Pembahasan soal MCQ no 1-4

Soal no 1
• A I-year-old child referred to our hospital with the diagnosis
of dengue shock syndrome. He is somnolen, tachycardia
and clammy acral. No data for the last urine output. The
previous hospital sent the patient because they found
difficulty in inserting iv line. The lab result showed
thrombocitopenia 13.000 and increased hematocrite to
46%.
• The next management is:
• A. inserting iv line peripheraly
• B. do the intraosseous access
• C. prepare central access
• D. venae sectie
• E. inserting nasogastric tube
• Intraosseous access was suggested for
children aged 6 years or younger, though
subsequent studies have shown that it is safe
in older children and adults.
• Successful infusions in newborns have further
suggested that access via the intraosseous
route is faster than access via umbilical veins.
• The Emergency Cardiovascular Care
Guidelines of 2000 recommended
intraosseous access in all children after two
failed attempts at IV access or during
circulatory collapse.
• In 2010, the American Heart Association
recommended intraosseous access if venous
access cannot be quickly and reliably
established.
• Intraosseous access may be easily established
by users with little training and is more rapidly
achieved than IV access.
• Intraosseous needles left in the marrow for
longer than 72 hours are at a higher risk of
local infection; thus, needles should be
removed as soon as permanent venous access
is established.
Indications
• One indication for intraosseous access is difficulty in establishing venous
access, as in the following settings:
• Burns
• Obesity
• Edema
• Seizures
Another is a condition necessitating rapid high-volume fluid infusion, such as
the following:
• Hypovolemic shock
• Burns
Another is to afford access to the systemic venous circulation, as with the
following:
• Cardiopulmonary arrest
• Burns
• Blood draws
• Local anesthesia
• Medication infusion
Contraindications
• Infection at the entry site
• Burn at the entry site
• Ipsilateral fracture of the extremity
• Osteogenesis imperfecta
• Osteopenia
• Osteopetrosis
• Previous attempt at the same site
• Previous attempt in a different location on the same bone
• Previous sternotomy (sternum insertion)
• Sternum fracture or vascular injury near the sternum (sternum
insertion)
• Inability to locate landmarks
Complications
• Infections such as cellulitis and osteomyelitis from poor antiseptic
technique or prolonged (>72 hr) needle placement
• Extravasation of blood or infusion into surrounding soft tissue from
poor technique or prolonged infusion
• Compartment syndrome from extravasation
• Bent needle from poor technique or a missed landmark
• Bone fracture or through-and-through penetration from excessive
force
• Pneumothorax, mediastinitis, or surrounding organ and tissue
injury from sternal puncture
• Clogged needle
• Rare complications include the following:
• The risk of a pulmonary fat embolus is present in adults,
though studies in piglets with intraosseous access during
cardiopulmonary resuscitation (CPR) showed no increased
risk over CPR alone [30]
• Concerns regarding fluid type have been reported, though
studies have shown no increase in risk of injury to
surrounding tissues with isotonic solutions as compared
with hypertonic solutions
• Concerns regarding bone growth from insertion exist,
though no cellular or marrow changes have been
demonstrated in animal studies [31]
Sumber: Vascular Access in Resuscitation Is There a Role for the Intraosseous Route?
 Soal no. 2
• A 2-year-old child hospitalized for waterry diarhea with
dehydration. All the laboratory examination at admission showed
normal results except for the sodium serum level was 169 mmol/l
and the potassium serum level at 2,6 mmol/l. correction for
potassium and sodium level was done. One day after that the
patient suffered fro seizure and decreased of consciousness. The
patient then reffered to PICU, the result of the last sodium level
before the patient reffered to PICU was 144 mmol/l. what is the
caused of the seizure:
• A. encephalitis
• B. meningoencephalitis
• C. severe dehydration
• D. edema cerebri
• E. Metabolic acidosis
 Pembahasan
• Dehidrasi hipernatremia umumnya merupakan konsekuensi
dari keadaan tidak dapat menerima cairan, akibat tidak
terdapatnya akses, gangguan rasa haus( akibat gangguan
neurologis), muntah intraktabel, atau anoreksia.
Perpindahan cairan dari ruang intraselular ke ruang
ekstravaskular selama dehidrasi hipernatremia menjaga
sebagian volume intavaskular. Produksi urin dapat
dipertahankan lebih lama, dan takikardi kurang bermakna.
• Anak dengan dehidrasi hipernatremia seringkali tampak
letargis dan iritabel. Hipernatremia dapat menyebabkan
demam, hipertonisitas, dan hiperrefleksia. Gejala
neurologis yang lebih berat dapat terjadi apabila terjadi
perdarahan serebral atau trombosis.
• Pengobatan dehidrasi hipernatremia yang terlalu cepat
dapat menyebabkan peningkatan mortalitas dan morbiditas
yang bermakna.
• Osmol idiogenik diproduksi otak selama terjadi
hipernatremia. Osmol idiogenik ini berfungsi untuk
menjaga pengerutan sel otak akibat perpindahan air ke
ruang ekstraseluler yang hipertonik.
• Selama koreksi hipernatremia, perlahan-lahan osmol
idiogenik menghilang. Penurunan osmolalitas cairan
ekstraseluler yang cepat, saat koreksi hipernaatremia dapat
mengakibatkan perpindahan cairan dari ruang ekstraseluler
ke dalam sel otak dan mengakibatkan edema serebri.
Sumber: Nelson pediatrics
 Soal no. 3
• A 8 year old child with recently diadnosed Leukemia Lymphoblastic
Acute develops septic shock after her first course of chemotherapy
when her absolout neutrophil count is 100/mm3. Appropriate
antibiotics are begun. She is resuscitated with 1 L of crystalloid and
her pulmonary capillary wedge pressure reading is 17 mmHg.
Epinephrine is begun at 4µg/minute and her heart rate goes from
110 beats/minute to 160 beats/minute. Systolic blood pressure
which was initially 80 mmHg is now 85 mmHg. What is the most
appropriate intervention at this time?
• A. begin dopamine at 10µg/kg/minute
• B. begin norepinephrine at 1 µg/kg/minute
• C. begin dobutamine at 7,5 µg/kg/minute
• D. begin phenyleprine at 5 µg/kg/minute
• E. begin dopexamine at 2 µg/kg/minute
 Soal no.4
• A 14 year old girl was admitted to the hospital with history of
consumption of some amount of wild cassava while she was
camping near the forrest. She was followed by vomitting, cephalgia,
and seizure. Her skin was reddish appearance like cherry. She was
brought to ER with respiratory distress and comatous after the
seizure attack. The blood pressure was 85/50 mmHg and heart rate
was irregulary 110 beat/minute. The antidotum for this patient is:
• A. natrium bicarbonat 84% 2 ml/kgBW
• B. sulphate atropine 0,05-0,1 mg/kgBW every 10-30’ until
atrophinization is ended
• C. sodium nitropussid 3% 0,33 mg/kgBW
• D. sodium thiosulphate 25% 1,6 mg/kgBW
• E. there is no antidotum for this situation, just doing the
symptomatic treatment
 Pembahasan
• Keracunan Singkong (Manihot Utilissima)
• Singkong atau cassava mengandung glikosida yang akan dihidrolisis
menjadi glukosa, hidrogen sianida, dan aseton.
• Manifestasi klinis
• Manifestasi klinis sering tidak spesifik, terutama menggambarkan
kekurangan oksigen --di otak dan jantung.
• Gejala awal: kelemahan, malaise, kebingungan, nyeri kepala, pusing, dan
napas pendek. --
• Keadaan lanjut: mual dan muntah, hipotensi kejang, koma, apnea, aritmia,
dan kematian --akibat henti jantung paru.
• Pemeriksaan fisis: bisa didapatkan warna merah --cherry pada kulit dan
merah pada arteri serta vena retina.
• Kadang-kadang dapat tercium bau seperti almond pahit pada napas
pasien.
• Pada keracunan berat, kematian biasanya terjadi dalam waktu 1-15 menit
• Tata laksana
• Penanganan harus dilakukan secepatnya. --
• Dekontaminasi isi lambung dengan bilas lambung dan arang aktif. --
• Selanjutnya adalah perawatan suportif: pemberian oksigen 100%,
resusitasi --kardiopulmonal
• Berikan antidotum (amil nitrit, Na-nitrit dan Na- tiosulfat).
• Sambil menunggu akses --vena, berikan amil nitrit per inhalasi.
Setelah akses vena terpasang, berikan Na-nitrit 10 mg/kg atau 0,33
mL/kg Na-nitrit 3%, untuk menghasilkan 20% methemoglobin.
Selanjutnya berikan Na- tiosulfat 25% sebanyak 1,6 mL/kg (400
mg/kg) sampai 50 mL (12,5 g), intravena dalam 10 menit.
Pemberian nitrit harus hati-hati karena dapat menyebabkan
hipotensi.
Sumber:PPM