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TATA LAKSANA

KEGAWATDARURATAN DI
BIDANG ILMU PENYAKIT DALAM

Pendahuluan
Pendekatan gawat darurat berdasarkan tanda
dan gejala
Basic Life Support
43 topik kajian dalam modul IMELS, tema
disajikan berdasarkan kekerapan ditemui dalam
keseharian pasien2 penyakit dalam
Menjaga serta meningkatkan kompetensi dokter
SpPD
Mampu memberikan pelayanan kegawatdarutan
yg optimal demi peningkatan pelayanan bagi
masyarakat.

Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam

Syok hipovolemik
Syok anafilaktik
Henti jantung
Intoksikasi dengan ancaman hidup
Sindrom distres pernafasan akut
Pneumonia berat
Pneumotoraks
Efusi pleura masif
Jejas paru karena suhu (trauma inhalasi)
Emboli paru
Gagal hati akut

Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam

Ensefalopati hepatikum
Kolangitis akut
Pankreatitis
Kolesistitis akut
Hematemesis melena
Hematoskezia
Ileus paralitik
Krisis hipertensi
Hipokalemia
Hiperkalemia
Hiponatremia

Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam

Hematuria masif
Gangguan ginjal akut
Bradikardia simtomatik
Takikardia dengan pulse
Sindroma koroner akut
Edema paru akut kardiogenik
Sindrom delirium akut
Koagulasi intravaskular diseminata
Sindrom vena kava superior
Sindrom lisis tumor
Ketoasidosis diabetikum

Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam

Hipoglikemia
Krisis tiroid
Sepsis
Leptospirosis (sindrom Weil)
Malaria berat
Tifoid toksik
Keracunan makanan
Tertelan zat korosif
Gigitan binatang berbisa
Sengatan panas

Shock

Definition
Epidemiology
Physiology and Pathophysiology
Classes of Shock
Clinical Presentation
Management
Controversies

Definition
A physiologic state characterized
by
Inadequate tissue perfusion

Clinically manifested by
Hemodynamic disturbances
Organ dysfunction

Epidemiology
Mortality
Septic shock 35-40% (1 month
mortality)
Cardiogenic shock 60-90%
Hypovolemic shock
variable/mechanism

Physiology
Basic unit of life = cell
Cells get energy needed to stay alive
by reacting oxygen with fuel (usually
glucose)
No oxygen, no energy
No energy, no life

Physiology
Cardiovascular System
Transports oxygen, fuel to cells
Removes carbon dioxide, waste products
for elimination from body
Cardiovascular system must
be able to maintain sufficient
flow through capillary beds to
meet cells oxygen and fuel
needs

Flow =
Perfusion

Adequate Flow
= Adequate
Perfusion

Inadequate Flow
= Indequate
Perfusion
(Hypoperfusion)

Hypoperfusio
n = Shock

Physiology
What is needed to maintain
perfusion?
Pump
Pipes
Fluid

: Heart
: Blood vessels
: Blood

How can perfusion fail?


Pump Failure
Pipe Failure
Loss of Volume

Pathophysiology
Imbalance in oxygen supply and demand
Conversion from aerobic to anaerobic
metabolism
Appropriate and inappropriate metabolic
and physiologic responses
Characterized by three stages
Preshock (warm shock, compensated shock)
Shock
End organ dysfunction

Pathophysiology
Compensated shock
Low preload shock tachycardia, vasoconstriction,
mildly decreased BP
Low afterload (distributive) shock peripheral
vasodilation, hyperdynamic state

Shock
Initial signs of end organ dysfunction
Tachycardia
Tachypnea
Metabolic acidosis
Oliguria
Cool and clammy skin

Pathophysiology
End Organ Dysfunction
Progressive irreversible dysfunction
Oliguria or anuria
Progressive acidosis and decreased CO
Agitation, obtundation, and coma
Patient death

Classification
Schemes are designed to simplify
complex physiology
Major classes of shock
Hypovolemic
Cardiogenic
Distributive

Hypovolemic Shock
Results from decreased preload
Etiologic classes
Hemorrhage - e.g. trauma, GI bleed,
ruptured aneurysm
Fluid loss - e.g. diarrhea, vomiting,
burns, third spacing, iatrogenic

Hypovolemic Shock
Hemorrhagic
Shock
Parameter
I

II

III

IV

Blood loss (ml)

<750

7501500

15002000

>2000

Blood loss (%)

<15%

1530%

3040%

>40%

Pulse rate
(beats/min)

<100

>100

>120

>140

Blood pressure

Normal

Decreased

Decreased

Decreased

Respiratory rate
(bpm)

1420

2030

3040

>35

>30

2030

515

Negligible

Normal

Anxious

Confused

Lethargic

Urine output
(ml/hour)
CNS symptoms
Crit Care. 2004; 8(5): 373
381.

Cardiogenic Shock
Results from pump failure
Decreased systolic function
Resultant decreased cardiac output

Etiologic categories
Myopathic
Arrhythmic
Mechanical
Extracardiac (obstructive)

Distributive Shock
Results from a severe decrease in
SVR
Vasodilation reduces afterload
May be associated with increased CO

Etiologic categories
Sepsis
Neurogenic / spinal
Other (next page)

Distributive Shock
Other causes
Systemic inflammation pancreatitis,
burns
Toxic shock syndrome
Anaphylaxis and anaphylactoid
reactions
Toxin reactions drugs, transfusions
Addisonian crisis
Myxedema coma

Distributive Shock
Septic Shock

Clinical Presentation
Clinical presentation varies with type
and cause, but there are features in
common
Hypotension (SBP<90 or Delta>40)
Cool, clammy skin (exceptions early
distributive, terminal shock)
Oliguria
Change in mental status
Metabolic acidosis

Evaluation
Done in parallel with treatment!
H&P helpful to distinguish type of shock
Full laboratory evaluation (including H&H,
cardiac enzymes, ABG)
Basic studies CxR, EKG, UA
Basic monitoring VS, UOP, CVP, A-line
Imaging if appropriate FAST, CT
Echo vs. PA catheterization
CO, PAS/PAD/PAW, SVR, SvO2

Treatment
Manage the emergency
Determine the underlying cause
Definitive management or support

Manage the Emergency


Your patient is in extremis
tachycardic, hypotensive, obtunded
How long do you have to manage
this?
Suggests that many things must be
done at once
Draw in ancillary staff for support!
What must be done?

Manage the Emergency

One person runs the code!


Control airway and breathing
Maximize oxygen delivery
Place lines, tubes, and monitors
Get and run IVF on a pressure bag
Get and run blood (if appropriate)
Get and hang pressors
Call your senior/fellow/attending

Determine the Cause


Often obvious based on history
Trauma most often hypovolemic
(hemorrhagic)
Postoperative most often hypovolemic
(hemorrhagic or third spacing)
Debilitated hospitalized pts most often septic
Must evaluate all pts for risk factors for MI
and consider cardiogenic
Consider distributive (spinal) shock in trauma

Case
85 y/o M 4 hours postop S/P sigmoid
resection for perforated diverticulitis
is hypotensive on a monitored bed at
70/40
Best actions for the first 5 minutes?

Definitive Management
Hypovolemic Fluid resuscitate (blood
or crystalloid) and control ongoing loss
Cardiogenic - Restore blood pressure
(chemical and mechanical) and prevent
ongoing cardiac death
Distributive Fluid resuscitate,
pressors for maintenance, immediate
abx/surgical control for infection,
steroids for adrenocortical insufficiency

Controversies
IVF Resuscitation
Limited resuscitation in penetrating trauma
Use of hypertonic saline resuscitation in
trauma
Endpoints for prolonged resuscitation

Pressors
Best pressors for distributive shock

Monitoring
Most appropriate timing and use for PA
catheterization or intermittent echocardiogram