SYOK

Topic Discussion with dr.

Nata, Sp.PD
By Edwin H. / 071 2011
0101

Outline
Definisi

+ Prinsip dasar

Tipe
Pendekatan
Tatalaksana

Klinis

Definisi
an
m
e
D
d

ply
p
u
S

O2 Demand >>> Supply

Hipoperfusi Global --> Rx Anaerob

--> Asidosis Metabolik
Hipoksia berkepanjangan --> Gagal
organ multipel --> Fin
!!! syok bisa terjadi dengan BP DBN,
sedangkan px dg hipotensi belum
tentu syok !!!

Tipe-Tipe
!

Bisa Overlapping !
Kardiogenik syok
terjadi pada semua
tahap akhir syok

Pendekatan Klinis
!! Concurrent Diagnostic & Therapeutic Efforts !!
ABCs

Monitor kardiorespi
Pulse O2
Suplemen O2
IV access
AGD, lab
Kateter urin
TTV --> Assessment cepat, murah, dan sederhana

Diagnosa

Anamnesa
PF (TTV, JVP, Th, Abd dan Perfusi perifer)
Sumber Infeksi
Labs:
CBC
Kimia darah (Ur-Cr, Elektrolit, OT-PT)
AGD --> Curiga Asidosis Laktat --> A. gap (Na HCO3
Cl)
Laktat
D-dimer
Kultur darah

Evaluasi Lbh Lanjut

CT
LP
Kultur Luka --> Ulkus DM, Luka lama
Pikirkan Akut Abdomen
USG abdomen
Fibrinogen, FDPs, D-dimer

Pendekatan Klinis ++
Hipovolemik
Pendarahan (melena, hemoroid,
menorrhagia), dehidrasi (muntah, diare,
intake )
Tanda2 curah jantung (tekanan nadi
<20 mmHg, akral dingin, CRT <2 dt)
Pemeriksaan lab (anemia, AKI)

Pendekatan Klinis
Septik
Demam
Tanda-tanda infeksi pada salah satu sistem organ
(sesak nafas/batuk, nyeri berkemih, dll)
Port de entre pada kulit (biasa pada individu dg
imun )
Kriteria SIRS (+)

Kardiogenik
Riw. Ggn jtg sebelumnya (px maupun keluarga)
S3 gallop, JVP , Takikardik
!! Bisa terjadi perbaikan bila diberi bolus cairan pd Th
awal --> JANGAN dianggap syok hipovolemik !!

Pendekatan Klinis
Obstruktif (Pneumotoraks, Kardiak
tamponade, PE)
Riw. Trauma
Gambaran klinis dari masing-masing
kelainan tsb.
Kecuali Kardiak tamponade; Becks Triad
(Hipotensi, JVP , Bunyi Jantung )

Prinsip Syok
Cari tanda gangguan perfusi :
Takikardi ---> abnormalitas yg paling awal
muncul
BP
o Textbook Presentation BP sistolik < 90 mmHg
o BP bisa normal pada syok (HT) --> >40 mmHg
dari BP awal
o Ukur BP dengan manometer manual
o Lihat tekanan nadi --> Berkorelasi dengan curah
jantung --> PP = CO & vice versa

Prinsip Syok
RR --> Kussmaul? --> Asidosis -->
pH arteri

Perubahan status mentalis/kesadaran

--> late sign
SI = RR/SBP (N = 0.5-0.7) ---> Severity
syok
MSI = RR/MAP (>1.3) ---> Mortality

Tujuan Terapi
ABCDE

Airway
Breathing Control
Optimalisasi Circulation
Pastikan Delivery O2 efektif
Capailah End points of resuscitation

Temukan + Selesaikan Root of the

Cause !!

Airway
Pertimbangkan Intubasi TAPI: fx
samping intubasi --> HIPOTENSI
Sedatif BP
PPV Preload

MUNGKIN perlu resusitasi cairan

sebelum intubasi utk cegah dekom

Breathing Control
Otot nafas juga mengkonsumsi O2

Takipneu --> Kerja otot nafas --> Asidosis

Laktat
Ventilasi & Sedasi beban kerja otot nafas

Optimalkan Circulation
Kristaloid isotonik
Target :
CVP 8-12 mm Hg (Bila dipasang)
Urine output 0.5-1 ml/kg/hr (30 ml/hr)
HR

Bisa mencapai 4-6 L

Koloid --> (-) Outcome benefit

++ Circulation
Gagal

membaik?

Dopamine (mcg/kg/min)
urine & renal blood flow
5-15
: renal blood flow , CO, HR,
cardiac contractility
20-50 : BP & vasoconstriction, risk of
tachyarritmia, (-) benefit to BP
Strong Beta-1 stimulator, Dose-dependent
Alpha-1 & Dopaminergic effects
1-5 :

Bingung??? Hehe
Adrenergik

Alpha
--> Vasokonstriksi --> preload AND
afterload
2 --> Feedback mech
1

Beta
--> Jantung (krono, ino, dromo), Renin
2 --> Vasodilasi PD Jantung dan otot
skeletal ( PVR)
1

Back to Topic
Dopamine (mcg/kg/min)
Strong Beta-1 stimulator, Dose-dependent
Alpha-1 & Dopaminergic effects
1-5 : urine & renal blood flow
5-15
: renal blood flow , CO, HR, cardiac
contractility
20-50 : BP & vasoconstriction, risk of
tachyarritmia, (-) benefit to BP
Dopaminergic effects: 0.5-2 --> Vasodilasi Renal &
Splanknik
Beta-1 effects : 2-10
Alpha effects : >10

Still ++ Circulation
Dobutamine

(mcg/kg/min)

Strong Beta-1, Weak Beta-2 & Alpha

effects
Cardiac Decom
0.5-1

initially, then

2-20
JANGAN

> 40

Low CO
2-20

lalu titrasi sesuai keperluan

JANGAN > 40

Pastikan Delivery O2 Efektif

Supplementasi O2
O2 demand:
Analgesik + Anxiolytik (p.r.n) --> tenangkan
px

Jaga Hb > 9-10 g/dL

Serial Laktat atau Sat. O2 Vena Sentral

---> Nilai Ekstraksi O2 pd lv jaringan

Capailah End Points of

Resuscitation
Goal:

Urine > 0.5 mL/kg/hr

CVP 8-12 mmHg
MAP 65 to 90 mmHg
Sat. O2 Vena Sentral > 70%

+ Identifikasi penyebab syok tentunya..!!

Hipotensi Persisten??

Vol. Resusitasi cukup

Pneumothorax
Cardiac tamponade
Occult Bleeding
Adrenal insufficiency
Alergi Obat

Praktisnya
Pantau Terus px seperti ini
TTV berkala:
Assess keberhasilan terapi
Tanda-tanda awal Syok dekom

Kerjasama dg perawat, sesama koas &

RMO : pastikan semua pihak terinfo px
ini JELEK! Hehehe

Plus2 :p

Sepsis
Two or more of SIRS criteria

Temp > 38 or < 36 C

HR > 90
RR > 20
WBC > 12,000 or < 4,000

Plus the presumed existence of infection

Blood pressure can be normal!

Septic syok
Sepsis (remember definition?)
Plus refractory hypotension
After bolus of 20-40 mL/Kg patient still has
one of the following:

SBP < 90 mm Hg
MAP < 65 mm Hg
Decrease of 40 mm Hg from
baseline

References
Sherman S, Weber J, Schindlbeck M, Patwari
R. Clinical emergency medicine.
Rivers et al. Early Goal-Directed Therapy in
the Treatment of Severe Sepsis and Septic
syok. NEJM 2001; 345(19):1368.
Berger T, Green J, Horeczko T, Hagar Y, Garg
N, Suarez A et al. syok Index and Early
Recognition of Sepsis in the Emergency
Department: Pilot Study. Western Journal of
Emergency Medicine. 2013;14(2):168-174.

Berger T, Green J, Horeczko T, Hagar Y, Garg N, Suarez

A et al. syok Index and Early Recognition of Sepsis in
the Emergency Department: Pilot Study. Western Journal
of Emergency Medicine. 2013;14(2):168-174.
Liu Y. Modified syok index and mortality rate of
emergency patients. World J Emerg Med. 2012;3(2):114.
Mutschler M, Nienaber U, Mnzberg M, Wlfl C, Schoechl
H, Paffrath T et al. The syok Index revisited a fast
guide to transfusion requirement? A retrospective
analysis on 21,853 patients derived from the
TraumaRegister DGU. Critical Care. 2013;17(4):R172.
Wira C, Francis M, Bhat S, Ehrman R, Conner D, Siegel
M. The syok Index as a Predictor of Vasopressor Use in
Emergency Department Patients with Severe Sepsis.
Western Journal of Emergency Medicine. 2014;15(1):6066.