LAPORAN KASUS

SYOK HEMORAGIK
Pembimbing dr. Azizah Masthura, Sp. An

Disusun oleh,
dr. Yoshie Patricia
CASE REPORT
IDENTITAS PASIEN
• Nama : Ny. V
• Usia : 33 tahun
• Pekerjaan : Ibu Rumah Tangga
• Agama : Islam
• Suku : Sunda
• Pendidikan : SMA
• Alamat : Neglasari
• No RM : 00269111
• Tanggal masuk : 26 Juni 2019
ANAMNESIS
Autoanamnesis dan alloanamnesis

Keluhan utama
• Perdarahan dari vagina

Keluhan Tambahan
• Lemas dan nyeri perut bawah
RIWAYAT PENYAKIT SEKARANG
• Perdarahan vagina berupa flek
• Dicetuskan bila berhubungan seksual dan nyeri setelah
1 tahun berhubungan
SMRS • Keputihan cairan berbau kadang

• Perdarahan vagina berupa flek setiap hari tanpa pencetus.

±6 bulan • Penurunan berat badan 8kg disertai penurunan napsu makan.
SMRS

• Perdarahan semakin banyak tidak berhenti, jumlah >1000cc

• Nyeri perut bawah
±6jam • Mual muntah, demam, sesak, penurunan kesadaran disangkal
SMRS
RIWAYAT PENYAKIT SEKARANG
• Perdarahan aktif, sadar penuh, demam-, nyeri perut
bawah, lemas, BAK +, mual muntah -
• Dilakukan oksigenisasi,
IGD RL 2000cc/24 jam,
26 Juni As tranexamat 3x500mg iv
cefadroxil 2x500mg, tampon vagina.
2019 Rencana transfusi PRC 2 unit
• Cek darah rutin Hb 7,1 , PP test negative.

Bangsal • Perdarahan aktif MASIF, pucat, sadar penuh, demam -

27 Juni • Tampak nafas cepat, BAK sedikit
2019 • Dilakukan pemeriksaan DR lengkap, ur cr dan elektrolit.
RIWAYAT PENYAKIT DAHULU
• Riwayat trauma dan operasi daerah perut disangkal
• Riwayat keganasan sebelumnya tidak ada
• Riwayat kelainan perdarahan tidak ada
• Riwayat alergi disangkal
• Riwayat imunokompromis/autoimun disangkal
• Riwayat ISK berulang disangkal
• Riwayat DM, hipertensi, jantung disangkal
• Riwayat vaksinasi cervix tidak ada
RIWAYAT KELUARGA
• Riwayat keganasan di keluarga tidak ada
RIWAYAT KEBIASAAN
• Riwayat berhubungan seksual berganti pasangan
disangkal
• Riwayat merokok, alcohol disangkal
• Penggunaan obat-obatan disangkal
• Riwayat konsumsi rendah sayur dan buah
RIWAYAT OBSTETRI
• Pasien menikah 8 tahun, ini pernikahan pertamanya
1.perempuan, spontan, bidan, lahir hidup, 7 tahun
2.laki-laki, spontan, bidan, lahir hidup, 6 tahun
3.laki-laki, spontan, bidan, lahir hidup, 3 tahun
4.perempuan, spontan, bidan, lahir hidup 14 bulan

• Riwayat menstruasi tidak teratur, tidak ingat HPHT

• Riwayat kontrasepsi : KB suntik 13 bulan yang lalu.

PEMERIKSAAN FISIK
• Keadaan umum : Tampak sakit berat

• Kesadaran : Compos mentis, GCS 15

• Tanda-tanda vital

BP : 80/60 mmHg
HR : 125x/menit , lemah, regular

RR : 30x/menit • Status Gizi :

Berat badan : 55 kg
t : 36.1
Tinggi badan : 152 cm
SaO2 : 100 % NRM 12 lpm IMT : 22.0 (normal)
PEMERIKSAAN FISIK
Pemeriksaan fisik Generalis

• Kepala : Normosefali, deformitas (-)

• Mata : konjungtiva anemis (+/+), sklera ikterik (-/-),
• Hidung : Deviasi septum (-)
• Mulut : Mukosa oral kering
• Leher : Trakea di tengah, pembesaran KGB (-), massa (-), JVP
tidak meningkat, retraksi sternocleido –
• Pulmo
I : pergerakan nafas simetris statis dan dinamis
P: fremitus simetris
P: sonor +/+, BPH di ICS V linea mid clavicularis dextra
dengan peranjakan I ICS
A: vesikuler +/+, ronki -/-, wheezing -/-
PEMERIKSAAN FISIK
• Cor
I : Iktus kordis tidak terlihat
P: Iktus kordis teraba
P:
Batas atas : ICS II linea parasternal kiri
Batas kanan : ICS IV linea parasternal kanan
Batas kiri : ICS V linea midklavikularis kiri
A: bunyi jantung I dan II regular, gallop (-), murmur (-)
• Abdomen
I: cembung
A: BU + 5-6 x/menit
P: supel, NT suprapubic, organomegaly -, massa-
P: timpani seluruh regio
• Ekstremitas : crt>2 detik, akral dingin, edema -/-/-/-
PEMERIKSAAN FISIK
Pemeriksaan ginekologi

Pemeriksaan inspekulo :
portio tertutup perdarahan, tampak massa

Pemeriksaan dalam :
dinding vagina normal, portio teraba massa, nyeri goyang -
, rapuh, perdarahan aktif.
PEMERIKSAAN PENUNJANG
DIAGNOSA KERJA
1. Syok hemoragik ec perdarahan pervaginam
massif ec ca servix
2. Anemia berat
3. Ca servix
TATALAKSANA
• Konsul SpAn → pro Intubasi dan pro ICU
• Resusitasi cairan 2 line : RL 2000cc + gelafusin 1000cc
• NE mulai 0,1 mcg/kgBB/mnt titrasi naik
• Rencana transfusi PRC 6 unit ( 2 unit di bangsal )
• Vit K 3x1 gr iv
• As tranexamat 3x1 gr iv
• Posisi tredelenburg
• Pasang kateter monitor UO, dan NGT.
• Kontrol perdarahan dengan pasang tampon.
• EKG,
• AGD, elektrolit , cek DR dan GDS
• Monitor TTV dan perdarahan
FOLLOW UP
• LINK KE WORD
LITERATURE VIEW
INTRODUCTION

Inadequate Tissue Irreversible ;

perfusion Reversible MOF, death
BASIC CARDIAC PHYSIOLOGY
BASIC CARDIAC PHYSIOLOGY
• DISTRIBUTION OF BLOOD VOLUME IN CV SYSTEM
OXYGEN TRASPORT
TISSUE OXYGENATION DETERMINED BY VO2 AND DO2,
NOT ONLY CARDIAC OUTPUT

DO2 = CO x CaO2 = (HR x SV) x (Hgb x SaO2 x 1.34) +

(0.003x PaO2)
 SHOCK

SHOCK OCCURS WHEN DEMAND (VO2) OF THE TISSUE AND

THE OXYGEN DELIVERY (DO2) TO TISSUE
VO2 = CO x Hb x (SaO2-SvO2) DO2 = CO x Hb x SaO2
PHYSIOLOGY RESPONSE
• Baroreseptor dan kemoreseptor BP = (HR x SV) x SVR
• Symphatetic activity BP = (HR x SV) x SVR
• Renin Angiotensin Aldosterone System

BP = (HR x SV) x SVR

SVR

Reabsorbsion;
blood volume
SHOCK AT SYSTEMIC LEVEL
Effects of compensated, uncompensated and relative (vasodilation)
hypovolaemiaon unstressed & stressed volumes and CO

. Perner A, De Backer D. Understanding hypovolaemia. Intensive Care Medicine. 2014;40(4):613-615.

 SHOCK IN CELLULAR LEVEL

Anaerob metabolism → Lactate + metabolic acidosis

Base deficit and/or lactate levels can be useful in determining the presence and severity of
shock. LACTATE >2 meq/L
CLASSIFICATION & ETIOLOGY
CLASSIFICATION & ETIOLOGY
• DIAGNOSTIC AND CLASSIFICATION OF SHOCK BASED ON OXYGEN
DELIVERY
PHYSICAL FINDING IN SHOCK
BASIC MANAGEMENT SHOCK; 1
OPTIMIZING DO2

DO2 = (SV x HR) x (Hb x SaO2)

BASIC MANAGEMENT SHOCK; 2
DECREASING VO2
HYPVOLEMIC SHOCK
ETIOLOGY
• Blood loss (hemorrhagic shock) :
GI, vaginal bleeding , surgical intervention, trauma.

• ECF loss
GI : vomiting, diarrhea, external drainage (fistula, stoma)
Renal: diuretic therapy, hyperglycemia
Skin : burn, hot and dry climate
Third space sequestration : pancreatitis, intestinal obst
PHYSICAL FINDINGS

In 70kg adult , EBV : 75mL x 70 = 5000 mL

• Average blood volume
ADULT ~ 7% BW

• Stress vs unstress volume

STRESSED
VOLUME
(ECBV), 30%

UNSTRESSED
VOLUME, 70%

ECBV = effective circulation blood volume

STRESSED VOLUME (ECBV) UNSTRESSED VOLUME

 INITIAL MANAGEMENT
HYPOVOLEMIC SHOCK
• Basic management principle :
STOP the bleeding (treat underlying cause), and
REPLACE the volume loss

• Assessing ABCDEs
Airway and Breathing
Circulation : Haemorrhage control
Disability : Neurological examination
Exposure : Complete Examination

Stop the bleeding, adequate oxygenation, ventilation, fluid resuscitation

MANAGEMENT
• AIRWAY AND BREATHING
Patent airway with adequate ventilation + oxygenation

• supplementary oxygen to maintain SaO2> 95%.

MANAGEMENT;
AIRWAY AND BREATHING
Criteria for establishing a definitive
airway

ATLS tenth edition 2018

 MANAGEMENT;
AIRWAY AND BREATHING

Viires N, Sillye G, Aubier M, Rassidakis A, Roussos C. Regional blood flow

distribution in dog during induced hypotension and low cardiac output.
Spontaneous breathing versus artificial ventilation. Journal of Clinical
Investigation. 1983;72(3):935-947
MANAGEMENT;
AIRWAY AND BREATHING

ROLE OF MECHANICAL VENTILATION in shock state

• < VO2 → > DO2 (< lactate)
• meredistribusi kembali aliran darah kembali ke organ penting
• Bukan sekedar lifesaving procedure , namun bagian dari TERAPI Shock
MANAGEMENT ;
CIRCULATION
THE GOALS OF TREATING HAEMORRHAGIC SHOCK:

Restoring venous return + control the source of bleeding.

• Stop the source of bleeding.

• Obtain iv access

• Fluid Therapy + Blood replacement

• Vasopressors are contraindicated as a first-line → worsen tissue perfusion

Volume repletion will allow recovery from the shock state only
when the bleeding has stopped

Identify electrolyte and acid-base disturbances

MANAGEMENT;
DEs
• Disability : neurological examination
Assessing cerebral perfusion , direct intracranial injury?

• Exposure : complete examination

Examine head to toe to search for additional injury
prevent hypothermia during exposing patient!

• Gastric dilatation (Decompression)

• Urinary Catheterization
genitourinary blood loss/trauma , evaluation renal perfusion
MONITORING
• Vital signs

• CBC, PT, aPTT, fibrinogen, ur cr, electrolyte

• Urine output ( adult :0.5mL/kg/hr ; pediatric :1-2 mL/kg/hr)

• intravascular fluid responsiveness

• Lactate / BE serial measurement.

Acidosis metabolic in hypovolemic shock→ NO place for bicarbonate

• Correct hypothermia

• Hb serial

• Recognition of other problems if patient fails to respond to terapy. ; chest

Xray, ECG, pelvis Xray, FAST
FLUID THERAPY;
• Isotonic Crystalloid : Adult : up to 1000 mL, children : 20ml/kgBB
Initial resuscitation fluid in hemorrhagic and septic shock
Cross rapidly from vascular to interstitial spaces (half-lives: 20-30min )
One 1/3 stays intravascular → 3-4 times volume needed .

• Ringer Lactate & Acetate :

The most physiological solution
lactate → bicarbonate (by muscle); acetate → bicarbonate (by liver)

• Normal saline :
preffered for hypochloremic metabolic alkalosis
large volume → dilutional hyperchloremic acidosis, AKI
FLUID THERAPY
• Crystalloids vs Colloids
FLUID THERAPY
FLUID THERAPY
• Colloids → Conjunction with crystalloids.

• Colloids have ‘dual advantage’

- Rapid and persistent plasma intravascular expansion (half lives 3-6 h)
→ 1:1 restores intravascular
- Increase P oncotic (Quickly achieve circulatory goals)

• Indications :
- Severe intravascular fluid deficits prior to the arrival of blood for
transfusion
- Presence of severe hypoalbuminemia or large protein losses (burn)
FLUID THERAPY
COLLOIDS SOLUTION

Synthetic HES

Dextran Complication:
• DILUTIONAL
gelatins COAGULOPATHY
• ANAPHYLAXIS
Natural Albumin 5%,25% • RENAL FAILURE

FFP
BLOOD REPLACEMENT
PACKED RED BLOOD CELLS
• Single unit PRC :
Ht 70-80% , volume 250-350mL
increase Hb 1.0 – 1.5 g/dL

• Whole blood =
(Hbx – Hb) X BB X 6
• Packed Red Cell =
(Hbx – Hb) X BB X 3
BLOOD REPLACEMENT
Restore oxygen carrying capacity of the intravascular volume

• Early use of blood products results in better outcomes.

• Crossmatch PRC, if unavailable : pRBC type O, Rh negative

• Hemorrhagic shock : transient and non responder

Transfusion trigger (controversial; restrictive vs liberal strategy)

- Healthy + younger : Hb 6-8Hb or less

- Older, critically ill, severcardiorespiratory : Hb 9 - 10 g/dL

BLOOD REPLACEMENT
In acute large blood loss and severe injury :
Early coagulopathy (consumption coagulant factor) +
dilution platelet and clotting factor (massive transfusion)

Recommendation :
• PRC : FFP : Platetet (damage control resuscitation)
1.5 PRC : 1 FFP, and 1 platelet : 6 PRC

• Tranexamic acid within 3 hours of injury

The first dose 1 gram iv over 10 minutes in the field,
follow up dose 1 gram infused over 8 hours
Jack C. Wells J. Trauma care—don’t delay with TXA. PubMed
Central (PMC). 2019 Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646726/
BLOOD REPLACEMENT
• Massive transfusion:
>10 units PRC within the first 24 hr of admission , or
> 4 units in 1 hour

- thrombocytopenia (dilutional) occurred after 15 to 20 units blood.

- Check aPTT PT and platelet count.

Some clinicians give FFP automatically to massively transfused

patients even without a demonstrated coagulopathy with improved
mortality rates.
 BLOOD REPLACEMENT
• FFP (Fresh Frozen Plasma)
Obtained from 1 unit of WB that is frozen within 6 hours
Contains all plasma protein : clotting factors.
Indication : correction coagulopathy, reversal warfarin, heparin
resistance
Initial therapy 10-15mL/kg
Use in patient received massive blood transfusion,

• FFP is given in specific ratios with RBC in trauma

• Complications : TRALI
BLOOD REPLACEMENT
• Platelet
treatment of Thrombocytopenia and dysfunctional platelets .
Prophylaxis (no risk) : Tr< 10.000-20.000
active bleeding : Tr < 50.000
Specific ratio in severe blood loss.

• Cryoprecipitate
Fraction of plasma that precipitates when FFP is thawed.
treating :
- hemophilia A (contains high concentrations of factor VIII in a
small volume) that is unresponsive to desmopressin.
- hypofibrinogenemia (induced by PRC) .
contains more fibrinogen than FFP
 BLOOD REPLACEMENT;
COMPLICATION
• Infectious
• Non infectious
TRALI
Transfusion related
immunomodulation
• Metabolic Abnormal
H, K, 2,3DPG , citrate
• Hypothermia
• Coagulation
• Transfusion reactions
febrile, allergic, hemolytic
 CONCLUSION
• Shock is a life-threatening condition of circulatory failure.

• The effects of shock are initially reversible, but rapidly become

irreversible, resulting in multiorgan failure (MOF) and death.

• Immediately initiate therapy while rapidly identifying the

etiology so that definitive therapy (source control and damage
control) can be administered to reverse shock and prevent MOF
and death.
 CONCLUSION
• Fluid resuscitation (replace volume) + control bleeding is the
mainstay of therapy in patients with severe hypovolemia. .

• ABCDEs

• Initial Fluid resuscitation : RL 1 liter (adult) and 20 ml/kg

(pediatric) and assess patient response.

• Isotonic crystalloid conjunction with colloid and blood

replacement in hemorrhagic shock

• Monitoring vital signs, lab values, acid base, response to

resuscitation
 BIBLIOGRAPHY
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versus artificial ventilation. Journal of Clinical Investigation. 1983;72(3):935-947.
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 BIBLIOGRAPHY
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 THANK YOU
cimacan, 24 July 2019