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https://emedicine.medscape.

com/article/760145-medication#1

Pada pasien gawat darurat segera berikan pertolongan pertama sesuai dengan prinsip
resusitasi ABC. Jalan nafas (A = air way) harus bebas jika perlu dengan pemasangan pipa
endotrakeal. Pernafasan (B = breathing) harus terjamin, jika diperlukan berikan ventilasi buatan
dan pemberian oksigen 100%. Defisit volume peredaran darah (C = circulation) pada syok
hipovolemik sejati atau hipovolemia relatif (syok septik, syok neurogenik, dan syok anafilaktik)
harus diatasi dengan pemberian cairan intravena dan bila perlu pemberian obat-obatan inotropik
untuk mempertahankan fungsi jantung atau obat vasokonstriktor untuk mengatasi vasodilatasi
perifer 2,6
.

Tiga tujuan tatalaksana pasien dengan syok hipovolemik sebagai


berikut:
(1) Memaksimalkan pengiriman oksigen dengan memastikan kecukupan
ventilasi, meningkatkan saturasi oksigen darah, dan memulihkan aliran
darah.
(2) Mencegah kehilangan darah lebih lanjut
(3) Resusitasi cairan

(1) Memaksimalkan pengiriman oksigen


Penilaian dan penstabilan jalan napas harus segera dilakukan pada saat
kedatangan. Kedalaman, laju pernapasan, serta suara napas harus segera
dinilai. Segera tangani jika didapatkan masalah yang mengganggu
pernapasan seperti : pneumotoraks, hemotoraks, flail chest. Pemberian
oksigen aliran tinggi melalui masker atau kanula dan ventilasi pendukung harus
diberikan kepada semua pasien yang memerlukan. Ventilasi tekanan
positif yang berlebihan dapat merugikan pasien dengan syok
hipovolemik.
Jika ditemukan kelainan secara klinis atau laboratorium analisis gas darah, pasien harus
diintubasi dan diventilasi dengan ventilator yang volumenya terukur. Volume tidal harus diatur
sebesar 12 – 15 ml/kg, frekuensi pernapasan sebesar 12 – 16 kali/menit. Oksigen harus
diberikan untuk mempertahankan PO2 sekitar 100 mmHg. Jika pasien “melawan” terhadap
ventilator, maka obat sedatif atau pelumpuh otot harus diberikan. Jika cara pemberian ini gagal
untuk menghasilkan oksigenase yang adekuat, atau jika fungsi paru – paru menurun harus
ditambahkan 3 – 10 cm tekanan ekspirasi akhir positif.

2. Mencegah kehilangan darah lebih lanjut


Kontrol perdarahan lebih lanjut bergantung pada sumber perdarahan dan
pada umumnya membutuhkan intervensi bedah. Pada pasien dengan
trauma, perdarahan eksternal harus dikontrol dengan penekanan
langsung sedangkan perdarahan internal membutuhkan intervensi bedah.
Patah tulang panjang harus ditangani dengan traksi untuk mengurangi
semakin banyaknya kehilangan darah.
Pada pasien dengan perdarahan GI, vasopresin intravena dan H2 blocker
dapat digunakan. Vasopresin umumnya dikaitkan dengan reaksi yang
merugikan, seperti hipertensi, aritmia, gangren, dan iskemia miokard
atau splanchnic. H2 blocker relatif aman tetapi tidak memiliki manfaat
yang terbukti.
Somatostatin dan octreotide telah terbukti mengurangi perdarahan
gastrointestinal yang disebabkan oleh varises dan ulkus peptikum.
Hampir semua penyebab perdarahan ginekologi akut yang menyebabkan
hipovolemia (mis., Kehamilan ektopik, plasenta previa, solusio plasenta,
kista pecah, keguguran) memerlukan intervensi bedah.
Setiap pasien harus dievaluasi secara individual, karena menunda
tatalaksana definitif dapat meningkatkan morbiditas dan mortalitas.
3. Resusitasi

Pada tahap resusitasi selain pemasangan akses intravena, posisi


pasien dapat
membantu meningkatkan sirkulasi; salah satu contohnya adalah
mengangkat kedua kaki pasien lebih tinggi dari posisi jantung. Posisi
Trendelenburg tidak lagi direkomendasikan untuk pasien hipotensi,
karena pasien cenderung mengalami aspirasi. Selain itu, posisi
Trendelenburg tidak meningkatkan kinerja kardiopulmoner dan dapat
memperburuk pertukaran gas.
Akses intravena dilakukan dengan memasang 2 kateter intravena ukuran besar (minimal nomor
16) pada vena perifer. Lokasi terbaik untuk intravena perifer pada orang dewasa adalah vena di
lengan bawah atau kubiti. Namun, bila keadaan tidak memungkinkan pada pembuluh darah
perifer, maka dapat digunakan pembuluh darah sentral. Bila kaketer intravena sudah terpasang,
contoh darah diambil untuk pemeriksaan golongan darah dan crossmatch, pemeriksaan
laboratorium yang sesuai, dan tes kehamilan pada semua wanita usia subur (American College of
Surgeons Committee on Trauma, 2008).

Setelah akses intravena terpasang, selanjutnya dilakukan resusitasi cairan . Tujuan resusitasi
cairan adalah untuk mengganti volume darah yang hilang dan mengembalikan perfusi organ
(Kelley, 2005).

Jumlah darah dan cairan yang diperlukan untuk resusitasi sulit diprediksi dalam evaluasi awal
pasien. Namun, Tabel 2.2 dapat menjadi panduan untuk menentukan kehilangan volume darah
yang harus digantikan.

Tahap awal terapi dilakukan dengan memberikan bolus cairan secepatnya. Cairan
yang
dapat digunakan untuk resusitasi antara lain larutan natrium klorida
isotonik, larutan Ringer laktat, garam hipertonik, albumin, fraksi protein
murni, plasma beku segar, hetastarch, pentastarch, dan dekstran 70. Cairan
resusitasi yang umum digunakan adalah cairan isotonik NaCl 0,9% atau Ringer Laktat dengan
dosis umumnya 1-2 liter untuk dewasa. Pada pasien syok derajat IV kristaloid dan
transfusi darah harus dimulai sejak awal.

Resusitasi mengunakan koloid meningkatan tekanan onkotik yang dapat


mengurangi edema paru. Koloid juga lebih sedikit diperlukan untuk
meningkatkan volume intravascular jika dibandikan kristaloid.
Larutan koloid sintetik, seperti hetastarch, pentastarch, dan dextran 70,
memiliki beberapa keunggulan dibandingkan dengan koloid alami
seperti fraksi protein murni, plasma beku segar, dan albumin. Larutan
koloid sintetik memiliki sifat memperluas volume yang sama, tetapi
karena struktur dan berat molekul tinggi, sebagian besar tetap di ruang
intravaskular, mengurangi terjadinya edema interstitial.
The European Society of Intensive Care Medicine (ESICM)
menyarankan agar tidak menggunakan hydroxyethyl starches (HES)
pada pasien dengan sepsis berat atau risiko cedera ginjal akut. Hindari
penggunaan koloid pada pasien dengan cedera kepala dan gelatin, HES
pada donor organ.
Kombinasi saline hipertonik dan dekstran dapat meningkatkan
kontraktilitas dan sirkulasi jantung. Dengan demikian, meskipun banyak
cairan resusitasi yang tersedia, rekomendasi saat ini masih
menganjurkan penggunaan larutan normal salin atau Ringer laktat.

Pemberian cairan terus dilanjutkan bersamaan dengan pemantauan tanda vital dan hemodinamik
(Hardisman, 2013). Jika setelah pemberian cairan tidak terjadi perbaikan tanda-tanda
hemodinamik, maka dapat dipersiapkan untuk memberi transfusi darah (Harisman,
2013). Tujuan utama transfusi darah adalah untuk mengembalikan kapasitas angkut
oksigen di dalam intravaskular (American College of Surgeons Committee on Trauma,
2008).

Untuk melakukan transfusi, harus didasari dengan jumlah kehilangan perdarahan,


kemampuan kompensasi pasien, dan ketersediaan darah dengan beberapa hal yang harus
diperhatikan, yaitu :

1) Darah yang belum dilakukan reaksi silang atau yang bergolongan O-negatif dapat
diberikan terlebih dahulu, apabila syok menetap dan tidak ada cukup waktu (kurang
lebih 45 menit) untuk menunggu hasil reaksi silang selesai dikerjakan.
2) Segera setelah hasil reaksi silang diperoleh, jenis golongan darah yang sesuai harus
diberikan.
3) Koagulopati dilusional dapat timbul pada pasien yang mendapat transfusi darah yang
masif. Darah yang disimpan tidak mengandung trombosit hidup dan faktor pembekuan
V dan VI. Satu unit plasma segar beku harus diberikan untuk setiap 5 unit whole blood
yang diberikan. Hitung jumlah trombosit dan status koagulasi harus dipantau terus-
menerus pada pasien yang mendapat transfusi masif.
4) Hipotermia juga merupakan konsekuensi dari transfusi masif. Darah yang akan
diberikan harus dihangatkan dengan koil penghangat dan suhu tubuh pasien dipantau.

Pada keadaaan yang berat atau hipovolemia yang berkepanjangan, dukungan inotropik
dengan dopamin, vasopressin atau dobutamin dapat dipertimbangkan untuk mendapatkan
kekuatan ventrikel yang cukup setelah volume darah dicukupi dahulu. Pemberian norepinefrin
infus tidak banyak memberikan manfaat pada hipovolemik. Pemberian nalokson bolus 30 mcg/kg
dalam 3 -5 menit dilanjutkan 60 mcg/kg dalam 1 jam dalam dekstros 5% dapat membantu
meningkatkan MAP.2

https://nursing.ceconnection.com/ovidfiles/00043860-200707000-
00009.pdf
CURRENT RECOMMENDATIONS FOR FLUID RESUSCITATION
The ATLS guidelines published by the American College of Surgeons address many factors when
managing patients requiring life support, including treatment of hemorrhagic shock. Initial
management includes rapid intravenous infusion of supportive fluids. There are debates among
healthcare providers on the type of fluid that is most effective in relieving shock. The ATLS guide-
lines suggest that diagnosis and treatment of shock need to occur simultaneously. Life-threatening
injuries must be assessed and managed immediately to prevent fatal com- plications. The initial
fluid therapy should be started as soon as possible and subsequent therapy determined on the basis
of the patient’s response to the initial fluids. The response should be continually assessed to
determine whether perfusion is adequate or not. The type and amount of fluid given must be
adjusted on the basis of the patient’s response. Many factors including age, previous health status,
other injuries, and medications can all affect a patient’s response to fluid resuscitation.1,56,57

The ATLS guidelines recommend that a crystalloid solution be administered intravenously


immediately. The estimated amount of fluid needed for replacement is 3 mL for every 1 mL of blood
loss because some of the fluid

156 Journal of Trauma Nursing • Volume 14, Number 3 July–September 2007

administered is lost into the interstitial and intracellular spaces. Other types of fluids used for
replacement are dis- cussed in detail in the next section.11

Normal saline/Ringer’s lactate solution


The American College of Surgeons ATLS guidelines rec- ommend the Ringer’s lactate solution as the
preferred choice for the initial treatment of uncontrolled hemor- rhagic shock. NS, a different
crystalloid, may also be used. However, there are concerns regarding hyper- chloremic acidosis
with the administration of NS. Acidosis is a physiologic problem that often complicates early
management of patients with hemorrhagic shock.58 Warmed LR solution provides intravascular
expansion and promotes stabilization of the vascular volume by replacing fluid losses in the
interstitial and intracellular spaces.11,54 The initial dose is 1 to 2 L for an adult or 20 mL/kg in a
pediatric patient. However, it is important to keep in mind that this volume concentration is a rough
guideline and close monitoring of the patient is critical. The responses that nurses should monitor
after the infu- sion of LR include urinary output, level of consciousness, respiratory rate, peripheral
perfusion, blood pressure, pulse pressure, and pulse rate. Lastly, recognizing the reversal of the
initial signs and symptoms of hemorrhagic shock is one of the main goals when administering
treatment.

One area of concern with LR administration is stimu- lation of apoptosis. Apoptosis is defined as
programmed cell death in a multicellular organism.59,60 A study by Rhee et al61 demonstrated an
increased apoptosis in intestinal mucosa, smooth muscle, liver, and lung cells with LR infusion
following hemorrhagic shock. However, fluid resuscitation with sham, plasma, fresh blood, and
hyper- tonic saline all demonstrated no significant apoptosis. The infusion of LR revealed increased
adhesion molecule expression, leading to increased neutrophil activation and release of ROS, thus
furthering apoptosis. Apoptosis then culminated in pulmonary edema and inflammation. However,
neutrophil activation did not occur with whole blood transfusions. The effects of hypertonic saline
on adhesion were between those of LR and whole blood.61

Colloids

Colloids are high-molecular weight substances such as albumin, dextran, and hetastarch that
increase plasma oncotic pressure.35 These substances can be used to rap- idly increase circulatory
volume. However, there is con- siderable controversy as to whether colloids are a better choice
than crystalloids for fluid resuscitation in hemor- rhagic shock. Colloids maintain intravascular
volume without causing tissue edema in comparison with crystal- loids. However, colloids are
associated with increased risk of coagulopathy, renal dysfunction, and hyper-

chloremic acidosis.62 Currently, the guidelines of the American College of Surgeons recommend the
replace- ment of 3 mL of colloids for every 1 mL of blood lost.35

Schierhout and Roberts63 found a 4% increase in the absolute risk of mortality with the use of
colloids during fluid resuscitation in patients with hemorrhagic shock. These authors
recommended that because of this increased risk and the increased cost, colloids should not be
used for volume replacement.63 However, Ferreira et al.64 demonstrated that early colloid
replacement with hydroxyethyl starch was more effective than LR in restor- ing cardiac output and
tissue perfusion.64 They also found that mean arteriolar pressure, central venous pressure, and
plasma colloid osmotic pressure were significantly higher after the infusion of hydroxyethyl starch
than with the infusion of LR. Hydroxyethyl starch maintained microcirculation, hemodynamics, and
colloidal osmotic pressure better than LR following hemorrhage.65 Rhee et al61 found that
hypotonic(isotonic solutions, including LR and artificial colloid solutions, caused a severe immuno-
logic response, coagulopathy, and renal failure after administration in hemorrhagic shock. This
effect, which plays a significant role in organ injury, was not observed with the use of plasma,
natural colloids (albumin), and whole blood during fluid resuscitation.61
Although there are multiple studies on the effectiveness and safety of crystalloids versus colloids in
fluid resusci- tation, the results are varied. Additional research is needed to determine optimal fluid
resuscitation for hem- orrhagic shock.66–68

Therapeutic drug: Dopamine

A side effect of using resuscitating fluids such as LR and NS in a patient with hemorrhagic shock is
hypoperfusion. Dopamine, an inotropic drug, may be used to increase cardiac output and blood
pressure in such patients. Dopamine is used not only to increase cardiac output but also to improve
renal output as a naturally occurring cat- echolamine.69 Dopamine is a sympathomimetic agent that
stimulates adrenergic receptors. The actions of this drug on different receptors are dose dependent.
Lower dosages ( 5 g/kg per minute) stimulate dopaminergic receptors, which cause renal,
mesenteric, cerebral, and coronary bed vasodilation, thus increasing blood flow to these tis- sues.70,71
Moderate dosages (5–10 g/kg per minute) stim- ulate -1 receptors, which increase myocardial
contractility and heart rate that improve cardiac output.72 Higher dosages ( 10 g/kg per minute)
stimulate - receptors and result in an increase in systemic vascular resistance, which may
counteract the actions of the dopaminergic and -1 receptors.33,69,73,74

The ATLS guidelines suggest that although the use of exogenous vasoconstrictors in hemorrhagic
shock increases peripheral vascular resistance, it does not

July–September 2007 Journal of Trauma Nursing • Volume 14, Number 3 157

necessarily indicate an increase in cardiac output and may further reduce end-organ perfusion and
oxygenation.11 There are previous and ongoing studies that suggest that dopamine benefits several
major organs during hemor- rhagic shock.75–80

An early study by Carvalho et al76 evaluated the effect of dopamine on blood flow to the
myocardium, intestine, kidney, and cardiac output of dogs after inducing hemor- rhagic shock.76
Dopamine was then given at a rate of 1 to 8 g/kg per minute with NS over a period of 30 to 200
minutes. The results of this study demonstrated that dopamine caused an increase in cardiac output
and sys- temic pressure. Coronary, renal, and mesenteric flow increased as the resistance to these
areas decreased. Trachte et al.75 found that dopamine injected at a rate of 4 g/kg per minute had
hemodynamically beneficial effects on hemorrhagic shock, raising mean arterial pres- sure and
liver blood flow, but did not improve the meta- bolic and cellular responses.75,77 Sakahira et al78
demonstrated that dopamine injected at a rate of 5 g/kg per minute increased renal blood flow.
However, at this concentration, it did not significantly improve cardiac output.78 A study by Nordin
et al80 demonstrated that a dopamine infusion (5 g/kg per minute) during crystal- loid volume
replacement led to enhanced tissue oxygen perfusion in the liver and subcutaneous and transcuta-
neous tissues. These effects were optimized when the dopamine was administered at the beginning
of resuscita- tion, before hemodynamic function had been restored.80

Blood products

Blood products are used to restore circulating volume, replace coagulation factors, and improve
oxygen-carry- ing capacity. The ATLS guidelines state that a transfusion should be given on the
basis of the patient’s response to the initial fluid resuscitation. A replacement of PRBCs is
recommended to maintain a hematocrit of more than 30%, which generally results in a volume that
is less than the 3:1 rule recommended for crystalloids. Type-specific blood is preferred, but if
unavailable, type O negative may be used. Platelets and/or fresh frozen plasma should be
administered to a patient with a platelet count of less than 10 000 L, transfusion of more than 6
units of PRBCs, or having abnormal coagulation studies.11

There are many studies that are currently examining alternatives for hemorrhagic shock fluid
resuscitation. One area of interest is the use of blood substitutes that have been modified from
human hemoglobin extracted from red blood cells. These substitutes were developed as an
alternative to the infusion of PRBCs and plasma.81 A study conducted by the Department of Surgery
at Denver Health Medical Center in 2002 examined the use of Polyheme in hemorrhagic shock
resuscitation. The study focused on measuring the inflammatory response in

patients using Polyheme versus PRBCs. The results demonstrated higher elevation in 3 interleukins
in patients resuscitated with PRBCs than those resuscitated with Polyheme.82 Another study found
that Polyheme may be a useful alternative to PRBCs. In this study, Polyheme maintained total
hemoglobin despite a marked fall in red blood cell count and a reduced use of allogenic blood.83
These products are currently in stage III clinical trials and have not yet received the Food and Drug
Administration approval.