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SHOCK
SYOK : Sirkulasi inadekwat Gagal perfusi
.
Shock can be result of
FUNGSI MITOCHONDRIA
1. Pembentukan ATP
2.Pengaturan ion Ca++ intraseluler
3.Sensor oksigen
4.Inisiatif awal program apoptosis dan nekrosis sel
5.Steroidogenesis dan sinyaling
.
Cellular hypoxia can incite
immature forms
Multiple Organ Dysfunction
Syndrome
cardiogenic shock
*A cellular or metabolic deficit :
in septic shock
*A maldistribution of blood flow :
in other types of shock
Shock states
Released various cytokines and interplay
IL-2
TNF
respiratory failure, capillary leak,
shunting, redistribution, depressed
myocardial function, oxygen uncoupling, and
cellular ischaemia
PAOP
C.O
SVR
----------------------------------------------------------Cardiogenic
Hypovolemic
Distributive
or N
or N or
Obstructive
or N or
EVALUATION OF SYMPTOMS
HISTORY
History
In distributive shock : infection or allergic
significant hypotension
agitation, stupor
Skin changes
volume,
decreased FRC
RENAL
*Decreased urine output, elevation in BUN
and creatinine levels, change in urine
electrolyte levels
micro
vascular shunts, cytokine release
Cardiovascular : circulatory failure,
, arrhythmia
Haematologic : bone marrow suppression,
dysfunction
cellular leak
Hypovolemic shock
Cause : depletion of fluid in the intravascular
Perdarahan
Kehilangan akut darah dari sistim sirkulasi
Volume darah normal :
* Dewasa : 7% BB ideal
*Anak : 8-9% BB ideal
Perdarahan
Mulai segera resusitasi cairan agressif
Pengobatan disesuaikan dengan respon
Tanda perdarahan
Klas I
-----------------------------------------------------------
Perdarahan ml
Perdarahan (%BV)
Nadi
Tensi
Tek Nadi (mmHg)
Nafas
Urine ml/jam
SSP/status mental
Penggantian cairan
(hukum 3:1)
sampai 750
sampai 15%
< 100
Normal
Normal atau naik
14 - 20
> 30
sedikit Cemas
Kristaloid
Tanda perdarahan
Klas II
-----------------------------------------------------------
Perdarahan ml
Perdarahan (%BV)
Nadi
Tensi
Tek Nadi (mmHg)
Nafas
Urine ml/jam
SSP/status mental
Penggantian cairan
(hukum 3:1)
750-1500
15-30%
>100
Normal
Turun
20-30
20-30
Cemas sedang
Kristaloid
Tanda perdarahan
Klas III
-----------------------------------------------------------
Perdarahan ml
Perdarahan (%BV)
Nadi
Tensi
Tek Nadi (mmHg)
Nafas
Urine ml/jam
SSP/status mental
Penggantian cairan
darah
(hukum 3:1)
1500-2000
30-40%
> 120
Turun
Turun
30-40
5-15
Cemas gelisah
Kristaloid &
Tanda perdarahan
Klas IV
-----------------------------------------------------------
Perdarahan ml
Perdarahan (%BV)
Nadi
Tensi
Tek Nadi (mmHg)
Nafas
Urine ml/jam
SSP/status mental
Penggantian cairan
darah
(hukum 3:1)
>2000
>40%
>140
turun
turun
>35
tak ada
gelisah/letargi
kristaloid &
Perdarahan bermakna
perlu konsultasi BEDAH
.
Keputusan Pengobatan
Respon pasien pada resusitasi cairan merupakan
INGAT
Bedakan antara hemodinamik stabil dan
hemodinamik normal
Keputusan Terapi
Respon cepat
*< 20% perdarahan
*Stabil : respon pada penggantian cairan
*Lanjutkan monitor
*Evaluasi dan konsultasi bedah
Keputusan Terapi
20-40% perdarahan
Tidak stabil : memburuk setelah terapi cairan awal
Lanjutkan cairan dan darah
Evaluasi dan konsultasi bedah
Perdarahan berlanjut : operasi
Keputusan terapi
Tak ada respon (minimal)
> 40% perdarahan
Tak ada respon pada terapi cairan
Singkirkan kemungkinan shock nonhemorrhagik
Operasi segera
Distributive shock
Septic shock
Anaphylactic shock, acute adrenal insufficiency,
neurogenic shock.
Problem : shunts and capillary leak
Haemodynamic : normal/increased CO, low SVR
Low-to-normal LVFP
Echo : low SV, increase aortic diameter
1044-50)
Obstructive shock
Direct mechanical obstruction to cardiac filling
Case : cardiac tamponade, massive increase in
intrathoracic pressure
Diagnostic testing
General laboratory : blood lactate, bicarbonate,
Complications of shock
Low flow tissue perfusion activating factor of SIRS
Differential Diagnosis
Distributive shock
Hypovolemic shock
Obstructive shock
Cardiogenic shock
DD
Distributive shock :
Sepsis
Anaphylaxis
Anaphylactoid reactions
Neurogenic shock
Adrenal gland dysfunction
Trauma, burns and pancreatitis
DD
Hypovolemic shock
Dehydration (low fluid intake, diarrhea, bowel
DD
Obstructive shock
Cardiac tamponade and restrictive pericarditis
Pulmonary embolism
Intrathoracic processes (pneumothorax, pulmonary
DD
Cardiogenic shock
AMI
Septal infarctions
Cardiomyopathies (viral, alcoholic, infectious)
General goals
Optimization of oxygen delivery
Hb level > 10 g/dl
Arterial oxygen saturation > 92%
Reversal of organ system dysfunction
Maintain urine output > 0.5 ml/kg per hour
Therapy
Fluid management
Shock in children
CO = SV x HR
In children : the cardiac output is primarily
Signs of Shock
Early
Late
----------------------------------------------------- Narrowed pulse pressure
Hypovolemic:
Pump is empty
ETIOLOGY
Trauma (hemorrhage)
Dehydration (Vomiting
etc)
Metabolic disease (DM)
pump
Congestive heart failure
Cardiomyopathy
Post-resuscitation
ETIOLOGY
------------------------------------------------------------ Distributive:
Sepsis
Anaphylaxis
of outflow
Cardiac tamponade
Pulmonary embolism
Fluid distribution
Dopamine
Cardiogenic shock
SVT: Adenosine or synchronized
cardioversion
VF: defibrillation
Note
The most common error in treating
Summary
Resuscitation of shock is based on
Kelainan Elektrolit
Harus dilihat secara menyeluruh adanya kelainan
yang lain
18
2.8
4.6
mosmol/Liter
Kausa hiponatremia
Hypotonic
Renal losses
Euvolemic
Hypervolemic
Isotonic (pseudo)
Hypertonic
Irritability, ataxia
Lethargy, coma, seizure
Kausa hipernatremia
Loss of water
Kausa hipokalemia
Shift into the cell
Reduced intake
Increased loss
Renal loss
Miscellaneous
GI loss (vomiting, diarrhea, fistulas)
Kausa hiperkalaemia
Factitious
Metabolic acidemia (acute)
Increased intake into the plasma
Oliguric RF
Impaired renin-aldosterone axis
Primary renal tubular potassium secretory defect
Inhibition of renal tubular secretion of K
Abnormal K distribution