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NYERI:NYERI: Ada gunanya merupakan mekanisme proteksi badan Ada gunanya merupakan mekanisme proteksi badan Terjadi akibat kerusakan jaringan, timbul rasa sakit, walau Terjadi akibat kerusakan jaringan, timbul rasa sakit, walau
rasang sangat kecil .rasang sangat kecil . Kulit iskemia , rasa sakit dan dapat pingsangKulit iskemia , rasa sakit dan dapat pingsang Rasa sakit : - cepat 0.1 detikRasa sakit : - cepat 0.1 detik - lambat 1 detik sampai 1 menit- lambat 1 detik sampai 1 menit Cepat : benda tajam, menyengat dan mendadakCepat : benda tajam, menyengat dan mendadak Listrik, jarum , kulit teririsListrik, jarum , kulit teriris TerbakarTerbakar Tidak perlu masuk ke dalam jaringan sampai dalamTidak perlu masuk ke dalam jaringan sampai dalam Mekanik dan termalMekanik dan termal Lambat: sakit, nausea, sakit kronis, kerusakan jaringan.Lambat: sakit, nausea, sakit kronis, kerusakan jaringan. Mekanik, termal. Dan kimiawiMekanik, termal. Dan kimiawi
Reseptor sakit: akhiran saraf bebas, tersebar di Reseptor sakit: akhiran saraf bebas, tersebar di seluruh permukaan kulitseluruh permukaan kulitDi jaringan tertentu: di dalam: periosteum, Di jaringan tertentu: di dalam: periosteum, dinding pembuluh darah, permukaan artikulasio.dinding pembuluh darah, permukaan artikulasio.
Rangsangan dapat: mekanik, termal dan kimiawiRangsangan dapat: mekanik, termal dan kimiawiKimiawi: disuntikkan dibawah kulit (bradikinin, Kimiawi: disuntikkan dibawah kulit (bradikinin, ion K, dan enzim proteolitik)ion K, dan enzim proteolitik)
Jika reseptor lebih sensitif, dinamakan Jika reseptor lebih sensitif, dinamakan hiperalgesia.hiperalgesia.
Termal yang menyebabkan nyeri = 45Termal yang menyebabkan nyeri = 45ooC , C , sebanding dengan kerusakan jaringan.sebanding dengan kerusakan jaringan.
Reseptor sakit tidak seperti reseptor yang lain:Reseptor sakit tidak seperti reseptor yang lain:
Adaptasi : sangat kecil/ tidak ada sama sekali, Adaptasi : sangat kecil/ tidak ada sama sekali, dalam kondisi tertentu eksitasi menjadi bertambah dalam kondisi tertentu eksitasi menjadi bertambah besarbesar
Rangsang berjalan terus , jaringan rusak.Rangsang berjalan terus , jaringan rusak.
Jaringan iskemia , sakit sekali. Aliran darah Jaringan iskemia , sakit sekali. Aliran darah tersumbat sakit beberapa menit. Metabolisme tersumbat sakit beberapa menit. Metabolisme bertambah merasa makin sakit.bertambah merasa makin sakit.
Sakit akibat akumulasi asam laktat di jaringanSakit akibat akumulasi asam laktat di jaringan
Kejang otot merasa sangat sakit, sindroma Kejang otot merasa sangat sakit, sindroma sakitsakit
Reseptor sakit, mekanosensitif (langsung)Reseptor sakit, mekanosensitif (langsung)
Rusak pembuluh darah iskemia (tidak Rusak pembuluh darah iskemia (tidak langsung)langsung)
Dual transmisi signal sakit menuju ke SSP:Dual transmisi signal sakit menuju ke SSP: fast, sharp pain pathwayfast, sharp pain pathway slow ,chronic pathwayslow ,chronic pathway
Dual, cepat jalan dulu, memberitahu sakit, Dual, cepat jalan dulu, memberitahu sakit, kemudian hindari, beberapa menit sampai kemudian hindari, beberapa menit sampai otakotak
Jalan sampai otak: Jalan sampai otak: traktus neospinotalamus untuk fast pain traktus neospinotalamus untuk fast pain
berhenti di brain stem dan talamus berhenti di brain stem dan talamus Mekanis, termalMekanis, termal
traktus paleospinotalamus untuk slow paintraktus paleospinotalamus untuk slow pain
Pain Suppression: bervariasi untuk Pain Suppression: bervariasi untuk menekan sakitmenekan sakit
Otak sendiri menahannya untuk tidak ke Otak sendiri menahannya untuk tidak ke sistem saraf,sistem saraf,
Dengan mengaktifkan sistem kontrol sakit Dengan mengaktifkan sistem kontrol sakit
= sistem analgesia= sistem analgesia
Sistem analgesia terdiri dari 3 Sistem analgesia terdiri dari 3 komponen:komponen:
1.1. periaqaeductal dan periventrikuler di periaqaeductal dan periventrikuler di mesensefalon dan pons ventrikel 3 mesensefalon dan pons ventrikel 3 dan 4 signal dari neuron-neuron dan 4 signal dari neuron-neuron dikirim kedikirim ke
2.2. nukleus rafe magnus di pons bawah nukleus rafe magnus di pons bawah medula atas, Diteruskan turun kemedula atas, Diteruskan turun ke
3.3. kornu dorsalis, medula spinaliskornu dorsalis, medula spinalis
Rangsang elektrik: dibawa ke periaqaeduct dan Rangsang elektrik: dibawa ke periaqaeduct dan nukleus rafe magnusnukleus rafe magnusDapat menekan signal sakit (kuat) pada waktu Dapat menekan signal sakit (kuat) pada waktu masuk ke dorsal spinal rootsmasuk ke dorsal spinal roots
Periaqaeduct, periventrikuler menekan sakit Periaqaeduct, periventrikuler menekan sakit tidak terlalu kuattidak terlalu kuatNeurotransmitter , supres sakit (sistem Neurotransmitter , supres sakit (sistem analgesia): enkefalin Serotoninanalgesia): enkefalin Serotonin
Nuklei periventrikuler dan periaqaeduct ke saraf Nuklei periventrikuler dan periaqaeduct ke saraf
ujung-ujung mensekresikan enkefalin.ujung-ujung mensekresikan enkefalin.Juga rafe magnus mensekresikan enkefalinJuga rafe magnus mensekresikan enkefalin
serabut-serabut asal dari nuklei ini dan berakhir serabut-serabut asal dari nuklei ini dan berakhir di kornu dorsalis medula spinalis mensekresikan di kornu dorsalis medula spinalis mensekresikan serotonin pada ujung-ujungnyaserotonin pada ujung-ujungnya
serotonin secara setempat merangsang sekresi serotonin secara setempat merangsang sekresi enkefalinenkefalin
enkefalin : presinaps inhibisi dan possinaps enkefalin : presinaps inhibisi dan possinaps inhibisiinhibisiPada serabut-serabut sakit A dan C dengan Pada serabut-serabut sakit A dan C dengan sinapsnya di kornu dorsalis dengan cara sinapsnya di kornu dorsalis dengan cara presinaps inhibisi dan blok kanal ion Ca, presinaps inhibisi dan blok kanal ion Ca, Ion Ca melepas transmiter di sinaps blok Ion Ca melepas transmiter di sinaps blok presinaps inhibisipresinaps inhibisi
Pemblok dapat kerja di sistem analgesik Pemblok dapat kerja di sistem analgesik mulai dengan menit sampai jammulai dengan menit sampai jam
Sistem analgesi dapat dihambat di Sistem analgesi dapat dihambat di permulaan masuk korda spinalispermulaan masuk korda spinalis
Sistem analgesia dapat menghambat Sistem analgesia dapat menghambat transmisi sakit di perjalanan di nuklei transmisi sakit di perjalanan di nuklei retikuler, batang otak, dan talamusretikuler, batang otak, dan talamus
Sistem opiat otak: endorfin dan enkefalinSistem opiat otak: endorfin dan enkefalin
Irritasi/rusak jaringan menghasilkan bahan-Irritasi/rusak jaringan menghasilkan bahan-bahan kimia seperti:bahan kimia seperti:
prostaglandin, kinins, dan ion kalium prostaglandin, kinins, dan ion kalium yang merangsang nociceptoryang merangsang nociceptor
Kondisi yang meningkatkan sakit:Kondisi yang meningkatkan sakit:
Jaringan meregang berlebihanJaringan meregang berlebihan
Kontraksi otot yang berkepanjanganKontraksi otot yang berkepanjangan
Kejang, iskemia (aliran darah kurang)Kejang, iskemia (aliran darah kurang)
Phantom Limb SensationPhantom Limb Sensation::
Seorang pasein yang telah diamputasi Seorang pasein yang telah diamputasi kakinya merasa sensasi seperti gatal, kakinya merasa sensasi seperti gatal,
tertekan tertekan atau sakit seakan-akan datang datang dari atau sakit seakan-akan datang datang dari kaki yang sudah diamputasikaki yang sudah diamputasi
Mengapa? Mengapa?
1)1) Korteks serebral menerima impuls datang dari Korteks serebral menerima impuls datang dari bagian proksimal saraf kaki yang telah hilangbagian proksimal saraf kaki yang telah hilang
3)3) Di otak sendiri ada jaringan neuron-neuron yang Di otak sendiri ada jaringan neuron-neuron yang menimbulkan sensasi pertahanan tubuh (neuron menimbulkan sensasi pertahanan tubuh (neuron masih aktif memberikan sensasi palsu)masih aktif memberikan sensasi palsu)
Kadang-kadang dirasa sangat sakit, dengan Kadang-kadang dirasa sangat sakit, dengan obat-obatan tidak meredaobat-obatan tidak mereda
VISCERAL PAINVISCERAL PAIN
Referred PainReferred Pain
Pain is initiated in area of the visceral organs Pain is initiated in area of the visceral organs and referred to an area on the body surfaceand referred to an area on the body surface
Pain may be referred to an area of the body Pain may be referred to an area of the body not exactly coincident with the location of the not exactly coincident with the location of the area producing the painarea producing the pain
The pain receptors adapt very little and The pain receptors adapt very little and sometimes not at allsometimes not at all
The average person first begins to The average person first begins to perceive pain when the skin is heated perceive pain when the skin is heated above 45above 4500CC
Pain receptor are free nerve endings in Pain receptor are free nerve endings in the skin and other tissuesthe skin and other tissues
They are widespread in the superficial They are widespread in the superficial layers of the skin, and internal tissues layers of the skin, and internal tissues (periosteum, arterial walls,joint surfaces, (periosteum, arterial walls,joint surfaces, and peritoneum)and peritoneum)
Pain is elevated by noxcious stimuli on Pain is elevated by noxcious stimuli on nociceptor (a sesory receptor cell sensitive nociceptor (a sesory receptor cell sensitive to xoxious stimuli)to xoxious stimuli)
Pain is importantPain is important
= is mainly a protective mechanisms for the = is mainly a protective mechanisms for the bodybody
= occurs whenever any tissues are being = occurs whenever any tissues are being damagedamage
= causes the individual to react to remove = causes the individual to react to remove the pain stimulusthe pain stimulus
Referred pain is important in clinical Referred pain is important in clinical diagnosis, because may visceral ailments diagnosis, because may visceral ailments cause no clinical signs except referred paincause no clinical signs except referred pain
Mechanical of referred painMechanical of referred pain
Branches of visceral pain fibers are shown Branches of visceral pain fibers are shown to synapse in the spinal cord on the same to synapse in the spinal cord on the same order of neuron that receive pain signals order of neuron that receive pain signals from the skinfrom the skin
When the visceral pain fibers are When the visceral pain fibers are stimulated, pain signal from the stimulated, pain signal from the viscera are then conducted through viscera are then conducted through at least some of the same neurons at least some of the same neurons that conduct pain signals from the that conduct pain signals from the skin, and the person has feeling that skin, and the person has feeling that the sensations originate in the skin the sensations originate in the skin itselfitself
Ischemia caused by occluding the blood Ischemia caused by occluding the blood supply to a large area supply to a large area stimulates many stimulates many diffuse pain fibers at the same time and can diffuse pain fibers at the same time and can result in extreme painresult in extreme pain
Ischemia causes visceral pain in the same Ischemia causes visceral pain in the same way that it does in other tissuesway that it does in other tissues
Presumebly because of the formation of Presumebly because of the formation of acidic metabolic end product or tissue acidic metabolic end product or tissue degeneration product such as bradykinin, degeneration product such as bradykinin, proteolytic enzymes, or others that stimulate proteolytic enzymes, or others that stimulate the pain nervesthe pain nerves
Pain threshold:Pain threshold:
The smallest intensity of a painful stimulus at The smallest intensity of a painful stimulus at
which a person perceives pain. which a person perceives pain.
All individuals have the same pain thresholdAll individuals have the same pain threshold
Pain tolerance:Pain tolerance:
The greatest intensity of painful stimulation The greatest intensity of painful stimulation
that a person is able to tolerate that a person is able to tolerate
Individuals vary in their tolerance to painIndividuals vary in their tolerance to pain
Analgesia, dengan cara menghambat Analgesia, dengan cara menghambat sintesis prostaglandin yang merangsang sintesis prostaglandin yang merangsang nociceptorsnociceptors
Dapat dengan memberikan obat atau zat Dapat dengan memberikan obat atau zat yang menghambat enzim yang yang menghambat enzim yang menyebabkan reaksi arakhidonat menjadi menyebabkan reaksi arakhidonat menjadi prostaglandin (siklooksigenase) prostaglandin (siklooksigenase)
Headache of Intracranial OriginHeadache of Intracranial Origin
The brain tissues themselves are almost The brain tissues themselves are almost totally insensitive to paintotally insensitive to pain
Therefore, it is likely that much or most of Therefore, it is likely that much or most of the pain of headache is not caused by the pain of headache is not caused by damage within the brain itselfdamage within the brain itself
HEADACHESHEADACHES
Headaches are a type of pain referred to the Headaches are a type of pain referred to the surface of the head from deep head surface of the head from deep head structuresstructures
Some headaches result from pain stimuli Some headaches result from pain stimuli arising inside the cranium, but others result arising inside the cranium, but others result from pain arising outside the cranium such from pain arising outside the cranium such as from the nasal sinusesas from the nasal sinuses
Conversely, tugging on the venous sinuses Conversely, tugging on the venous sinuses around the brain, damage or stretching the around the brain, damage or stretching the dura at the base of the brain can cause dura at the base of the brain can cause intense pain that is recognized as headache intense pain that is recognized as headache (trauma, blood vessels of meninges)(trauma, blood vessels of meninges)
Headache of Extracranial OriginHeadache of Extracranial Origin
Headache resulting from muscle spasmHeadache resulting from muscle spasm Emotional tension often causes many of the Emotional tension often causes many of the
muscles of the head, especially those muscles of the head, especially those muscles attached to the scalp and the neck muscles attached to the scalp and the neck muscle attached to the occiput, to become muscle attached to the occiput, to become spasticspastic
Headache caused by irritation of nasal and Headache caused by irritation of nasal and accessory nasal structuresaccessory nasal structures
The mucous membranes of the nose and The mucous membranes of the nose and nasal sinuses are sensitive to painnasal sinuses are sensitive to pain
Irritative processes in widespread areas of Irritative processes in widespread areas of the nasal structure often summate and the nasal structure often summate and cause headache , --> referred behind the cause headache , --> referred behind the eyeseyes
Also, pain from the lower sinuses such as Also, pain from the lower sinuses such as from the maxillary sinuses, can be felt in the from the maxillary sinuses, can be felt in the face face
Headache originate in the eyes or the extra Headache originate in the eyes or the extra occular spasm of the muscle, the pain is occular spasm of the muscle, the pain is referred to the surface of the head or retro-referred to the surface of the head or retro-orbitally.orbitally.