Hemorrhagic Shock

in the Injuried Patient

Hasanul Arifin
Departemen Anestesiologi dan Reanimasi
Fakultas Kedokteran USU
 CaO2

Oxygen Bound (HbO2)

Oxygen dissolved (plasma)
CaO2 = Hb x SaO2 x 1.34 + PaO2 x 0.0031

Oxygen Bound (HbO2)

Oxygen dissolved (plasma)

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Initial Management of
Hemorrhagic Shock
 Pasien Trauma
(dianggap menderita shock hypovolemia)

Hentikan Perdarahan, Ganti

Kehilangan Volume
 Physical Examination
( ABCDE)
Airway & Breathing
Keep the airway clear
Ventilasi & Oksigenasi
Beri O2
SpO2 96-98%

Circulation ( kontrol perdarahan)

Penekanan
PASG (Pneumatic Anti shock Garment)
Operatip
 Physical Examination
( ABCDE)
Disability (neurologi)
Brain perfusion
GCS
Respon pupil

Exposure
Head to Too
Cegah hypothermia ( penghangatan internal,
eksternal)
 Tindakan lain
Dekompressi ( Maag dilatation)
Maag dilatasi
vagal stimulation
bradikardia,
hypotensi
Risiko aspirasi
Insersi NGT no besar untuk dekompressi, suction aktif

Urinary Catheter
Hematuria?
Jumlah urine
renal perfusion
 iv. line
2 (dua) iv catheter no. besar (16G, 18G)
Vena lengan bawah
Kalau kesulitan, akses vena besar :
Dilakukan oleh tenaga yang
 v. subclavia terlatih, jangan sampai
menimbulkan komplikasi
 v. jugularis interna ( peneumothorax,
 v. femoralis hematothorax, arterial
puncture )

 Sekalian ambil contoh darah (laboratorium)

Vein Selection
Both upper limbs should be inspected to
identify possible veins for cannulation.
Potential veins can then be palpated to assess
their condition.
An ideal vein is soft and bouncy when
palpated.
Veins that are tender, thrombosed or hard
should be avoided
Device selection
It is important to select the correct vascular
access device for the patients specific clinical
situation
PUR (polyurethane), modern, softer, cause
less intimal damage and are kink resistant
which reduces the incidence of cannula failure
PVC, Teflon, older materials are more rigid,
higher incidence of thrombophlebitis.
 equipment
Infusion standart
Fluid (RL, NaCl, etc)
Infusion tubing
The following equipment for cannulation should be
assembled and placed on a clean tray:
cannula, antiseptic, sterile gauze, sterile saline flush,
single or multiway adapter (primed with sterile saline)
with integral needle-less device, sterile moisture-
permeable transparent dressing, tape, and a small
sharps container.
 Theoretical Maximum Flow Rates

Colour Gauge Flow

Yellow 24G 13 ml/min

Blue 22G 30 ml/min

Pink 20G 55 ml/min

Green 18G 80-100 ml/min

White 17G 135 ml/min

Grey 16G 180 ml/min

Orange or Brown 14G 270 ml/min

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 Estimated Fluid and Blood Losses Based on
Patients Initial Presentation
Class I Class II Class III Class IV
Blood--Loss[ml]
Blood ->750 750-
750-1500 1500-
1500-2000 >2000

Blood--loss [%BV]
Blood ->15% 15
15--30% 30
30--40% >40%

Pulse--Rate [x/min.]
Pulse <100 >100 >120 >140

Blood--Pressure
Blood Normal Normal Decreased Decreased

Pulse--Pressure
Pulse N or Decreased Decreased Decreased
increased
Respiratory Rate 14
14--20 20
20--30 30
30--35 >35

Urine out-
out-put >30 20
20--30 5-15 Negligible
[ml/hour]
Mental status/CNS Slightly Midly Anxious Confused
anxious anxious and and
confused lethargic

EBV = 70 ml/kg
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 Kegunaan Klinis
Tabel Prakiraan Kehilangan Darah
Dengan menyesuaikan tanda dan gejala dari penderita pada
tabel, dapat diperkirakan berapa kehilangan darah yang sdh
terjadi.
Kemudian kita dapat memperhitungkan berapa jumlah cairan
yang harus diberikan untuk resusitasi
Bila post resisitasi belum ada tanda perbaikan, maka
kemungkinan :
Ongoing loss
Prakiraan ada kesalahan (BB tidak sesuai, kurang jeli menilai tanda dan
gejala
Ada tambahan kehilangan cairan lain selain perdarahan
Shock bukan ok. perdarahan
 Initial Fluid Therapy
Tujuan :
mengisi intravaskular dalam waktu singkat
preload
mekanisme
hemodinamik
Cairan :
Kristalloid
Ringer Lactat
Ringer Asetat
NaCl 0.9%
Rule : 3 for 1 (1000 mL perdarahan ganti 3000 mL)

Kolloid
rule 1 : 1 ( 500 mL perdarahan ganti 500 mL)

Physiologic principles of
fluid management

TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

60 kg 36 L

9L 3L 24 L

ISF
ISF IVF ICF

Hasanul, 2002
26/08/2010 25
 Physiology
definition
Crystalloid is the term commonly
applied to solutions that do not
contain any high-
high-molecular
molecular--weight
compounds and thus have an oncotic
pressure of zero
Colloid is the term used to denote
solutions that have an oncotic
pressure similar to that of plasma.
Jenis cairan yang beredar :
Kristalloid ( D5W, RL, RA, NaCl )
Kolloid ( Albumin, HES, Expafusin,
Gelatine)
Cairan Nutrisi ( Intrafusin, Ivelip,
Triofusin)

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Physiologic principles of
fluid management

D5W
3L

9L 3L 24 L
750 ml 250 ml 2L

ISF
ISF IVF ICF

Hasanul, 2002
26/08/2010 28
Physiologic principles of
fluid management

RL,NaCl

3L

9L 3L 24 L
2250ml 750 ml

ISF
ISF IVF ICF

Hasanul, 2002
26/08/2010 29
Physiologic principles of
fluid management

Albumin-
Albumin-
5%
1L

9L 3L 24 L
1L

ISF
ISF IVF ICF

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Physiologic principles of
fluid management

HES--6%
HES
1L

9L 3L 24 L
1000ml

ISF
ISF IVF ICF

Hasanul, 2002
26/08/2010 31
Physiologic principles of
fluid management

Albumin-
Albumin-
25%
Volume expander 100 cc

9L 3L 24 L
400 500

ISF
ISF IVF ICF

26/08/2010 Hasanul, 2002 32

Physiologic principles of
fluid management

Haemacel
1L

9L 3L 24 L
300ml 700ml

ISF
ISF IVF ICF

Hasanul, 2002
26/08/2010 33
 FLUID REPLACEMENT
3 : 1 Rule
Class I Crystalloid
Class II Crystalloid
+ Colloid ?
Class III Crystalloid
+Colloid, Blood
Class IV Crystalloid
+Colloid, Blood
Hasanul,, 2009
Hasanul 34
26/08/2010
 Pola kerja penanganan shock
perdarahan
Hasanul,, 2009
Hasanul

Penderita datang dengan

perdarahan

Pasang infus jarum kaliber Ukur tekanan darah, hitung

besar (16G, 18G), ambil nadi, nilai perfusi, produksi
sample darah urine

Tentukan estimasi jumlah

perdarahan, minta darah

Guyur cepat Ringer Laktat atau NaCl

0.9% [hangat, 390C] 3x prakiraan lost-
lost-
volume [1-
[1-2 liter] evaluasi
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 Pulse-
Pulse-Rate [x/min.]
Blood
Blood--Pressure
Pulse
Pulse--Pressure
Respiratory Rate
evaluasi

Urine out-
out-put [ml/hour]
Mental status/CNS

normal
 Thank you for listening
and to be continued

8/26/2010 37
 Management selanjutnya
Rapid response,
perdarahan <20%
Transient response,
perdarahan 20-40% BV
ongoing loss
resusitasi tdk adekwat
RL, NaCl 0.9%, Kolloid, Darah ?
Minimal, no response
Perdarahan >40%
Tindakan bedah segera
Transfusi darah

Hasanul, 2003

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 Efek volume infus 1 L cairan Kolloid pada
kompartement tubuh [BB,70kg]
Laruta n Vol. plasma Vol. interstetial Vol.intrasel

Albumin-5% 1000 - -
PPF [Plasma Protein
Fraction-5%] 1000 - -
Gelafundin 1000 - -

Haemacel 700 +300 -

Dextran-40 1600 -260 -340

Dextran-70 1300 -130 -170

Expafusin 1000 - -

Haes-steril-6% 1000 - -

Haes-steril-10% 1450 -450 -

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Hasanul, 2003 41
 TRANSIENT RESPONSE,
DARAH BELUM DATANG,

KOLLOID
1:1

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 Transfusion, indications
Indications for transfusion in normovolemic
anemia,
VO2 < normal range (indicating an oxygen debt)
Blood lactate > 4 mmol/L
O2ER > 0.5

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 Transfusi,
Target 7 - 9g%

Rule of - 5
ml Whole-
Whole-Blood = 5 x delta Hb x BB
contoh:
BB 60 kg, Hb 6g%, WB yang dibutuhkan = 5 x 3 x 60
= 900 ml

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= 4 bag [unit] 44
Hasanul,, 2009
Hasanul
 Why does hypothermia happen?

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 Hypothermia
 Casualties who are hypovolemic quickly
become hypothermic.
 Body temperatures below 91 F causes the
vicious triad.
Hypothermia
Acidosis
Coagulopathy

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