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Shock Kardiogenik

Dr. MUHAMMAD SYUKRI, Sp JP(K), FIHA, FSCAI, FAPSIC

CARDIAC CENTER
REGIONAL CARDI0VASCULAR CENTER
RS. DR. M DJAMIL, PADANG

JANTUNG SEBAGAI POMPA

Kanan

Kiri

FAKTOR PENENTU FUNGSI JANTUNG

Kontraktilitas
PRELOAD

AFTERLOAD

STROKE
VOLUME

HEART RATE

CARDIAC OUTPUT

HEMODINAMIK
Ilmu yang mempelajari
Fungsi jantung sebagai pompa
Sistem sirkulasi darah
Autoregulasi sistem kardiovaskuler

Cardiac Output
Cardiac Output is the volume of blood pumped each
minute, and is expressed by the following equation:

CO = SV x HR
Where:
CO is cardiac output expressed in L/min (normal ~5
L/min)
SV is stroke volume per beat
HR is the number of beats per minute

PEREDARAN DARAH TEPI


DITENTUKAN OLEH :

Ukuran( Size )
Panjang pembuluh darah
Tahanan
Viskositas

Prinsip fisika aliran : Hukum Poiseulles


SVR = 8 length X Viscosity
R4

KORELASI KLINIK GANGGUAN


HEMODINAMIK DAN KONTROL SISTEM
KARDIOVASKULER

SHOK ( GAGAL SIRKULASI )


HIPERTENSI
HIPOTENSI

KONTROL SISTEM KARDIOVASKULER


Kontrol jangka pendek
Baroreseptor
Sistem Simpatik/Para simpatik
Jantung dan Pembuluh darah

Kontrol jangka panjang


Juxta Glomerulus Renal
Renin Angiotensin- Aldosteron

Shock
Suatu keadaan dimana perfusi jaringan tidak
adekuat menyebabkan kekurangan oksigen dan
pengkutan bahan bahan metabolik terganggu.
Gangguan produksi dan pemanfaatan energi,
perubahan metabolisme sel, asidosis, cedera sel,
rusaknya integritas sel, disfungsi jaringan dan
organ dan akhirnya kematian bila tidak di atasi
secara cepat dan agresif.

Gambaran Klinis
A.
B.
C.
D.

Tanda Vital
Kulit
Volume Urine
Status Mental

Tanda Vital
Pulsa Nadi : Takikardia
Tekanan Darah :
TDS < 90 mmHg

Shock Index :

HR
TD

N = 0.5 0.7

Kulit
Dingin
Clammy (lembab dan basah)
Diaphoretic

Volume Urine

Pekat
Jumlah urine menurun
Oliguria < 0.5 cc/kg/jam
Anuria

Status Mental

Confuse
Agitasi
Lethargi
Coma

Triad kardiovaskular
1. Problem irama atau frekuensi jantung.
2. Problem pompa Jantung.
3. Problem volume atau tahanan
vaskular

Problem Irama Atau Frekuensi


Jantung
Irama cepat
SVT
AF
VT

Irama Lambat
Sinus bradikardia
Junctional Rhythm
AV block

Problem pompa Jantung

Primer

Myokardial Infark
Cardiomyopathy
Myocarditis
IVS rupture
Disfungsi katup akut

Sekunder

Myxoma atrium
Tamponadde jantung
Emboli Paru
Tension Pneumothorak
Obstruksi vena kava
Obat yang dapat mendepresi myocard

Problem volume atau


tahanan vaskular

Volume cairan berkurang

Perdarahan
Muntah/diare
Luka bakar
Diabetes Insipidus
dll

Ukuran vaskular yang bertambah

Anaphylaxis
CNS injury
Toxin
Obat-obtan

Pasien Monitor
Monitor ketat

Tanda Vital
Irama Jantung
Saturasi Oksigen ( Pulse Oximetry)
Volume Urine
Penilaian pasien

Monitor Invasif
Artery Line
Central venous Pressure
Pulmonary artery catheterization ( Swan-Ganz )

Perawatan Pasien Shock


a.
b.

c.
d.

Nilai, amankan dan atasi jalan nafas dan sirkulasi


sesuai dengan indikasi
Secara bersamaan berikan 02, pasang IV line,
monitor kontinu Sat o2 dan irama jantung
Segera dapatkan data tanda vital, ECG, BGA,
Riwayat penyakit
Segera kerjakan Chest X- Ray, Laboratorium yang
relevan.

Cardiogenic Shock and


Hemodynamics

Outline
Cardiogenic Shock
Etiologies
Pathophysiology
Clinical Findings
Treatment

Shock Kardiogenik
Definition

<90 mmHg

<2.2 li/min.m2

>15 mmHg

SHOCK Registry JACC Sept. 2000, Supp. A

Spectrum of Clinical Presentations


Mortality

Respiratory
Distress

Hypotension Hypoperfusion

21%

22%

1.4%

5.6%

70%
60%

28%

65%

SHOCK= Inadequate Tissue Perfusion


Mechanisms:
Inadequate oxygen delivery
Release of inflammatory mediators
Further microvascular changes,
compromised blood flow and further
cellular hypoperfusion

Clinical Manifestations:
Multiple organ failure
Hypotension

Schematic
LVEDP elevation
Hypotension
Decreased coronary
perfusion
Ischemia
Further myocardial
dysfunction
Neurohormonal
activation
Vasoconstriction
Endorgan hypoperfusion

Hemodynamic Parameters
Systemic Vascular Resistance (SVR)
Cardiac Output (CO)
Mixed Venous Oxygen Saturation
(SvO2)
Pulmonary Capillary Wedge Pressure
(PCWP)
Central Venous Pressure (CVP)

Normal Values
Right Atrial
Pressure, CVP

Mean

0-6mmHg

Pulmonary
Systolic
Artery Pressure End-diastolic
mean
PCWP
Mean

15-30mmHg
4-12mmHg
9-19mmHg
4-12mmHg

Cardiac Output

4-8 L/min

Mixed Venous
O2 Sat
SVR

>70%
800-1200

Differentiating Types of Shock

Clinical Findings
Physical Exam: elevated JVP, +S3, rales, oliguria,
acute pulmonary edema
Hemodynamics: dec CO, inc SVR, dec SvO2
Initial evaluation: hemodynamics (PA catheter),
echocardiography, angiography

4 Potential Therapies
Pressors
Intra-aortic Balloon Pump (IABP)
Fibrinolytics
Revascularization: CABG/PCI

Refractory shock: ventricular assist


device, cardiac transplantation

Pressors do not change outcome


Dopamine
<2 renal vascular dilation
<2-10 +chronotropic/inotropic (beta effects)
>10 vasoconstriction (alpha effects)

Dobutamine positive inotrope, vasodilates,


arrhythmogenic at higher doses
Norepinephrine (Levophed): vasoconstriction,
inotropic stimulant. Should only be used for
refractory hypotension with dec SVR.
Vasopression vasoconstriction
VASO and LEVO should only be used as a last
resort

IABP is a temporizing measure


Augments coronary blood flow in diastole
Balloon collapse in systole creates a vacuum effect
decreases afterload
Decrease myocardial oxygen demand

IABP

Indication for IABP

Contraindications to IABP
Significant aortic regurgitation or significant
arteriovenous shunting
Abdominal aortic aneurysm or aortic dissection
Uncontrolled sepsis
Uncontrolled bleeding disorder
Severe bilateral peripheral vascular disease
Bilateral femoral popliteal bypass grafts for severe
peripheral vascular disease.

Complications of IABP
Cholesterol Embolization
CVA
Sepsis
Balloon rupture
Thrombocytopenia
Hemolysis
Groin Infection
Peripheral Neuropathy

Revascularization SHOCK
trial
Overall 30-Day Survival in the Study

Hochman J et al. N Engl J Med 1999;341:625-634

SHOCK trial

Hochman J et al. N Engl J Med 1999;341:625-634

SHOCK 6 years later


Kaplan-Meier Long-term Survival of All Patients and Those Discharged Alive
Following Hospitalization

Hochman, J. S. et al. JAMA 2006;295:2511-2515.


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