Shock
• Hypovolemic shock
• Cardiogenic shock
• Distributive shock
• Obstructive shock
Triage
Poisoning
Trauma, Primary Survey
Airway and C – Spine control
Pasien Berbicara Lancar -> airway baik
Curiga cedera cervical bila pasien tidak
Trauma Maksilofasial sadar, high-velocity and high impact injury,
defisit neurologis, C spine tenderness
Gurgling • liquid or semisolid foreign material in the main airway -> Suctioning
Nasopharingeal Airway
• Prosedur ini digunakan apabila pasien terangsang untuk
muntah pada penggunaan OPA
• Tidak boleh digunakan pada kecurigaan fraktur basis cranii
unsuccesfull
Consider adjunct -> GEB/LMA/LTA
Definitif arway
surgical
Airway definitif Orotracheal Tube
Nasotracheal Tube
Airway surgical :
Adalah tabung yang terpasang di dalam trakea, dengan balon
Krikotiroidotomi
yang dikembangkan di bawah pita suara. Tabung
dihubungkan ke sumber oksigen melalui alat bantu ventilasi Trakheostomi
Cricothyroidotomy Tracheostomy
Memegang leher adalah tanda
universal bahwa korban
sedang tersedak
AHA Choking Algorithm
UPPER
LOWER
Bronchoscopy
is an endoscopic technique
of visualizing the inside of
the airways for diagnostic
and therapeutic purposes.
Manual Assisted Ventilation
• Apply face mask
– Oro/naso-pharyngeal airway
adjuncts
– Mouth opening
– Hand positioning
• Elevate mandible and chin
• Resuscitation bag compression –
volume and frequency
• Frequency = 10-12 x/minute (apneu
without cardiac arrest), 8-10
x/minute (apneu with cardiac arrest)
• Ensure adequate chest wall
expansion everytime ventilation
given
Shock – Definition
A physiological state characterized by a
significant, systemic reduction in tissue
perfusion, resulting in decreased tissue oxygen
delivery and insufficient removal of cellular
metabolic products, resulting in tissue injury.
Classification of Shock
Hypovolemic Cardiogenic
Obstructive Distributive
Pathophysiology of Shock
Preload
Afterload Stroke Volume x Heart Rate
Contractility
O2 Content Cardiac
Resistance
Output
x x
Cara : O2, cairan, kontrol suhu, antibiotik, koreksi kelainan metabolik, Inotropik
Breathing :
• Awal : O2 100 %, monitor saturasi
Sirkulasi
• Akses IV scr cepat.
• Intra osseus: anak 4 – 6 th
• Kateter vena sentral
HYPOVOLEMIC SHOCK
Perkiraan Kehilangan Darah
Kelas I Kelas II Kelas III Kelas IV
Kehilangan darah <750 750-1500 1500-2000 >2000
(mL)*
Kehilangan darah <15% 15-30% 30-40% >40%
(% volume darah)
Nadi <100 >100 >120 >140
Tekanan darah Normal Normal Menurun Menurun
Tekanan nadi Normal atau naik Menurun Menurun Menurun
Frekuensi nafas 14-20 20-30 30-40 >35
Produksi urin >30 20-30 5-15 Tidak berarti
(ml/jam)
Status mental Sedikit cemas Agak cemas Cemas, bingung Bingung, letargis
Penggantian Kristaloid (3 for 1 Kristaloid (3 for 1 Kristaloid (3 for 1 Kristaloid (3 for 1
cairan rule) rule) rule)dan darah (1 rule)dan darah (1
for 1 rule) for 1 rule)
Perempuan = 65 cc/kgBB
Infant = 80 cc/kgBB
Neonatus = 85 cc/kgBB
TUJUAN
• VOL. INTRAVASKULER TERCUKUPI
• KOREKSI ASIDOSIS METABOLIK
• OBATI PENYEBAB
REASSES PERFUSI, UO, TANDA VITAL
PILIHAN :
• KRISTALOID ISOTONIK : 1-2 LITER ATAU 20 CC/KG (ANAK) SECARA
BOLUS CEPAT BILA FUNGSI JANTUNG NORMAL
• NS DAPAT MENYEBABKAN ASIDOSIS HIPERCHLOREMIK
IV fluids
Crystalloid solutions (isotonic)
• Both 0.9% saline and RL are equally effective
• RL may be preferred in hemorrhagic shock because it
somewhat minimizes acidosis and will not cause
hyperchloremia.
• For patients with acute brain injury, 0.9% saline is preferred.
• Risiko untuk edema otak lebih rendah, • Laktat akan dimetabolisme di hepar
sehingga dipilih untuk kasus cedera menjadi bikarbonat (HCO3), pada
kepala dan stroke. pasien sirosis hepar akan terjadi
penumpukan laktat (Alt: Ringer
asering, karena dimetabolisme di
otot)
• Kadar Klorida yang tinggi, sehingga • Mengandung Kalsium sehingga
pemberian volume yang banyak dapat memicu koagulasi
berakibat Hiperkloremik asidosis.
SE: Hiperkloremik Asidosis SE: Hiperkalemia
• is the pressure in the superior vena cava, reflecting right ventricular end-
diastolic pressure or preload.
• Normal CVP: 2 to 7 mm Hg (3 to 9 cm H2O)
• CVP > 12 to 15 mm Hg : fluid administration risks fluid overload
CARDIOGENIC SHOCK
Therapy - Cardiogenic
• Terapi Inisial Dg. Pemberian Cairan
DISTRIBUTIVE SHOCK
Distributive Shock
Inflammatory mediators disruption of cellular metabolism
peripheral vasodilation decreased PVR
Etiology
• Anaphylaxis
• Septic
• Neurogenic
• Spinal
• Febrile, tachycardia, clear lungs *, warm extremities, flat neck veins, oliguria
Anaphylactic Shock
Anaphylactic shock
• a type of distributive shock, which involves the immune system
(Hurst, 2008)
Type 1 hypersensitivity
• antigen binds to IgE antibodies on mast cells, which leads to
degranulation of the mast cells.
KOMPENSASI →SVR ↑
PENYEBAB :
• TAMPONADE PERIKARD
• TENSION PNEUMOTHORAX
• CRITICAL COARCTASIO AORTA
• STENOSIS AORTA
TERAPI
• CAIRAN
• ATASI PENYEBAB
START
Simple Triage and Rapid Treatment
• TRIASE
– proses pemilihan pasien berdasarkan beratnya kondisi pasien
• Situasi
– Multiple casualties (jumlah pasien/cedera >1, namun tidak melampaui
kemampuan dan fasilitas rumah sakit) pasien dengan masalah yang
mengancam jiwa dan multi trauma akan dilayani terlebih dahulu
– Mass casualties (jumlah pasien dan beratnya cedera melampaui
kemampuan dan fasilitas rumah sakit pasien dengan kemungkinan
bertahan hidup yang terbesar, serta membutuhkan waktu, perlengkapan,
dan tenaga paling sedikit
• Terdiri dari 4 prioritas penanganan:
– Merah immediate care/life-threatening
– Kuning urgent care/can delay up to 1 hour
– Hijau delayed care/can delay up to 3 hours
– Hitam dead/no care required
RPM
respirasi, perfusi, mental
- Semua proses evaluasi
dalam START harus
dilakukan dalam waktu
kurang dari 60 detik.
:
pH: 7,35-7,45
PCO2: 35-45 mmHg
HCO3: 22-26 mmol/L.
Tanda
Terkompensasi
(sebagian/sepe
nuhnya)
ditandai dgn
ARAH panah
yang SAMA
Antara PaCO2
dengan HCO3
Step 1 Step 3 Lihat
kompensasi
(uncompensate
Step 2 d arah tanda
Lihat Lihat kausa
panah PaCO2
dan HCO3 tidak
pH (respiratorik
PaCO2;
searah; partially
compensated
(<7,35 atau PaCO2 dan
HCO3 searah
metabolik
= asam HCO3), naik.turun, pH
masih abnormal,
Gunakan
atau ROME
fully PaCO2
dan HCO3
>7,45 = searah
naik.turun, pH
basa) sudah normal)
Anion gap
Fisiologi manusia adalah isoelektrik, sehingga:
Anion Gap akan meningkat saat terjadi kondisi peningkatan asam yang tidak
terukur: Laktat, Keton (Ketoasidosis), Alkohol, Aspirin, Parasetamol, Sulfate, dsb.
Organophosphate Poisoning
Sources
• Insecticides, herbicides
Mechanism
• Inhibit acethylcholinesterase
• ACh accumulates throughout the nervous system
• Overstimulation of muscarinic and nicotinic receptors
Characteristics
• DUMBBELS
Organophosphate Poisoning
ORGANOPHOSPOSPHATE POISONING
SIGN AND SYMPTOM
Atropine
Competitive inhibitor at autonomic postganglionic cholinergic receptors (GI &
pulmonary smooth muscle, exocrine glands, heart, and eye)
• JENGKOL bean
Mechanism
Characteristics
Treatment
Mechanism
Characteristics
CNS Cardiovascular
Pulmonary Gastrointestinal
Cyanide Diagnosis
• Clinical picture : sweet almond breath
• Lactic acidosis
• ABG:
– metabolic acidosis
”Arterialization of the
venous blood”
Treatment
• Remove from source
• Oxygen
• Cyanide antidote kit:
– Amyl nitrite perle (inhalation)
• until IV established
– Sodium Nitrite (300mg IV)
• Peds: 0.33 ml/kg of 10% solution)
– Sodium Thiosulfate (12.5g IV)
• Peds: 1.65 ml/kg of 25% solution
– Hydroxocobalamine (5 g)
• Peds: 70 mg/mg (max 5 g)
Treatment with amyl nitrite or sodium nitrite is contraindicated in cases of
concurrent carbon monoxide toxicity, because of methemoglobin production
Methanol Toxicity
• Methanol
– wood alcohol
– organic solvent that, because of its toxicity, can
cause metabolic acidosis, neurologic sequelae,
and even death, when ingested
• Complication
– Visual loss (optic nerve damage)
– Metabolic acidosis
– Movement disorder (damage in putamen >>)
Parkinsonian motor impairment
Therapy
Therapy
• Hemodialysis can easily remove methanol and
formic acid.
Botulinum Toxin
Treatment
Monitoring
• Pulse oximetry
• Spirometry
• ABG
• Ventilation, perfusion, upper airway integrity
Antitoxin
• Equine serum heptavalen botulism antitoxin children >1 year old and adult
• Human-derived botulism immune globin infant ≤ 1 year old
Antibiotics
• Penicillin G (3 million units IV every four hours in adult)
• Metronidazole (500 mg IV every eight hours) is a possible alternative for penicillin-allergic patients
Other treatments
• Laxatives, enemas