytm is VF.

LEARNING TASK :
1. What are you going to do?
- DOA - cardiac arrest
- RJP, AED (shock)
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT

- !
2. How long we need to do CPR at this patient?
- 10 detik
3. Explain the algorithm of Shockable cardiac arrest
- VT/VF

SCENARIO 4
As doctor on duty at emergency room, you received a 50 years old man with
history of chest pain and suddenly unconscious in front of you. After doing fast
examination, you diagnose the patient as cardiac arrest with VT pulseless

LEARNING TASK :
1. Explain about the resuscitation team to perform good CPR on this patient.
- 2 penolong untuk kompresi
- 1 penolong untuk ventilasi
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
- 1 penolong untuk pemberian adrenalin
- 1 penolong untuk AED
- 1 penolong untuk mencatat waktu
2. How would you build a good resuscitation team?
- komunikasi antar anggota team
- terdapat team leader
- ada kritik yang membangun
- tindakan sesuai alogoritme
3. Explain how would you doing defibrillation on this patient.
- mulai siklus 30 kompresi dan 2 napas buatan, gunakan AED segera
setelah tersedia. Kemudian periksa ritme detak jantung, apakah ritme
shockable / non shockable. Jika shockable maka terapkan 1 shock,
kemudian segera lanjutkan dengan CPR kurang lebih selama 2
menit( hingga AED membolehkan pemeriksaan ritme kembali).
Lanjutkan hingga tenaga ALS mengambil alih atau px mulai bergerak /
sadar.
- Jika ritme tidak dapat dikejut, segera lanjutkan CPR kurang lebih
selama 2 menit( hingga AED membolehkan pemeriksaan ritme
kembali). Lanjutkan hingga tenaga ALS mengambil alih atau px mulai
bergerak
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT

Lecture 14 : PAIN MANAGEMENT

dr. Made Agus Kresna Sucandra, SpAn KIC

SCENARIO 1
A 55-year-old man has severe pain on gentle touching of the arm. Six months
ago, the median nerve was damaged during creation of an arteriovenous
fistula for dialysis.

LEARNING TASK :
1. What is the best terms to describes this phenomenon, explain about it?
- suspek median nerve palsy ➔ kalau median nerve damage jadi
terganggu kemampuan abduksinya
2. What is pain and chronic pain?
- pain ➔ an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage
- chronic pain ➔ pain that continues a month or more beyond the usual
recovery period for an injury or illness or goes on for months or years

due to a chronic condition.

3. Explain about three different types of chronic pain and give the examples!
- neuropathic pain ➔ Paroxysmal and lancinating has a burning quality
and is associated with hyperpathia.
- deafferentiation pain ➔ Neuropathic pain associated with loss of sensory
input into the CNS.
- sympathetically mediated pain ➔ sympathetic symptoms plays a major
role

SCENARIO 2
A 21-year-old female softball pitcher had a surgical ulnar nerve transposition/
release for pain in her pitching arm three months ago. Now she still complains
of severe pain daily. She can barely bend her elbow and has decreased
function of her hand. She notes increased sensitivity to cold temperatures and
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
generalized swelling, which is more pronounced on the ulnar side of her hand.
She is in your office for pain management.

LEARNING TASK :
1. What is her diagnosis?
- neuropatic pain somatis
2. How will you confirm the diagnosis?
- anamnesis ➔ B4S7
- pemeriksaan neurologis
- pemeriksaan lanjutan ➔ imaging (plain foto, CT scan)
- scoring pain ➔ VAS
3. How will you treat the patient’s pain?
- farmakologi :
• karena kronik, bisa non opioid seperti NSAID, ketorolac + adjuvant
antidepresan seperti amitriptiline
• apabila nyeri dan tidak ada perubahan, berikan non opioid yang lebih
baik seperti codein + adjuvant
• berikan opioid seperti tramadol
- non farmakologi :
• pengukuran fisik seperti exercise
• modalitis radiasi
- kognitif
• relaksasi
- invasif

SCENARIO 3
A 47-year-old female presents for a total knee arthroplasty. Her medical
history is positive for hypertension, rheumatoid arthritis, and a previous history
of drug abuse. Her current medications include hydrochlorothiazide (HCTZ),
lisinopril, and buprenorphine hydrochloride (Subutex).

LEARNING TASK :
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
1. What is the definition of opiois addiction and tolerance?
- addiksi opioid ➔ kondisi seseorang yang memakai merasa
ketergantungan
- toleransi opioid ➔ orang yang menggunakan ingin dosis lebih tinggi dari
sebelumnya, semakin lama semakin myentu dan menyesuaikan tubuh
pasien
2. Mention opioid receptor types!
- Mu
- delta
- kappa
- sigma
3. Mention side effects of opioid!
- sedation
- dizziness
- nausea
- vomiting
- constipation
- liver damage
- respiratory depression
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT

Lecture 15 : EMERGENCY TOXICOLOGY AND POISONING

Dr.dr. Agus Somya, SpPD. KPTI

SCENARIO 1
Male 20 years, student, came to the ER Sanglah, was brought by his parents in
a state of unconsciousness. On physical examination found coma, blood
pressure 80/60 mm Hg, pulse 48 beats per minute, frequency of breathing 12
times per minute. The pupils: miosis. Abdominal examination: decreased
bowel sounds. At the forearm found needle track marks.

LEARNING TASK PPT

1. Describe the symptoms and clinical signs in these cases?
- penurunan kesadaran
- pupil miosis
- hipotensi
- bradypneu
- bradykardia
- penurunan bising usus
- found needle track marks at the forearm
2. What are the other anamnesis and the other physical examination that
needed
- anamnesis :
• kalau tidak bisa dianamnesis pasiennya, heteroanamnesis ➔ orang tua
• apa yang terjadi dan kapan terjadinya
• kronologi
• apa bahan yang disuntikkan
• apakah ada bahan lain yang ditambahkan atau digunakan
• seberapa banyak ( dosis)
• selain melalui jarum suntik, apakah ada rute lain seperti di hirup,
diminum, kontak dengan kulit dll
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
• apakah terdapat benda yang berhubungan (wadah bahan yg
digunakan, surat bunuh diri dll)
- pemeriksaan fisik :
• vital signs
• pupil
• look, feel and smell
3. What the laboratory examination is needed to confirm the diagnosis
- general test :
• pemeriksaan darah lengkap
• blood sugar
• BUN (blood urea nitrogen)
• electrolyte
- toxic specific test :
• Quantitative opioid blood level
• Qualitative analysis of the urine
4. What the differential diagnosis above case
- intoksikasi alkohol ➔ kalau diberi naloxone tidak ada perubahan pada
pupil
5. What the diagnosis above case
- suspek intoksikasi opioid
6. How to manage the above case
- ABC
- kondisi umum
- antidote yang diberikan :
• naloxone ➔ competitive binds to receptor sites and blocks the agonist
effect with dosis 0.4-2 mg. repeated boluses should be given at 1-2
minute interval for a total dose 10 mg. IV/IM

SCENARIO 2
Male, 20 years old, a builder, came to the ER escorted by his friend, the pain
after accidentally ingesting drinking colored floor cleaning liquid is clear and
odorless. On physical examination lip until pharing area look red and swollen.
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT

LEARNING TASK PPT

1. Describe the symptoms and clinical signs in these cases?
- nyeri
- bibir hingga area faring terlihat merah dan bengkak
- rasa terbakar pada mulut
- sakit saat menelan
2. What are the other anamnesis and the other physical examination that
needed
- anamnesis :
• kalau tidak bisa dianamnesis pasiennya, heteroanamnesis ➔ orang tua
• apa yang terjadi dan kapan terjadinya
• kronologi
• apa bahan yang disuntikkan
• apakah ada bahan lain yang ditambahkan atau digunakan
• seberapa banyak ( dosis)
• selain melalui jarum suntik, apakah ada rute lain seperti di hirup,
diminum, kontak dengan kulit dll
• apakah terdapat benda yang berhubungan (wadah bahan yg
digunakan, surat bunuh diri dll)
- pemeriksan fisik :
• vital signs
• pupil
• look, feel and smell
• airway ➔ obstruksi seperti stridor, suara serak, dysphonia atau
aphonia, batuk, tachypnea
3. What the laboratory examination is needed to confirm the diagnosis
- Darah lengkap
- analise gas darah urin
- elektrolit
- serum
- pemeriksaan fungsi hari dan ginjal
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
4. What the differential diagnosis above case
- intoksikasi asam atau basa
5. What the diagnosis above case
- alkaline agent poisoning
6. How to manage the above case
- A,B,C,D (stabilisasi)
- dilutional therapy
- management of complication

SCENARIO 3
Male 30 years old come to the ER, in between by his girlfriend, complained of
fatigue and vomiting - vomiting after drinking Baygon (insecticide),
approximately 6 hours ago. Patients also complain of frequent urination and
defecation. On physical examination found the pulse of 48 beats per minute,
miosis, lacrimation, salivation.

LEARNING TASK PPT

1. Describe the symptoms and clinical signs in these cases?
- rasa lelah lemas lemah
- muntah muntah
- sering buang air kecil dan besar
- miosis
- bradikardi
- lakrimasi
- salivasi
2. What are the other anamnesis and the other physical examination that
needed
- anamnesis :
• kalau tidak bisa dianamnesis pasiennya, heteroanamnesis ➔ orang tua
• apa yang terjadi dan kapan terjadinya
• kronologi
• apa bahan yang disuntikkan
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
• apakah ada bahan lain yang ditambahkan atau digunakan
• seberapa banyak ( dosis)
• selain melalui jarum suntik, apakah ada rute lain seperti di hirup,
diminum, kontak dengan kulit dll
• apakah terdapat benda yang berhubungan (wadah bahan yg
digunakan, surat bunuh diri dll)
- pemeriksan fisik :
• vital signs
• pupil
• look, feel and smell
3. What the laboratory examination is needed to confirm the diagnosis
- darah lengkap
- Urinalysis ( untuk melihat waktu paparan, jika masih terdapat di urin
maka baru terjadi)
- Serum electrolyte ( mengalami ketidakseimbangan elektrolit)
- Kidney function ( menyebabkan AKI)
- Chest radiograph ( terjadi respiratory distress seperti pneumonitis )
- Electrocardiography ( kebanyakan px terdapat prolong QT interval,
takikardi, bradikardi, ST elevasi)
4. What the differential diagnosis above case
- Carbamat poisoning ➔ efek racun karbamat cepat hilang dan cepat
muncul gejala yang ditimbulkan
5. What the diagnosis above case
- organophosphat poisoning
6. How to manage the above case
- stabilisasi (A,B,C)
- dieliminasi dalam 4 jam bisa dilakukan kumbah lambung, kalau lebih
dari 6 jam dialisis
- toxin ➔ atrophine (antidote), Pralidoxime chloride
- managemen complication

SCENARIO 4
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
Male 25 years, came to the ER carried by his family in a state of
unconsciousness. After approximately 24 hours ago attend the party. Previous
patients with mild drunk and sleepy, then complained of blurred vision and blind

LEARNING TASK PPT

1. Describe the symptoms and clinical signs in these cases?
- kesadaran menurun
- penglihatan kabur dan buta
2. What are the other anamnesis and the other physical examination that
needed
- anamnesis :
• kalau tidak bisa dianamnesis pasiennya, heteroanamnesis ➔ orang tua
• apa yang terjadi dan kapan terjadinya
• kronologi
• apa bahan yang disuntikkan
• apakah ada bahan lain yang ditambahkan atau digunakan
• seberapa banyak ( dosis)
• selain melalui jarum suntik, apakah ada rute lain seperti di hirup,
diminum, kontak dengan kulit dll
• apakah terdapat benda yang berhubungan (wadah bahan yg
digunakan, surat bunuh diri dll)
- pemeriksan fisik :
• vital signs
• pupil
• look, feel and smell
3. What the laboratory examination is needed to confirm the diagnosis
- darah lengkap
- urinalisis
- kidney function
- serum electolyte
- arterial blood gases
- blood alcohol level
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
- blood level of metanol
4. What the differential diagnosis above case
- diabetic ketoacidosis
- pancreatitis
- Nephrolithiasis
- Meningitis
- Subarachnoid hemorrhage
- Retinal detachment
5. What the diagnosis above case
- intoksikasi metanol
6. How to manage the above case
- stabilisasi (A,B,C)
- hemodialisis
- antidote : etanol, methylpyrazole, folinic acid
- management of complication
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT

Lecture 16 : SKIN EMERGENCIES

dr. Nyoman Suryawati, SpKK

SCENARIO 1
A 22 years old male come to emergency unit sanglah hospital with blistering
skin rash since 5 days ago. He was HIV patient got medication such us
antiretroviral, cotrimoxazole, and fluconazole since 4 months ago. Patient with
weak condition, BP 100/80 mmHg, temp 39°C, RR 22x/minutes. From eye
examination there is redness and secret on conjungtiva, from mouth and
genetalia examination we find multiple erosion with hemmoragic crust. From
his extremities, face and trunk we find multiple purpuric lesion and some part
of rash with bullous and erotion that involve 40% BSA.

LEARNING TASK PPT

1. According this case, what is the most likely diagnosis?
- diagnosis ➔ TEN (toxic epidermal necrolysis)
2. What is the differential diagnosis of this case?
- SJS
- SSSS
3. What other information do you need to support the diagnosis?
- riwayat konsumsi obat dalam 8 minggu
- apa pernah mengalami gejala yang sama
- riwayat alergi di keluarga dan pribadi
- riwayat penyakit kulit ➔ infeksi, herpes, influenza dan mums
4. What other examination you should do to this patient?
- nikolsky sign, intraepidermal sign
5. What monitoring should you do to this patient?
- ABC, cairan, nyeri, RR, tekanan darah, suhu
- monitoring di ICU
- lihat apakah ada komplikasi ➔ infeksi sekunder
6. How do you manage this patient?
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
- hospitalisation ➔ airway, hemodynamic stability, fluid status
- fluid replacement
- corticosteroid ➔ methylprednicone
- stop semua konsumsi obat
- denoded ➔ compress with saline
7. What is the complication of this condition?
- dehindration ➔ syok hipovolemik
- sepsis
8. What information you should give to patient and his family?
- menginformasi mengenai kondisi pasien ➔ akibat reaksi obat
- menginformasi mengenai tindakan yang akan dilakukan dan tujuan
tindakan reaksi dan tindakan yang dilakukan apabila ada reaksi

SCENARIO 2
A 8 month-old baby come with her mother to emergency room Sanglah
hospital with skin rash all over the body. She had a fever, cough and rhinitis 4
days before. Two days later, she developed erythematous rash around the nose
and the rash widespread all over her body with the skin peel easyly. Her
mother give her paracetamol and Actifed ® syrup but there is no
improvement. Patient with weak condition, temp 40°C, HR 90X/minutes, RR
28x/minutes. Skin effloresence from face, trunk, back, and extremities, we find
erythematous macule, some part of the lesion with multiple vesicle and
desquamation skin.

LEARNING TASK PPT

1. According this case, what is the most likely diagnosis?
- SSSS
2. What is the differential diagnosis of this case?
- SJS
- TEN
3. What other information do you need to support the diagnosis?
- riwayat alergi obat
SGD B5 : SUCAH, ANTHON, YUCAN, AMIRAH, JOHN, LATHA, MISYEL, SATYA,
HAIKAL, YOGIK, GRACE,EVIT
- keluhan sama
- riwayat penyakit infeksi
4. What other examination you should do to this patient?
- pemeriksaan fisik ➔ nikolsky sign, intraepidermal sign
- pemeriksaan penunjang
• biopsy
• DL ➔ exotoxin stap aureus
• kultur
5. What monitoring should you do to this patient?
- monitoring ABC, cairan, nyeri, RR, blood pressure, suhu, luka
- lihat apakah ada komplikasi ➔ infeksi sekunder
6. How do you manage this patient?
- hospitalisation
- oral antibiotic or IV antibiotic ➔ penicilin, fluidocillin
- paracetamol ➔ fever, pain
- fluid and electrolyte intake
- skin care
7. What is the complication of this condition?
- dehidrasi
- syok
- sepsis
8. What information you should give to patient and his family?
- menginformasi mengenai kondisi pasien ➔ infeksi staphylococcus
aureus
- menginformasi mengenai tindakan yang akan dilakukan dan tujuan
tindakan