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Study Guide Emergency Medicine September 2014

INTRODUCTION
Emergency Medicine has long been established especially in Australasia, Canada, Ireland, the United Kingdom
and the United States, in Asiaothe emergency medicine officially inauguration of Asian Society of Emergency
Medicine in Singapore on the 24th of October 1998 at the first Asian Conference on Emergency Medicine which
as Prof.DR.dr. Eddy Rahardjo,SpAnKIC and dr. Tri Wahyu Murni sat as member of Board Director.
It is thus sometimes seen to be synonymous with emergency medical careand within the province and expertise
of almost all medical practitioners. However, theEmergency Medicine incorporates the resuscitation and
management of allundifferentiated urgent and emergency cases until discharge or transfer to the care ofanother
physician. Emergency Medicine is an inter-disciplinary specialty, one which isinterdependent with all other
clinical disciplines. It thus complements and does not seekto compete with other medical specialties.
Basic science concepts to help in the understanding of the phatophysiology and treatment of disease.The
medical curriculum has become increasingly vertically integrated, with a much greater use of clinical examples
and cases to help in the understanding of the relevance of the underlying basic science, The Emergency
Medicine block has been written to take account of this trend, and to integrate core aspects of basic science,
pathophysiology and treatment into a single, easy to use revision aid.
In accordance the lectures that have been full integrated for studens in 6Th semester,
period of 2014, one of there is The Emergency Medicine Block.
There are many topics will be discuss as below:
Seizure and mental status changes, acute Psychiatric episode, Acute respiratory distress syndrome and failure,
Bleeding disorders (epistaxis, dental bleeding, vaginal bleeding) ,Shock, Cardiac critical care (Cardiac arrest and
CPR), Emergency toxicology and poisoning, Pregnancy induce Hypertension, Shoulder dystocia, Urologic
concern in critical care, Phlegmon, Acute Blistering and Expoliative skin, Trauma which potentially disabling and
Life threatening condition and Basic Clinical Skill
Beside those topics, also describes the learning outcome, learning objective, learning task,
self assessment and references. The learning process will be carried out for 4 weeks (20
days).
Due to this theme has been prepared for the second time, so many locking mill is available
on it. Perhaps it will better in the future

Thank you.
Planner

Medical Education Unit Faculty of Medicine Udayana University

Study Guide Emergency Medicine September 2014

CURRICULUM CONTENTS
Mastery of basic knowledge with its clinical and practical implication.
Establish tentative diagnosis, provide initial management and refer patient
with :

Seizure and mental status changes


Acute Psychiatric episode
Acute respiratory distress syndrome and failure
Bleeding disorders (epistaxis, dental bleeding, vaginal bleeding)
Shock
Cardiac critical care (Cardiac arrest and CPR)
Emergency toxicology and poisoning
Pregnancy induce Hypertension, Shoulder dystocia
Urologic concern in critical and non critical care
Phlegmon
Acute Blistering and Expoliative skin
Trauma which potentially disabling and Life threatening condition

SKILLS

To implement a general strategy in the approach to patients with critical ill through
history and physical examination and special technique investigations
To manage by assessing, provide initial management and refer patient with critical ill

PERSONAL DEVELOPMENT/ATTITUDE
Awareness to :

Ethic in critical care


Basic principle of critical care
The importance of informed consent to patient and family concerning critical ill
situations
Risk of patient with critically ill and its prognosis

COMMUNITY ASPECT :

Communicability of the critical cases


Cost effectiveness
Utilization of health system facilities
Critical ill patient

Medical Education Unit Faculty of Medicine Udayana University

Study Guide Emergency Medicine September 2014

PLANNERS TEAM
NO.

NAME

DEPARTMENT

1.

dr. Tjok Gde Agung Senapathi,Sp.AnKAR


(Chairman)
dr. I Ketut Suyasa, Sp.B,Sp.OT(K) (Secretary)
dr. IGN Budiarsa,Sp.S
dr. Sari Wulan,Sp.THT
Drg, I G A G Oka
dr. Agus Somya, Sp.PD
dr. Dewa Made Artika, Sp.P
dr. Dyah Kanyawati, Sp.A
dr. Wayan Megadana, Sp.OG(K)
dr. Megaputra, Sp.OG(K)
dr. Gd Wirya Kesuma Duarsa, Sp.U,M.kes
dr. Budi Santosa,Sp.U
dr. Sri Laksminingsih Sp.R (K)
dr. Ratep,Sp.KJ
dr. Nyoman Suryawati,SP.KK

Anesthesiology and
Intensive Therapy
Surgery
Neurology
ENT
Dentistry
Internal Medicine
Pulmonology
Pediatric
Obstetric-Gynecologic
Obstetric-Gynecologic
Surgery
Surgery
Radiology
Psychiatric
Dermatology

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
12.
13.

LECTURERS
NO.
1.

NAME
dr.Tjok Gde Agung Senapathi,
Sp.AnKAR (Chairman)

2.

dr.K
Suyasa,
SpB,SpOT(K)
(Secretary)
dr. IGN Budiarsa,SpS
dr.IGN
Mahaalit
Aribawa,
SpANKAR

3.
4.
5.

dr. IGAG Utara Hartawan, SpAn


MARS

6.
7.
5.
6.
7.
8.
9.

dr. Wayan Sucipta,SpTHT


dr. Sari Wulan, SpTHT
Drg. Nyoman Ayu Anggayanti,
MBioMed
dr. Agus Somya, SpPDKPTI
dr. Dewa Made Artika, SpP
dr. Dyah Kanyawati, SpA
dr. Wayan Megadana, SpOG(K)

10.

dr. Megaputra, SpOG(K)

DEPARTMENT
Anesthesiology
and Intensive
Therapy
Surgery
Neurology
Anesthesiology
and Intensive
Therapy
Anesthesiology
and Intensive
Therapy
ENT
ENT
Dentistry
Internal Medicine
Pulmonology
Pediatric
ObstetricGynecologic
ObstetricGynecologic

Medical Education Unit Faculty of Medicine Udayana University

PHONE
081337711220
03617879748
081558724088
0811399673
0811396811
08123868126
082236088687
081237874447
08113853707
08123989353
08123875875
085737046003
08123917002
08123636172

Study Guide Emergency Medicine September 2014


11.
12
13.
14.
15
16.

dr. Gd Wirya Kesuma Duarsa,


SpU,Mkes
dr. Budi Santosa, SpU
dr. Ratep,SpKJ
dr. Nyoman Suryawati, SpKK
dr. Wayan Subawa, SpOT
dr. Sri Laksminingsih,SpR

Surgery

08155753377

Surgery
Psychiatric
Dermatology
Surgery
Radiology

081339977799
08123618861
08970111090
081337096388
03617456639

Medical Education Unit Faculty of Medicine Udayana University

Study Guide Emergency Medicine September 2014

FACILITATORS
(REGULAR CLASS)
NO
1
2
3
4

NAME

GROU
P
1

Dr.rer. Nat. dr. Ni Nyoman Ayu


Dewi, M.Si

dr. I Gusti Nyoman Sri Wiryawan


, M.Repro

dr. I G Kamasan Nyoman


Arijana, M.Si.Med

dr. I Wayan Eka Sutyawan,


Sp.M

dr. I Wayan Arya biantara, Sp.


An

9
10

NO
1
2
3
4
5
6
7
8
9
10

dr. I Putu Kurniyanta, Sp.An


dr. I Putu Kurniawan
Dhanasaputra, Sp.KK
dr. I Putu Eka Widyadharma,
MSc,SpS

NAME
dr. I Putu Adiartha Griadhi,
M.Fis
Drs. I Gede Made Adioka, Apt,
M.Kes
dr. I Nyoman Sutarsa , MPH
dr. I Nyoman Arcana, Sp.Biok
dr. I Made Susila Utama,
Sp.PD-KPTI
dr. I Made Suka Adnyana,
Sp.BP.
dr. I Made Sudipta, Sp.THT-KL
dr. I Made Putra Swi Antara ,
S.Ked
dr. I Made Pande Dwipayana,
Sp.PD
dr. I Made Oka Negara, S.Ked

Biochemistry

081337141506

Radiology

08164745561

Histology

08123925104

Microbiology

08179747502

Histology

085339644145

Opthalmology

081338538499

Anasthesi

08123822009

Anasthesi

081805755222

Dermatology

081236234153

Neurology

081328049360

PHONE

dr. Sri Laksminingsih, Sp.Rad

I B. Putra Dwija, S.Si, M.Biotech

DEPT

8
9
10

FACILITATORS
(ENGLISH CLASS)
GROUP
DEPT
1
2
3
4
5
6
7
8
9
10

Medical Education Unit Faculty of Medicine Udayana University

PHONE

Fisiology

081999636899

Pharmacy

0361 - 8000382

Public Health

087860380028

Biochemistry

0811397960

Interna

08123815025

Surgery

081236288975

ENT

08123837063

Cardiology

08123804782

Interna

08123657130

Andrology

08123979397

VENUE
3nd floor:
R.3.09
3nd floor:
R.3.10
3nd floor:
R.3.11
3nd floor:
R.3.12
3nd floor:
R.3.13
3nd floor:
R.3.14
3nd floor:
R.3.15
3nd floor:
R.3.16
3nd floor:
R.3.17
3nd floor:
R.3.19

VENUE
3nd floor:
R.3.09
3nd floor:
R.3.10
3nd floor:
R.3.11
3nd floor:
R.3.12
3nd floor:
R.3.13
3nd floor:
R.3.14
3nd floor:
R.3.15
3nd floor:
R.3.16
3nd floor:
R.3.17
3nd floor:
R.3.19

Study Guide Emergency Medicine September 2014

TIME TABLE
Regular Class
DAY/DATE

TIME

1.
Tue,
9 Sept
2014

08.00-09.00

2.
Wed,
10 Sept
2014

3.
Thu,
11 Sept
2014

4.
Fri,
12 Sept
2014

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00
08.00-09.00

LEARNING
ACTIVITY

VENUE

Highlight in
Class room
Emergency
Medicine(Chairman)
Individual Learning
SGD
Disc room
Break
Student Project
Plenary
Class room
Lecture 2.
Status Epilepticus
and Other Seizure
Disorders
Individual Learning
SGD
Break
Student Project
Plenary
Lecture 3.
Acute Psychiatric
Episodes
Individual Learning
SGD
Break
Student Project
Plenary

Class room

08.00-09.00

Lecture 4.
Acute Respiratory
Distress Syndrome
and Failure

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

Individual Learning
SGD
Break
Student Project
Plenary

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00
08.00-09.00
09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

Medical Education Unit Faculty of Medicine Udayana University

CONVEYER
dr. Tjok Gde Agung
Senapathi, Sp.AnKAR
Facilitators
dr. Tjok Gde Agung
Senapathi, Sp.AnKAR
dr. IGN Budiarsa,SpS

Disc room

Facilitators

Class room
Class room

dr. IGN Budiarsa,SpS


dr. Ratep,SpKJ

Disc room

Facilitators

Class room

dr. Ratep,SpKJ

Class room

dr Sucipta, SpTHT KL
( and ENT Team), Dr.
Dewa Made Artika, SpP,
dr. Dyah Kanyawati,SpA,
dr. Srie Laksminingsih,
SpR

Disc room

Facilitators

Class room

dr Sucipta, SpTHT KL
( and ENT Team)
Pulmo, Pediatric,
Radiology

Study Guide Emergency Medicine September 2014

DAY/DATE

TIME

5.
Mon,
15 Sept
2014

08.00-09.00

6.
Tue,
16 Sept
2014

7.
Wed,
17 Sept
2014

VENUE

Lecture 5.
Shock on Adult and
Pediatrik
Individual Learning
SGD
Break
Student Project
Plenary

Class room

08.00-09.00

Lecture 6.
Bleeding Disorder

Class room

09.00-10.30

Individual Learning

10.30-12.00

SGD

12.00-12.30

Break

12.30-14.00

Student Project

14.00-15.00

08.00-09.00

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00
8
Thu,
18 Sept
2014

LEARNING
ACTIVITY

08.00-09.00

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

Disc room
Class room

CONVEYER
dr. IGAG Uttara Hartawan
, SpAnMARS; dr. Dyah
Kanyawati, SpA
Facilitators
dr. IGAG Uttara Hartawan
, SpAnMARS; dr. Dyah
Kanyawati, SpA
dr SariWulan, SpTHT KL
( and ENT Team)
dr. Megadhana, SpOG(K)
OBGYN
-

Disc room

Facilitators

Plenary

Class room

Lecture 7.
Cardiac Arrest and +
Cardiopulmonary
Resuscitaton
Individual Learning
SGD
Break
Student Project
Plenary

Class room

dr SariWulan, SpTHT KL
( and ENT Team)
dr. Megadhana, SpOG(K)
OBGYN
dr. IGN Mahaalit Aribawa,
SpANKAR

Lecture 8
Emergency
Toxicology and
Poisoning
Individual Learning
SGD
Break
Student Project
Plenary

Class room

Medical Education Unit Faculty of Medicine Udayana University

Disc room

Facilitators

Class room

dr. IGN Mahaalit Aribawa,


SpANKAR
dr. Agus Somya, SpPD
KPTI

Disc room

Facilitators

Class room

dr. Agus Somya, SpPD


KPTI

Study Guide Emergency Medicine September 2014

DAY/DATE
9
Fri,
19 Sept
2014

10
Mon,
22 Sept
2014

11.
Tue,
23 Sept
2014

12.
Wed,
24 Sept
2014

TIME
08.00-09.00

VENUE

Lecture 9
Pregnancy Induce
Hypertension
Individual Learning
SGD
Break
Student Project
Plenary

Class room

08.00-09.00

Lecture 10
Shoulder Dystocia

Class room

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

Individual Learning
SGD
Break
Student Project
Plenary

08.00-09.00

Lecture 11.
Trauma Which Potentially
Disabling and life
Threatening Conditions

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

Individual Learning
SGD
Break
Student Project
Plenary

08.00-09.00

Lecture 12
Acute Blistering and
Exfoliative Skin (TEN &
SJS)
Individual Learning
SGD
Break
Student Project
Plenary

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

DAY/DATE

LEARNING ACTIVITY

TIME

LEARNING

Medical Education Unit Faculty of Medicine Udayana University

Disc room
Class room

Disc room
Class room

CONVEYER
dr. Megaputra,
SpOG(K)
Facilitators
dr. Megaputra,
SpOG(K)
dr. Wayan
Megadhana,
SpOG(K)
Facilitators
dr. Wayan
Megadhana,
SpOG(K)
dr. Ketut Suyasa,
SpB SpOT(K) Spine
dr. Wayan Subawa,
SpOT
Fasilitator

Class Room

Disc room
Class Room

VENUE

dr. Ketut Suyasa,


SpB SpOT(K) Spine
dr. Wayan Subawa,
SpOT
dr. Ketut
Suryawati,SpKK
Fasilitators
dr. Ketut
Suryawati,SpKK

CONVEYER

Study Guide Emergency Medicine September 2014

ACTIVITY
13
Thu,
25 Sept
2014

14
Fri,
26 Sept
2014

15
Mon,
29 Sept
2014

08.00-09.00

Lecture 13.
Phlegmon & Carries

Class room

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00

Individual Learning
SGD
Break
Student Project
Plenary

Disc room

08.00-09.00

Class room

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00

Lecture 14.
Urologic Concern in
Critical Care for
NonTrauma Case
Individual Learning
SGD
Break
Student Project

14.00-15.00

Plenary

Class room

08.00-09.00

Lecture 15
Urologic Concern in
Critical Care for
Trauma Case
Individual Learning
SGD
Break
Student Project
Plenary

Class room

08.00-selesai

Basic clinical skill (1)


(CPR)

Clinical skill lab

dr. Budi Santosa,


SpU
Team

08.00-selesai

Basic clinical skill (2)


(CPR)

Clinical skill lab

Team

08.00-selesai

Basic clinical skill (3)


(CPR)

Clinical skill lab

Team

08.00-selesai

Basic clinical skill (4)


Basic Trauma Care

Clinical skill lab

Team

08.00-selesai

Basic clinical skill (5)


Basic Trauma Care

Clinical skill lab

Team

09.00-10.30
10.30-12.00
12.00-12.30
12.30-14.00
14.00-15.00
16.
Tue,
30 Sept
2014
17.
Wed,
1 Oct
2014
18.
Thu,
2 Oct
2014
19.
Fri,
3 Oct
2014
20.
Mon,
6 Oct
2014

Class room

Disc room

Disc room
Class room

drg. Nyoman Ayu


Anggayanti,
MBioMed
Facilitators
drg. Nyoman Ayu
Anggayanti,
MBioMed
dr. I Gede Wirya
Kusuma Duarsa,
MsC, SpU(K)
Facilitators

dr. I Gede Wirya


Kusuma Duarsa,
MsC, SpU(K)
dr. Budi Santosa,
SpU
Facilitators

21-22

Medical Education Unit Faculty of Medicine Udayana University

Study Guide Emergency Medicine September 2014


Tue-Wed,
7-8 Oct
2014.
23
Thu,
9 Oct
2014.

Break Prepare For


The
Examination
Team
Examination

English Class
DAY/DATE
1.
Tue,
9 Sept
2014

2.
Wed,
10 Sept
2014

3.
Thu,
11 Sept
2014

4.
Fri,
12 Sept
2014

TIME
09.00-10.00

LEARNING
ACTIVITY

VENUE

Highlight in
Emergency
Medicine(Chairman)
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Class room

Lecture 2.
Status Epilepticus
and Other Seizure
Disorders
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary
Lecture 3.
Acute Psychiatric
Episodes
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Class room

09.00-10.00

Lecture 4.
Acute Respiratory
Distress Syndrome
and Failure

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00
09.00-10.00

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00
09.00-10.00
10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

Medical Education Unit Faculty of Medicine Udayana University

CONVEYER
dr. Tjok Gde Agung
Senapathi, Sp.AnKAR
-

Disc room
Class room

Facilitators
dr. Tjok Gde Agung
Senapathi, Sp.AnKAR
dr. IGN Budiarsa,SpS

Disc room
Class room
Class room

Facilitators
dr. IGN Budiarsa,SpS
dr. Ratep,SpKJ

Disc room
Class room

Facilitators
dr. Ratep,SpKJ

Class room

dr Sucipta, SpTHT KL ( and


ENT Team), Dr. Dewa Made
Artika, SpP, dr. Dyah
Kanyawati,SpA, dr. Srie
Laksminingsih, SpR

Disc room
Class room

Facilitators
dr Sucipta, SpTHT KL ( and
ENT Team)
Pulmo, Pediatric, Radiology

10

Study Guide Emergency Medicine September 2014

DAY/DATE

TIME

5.
Mon,
15 Sept
2014

09.00-10.00

6.
Tue,
16 Sept
2014

7.
Wed,
17 Sept
2014

VENUE

CONVEYER

Lecture 5.
Shock on Adult and
Pediatrik
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Class room

dr. IGAG Uttara Hartawan


, SpAnMARS; dr. Dyah
Kanyawati, SpA
-

Disc room
Class room

09.00-10.00

Lecture 6.
Bleeding Disorder

Class room

10.00-11.30

Student Project

Facilitators
dr. IGAG Uttara Hartawan
, SpAnMARS; dr. Dyah
Kanyawati, SpA
dr SariWulan, SpTHT KL
( and ENT Team)
dr. Megadhana, SpOG(K)
OBGYN
-

11.30-12.00

ISTIRAHAT

12.00-13.30

Individual Learning

13.30-15.00

SGD

Disc room

Facilitators

15.00-16.00

Plenary

Class room

09.00-10.00

Lecture 7.
Cardiac Arrest and +
Cardiopulmonary
Resuscitaton
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Class room

dr SariWulan, SpTHT KL
( and ENT Team)
dr. Megadhana, SpOG(K)
OBGYN
dr. IGN Mahaalit Aribawa,
SpANKAR

Lecture 8
Emergency
Toxicology and
Poisoning
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Class room

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00
8
Thu,
18 Sept
2014

LEARNING ACTIVITY

09.00-10.00

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

Medical Education Unit Faculty of Medicine Udayana University

Disc room
Class room

Disc room
Class room

Facilitators
dr. IGN Mahaalit Aribawa,
SpANKAR
dr. Agus Somya, SpPD
KPTI

Facilitators
dr. Agus Somya, SpPD
KPTI

11

Study Guide Emergency Medicine September 2014

DAY/DATE

9
Fri,
19 Sept
2014

10
Mon,
22 Sept
2014

11.
Tue,
23 Sept
2014

12.
Wed,
24 Sept
2014

TIME

09.00-10.00

VENUE

Lecture 9
Pregnancy Induce
Hypertension
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Class room

09.00-10.00

Lecture 10
Shoulder Dystocia

Class room

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

09.00-10.00

Lecture 11.
Trauma Which
Potentially Disabling
and life Threatening
Conditions

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

09.00-10.00

Lecture 12
Acute Blistering and
Exfoliative Skin (TEN &
SJS)
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Disc room
Class Room

LEARNING ACTIVITY

VENUE

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

DAY/DATE

LEARNING ACTIVITY

TIME

Medical Education Unit Faculty of Medicine Udayana University

CONVEYER

dr. Megaputra,
SpOG(K)
-

Disc room
Class room

Disc room
Class room

Facilitators
dr. Megaputra,
SpOG(K)
dr. Wayan
Megadhana,
SpOG(K)
Facilitators
dr. Wayan
Megadhana,
SpOG(K)
dr. Ketut Suyasa,
SpB SpOT(K) Spine
dr. Wayan Subawa,
SpOT
-

Disc room
Class Room

Facilitators
dr. Ketut Suyasa,
SpB SpOT(K) Spine
dr. Wayan Subawa,
SpOT
dr. Ketut
Suryawati,SpKK
Facilitators
dr. Ketut
Suryawati,SpKK

CONVEYER

12

Study Guide Emergency Medicine September 2014

13
Thu,
25 Sept
2014

14
Fri,
26 Sept
2014

15
Mon,
29 Sept
2014

09.00-10.00

Lecture 13.
Phlegmon & Carries

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

09.00-10.00

Class room

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00

Lecture 14.
Urologic Concern in
Critical Care for
NonTrauma Case
Student Project
ISTIRAHAT
Individual Learning
SGD

Disc room

Facilitators

15.00-16.00

Plenary

Class room

dr. I Gede Wirya


Kusuma Duarsa,
MsC, SpU(K)

09.00-10.00

Lecture 15
Urologic Concern in
Critical Care for
Trauma Case
Student Project
ISTIRAHAT
Individual Learning
SGD
Plenary

Class room

10.00-11.30
11.30-12.00
12.00-13.30
13.30-15.00
15.00-16.00

Class room
Disc room
Class room

drg. Nyoman Ayu


Anggayanti,
MBioMed
Facilitators
drg. Nyoman Ayu
Anggayanti,
MBioMed
dr. I Gede Wirya
Kusuma Duarsa,
MsC, SpU(K)
-

Disc room
Class room

dr. Budi Santosa,


SpU
Facilitators

16.
Tue,
30 Sept
2014
17.
Wed,
1 Oct
2014
18.
Thu,
2 Oct
2014
19.
Fri,
3 Oct
2014

08.00-selesai

Basic clinical skill (1)


(CPR)

Clinical skill lab

dr. Budi Santosa,


SpU
Team

08.00-selesai

Basic clinical skill (2)


(CPR)

Clinical skill lab

Team

08.00-selesai

Basic clinical skill (3)


(CPR)

Clinical skill lab

Team

08.00-selesai

Basic clinical skill (4)


Basic Trauma Care

Clinical skill lab

Team

20.
Mon,
6 Oct
2014

08.00-selesai

Basic clinical skill (5)


Basic Trauma Care

Clinical skill lab

Team

Medical Education Unit Faculty of Medicine Udayana University

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Study Guide Emergency Medicine September 2014


21-22
Tue-Wed,
7-8 Oct
2014.
23
Thu,
9 Oct
2014.

Individual Learning
Prepare For The
Examination
Team
Examination

ASSESSMENT METHOD
Assessment will be carried out onMonday 5 th of October2014. There will be 100 questions
consisting mostly of Multiple Choice Questions (MCQ) and some other types of questions.
The minimal passing score for the assessment is 70.Other than the examinations score,
your performance and attitude during group discussions will be consider in the calculation of
your average final score.Final score will be sum up of student performance in small group
discussion (5% of total score) and score in final assessment (95% of total score). Clinical
skill will be assessed in form of Objective structured clinical examination (OSCE) at the end
of semester as part of Basic Clinical Skill Blocks examination.

STUDENT PROJECT
Students have to write a paperwork with topic given by the lecturer. The topic will be
chosen randomly on the first day. Each small group discussion must work on one paperwork
with different tittle. The paperwork will be written based on the direction of respective
lecturer. The paperwork is assigned as student project and will be presented in class. The
paper and the presentation will be evaluated by respective facilitator and lecturer.
Format of the paper :
1. Cover

Title (TNR 16)


Name
Green coloured cover
Student Registration Number
Faculty of Medicine, Udayana University 2014

2.
3.
4.
5.

Introduction
Journal critism/literature review
Conclusion
References

Example :
Journal
Porrini M, Risso PL. 2005. Lymphocyte Lycopene Concentration and DNA Protection from
Oxidative Damage is Increased in Woman. Am J Clin Nutr 11(1):79-84.
Textbook
Abbas AK, Lichtman AH, Pober JS. 2004. Cellular and Molecular Immunology. 4th ed.
Pennysylvania: WB Saunders Co. Pp 1636-1642.
Note.
Minimum 10 pages; line spacing 1.5; Times new roman 12

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LEARNING PROGRAMS
Abstracts of Lectures
LECTURE 1 : HIGHLIGHT
EMERGENCY MEDICINE
Tjok Gde Agung Senapathi
Objective
To describe
1.
2.
3.
4.

HighlightEmergency Medicine
Basic principal of Emergency Medicine
Triad Emergency Medicine
Ethics in critical care

Medical ethics is the art of resolving conflicts that arise around treatment and
treatment decisions. The conflict may involve the patient, family, caregivers, or society. An
approach to these conflicts is as necessary as, say, an approach to hypotension or oliguria.
Without an approach we would be ignoring the mechanism that led the conflict or problem in
the first place. A little preparation will allow one to be more comfortable when confronting
these situations, making responses more likely to be useful (and less likely to make things
worse).
There are four basic principles or medical ethics that give us the tools to begin to
resolve some of these conflicts : autonomy, beneficence, and justice. The weight we give
each of these four different principles is often determined by our individual and societal
morals.

Lecture 2 : SEIZURE AND MENTAL CHANGES DISORDER


STATUS EPILEPTICUS
DPG Purwa Samatra
IGN Budiarsa
Status epilepticus is defined as a condition in which epileptic activity persists for 30 minutes
more.
The seizures can take the form of prolonged seizures or repetitive attacks without recovery
in between. There are various types of status epilepticus and a classification :
(Table below)
Status epilepticus confined to early childhood
1. Neonatal status epilepticus
2. Status epilepticus in specific neonatal epilepsy syndrome
3. Infantil spasms
Status epilepticus confined to later childhood
1. Febrile status epilepticus
2. Status in childhood partial epilepsy syndrome
3. Status epilepticus in myoclonic static epilepsy
4. Electrical status epilepticus during slow wave sleep
5. Landau Kleffer syndrome

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Status epilepticus occurring in childhood and adult life
1. Tonic clonic status epilepticus
2. Absence status epilepticus
3. Epilepsia partialis continua
4. Status epilepticus in coma
5. Specific form of status epilepticus in mental retardation
6. Syndrome of myoclonic status epilepticus
7. Simple partial status epilepticus
8. Complex partial status epilepticus
In clinical practice status epilepticus classified :
A. Convulsive status epilepticus
B. Non convulsive status epilepticus
Principle of management of status epilepticus
1. Lifesaving (ABC)
2. Stop seizures immediately
3. Manage in ICU
COMA AND DECREASE OF CONCIOUSNESS
DPG Purwasamatra
IGN Budiarsa
Objectives : To diagnosis and manage patients with decrease of conciousness
Conciousness is the state of awareness of the self and the enviroment and coma its
opposite, i.e. the total absence of awareness of self and enviroment even when the subject
is externally stimulated.
Conciousness is maintened by each cerebral hemisphere with constant prodding from the
reticular activating system within the central core of the brainstem tegmentum. Disruption of
the reticular activating system or extensive damage to both cerebral hemispheres impairs
conciousness.
The five basic physiologic explanation for loss of conciousness are:
Bilateral cerebral hemisphere disease, unilateral cerebral hemisphere lesion with
compression of the brainstem, primary brainstem lesion, cerebellar lesion with secondary
brainstem compression and nonorganic or feigned stupor.
Coma, however, is an emergency that the physician must treat before pursuing a diagnosis.

LECTURE 3 : ACUTE PSYCHIATRIC EPISODE


Ratep
Objective :
1. To describe etio-pathogenesis and pathophysiology of acute psychiatric episodes
2. To implement a general strategy in the approach to patients with acute psychiatric
episodes through history and special technique investigations
3. To manage by assessing, provide initial management and refer patient with acute
psychiatric episodes
4. To describe prognosis patient with acute psychiatric episodes
Emergency occur in psychiatric just as we do in every field of medicine. However,
psychiatric emergencies are often particularly disturbing because we do not just involve the
bodys reactions to an acute disease state, as must as actions directed against the self or

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others. These emergencies, such as suicidal acts, homicidal delusions, or a serve in ability
to care for oneself, are more likely than medical ones to be sensationalized when they are
particularly dramatic or bizarre.
Psychosis is difficult term to define and is frequently misused, not only in the
newspaper, movies, and on television, but unfortunately among mental health professionals
as well. Stigma and fear surround the concept of psychosis and the average citizens
worries about long-standing myths of mental illness, including psychotic killers, psychotic
rage, and equivalence of psychotic with the pejorative term crazy. Aggressive and hostile
symptoms can overlap with positive symptoms but specifically emphasize problems in
impulse contro
For example, a mother killing her five children in the belief that they are inhabited by
Satan, a famous poet killing herself, the delusional murder of legendary musician, the son of
prominent family found wondering confused and malnourished in a city park, all of these are
psychiatric emergencies that can and up on the front pages of newspaper.
Psychiatric emergencies occur everyday to people. Psychiatric emergencies arise
when mental disorders impair peoples judgment, impulse control, and reality testing. Such
mental disorders include all the psychotic disorders, manic and depressive episodes in
mood disorders, substance abuse, borderline, and antisocial personality disorders and
dementias. There may also be emergencies related to particularly severe reactions to
psychiatric medications, such as neuroleptic malignat syndrome or acute granulocytosis,
that must be recognize, diagnosed and treated immediately.

LECTURE 4 : ACUTE RESPIRATORY DISTRESS SYNDROME AND


FAILURE
Dewa Artika
ARDS is an emergency in the lung area due to disturbance in alveolocapiler
membrane permeability by a number of thing causing liquid accumulation/build up inside
alveoli or bronchus oedema. While ARF is a kind of ARDS complication which is a distability
of lung to do respiration function causing accumulation of CO 2 and decrease in O2 inside the
artery. Incident of ARDS is high. In the USA, 150.000 cases were found per year and 50% of
them died due to breathing failure.
Diagnosed based on : complaint, sudden breathing difficulties, coughing, tiredness
and decrease in consciousness and usually preceded by basic illness and triggering factors.
On the thorax photo it was found infiltrate diffuse in the two lungs region, while in ARF
depend on basic illness. The important thing is examination of blood gas analyses where
there is a decrease on PaO2 until below 50 and PaO2 above 50 or refer to as rule of fifty.
Principle of procedure is to give the Oxygen, CO 2 removal either with or without
ventilator, liquid restriction, clearing of breathing pathway, overcoming obstruction using
bronchodilator, etc.
Learning Objective
Students are able to describe pathogenesis, to set diagnoses, propose examination, give
medication and evaluate ARDS and ARF patients.

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ACUTE UPPER AIRWAY OBSTRUCTION


Wayan Sucipta
Abstract
Acute upper airway can result from a variety of disorders including trauma, neoplasm,
infection, inflammatory process, neurologic dysfunction, presence of a foreign body.
Affected site can include the oral cavity, oropharynx, larynx and trachea.
Emergency airway management principles include the determination of the site and degree
of obstruction, airway control by ventilation, intubation or surgical bypass of the obstructed
site with a crico thyroidectomy or tracheostomy and treatment of the precipitating cause of
obstruction

NEONATAL RESUSCITATION and ELECTROLITE IMBALANCE


Dyah Kanyawati
Abstract
Ninety percent of asphyxia insults occur in the antepartum or intrapartum periods a a result
of placental insufficiency. After delivery, the babys ineffective respiratory effort and decrease
cardiac output. Hypoxic tissues begin anaerobic metabolism, producing metabolic acids that
are initially buffered by bicarbonate.
The incidence of perinatal asphyxia usually related to gestational age and birth weight. The
basic goal of resuscitation are : to expend the lungs and maintain adequate ventilation and
oxygenation, to maintain adequate cardiac output and tissue perfusion. Neonatal
resuscitation equipment and emergency medications should be immediately available.

RADIOLOGY
Srie Laksminingsih
Learning Objective
At the end of meeting, the student will be able to :
1. Describe the radiology imaging of thorax photo for IRDS (Idiopathic Respiratory
Distress Syndrome) case, Bronchopneumonia, CHD, Pericardial Effusion, Lung
Edema, Pneumothorax, Pleural Effusion, Vena Cava Superior Syndrome.
2. Describe the imaging of abdominal plain photo in : Illeus Obstruction, Paralytic Illeus,
Stone in the Urinary Bladder, Peritonitis, NEC, Cholelithiasis & Acute Cholecystitis.

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LECTURE 5 : BLEEDING DISORDER


HEMORRHAGE IN PREGNANCY : ANTEPARTUM AND POST
PARTUM
Wayan Megadhana
ANTEPARTUM HEMORRHAGE
Objectives :
1. Recite the incidence of antepartum hemorrhage
2. List the etiology of antepartum hemorrhage
3. Distinguish the differences in the diagnosis of placenta previa and abruption
placenta
4. Apply the principles of fetal and maternal stabilization in the management of
anterpartum
Anterpartum hemorrhage is vaginal bleeding from 20 weeks to term. In the non pregnant
state, the uterus receives approximately 1% of cardiac output, whereas in the third trimester
it receives approximately 20%. Uterine bleeding in the third trimester can be massive and
can result in a hemodynamically unstable patient. Ante partum hemorrhage occurs in 25 to
5 % of all pregnancies.
Placenta praevia and obtruption account for slightly more than half of the cases of
antepartum hemorrhage and are two leading causes of perinatal morbidity and mortality in
the third trimester
POSTPARTUM HEMORRHAGE
Objectives :
1. Devine postpartum hemorrhage
2. Recognize etiologic factors for postpartum hemorrhage
3. Apply appropriate preventive strategies
4. Employ the principles of resuscitation in management of postpartum hemorrhage
Traditionally, the definition of postpartum hemorrhage has been blood loss in excess of 500
cc in vaginal delivery and in excess of 1000cc in abdominal delivery. For clinical purposes,
any blood loss that has the potential to produce hemodynamic in stability will depend on the
pre-existing condition of the woman. Hemodynamic compromise is more likely to occur in
condition such as anemia or volume contracted states.
The most common and important cause of postpartum hemorrhage is uterine atony. The
primary mechanism of immediate hemostatis following delivery is myometrial contraction
causing occlusion of uterine blood vessels, the so called living ligatures of the uterus.

EPISTAXIS
Sari Wulan
Abstract
Epiptaxis is an alteration of normal hemostasis whitin nose. Hemostasis is compromised by
mucosal abnormalities, vessel pathology or disorders of coagulation. Etiology of epistaxis
may be local or systemic. The local epistaxis commonly causes by trauma, mild. The
systemic causes emperaly causes by hypertension and sever
Management of epistaxis is stop the bleeding, avoid complication treatment of initial
disorders.

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LECTURE 6 : SHOCK On Adult


Utara Hartawan
Objective
:
1.
To describe the term, etio-pathogenesis and pathophysiology of shock
2.
To implement a general strategy in the approach to patients with shock through
history, physical examination and special tehnique investigations.
3.
To manage by assesing, differential diagnosis, provide initial management and refer
patient with shock
4.
To describe prognosis patient with shock
Abstracts
Shock is a clinical syndrome due to deficiency of cell perfusion or failure of oxygen intake
by cells which leads to hypoxia and oxygen debt that causes cellular dysfunction. Deficiency
of cell perfusion can be caused by (1) failure of heart contraction (shock cardiogenic) (2)
reduction in blood volume (shock hypovolemic) (3) disturbance in blood volume distribution
(shock distributive) (4) heart function restriction due to tamponade and pericarditis and
blood flow restriction due to pulmonary artery emboli (shock obstructive)
Hypoxia and cell oxygen debt causes cellular metabolism changes, that leads to cellular
dysfunction and finally it becomes a multiple organ dysfunction syndrome.
General strategy to obtain a diagnosis is done by subjective approach or anamnesis and
objective approach by physical examination and a few other diagnostic examination to find
the primary signs and symptoms of shock and the secondary signs and symptoms from
other organ system perfusion disturbance.
The basic shock managements are: hemodynamic support, optimal oxygen distribution to
cell and treating organ system disfuntion. Then, by overcoming the underlying cause by
medical/surgical approach after media consultation followed by referral if necessary.
Once the diagnostic management and early treatment and definitive treatment is done
optimally especially in shock hypovolemic good prognosis is obtained but for other shocks
the prognosis are uncertain.

LECTURE 7 : CARDIAC ARREST AND CARDIOPULMONAR


RESCUSTATION
Mahaalit Aribawa
Objective
:
1.
To describe etio-pathogenesis and pathophysiology of cardiac arrest
2.
To implement a general strategy in the approach to patients with cardiac arrest
through history, physical examination and special tehnique investigations.
3.
To manage by assesing, provide initial resuscitation and refer patient with post
resuscitation cardiac arrest
4.
To describe prognosis patient with post cardiac arrest
Abstract
Medical emergencies that threaten lives can occur anywhere, anytime and to anybody. It
can be because of a disease or due to road accident, drowning, poisoning and others that
are capable of causing respiratory and cardiac arrest.

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Air way obstruction such as hypoventilation, respiratory arrest, shock, even cardiac
arrest, causes death quickly if fast and appropriate help is not given. Death of patients due
to the causes mentioned above can be avoided if resuscitation is done immediately on the
spot.
Permanent brain damage can occur if blood circulation has stopped for more than a few
minutes (now it has been agreed more than 4-6 minutes) or after a trauma with severe
hypoxia or loss of lots of blood which are not corrected. If resuscitation is given immediately
and correctly brain death can be avoided and the patient recovers completely.
General strategy to obtain the diagnosis of acute respiratory failure and cardiac arrest, is
done by a subjective approach or anamnesis and objective approach with physical
examinations and few other diagnostic criteria to find the primary signs and symptoms of
respiratory and cardiac arrest. The diagnosis of respiratory and cardiac arrest should be
done immediately and accurately. Delay in diagnosis will cause delay in resuscitation and
this will cause death to even the patients with higher living chances.
Resuscitation can be done anywhere, anytime, with or without equipment by trained
whether public or health personnel. CPR (cardiopulmonary resuscitation) is an effort of
medical emergency to cure respiratory function and circulation which has failed drastically
on a patient that has the chances of living.
For an immediate failure, the lung and heart are in good shape, compared to those due
to chronic diseases, that cure is possible. Besides that, how are we to know a patients
condition that still has a chance of living? To know the prognosis, a senior doctor/consultant
with knowledge, experience and mature considerations is needed.

LECTURE 8 :EMERGENCY TOXICOLOGY AND POISONING


Agus Somya
BASIC MANAGEMENT OF INTOXICATION
OBJECTIVE: Intoxication or poisoning should be think in patient suddenly onset of
disease, with previously healthy condition, and difficult to explain or unclear of the causes.
It is complex situation included possibility crime and law, even that the emergency and life
threatening. To Underetand of Toxic syndrome is once of method for identification of the
toxicant, by specific odor, colour of urine, heart rate, pulse rate, reapiratory rate, body
21ransaction and consiousness. Laboratory test is important for to known serum level of the
agent,and target organ effect. Osmolar gap and ion gap is also important in toxicology
21ransact to support the diagnosis. The time of the first contact with tocicant is very I for
determine of prognosis and treatment. The antidote is 21ransact therapy for management of
patient intoxication, but not always available and should be used carefully because can
induced intoxication. The basic treatment of emergency cases is base on ability to control of
airways, breathing and circulation( or ABC 21ransacti). The specific presedure in
intoxication cases beside ABC also DE (Decontamination and Elemination). The heathcare
of patient intoxication should be comprehendsive by Team care depend on targen organ
damage.
ORGANOPHOSPHAT INTOXICATION
OBJECTIVE : Organophosphorus insecticides are the most common cause of toxicity
among all pepticides. Organophosphat bind irreversibly to and inhibit cholinesterase in the
nervous system, than accumulation in the synapses and neuromuscular junction.
Organophosphate intoxication manifested systemically as a muscarinic,nicotinic and

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systemic CNS over stimulation effect. Muscarinic overstimulation resulted SLUDGE
Syndrome (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal and Emesis), and
Killer B effect (Bronchospasm, Bronchorhea and Bradycardia). Additional manifestation
was blurred vision associated with miosis. Nicotinic effect included fasciculation, muscle
weakness, 22ransaction tachycardia and mydriasis. Central Nervous System (CNS) effect :
tremor, confusion, seizure and coma. Organophosphate intoxication can caused
intermediate and delayed syndrome, with occurs 1-4 days and 1-3 weeks respectively after
acute poisoning. Emergency care : Symtomatic patient require emergent attention to
airways protection and ventilation, supplement oxygen should administered to maintain
oxygen saturation moe than 95%. Decontamination: dermal exposures can be performed
using soap and water with dilute blech, Gastric aspiration by nasogastric tube and
administration of active charcoal should be performed in significant ingestion. Administration
of specific antidote ( 22ransact, pralidoxime) my be appropriate for selective patient and
selective agent.
CAUSTIC INTOXICATION
OBJECTIVE : Caustic intoxication devide in alkali exposures and acid exposures, the most
common caustic exposures is household bleach. The strength of caustic and duration of
exposure determine its ability to cause damage. Alkali penetrate deeply into tissue through
liquefaction necrosis, alkali ingestion caused more proximal damage to the esophagus
rather than to the stomach, 22ransac with focal burn in the oropharynx and esophagus.
Stong acid tend to produce coagulation necrosis, early eschar formation to protects against
deeper injury in esophagus, regadless the esophagus and gastric injury can accur. Alkalis
are relatively tasteless and odorless, and caused esophageal perforation and stricture.In the
sevire injury manifested by mediastenitis or peritonitis. Acid tend to be more smelling and
tasting. Acid can caused injury of the esophagus and they tend to pool in the stomach,
leading gastric hemorrhage,necrosis, and perforation. Systemic effect of acid intocication :
metabolic acidosis, hemolysis and renal failure. Caustic ingestion can cause distal GI injury
without necessarily causing oral burn. Endoscopy is the diagnosis test of choice in
evaluation for serious esophageal and gastric injury, it is indicated in vomiting progesive,
drooling, dyspnea, stridor and sevire oropharyngal burn. Early endoscopy within several
hours of ingestion can be safe and useful in determining the extend of injury as well as the
need for admission. Emergency care : Dilutional is the important once. Gastric
decontamination with charcoal, ipecac and gastric lavage is contraindicated. Only in cases
of strong aci ingestion may NGT be inserted for removal of excessive acid in the
stomach( with strong precaution). Dilution is indicated only for solid alkali ingestion.
Neutralization cannot be routinely recommended. Steroid are controversial in alkali
ingestion, but can be used depend on endoscopic result ( grade II erotion). Antibiotic is
reversed for patients with steroid treatment or perforation. Urgent GI consultation should be
obtained for any caustic ingestion.

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LECTURE 9 :
PREGNANCY INDUCED HYPERTENSION
Megaputra
Objective :
1. Define pregnancy induced hypertension
2. Review appropriate fetal/maternal assessment
3. Discuss appropriate anti hypertension and anti seizure therapy
4. Recognize when and how to transport patient with pregnancy induced hypertension
Hypertensive disorders in pregnancies are the leading causes of maternal death in
emerging countries. All caregivers must be able to promptly recognized the signs,
symptoms and laboratory findings of gestational hypertension with or without proteinuria
and with other adverse manifestation. Caregivers must appreciate fully the seriousness of
gestational hypertension, its potential for multi organ involment and the risk for perinatal
and maternal morbidity and mortality. The appropriate management of gestational
hypertension may vary based on the availability of resources. In this lecture student will
discuss such as : the classification and definition of hypertensive disorders in pregnancy;
management and treatment of gestational hypertension.
Severe gestational hypertension is an obstetrical emergency, which requires prompt
recognition, stabilization of mother and fetus and multi disciplinary approach to
management and treatment

LECTURE 10 :
SHOULDER DYSTOCIA
Wayan Megadhana
Objective
Use a systematic approach to the reduction of shoulder dystocia based upon the
physical mechanism of impact and disimpaction.
Shoulder dystocia is one of emergency problems during delivery. Following the
delivery of the head, there is impaction of the anterior shoulder on the symphysis pubis in
the AP diameter, in such a way that the remainder of the body cannot be delivered in the
usual manner. More than 50% of cases shoulder dystocia occur in the absence of any
identified risk factor. The student will discuss the assessment of shoulder dystocia, the
complication for fetus and mother, identification of risk factor, diagnosis and management

LECTURE 11 : UROLOGYC CONCERN IN CRITICAL CARE


Gede Wirya Kusuma Duarsa
Budi Santosa
Objectives :
1. To understand the basic principles of trauma and non trauma Urologic emergency
2. Comprehend the definition, etiology, special investigation and basic management the
acute urinary retention, acute scrotum

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3. To understand the definition, etiology, special investigation and basic management of
colic, urosepsis, hematuri
4. Comprehend the etiology and basic management of urologic trauma
Acute urinary retention is defined as the sudden inability to void despite a distended bladder
(urine volume in the bladder more than its capacity). It is usually preceded by a history of
progressively decreasing force of stream. It is a usually secondary to some form bladder
outlet obstruction, but may be caused by neuromuscular detrusor failure, or some
combination of both causes. The major etiologies for acute urinary retention may be
subdivided into obstructive, infectious, pharmacologic, and neurogenic.
The most common obstructive cause of acute urinary retention is benign prostatic
hyperplasia. Advanced prostate cancer, urethrak structure, bladder stones or bladder
tumors may also cause obstructive urinary retention, hematuria and clots should be
suspected of harboring an underlying bladder tumor. Less common obstructive etiologies
include erethral foreign bodies, penile constricting bands, and meatal stenosis. The most
common infectious cause for acute retention is acute prostatitis. Other infectious causes of
retention include urethral herpes, periurethral abscesses, and tuberculous cystitis. There are
many pharmacologic agents that may contribute to urinary retention. Neurogenic causes of
urinary retention may be broadly categorized into upper motor neuron lesions, lower motor
neuron lesions, and peripheral nerve lesions.
The kidney is injured in as many as 5% of abdominal a trauma cases. As such, it is the
genitourinary organ most susceptible to injury. Approximately 90% of these injured result
from blunt trauma to the abdomen or flank. Although most blunt trauma to the kidney is
minor and may be managed safely nonoperatively, penetrating injuries require renal
exploration and repair more frequently.
The urinary bladder may be injured secondary to blunt or penetrating forces. Penetrating
trauma may be secondary to gunshots, knives, or spike impalement injuries. Blunt trauma to
the bladder is usually secondary to motor vehicle accidents
Testis torsion may occur in the neonatal period secondary to lack of fixation of the tunica
vaginalis to the scrotal wall. This know as extravaginal torsion. Neonatal torsion has a low
salvage rate. If the tunica vaginalis inserts in an abnormally high position on the spermatic
cord ( the bell clapper deformity), the testis may freely rotate on the cord.

LECTURE 12 : DERMATO - EMERGEMENCIES


Nyoman Suryawati
Objective
To understand the basic principle of dermato-emergencies
Able to identify of dermato-emergencies
Able to mange of emergencies skin diseases
Able to refferral of dermato-emergencies
Stevens Johnson Syndrome and Toxic Epidermal Necrolysis
Stevens Johnson Syndrome(SJS) and Toxic Epidermal Necrolysis (TEN) is characterized
emergencies in skin disease by target lesions, with or without blisters in skin and mucous
membrane. SJS involve less than 30% of the cutaneous surface, and in TEN involvement of
more than 30% of the cutaneous surface.

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Toxic Epidermal Necrolysis (TEN) is characterized by widespread erythematous macules
and targetoid lesions; Fullthickness epidermal nekrosis, at least focally. Nearly all cases of
SJS/TEN are induced by medications, and the mortality rate can approach 40%.
Clinical manifestation of SJS/TEN : 1. Constitutional symptoms, such as fever,
cough, or sore throat, may appear 1 -3 days prior to any cutaneous lesions. Patients may
complain of a burning sensation in their eyes, photophobia, and burning rash that begins
symmetrically on the face and the upper part of the torso. 2. Skin lesions, the initial skin
lesions of SJS/TEN are poorly defined erythematous macules with darker purpuric centers.
The lesions differ from classic target lesion of central dusky purpura or a central bulla, with
surrounding macular erythema. Flaccid blisters are typically present with full thickness
epidermal necrosis. A Nilolsky sign is easly demonstrated by applying lateral pressure to
bullae . 3. Mucous membranes, involvemet is present in nearly all patient and may precede
skin lesions, appearing during the prodrome.
Management, hospitalization shoul be considered for patients wit an initially benign
presentation of SJS ant TEN, because predicting which patients will progress to more
severe manisfestations. In severe condition can be treated in an ICU or burn unit under the
coordinated care of an ICU tam and consultants. The broad principles of management are
fluid replacement, nutritional supplementation, sterile technique, and wound care. Sterile
technique is essential to prevent complications from endogenous and exogenous sources.
Broadspectrum prophylactic antibiotics are not recommended or still debate according the
condition.
Staphylococcal Scalded Skin Syndrome
Staphylococcal scalded skin syndrome (SSSS) is an illness characterised by red blistering
skin that looks like a burn or scald, hence its name staphylococcal scalded skin syndrome.
SSSS is caused by the release of two exotoxins (epidermolytic toxins A and B) from
toxigenic strains of the bacteria Staphylococcus aureus. Desmosomes are the part of the
skin cell responsible for adhering to the adjacent skin cell.SSSS has also been called
Ritters disease or Lyells disease when it appears in newborns or young infants.
Clinical Feature SSSS usually starts with fever, irritability and widespread redness of
the skin. Within 24-48 hours fluid-filled blisters form. These rupture easily, leaving an area
that looks like a burn. Tissue paper-like wrinkling of the skin is followed by the appearance
of large fluid-filled blisters (bullae) in the armpits, groin and body orifices such as the nose
and ears.
Managementusually requires hospitalisation, as intravenous antibiotics are generally
necessary to eradicate the staphylococcal infection.Other supportive treatments include:
antipyretic, maintaining fluid and electrolyte inteake and skin care (the skin is often very
fragile).

LECTURE 13 : TRAUMA WHICH POTENTIALLY DISABLING AND


LIFE THREATENING CONDITIONS
I Ketut Suyasa
Wayan Subawa
Objectives :
To implement a general strategy in the approach to patient with trauma which
potentially disabling and life threatening conditions through history, physical
examination and special technique investigations
To manage by assessing, provide initial management and refer patient with trauma
which potentially disabling and life threatening conditions
To describe prognosis patient with trauma which potentially disabling and life
threatening conditions

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The field of trauma, or injury, is continuously evolving as knowledge is gained in to


therapeutic management. There is a trimodal distribution of death due to trauma, Early or
immediate death (45%) occurs at the scene of the incident and is related to a devastating
and catastrophic injury such as cerebral herniation, aortic 26ransaction or cardiac rupture.
Other than preventive measures, there is little medically that can be done. Although rapid
transport from the scene has allowed some of these patients to arrive in extremis in the
emergency room, lethality is uniform. The second group (35%) are those that arrive in the
emergency department. And require aggressive evaluation and therapy. The third mode of
death (20%) occurs days or weeks after admission in patient who usually reside in the ICU.
In the following section on trauma assessment and resuscitation, methods of care
are discussed so as to prevent the progression to this most serious of clinical condition.

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LEARNING TASK
Day 1
HIGHLIGHT EMERGENCY MEDICINE

SELF ASSESMENT:
1.
Explain briefly about the scope of Emergency Medicine
2.
Explain the basic principals of Emergency Medicine
3.
Elaborate briefly about the details in Triad Emergency Medicine
LEARNING TASK
1.
As a general practitioner who works in public health centre, you were visited by a 40
years old man, who brought his brother 35 years old with seizure all over his body and
bubbles in his mouth.
(a) As a doctor what would you do?
(b) After the first aid the seizure has stopped but the patient is still unconscious.
What do you do next?
After a while the patient has seizure again, even before gaining consciousness.
(c) What caused the patient to seizure again?
(d) If u were working in the emergency room at the hospital, what would your
action be?
2.
When would you suggest a surgical intervention to an epileptic patient?
SELF ASSESSMENT
1.
Able to explain the causes of status epileptikus
2.
Able to give first aid for status epileptikus
3.
Able to identify patient with refractory epilepsy

ACUTE PSYCHIARTIC EPISODE


LEARNING TASK
1. The Presence of medical illness should be strongly considered when psychiatric
symptoms appear suddenly in a previously well-functioning person. An old patient
with psychotic symptoms appearing for the first time, an awareness or conviction
that the symptoms are foreign, and especially with concomitant symptoms of
cognitive dysfunction should be considered to have a possible organic illness.
a) A patient with delirious condition usually have personality disorders
b) Increase of temperature, pulse and respiratory rate is common in psychiatric
patient, especially paranoid schizophrenia.
c) Suicide attempted are an easily manage, because they are only seeking
attention
d) Cognitive dysfunction should be considered to have a possible organic
illness.
e) A patient under the age 30 with psychotic symptoms appearing for the first
time should be considered to have an organic brain disorder.
2. The patient was a 25-year old female graduate student in physical chemistry who
was brought to the emergency room by her roommates, who found her sitting in her
car with the motor running and the garage door closed at 1.00 AM. She was crying,
looked tiredness, and difficulty in falling a sleep. What is the considerable of the
patient treatment?

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SELF ASSESSMENT
1. Mampu menegakkan diagnosis Gangguan Mental Organik, membedakannya
dengan Gangguan Psikosis fungsional lainnya.
2. Mampu melakukan wawancara singkat untuk menggali data dan merencanakan
pemeriksaan penunjang yang diperlukan untuk kasus-kasus Accute Psychiatry.
3. Mampu membuat perencanaan awal untuk menangani kasus-kasus Accute
Psychiatry.
4. Mengerti etio-patogenesis, pato-fisiologis dan psikodinamika terjadinya kasus-kasus
Accute Psychiatry.
5. Mampu membuat prediksi/prognosis suatu kasus AccutePsychiatry serta tahu kapan
harus merujuk pasien tersebut.
LEARNING RESOURCES
1. Kaplan & Saddocks Synopsis of Psychiatry, 10th ed
2. Kaplan & Saddocks Study Guide and Self Examination Review in Psychiatry, 7th ed.

ACUTE RESPIRATORY DISTRESS SYNDROME AND FAILURE


CASE 1 :
A patient was brought to emergency unit by their family with complaint for sudden
breathing difficulties and decrease in consciousness. Five days before the patient suffered
from high temperature until shivering together with purulent cough and breathing difficulties.
During physical examination it was found T. 100/70, N. 120/m, RR. 30 times/m temp.39 oC.
in the lung it was found ronki diffuse, wheezing. On the thorax photo it was found homogen
covering on the two lung areas and consolidation in the center right side part. During
examination of blood gas analyses it was found PaO2, 45 mmHg while PaCO2 65 mmHg.
SELF ASSESSMENT
1. Discuss about that case assessment
2. Other recommended examination
3. What is the procedure
4. How is the pathophysiology of ARDS
5. Explain etiopathogenesis of ARF
6. Distinguish between ARF Hypoxemia and Hyperkapnea
7. Objective of ventilator installation
RESOURCES
Polly E. Parson, MD. Acute Respiratory Distress Syndrome in Michael E. Hanley, Carolyn H.
Welsh, Lange Current Diagnosis & Treatment in Pulmonary Medicine 2003, 161 166.
ACUTE UPPER AIRWAY OBSTRUCTION
LEARNING TASK :
Case 2.
Male, 9 month years old complained by his parent with dyspneu, stidor and cough,
immediately after choking peanut without history of upper respiratory infection.
QUESTION
1. What you should ask to complete the anamnesis?
2. What will you find from the physical examination?

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3. What kind of other examination to support the diagnosis?
4. What possibility diagnosis of this patient?
5. How to manage and provide initial management and when do tou refer the patient?
SELF ASSESSMENT
1. Describe and discuss of specific symptoms of upper airway obstruction
2. Describe etiology and pathophysiology of each symptoms of upper airway
obstruction
3. Manage and provide initial management or refer patient with upper airway
obstruction
REFERENCE
1. Boies LR, Laryngeal Obstruction. In : Fundamentals of Ofolaryngology Third Edition.
Philadelphia, London : W. B. Saunders, Company ; 1984, p. 396 406
2. Adams GL, Boies LR, Hilger PA, Foreign Body Aspiration In : Fundamental of
Ofolaryngology Sixth Edition. Philadephia, London : W.B. Saunders, Company ;
1989, p. 483 489.
3. Eisele D. W, MC Quone S.J. in : Emergencies of the Head and Neck. Philadelphia,
Lomdon : MOSBY. INC copyright 2000, p. 111 163

NEONATAL RESUSCITATION
LEARNING TASK :
Case 3 :
A baby born at 33 weeks gestation following a caesarean section present with respiratory
distress soon after birth with bradypnoea (RR : 18 times/minutes). Heart rate 80
times/minutes regulary. The baby is requiring oxygen, an intravenous line inserted to
provide maintenance fluids. The mother had a temperature of 380 C.
TASK :
1. What is the diagnosis?
2. What investigation should be carried out?
3. What treatment would you institute of this condition?
4. Despite your effort above the baby has a cardio respiratory arrest with the ECG
monitor, what is the immediate management?
5. what is the prognosis?
SELF ASSESSMENT :
1. To describe definition of perinatal asphyxia
2. To describe pathophysiology and etiology of asphyxia
3. To describe :
Perinatal management
Delivery room management
Postnatal management
4. To describe prognosis of perinatal asphyxia

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RADIOLOGY
LEARNING TASK
1. Describe the radiology imaging of thorax which is specific for :
a. IRDS
b. Bronchopneumonia
c. Congenital Heart Disease
d. Lung Edema
e. Pneumothorax
f. Pleural Effusion
g. Vena Cava Superior Syndrome.
SELF ASSESMENT :
1. A mother who have a new born baby complaint that her babys lips is blue and
always breathing so fast.
a. What kind of congenital anomalies do you think about this case ?
b. What kind of simple radiology examination that you suggest to do ?
c. What kind of radiology imaging you can find in this case ?
2. An old man, complaint cough with sputum every morning, suddenly feel shortness
of breath and suffered from ches pain in his right chest, Patient also complaint that
he didnt got a fever.
a. What do you think about this case ?
b. What kind of radiology examination that you suggest to do ?
c. What kind of radiology imaging you can find in this case ?

BLEEDING DISORDERS
CASE 1 :
, 66 years old come to hospital with profuse bleeding in both of his nose and can not stop
spontaneusy. He never had nasal blocked symptom and he commonly complained head
ache and fluctuated blood pressure
QUESTION
1. What is the initial disease/disorder of the patient ?
2. How to manage the patient ?
3. What is the complication of the epistaxis and after managed the patient ?
SELF ASSESSMENT
1. Describe and discuss of causes of epistaxis
2. Describe kind of epistaxis
3. Manage and provide initial management and how to refer the patient
REFERENCE
1. Byron Bailey J., M.D, Epistaxis. In : Head and Neck Surgery Otolaryngology
Third Edition, Volume One. Philadelphia, London : LIPPINCOTT WILLIAMS &
WILKINS, Company ; 2001, p. 415-428
2. Eisele D W, MC Quone S.J.,Epistaxis. In : Emergencies of the Head and Neck.
Philadelphia, London : MOSBY. INC copyright 2000, p 239-262.

CASE 2 :

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A 25 years old G3 woman presents to the maternity unit with vaginal bleeding. Fetal heart
rate is 140 per minute and her blood pressure is 110/60 and her HR is 85/minute. Fundal
height is 28 cm. she has been given nothing. What are the possible diagnosis?
CASE 3 :
You have just delivered a 37 weeks twins pregnancy pervaginam. The third stage is
complicated by postpartum hemorrhage unresponsive to uterine massage and use of
oxytocin. What would your next management steps be ?
LEARNING TASK
Case Scenario I
A male patient, aged 34 years old comes to the PUSKESMAS with chief complaint of
having cough and flu since 3 days. After examination, the doctor prescribed the
medicine and as usual, the PUSKESMAS nurse gave the injection. After a few seconds,
the patients collapses suddenly, unconscious, looking pale and sweaty, fast and deep
breath, weak and fast pulse.
Task:
1.
2.
3.
4.

Based on immediate observation, what is the patient going through and what
examination actions should be done to obtain the working diagnosis.
Describe briefly the immediate act of first aid that should be done to overcome the
emergency and what is the next step/therapy?
Based on your analysis what would have caused this emergency and explain its
pathogenesis and pathophysiology.
Explain the patients prognosis.

Case Scenario II
A male patient, 46 years old was brought to the PUSKESMAS by so many people after
being attacked by a fighter cock on his right leg. Blood splashing out of the back of his
knees was noted and it had been bandaged using normal cloth. At an early exam, the
patient was alert but anxious, complained of pain, looked pale, breathing increased and
his pulse were weak and fast.
Task:
1. Based on immediate observation, what is the patient going through and what
examination actions should be done to obtain the working diagnosis.
2. Describe briefly the immediate act of first aid that should be done to overcome the
emergency and what is the next step/therapy? Should this patient be referred? If
yes, where?
3. Based on your analysis what would have caused this emergency and explain its
pathogenesis and pathophysiology.
4. Explain the patients prognosis.
Case Scenario III
A girl aged 21 years was sent to the PUSKESMAS by family after having fever, vomiting
and refuses to drink-eat since 3 days ago. At an initial examination, patient was
conscious but quite anxious, complained of pain, looked pale, body felt hot, breath fast
and deep, pulse weak and fast, and stomach looked stretched. Extra informations were
that the patient was not married, delayed menses and have gotten treatment from
dukun beranak
Task:
1. Based on immediate observation, what is the patient going through and what
examination actions should be done to obtain the working diagnosis.

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2. Describe briefly the immediate act of first aid that should be done to overcome the
emergency and what is the next step/therapy? Should this patient be referred? If
yes, where?
3. Based on your analysis what would have caused this emergency and explain its
pathogenesis and pathophysiology.
4. Explain the complication and prognosis of this patient.
SELF ASSESSMENT
1. Explain the etiopathogenesis and pathophysiology of shock
2. Explain the diagnosis step of hypovolemic, cardiogenic, distributive and obstructive.
3. Elaborate briefly about the first aid to shock patient and what should the next
action/treatment be? Should this patient be referred? If yes where to?
4. Explain the complication and prognosis of shock
LEARNING RESOURCES
1.
2.
3.

Diagnosis and Management Of Shock, in Critical Care Support Fundamental Book,


1996, p.69-80
Approach to Shock, in The Hand Book of Critical Care, 2001, p55-70.
Pathophysiology and Classification of Shock State, in Textbook of Critical Care, 9 th
Edition, 2005, p.887-910.

LEARNING TASK
Case Scenario I
One Sunday morning, you are enjoying the fine morning at the Sanur Beach. At a
distance, you could see people looking panicked, is screaming for help. There was
young couple being dragged by a wave while they were bathing. The lady managed to
safe herself, where else the man at the beginning who are trying to safe his friend, was
dragged into the water. Then the life guard managed to safe the man and immediately
gave him first aid. You as a medical personnel, coincidently being there, should also give
first aid.
Task:
1. Based on immediate observation, what is the patient going through and what
examination actions should be done to obtain the working diagnosis.
2. Describe briefly the immediate act of first aid that should be done to overcome the
emergency and what is the next step/therapy?
3. Based on your analysis what would have caused this emergency and explain its
pathogenesis and pathophysiology.
4. Explain the complication and prognosis of this patient.
Case Scenario II
Once you were riding your personal car on the road. At one of the junctions you find a
stopping suddenly in the middle of the road, the driver was a male, age around 60 years
old, looked quiet, not moving and his right hand on his left chest. You as a medical
personnel, coincidently being there, should also give first aid.
Task:
1. Based on immediate observation, what is the patient going through and what
examination actions should be done to obtain the working diagnosis.
2. Describe briefly the immediate act of first aid that should be done to overcome the
emergency and what is the next step/therapy?
3. Based on your analysis what would have caused this emergency and explain its
pathogenesis and pathophysiology.
4. Explain the prognosis of this patient.

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SELF ASSESSMENT
1. Explain the etiopathogenesis and pathophysiology of cardiac arrest
2. Explain the diagnostic steps of cardiac arrest
3. Elaborate briefly the first aid on cardiac arrest patient at the incident place, during
transportation and after reaching the emergency ward. Since the heart beat is
stable, where should the patient be referred?
4. Explain the complication and prognosis of cardiac arrest.
LEARNING RESOURCES
1. Cardiopulmonary Resuscitation, in Critical Care Support Fundamental Book,
Chapter 2, 1996, p.15-25
2. Buku Panduan Resusitasi Jantung Paru-Otak, Bantuan Hidup Lanjut, Diterbitkan
oleh DEPKES RI 2000
3. Resuscitation, in Perioperative Care Book, Anesthesia, Pain Management and
Intensive Care, 2003.

EMERGENCY TOXICOLOGY AND POISONING


BASIC MANAGEMENT OF INTOXICATION
LEARNING TASK
1. Able to known intoxication cases by Toxic Syndrome
2. Able to to manage intoxication cases by ABCDE Prosedure
3. Able to treatment the patient by antidote
CASE 1 :
The patient is Mr. Agus , 28-year old hospitalized, refered from his family because of
decreas of consiousness, 6 hours previously look like healthy and done his job as a
salesmen. There are no history of Diabetes , Hypertension, Liver and Kidney Disease.
Some time He drink alcohol and as a smoker. The patient shown pale, sweaty, blood
pressure 90/60 mmHg, Respiratory rate 10 time/mnt with alcohol like smell, pulse rate is
weak about 50 time/mnt, and pupil miosis. In the forearm shown nedle steak injury.The
patient than refered to High care Unit for ventilator machine procedure.
ASSIGNMENT :
1. If you are a Doctor, do you think this case is Intoxication or organic Disease with
severe manifestation ?
2. What the sign of toxic syndrome in this cases.
3. If this patient do you diagnosis as intoxication , what the basic procedure should be
done.
4. When should be treatment the patient whit antidote ?
SELF ASSESSMENT :
1. Describe sign of toxic syndrome
2. Describe basic management of intoxication
3. The kind of antidote, indication and point of moment to giving antidote

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ORGANOPHOSPHAT INTOXICATION
LEARNING TASK
1. Able to diagnosis organophosphate intoxication by toxic syndrome.
2. Able to manage organophosphate intoxication by basic prosedure treatment of
intoxication (Decontamination and Elemination)
3. Able to use specific antidote atropin and monitoring of side effect.
CASE 2 :
The patient was Miss. Lina, whit progressive vomiting after drink one cup of liquid (in after
that is known as organophosforus) unintensionaly, 2 hours after hospitalized. The patient
shown weak and the breathing was Baygon in smell. Pupil miosis, blood pressure 100/70
mmHg, pulse rate 60 time/ mnt, respiratory rate 18 time / mnt, in auscultation shown rale in
all of chest field and defication. The patient there are no history of health disease,
neurologic disease, Diabetes mellitus and Pulmonary disease.
ASSIGNMENT :
1. If you are a docter, what do you do for helping this patient.
2. Do you insert NG tube, but you were knowed that organophosphate diluted by
hydrocarbon
3. Do you washing all of bodies exposure ?
4. What is the technic to used atropin as a antidote, and how to known atropinisation
5. When the patient should be refered to the ward.
SELF ASSESSEMENT :
1. Describe sign of organophosphate intoxication
2. Basic treatment of organophosphate intoxication
3. Describe of severety of organophosphate intoxication
4. Describe technic to used atropin as antidote, an monitoring

CAUSTIC INTOXICATION
LEARNING TASK
1. Able to differentiate clinical manifestation of alkali or acid injury
2. Able to manage alkali and acid injury, by basic intoxication procedure
3. Able to monitor and early detection of serious complication and urgent consultation.

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CASES 3 :
The patient was Miss. Ayu, 25 year-old, hospitalized because of bloody vomiting and chest
pain, the patient refered by her boy frend to emergency room Sanglah Hospital, after
ingestion of liquid for washing the metal, she was needed fo suicide, previously she same
problem with her friend, she come with multiple erotion in her mouth, tongue, pharyng and
bowel meteorism with rebound of pain. Rectal examination shown melena (blacky stool).
Urgent endoscopic shown multiple erotion in area upper spincter of esophagus and in area
antrum of stomach grade II B, blood pressure 90/mm Hg, Respiration rate 26 time/ mnt,
body temprature 37.8 C, Hb 7 mg/dl, WBC 12.000, rale/ ronchy in left chest, Chest X-ray
shown infiltrate in lower lobe of the left lung.
ASSIGNMENT :
1. If you are a doctor, what are you doing for help this patient
2. Do you insert NG tube for decontamination prosedure ?
3. Do you give the patient with active charcoal ?
4. When should consultation for endoscopic examination ?
5. Do you treat the patient with corticosteroid and antibiotic ?
6. What your planing to care this patient for prevent serious complication ?
SELF ASSESSEMENT :
1. Describe sign and symptom alkali and acid intoxication
2. Describe spesific management of caustic injury
3. Describe basic care and prosedure follow up the patient with caustic intoxication.
REFERENCES :
1. Tamaszewski CA., Caustic , In: Emergency Medicine,Second ed, Mc Graw Hill,
2004, 392
2. Tamazszewski CA., Insecticides, Herbicides,and Rodenticides, In: Emergency
Medicine,Second ed, Mc Graw Hill, 2004, 394
3. Phillips SD., Organoclorin, Pyrethrin, and Pyrethroid Insecticides, In : Critical Care
Toxicology, Diagnosis and Managemnent of the critically Poisoned Patient, Ed:
Brent, Wallace et al, Elsevier Mosby, 2005, 929
4. Rella JG and Hoffman RS.,Caustic, In : Critical Care Toxicology, Diagnosis and
Managemnent of the critically Poisoned Patient, Ed: Brent, Wallace et al, Elsevier
Mosby, 2005, 1035
5. Gregus Z and Klaassen CD., Mechanism of Toxicology, In : Essentias of Toxicology,
Ed: Klaassen, Watkins, Mc GrawHill, 2003,

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PREGNANCY INDUCED HYPERTENSION


CASE :
A 35 years-old G1P0 woman present for her prenatal visit at 34 weeks gestation. Her BP is
165/110. she has no history of hypertension. What steps do you perform as part of your
initial investigation?. And what is the plan for management and treatment of his case ?

SHOULDER DYSTOCIA
CASE :
In the labor ward, you as a intern help a pregnant woman in second stage of labor.
Following and easy application, after two time maternal pushing, there is moderately good
descent during the first pull but this slows down as the head is half out. What are potential
causes for this and what is your plan of action at this point?. If shoulder dystocia is
confirmed, what is your management?

UROLOGYC EMERGENCY
Case 1 An Old man that unable to void
A 73 years old man with multiple medical problems presented with complaints that he
could not void and had pain in the lower abdomen. He had a mild dementia, so much of the
history was from his wife, who accompanied him to the clinic. She stated that he had neither
incontinence, fever, nauses, nor vomiting, and he had any recent acute illnesses. The
patient had not had any recent change in medication, doses or frequency of dosing of his
pain medication. He had similar problems in the past, but the symptoms had resolved after
he underwent a transurethral resection of the prostate (TURP) 2 years ago. His wife also
stated that he had been able to void normally up until earlier this morning. Since that time
he had complained frequently about the urge to void and being to do so.
The patients medical history was extensive. Of particular note, he had metastatic
squasmous cell lung cancer and was placed in hospice care 2 weeks before presentation.
He had type 2 diabetes, hypertension, glaucoma, and benign prostatic hypertrophy (BPH)
His medication included an extended release morphine tablet for pain, rosiglitazone for his
diabetes, and recently discontinued ramipril and hydrochlorothiazide, which he had taken in
the past for his hypertension.
On examination, he was midly tender over the bladder, which was palpably distended. He
attempted to void for a urinalysis specimen and was unable to do so. A Foley catheter was
placed, and 240 ml of urine was collected. The urinalysis showed a trace of protein, and
results were otherwise negative; the pH was 7,3.
Question :
1. What are some cuases of acute urinary retention?
2. What are some typical symptoms of acute urinary tract obstruction?
3. What tests would be helpful in determining the cause of this patients urinary
retention?
4. What treatments would be useful in relieving the symptoms?
5. What are some complications of untreated acute urinary retention?

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Dermato emergencies
Case
A male twentytwo-year-old, who was started on Phenobarbital after his third febrile seizure.
Seven days later, he developed erythematous lesions over his extremities, face and trunk.
Over the next three days he developed fever to 105 degrees, and the erythematous lesions
became vesicular and bullous, and he was admitted to Sanglah General Hospital.
On arrival, the patient had diffuse involvement of his oral mucosa and conjunctiva. He was
intubated electively to protect his airway. Fiberoptic laryngoscopy revealed erosive mucosal
lesions in the mouth and oropharynx to the level of the larynx, which was not involved.
The patient's condition deteriorated. He required vasopressor support, developed gross
hematuria and significant hemorrhage from his lips and gums, requiring placement of
multiple oral packs and treatment with topical thrombin spray. Approximately 40% of his
body surface area was involved. Currently, he is slowly improving in the joint care in
Intensive Care Unit.
LEARNING TASK
1. According this case, what is the most likely diagnosis?
2. What does you needs the history of the patients to support the diagnosis?
3. What does the complete assessment of this patient?
4. What does your planning for management in this case?
SELF ASSESSMENT
1. Describe the principle clinical features of SJS, TEN and SSSS.
2. Describe the pathogenesis of emergencies skin disease.
3. Explain more detail the basic principle of management of the emergencies skin
disease.
4. Describe the prognosis and complication of the emergencies skin disease.

TRAUMA WHICH POTENTIALLY DISABLING AND LIFE THREATENING


CONDITIONS
LEARNING TASK
Case 1.
Male , 24 years old, admitted to our hospital after traffic accident, he was riding a motor
bike. He suffered crush injury on his right lower leg 4 hours before admitted.
Primary survey : airway and breathing clear, circulation ; BP : 90/60 mmHg, HR : 120
x/minute. Distal part of lesion : pale, cold and non palpable pulsation of dorsalis pedis artery.
1. What is your initial assessment ?
2. How to manage this patient ?
Case 2
Male, 20 years old, came to our hospital after traffic accident, He was getting difficulty of
taking his breath and restlessness.
On physical examination :
- A symetrically of thoracic movement
- Breathing sound (-) on the right side and hypersonor on percussion
1. What is your conclusion ?
2. How to manage the patient ?
Case 3

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Girl, 13 years old, came to emergency department after traffic accident.
She got lower leg pain on the left side
Physical examination ( Left lower leg)
- Swelling
- Tense feeling
- Painfull
- Stretch pain (+)
1. What is your conclusion
2. How to work up the diagnostic
3. How to treat the patient ?
NB:
THERE WILL BE SOME LEARNING TASK WILL BE GIVEN BY THE LECTURERS AND
TEAM IF IT'S NECESSASY PLEASE BE CONFIRM THE LECTURERS AND TEAM.

~ CURRICULUM MAP ~
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Smstr

Program or curriculum blocks

10

Senior Clerkship

Senior Clerkship

Senior clerkship

Medical
Emergency
(3 weeks)

Special Topic:
-Travel medicine
(2 weeks)

Elective Study III


(6 weeks)

Clinic Orientation
(Clerkship)
(6 weeks)

BCS (1 weeks)
The Respiratory
System and
Disorders
(4 weeks)

The
Cardiovascular
System and
Disorders
(4 weeks)

The Urinary
System and
Disorders
(3 weeks)

The Reproductive
System and
Disorders
(3 weeks)

BCS (1 weeks)
Alimentary
& hepatobiliary systems
& disorders
(4 Weeks)

BCS (1 weeks)
The Endocrine
System,
Metabolism and
Disorders
(4 weeks)

BCS (1 weeks)
Clinical Nutrition
and Disorders
(2 weeks)

BCS (1 weeks)

BCS (1 weeks)

Musculoskeletal
system &
connective
tissue disorders
(4 weeks)

Neuroscience
and
neurological
disorders
(4 weeks)

Behavior Change
and disorders
(4 weeks)

BCS (1 weeks)
Hematologic
system & disorders & clinical
oncology
(4 weeks)

BCS (1 weeks)
Immune
system &
disorders
(2 weeks)

BCS(1 weeks)
Infection
& infectious
diseases
(5 weeks)

BCS
(1 weeks)
The skin & hearing
system
& disorders
(3 weeks)

BCS (1 weeks)
Medical
Professionalism
(2 weeks)

BCS(1 weeks)
Evidence-based
Medical Practice
(2 weeks)

BCS (1 weeks)
Health Systembased Practice
(3 weeks)

BCS(1 weeks)
Community-based
practice
(4 weeks)

BCS (1 weeks)
Studium
Generale and
Humaniora
(3 weeks)

Medical
communication
(3 weeks)

BCS (1 weeks)
The cell
as biochemical machinery
(3 weeks)

Growth
&
development
(4 weeks)

BCS (1 weeks)

BCS(1 weeks)

BCS: (1 weeks)

BCS (1 weeks)
Elective Study
II
(1 weeks)
5

BCS (1 weeks)

Special Topic :
- Palliative
medicine
-Compleme
ntary &
Alternative
Medicine
- Forensic
(3 weeks)

Elective
Study II
(1 weeks)

Special Topic
- Ergonomi
- Geriatri
(2 weeks)

Elective
Study I
(2 weeks)

The Visual
system &
disorders
(2 weeks)

Pendidikan Pancasila & Kewarganegaraan (3 weeks)

Medical Education Unit Faculty of Medicine Udayana University

39

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