Syok dan Penanganannya

Nurcholid Umam K

Definisi :
Sindrom klinis akibat kegagalan sistem sirkulasi untuk mencukupi :
Nutrisi, oksigen pasokan utilisasi metabolisme jaringan tubuh defisiensi O2 seluler

FASE syok :
KOMPENSASI
DEKOMPENSASI
IREVERSIBEL
Etiologi Syok :
Type Primary Insult Common Causes

Hypovolemic Decreased circulating blood vol Dehydration, hemorrhage, capilarry

leaks

Distributive Vasodilation venous pooling Sepsis, anaphylaxis, drug intoxication,

decreased preload spinal cord injury

Obstructive Obstruction of cardiac Cardiac tamponade, tension

filling/out flow pneumothorax, pulmonary embolus

Cardiogenic Decreased contractility Congenital heart disease, myocarditis,

dysritmia

Dissociative O2 not released from CO poisoning, , methemo

hemoglobin globinemia

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RS PKU Muh Bantul 2015
Syok dan Penanganannya
Nurcholid Umam K

Patofisiologi Syok

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RS PKU Muh Bantul 2015
 Syok dan Penanganannya
Nurcholid Umam K

Manifestasi klinis syok

Clinical Signs Compen Uncompen Irreversible

sated sated

Blood loss (%) Up to 25 25 - 40 > 40

Heart rate Tachycardia Tachycardia Tachy/

+ ++ bradycardia
Systolic BP N N or falling Plummeting

Pulse volume N/ + ++

Capillary refill N/ + ++

Skin Cool, pale Cold, mottled Cold, deathly pale

Respiratory rate Tachypnoea + Tachypnoea ++ Sighing rsp.

Mental state Mild agitation Lethargic Uncooperative Reacts only to pain or

unresponsive

Type shock (AAP, 2005)

Type of Shock Pathophysiology Signs and Symptoms Treatment

Hypovolemic CO, SVR HR, pulses, delayed CR, Repeat boluses of 20 mL/kg
intravascular hyperpnea, dry skin, sunken crystalloid as indicated Blood
interstitial volume eyes, oliguria BP normal until products as indicated for
loss late acute blood loss

Septic CO, SVR (classic HR, BP, pulses, delayed Repeat boluses of 20 mL/kg
adult, 20% pediatric) CR, hyperpnea, MS changes, crystalloid; may need >60
third-spacing, edema mL/kg in first hour Consider
colloid if poor response to
crystalloid

Pharmacologic support of BP
with dopamine or
norepinephrine

CO, SVR (60% HR, normal to BP, Repeat boluses of 20 mL/kg

pediatric) pulses, delayed CR, crystalloid; may need >60
hyperpnea, MS changes, mL/kg in first hour Consider
third-spacing, edema colloid if poor response to
crystalloid

Pharmacologic support of CO
with dopamine or
epinephrine

CO, SVR (20% HR, BP, pulses, delayed
pediatric) CR, hyperpnea, MS changes,
third-spacing, edema
Repeat boluses of 20 mL/kg
crystalloid; may need >60
mL/kg in first hour Consider
colloid if poor response to
crystalloid

Pharmacologic support of CO

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RS PKU Muh Bantul 2015
 Syok dan Penanganannya
Nurcholid Umam K

and BP with dopamine or

epinephrine

Distributive Anaphylacxis: Angioedema, rapid third Repeat boluses of 20 mL/kg

CO, SVR space of fluids, BP, crystalloid as indicated
respiratory distress Pharmacologic support of
SVR with norepinephrine or
phenylephrine

Spinal cord injury: BP with normal HR, Pharmacologic support of

normal CO, SVR paralysis with loss of SVR with norepinephrine or
vascular tone phenylephrine

Fluid resuscitation as
indicated by clinical status
and associated injuries

Cardiogenic CO, normal to SVR Normal to HR, pulses, Pharmacologic support of CO

delayed CR, oliguria, JVD, with dobutamine, milrinone,
hepatomegaly BP normal dopamine Judicious fluid
until late in course replacement as indicated
clinically

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RS PKU Muh Bantul 2015
Tatalaksana resusitasi syok :
Resusitasi awal
Oksigen 100% + ventilatory support
Pasang akses vaskuler (90 detik)
Fluid challenge (20 ml/kg bb)
o Secepatnya < 10 menit
o Dpt diulangi 2-3 kali
o Kristaloid/koloid

Pemantauan awal
Respon thd fluid challenge
Pantau prod. Urin (kateter)
Stat. Lab/penunjang

Resusitasi lanjut
Bila fluid challenge non responsive
Intubasi & vent. Mekanik
Pasang cvp & loading hati-hati
Koreksi efek inotropik negatif
hb < 5 g/dl prc 10 ml/kg bb (ht 40-50 vol %)
Obat inotropik

Pemantauan lanjut
Cari penyebab syok (cxr, konsultasi)
Evaluasi fungsi sist. Organ lain :
o Atn/pre renal failure
o Ards
o Cardiac function
o Ggn. Koagulasi/dic
o Organ-organ lain
Bagan penanganan shock :
 Stadium Syok septik dan
manifestasi klinis

Stadium Tanda Klinis Gang fisiologis Biokimiawi

Warm Shock perfusi perifer (N) Smv O 2

hipokarbia
(Hiperdinamik) kulit hangat kering VO 2 hopoxia
HR nadi bounding CO kadar laktat
suhu / (tak stabil) SVR hiperglikemia
RR , gg. kesadaran

Cold Shock sianosis CO hipoxia

(Hipodinamik) kulit dingin lembab SVR
asidosis metab
nadi kecil, lemah CVP koagulopati
HR , Oliguria Smv O 2
hipoglikemi
shallow breathing
pe kesadaran

MOSF bergantung sistem Koma susai yang

terkena ARDS, CHF, RF jenis
GI bleeding/DIC organ failure

Tatalaksana syok septik pada anak

 (AAP, 2005)

Tatalaksana syok septik neonatus

 (AAP, 2005)

Obat obat vasoaktif

Agent (dose range) Site of Action Clinical Effect

Dopamine (3 to 20 mcg/kg Beta, increasing alpha with Inotrope, vasoconstriction,

per min) increasing dose chronotrope, increases PVR

Dobutamine (1 to 20 Beta >beta Inotrope, vasodilation (beta ),

2 1 2
mcg/kg per min)
decreases PVR

Epinephrine (0.01 to 1.0 Beta>alpha Inotrope, chronotrope,

mcg/kg per min) vasoconstriction

Norepinephrine (0.01 to Alpha>beta Vasoconstriction, increases

1.0 mcg/kg per min) SVR, inotrope, chronotrope

Phenylephrine (0.1 to 0.5 Alpha Vasoconstriction, increases

mcg/kg per min) SVR

Amrinone (1 to 20 mcg/kg Type III phosphodiesterase Inotrope, chronotrope,

per min) inhibitor vasodilator

Milrinone (0.25 to 1.0

mcg/kg per min)

Nitroprusside (0.5 to 10 Vasodilator, arterial>venous Decreases afterload

mcg/kg per min)

Vasopressin (0.0003 to V vascular receptor Vasoconstriction, vasodilation

1
0.008 U/kg per min) of circle of Willis, stimulation
of cortisol secretion

Titik tangkap obat vasopressor

(AAP, 1993)
 Alpha 1: vaskuler, jantung, hatiresisten vaskuler , kontraktilitas jantung , sintesis
glukosa hati
Alpha 2: vasokonstriksi vaskuler otot
Beta 1: jantung: kontraktilitas, laju jantung
Beta 2: vaskuler (vasodilatasi), bronkus
Dopa: renal, splanknik: renal flow, vasodilatasi

Tatalaksana syok septik

Ab broad spectrum sesuai kultur
Resusitasi cairan : koloid/kristaloid
Obat inotropik :
Dobutamin + dopamin
isoprenalin/adrenalin
svr vasodilatasi perifer
Koreksi : - hipo/hiperglikemi
- asam basa
- elektrolit

Tatalaksana Syok Anafilaktik

Stop alergen penyebab + adrenalin (im)
Air way & respiration adekuat
o Wheezing nebulisasi adrenalin/salbutamol
o Obstruksi intubasi/surgical airway
Sirkulasi & hemodinamik
o Vaso presor : adrenalin (10 mg/kg bb)
o Fluid loading : kristaloid (20 ml/kg bb/iv-io)
Re assessment abc resusitasi
o Wheezing (+) nebulisasi salbutamol
bila perlu (+) hidrokortison (iv)
(+) aminopilin/salbutamol drip
Syok berlanjut : koloid + inotropik

Tatalaksana syok kardiogenik

Oksigenisasi adekuat
 Koreksi ggn asam basa & elektrolit
Kurangi rasa sakit & ansietas
Atasi disritmia jantung
kelebihan preload : diuretika
kontraktilitas: fluid challenge sesuai cvp/poap, obat inotropik (+)
beban afterload (svr ) : vasodilator
Koreksi penyebab primer

Kristaloid :
Kristaloid utk resusitasi: normal salin dan RL
Keuntungan: tersedia dan murah
Koloid: albumin 5%, dekstran, hidrokxyethyl starch, produk darah
Molekul besar, relatif impermeabel, volume intravaskuler
Gunakan kristaloid utk resusitasi inisial 40-60mL/kg

Transfusi :
Indikasi: perdarahan aktif atau gangguan komponen darah, mis: DIC
PRC: 15-20mL/kgmenaikkan Hb 5 Gram/dL
Trombosit: 1U/10kg 105
FFP: 10-20 mL/kg
Cryopresipitate fib<100 mg/dL

Vasopresin :
Vasopresin (ADH): vasokonstriksi sistemik dan vasodilatasi pada sirkulus Willis dan
pulmoner pd dosis tinggi
Memacu sekresi ACTH
Indikasi: katekolamin tidak efektif

Syok bila
MAP
0 1 bulan < 40 mmHg
1 12 bulan : < 40 mmHg
1 5 tahun : < 45 mmHg
5 12 tahun : < 50 mmHg
>12 tahun : < 60 mmHg

Map = 1 sistolik + 2 Diastolik

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