UKDI MANTAP
dr. Andreas W Wicaksono
dr. Anindya K Zahra
dr. Arius Suwondo
dr. M. Dzulfikar Lingga Q M
dr. Marika Suwondo
dr. Alexey Fernanda N
dr. Denise Utami Putri
dr. Aditya Wicaksana
Shock
• Hypovolemic shock
• Cardiogenic shock
• Distributive shock
• Obstructive shock
Triage
Poisoning
Algorhythm
Airway and C – Spine control
Pasien Berbicara Lancar -> airway baik
Curiga cedera cervical bila à 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
unsuccesfull
Consider adjunct -> GEB/LMA/LTA
Definitif arway
surgical
Oropharingeal Airway
• Digunakan untuk ventilasi sementara pada pasien yang tidak
sadar sementara intubasi pasien sedang disiapkan
• Tidak boleh digunakan pada pasien yang sadar karena dapat
menyebabkan sumbatan, muntah dan aspirasi.
Nasopharingeal Airway
• Prosedur ini digunakan apabila pasien terangsang untuk
muntah pada penggunaan OPA
• Tidak boleh digunakan pada kecurigaan fraktur basis cranii
Cricothyroidotomy Tracheostomy
Look externally = adakah penyulit jalan napas seperti obesitas, micrognathia,
abnormalitas dental (edentulous, gigi besar), narrow face, rahang yang menonjol, high
and arched palate, leher pendek atau tebal, trauma wajah atau leher?
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
• DO2 = CO x CaO2
• CaO2= (Hb x sat x 1.34) + (PaO2 x 0.003)
Pathophysiology
Shock CO SVR
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 Kristaloid Kristaloid dan Kristaloid dan
cairan darah darah
*) untuk laki-laki dengan berat badan 70kg
Estimated Blood Volume (EBV)
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.
• 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 à disruption of cellular metabolism à
peripheral vasodilation à 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) à 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 à pasien dengan kemungkinan
bertahan hidup yang terbesar, serta membutuhkan waktu, perlengkapan,
dan tenaga paling sedikit
• Terdiri dari 4 prioritas penanganan:
– Merah à immediate care/life-threatening
– Kuning à urgent care/can delay up to 1 hour
– Hijau à delayed care/can delay up to 3 hours
– Hitam à dead/no care required
RPM
respirasi, perfusi, mental
- Semua proses evaluasi
dalam START harus
dilakukan dalam waktu
kurang dari 60 detik.
Acid Base Regulation
Gangguan Asam Basa
Gangguan asam pH PCO2 HCO3 Penyebab umum
basa
Asidosis respiratorik ¯ jika PPOK, asma, ARDS
terkompensasi
Alkalosis respiratorik ¯ ¯ jika Hiperventilasi,
terkompensasi sepsis
Asidosis metabolik ¯ ¯ jika ¯ Dehidrasi berat,
terkompensasi DM, gagal ginjal,
starving, syok
hipovolemik
Alkalosis metabolik jika Muntah
terkompensasi
Keterangan: angka normal analisis gas darah (arteri):
pH: 7,35-7,45
PCO2: 35-45 mmHg
HCO3: 22-26 mmol/L.
Tanda
Terkompensasi
(sebagian/sepe
nuhnya) à
ditandai dgn
ARAH panah
yang SAMA
Antara PaCO2
dengan HCO3
Organophosphate Poisoning
Sources
• Insecticides, herbicides
Mechanism
• Inhibit acethylcholinesterase
• ACh accumulates throughout the nervous system
• Overstimulation of muscarinic and nicotinic receptors
Characteristics
• SLUD + GEM
Organophosphate Poisoning
Sign and Symptom
• + GEM
• G : Gastrointestinal
• E : Emesis
• M : Miosis
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
ABG sample
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 (12.5gm IV)
• Peds: 1.65 ml/kg of 25% solution
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 >>) à
Parkinsonian motor impairment
Therapy
Therapy
• Hemodialysis can easily remove methanol and
formic acid.
Arsenic Toxicity
Management
• Decontamination
– Skin Decontamination
– Gastrointestinal decontamination : nasogastric
suction, and administer activated charcoal
• Fluids – Administer intravenous fluids to maintain
adequate urine flow.
• Monitoring – Patients should have continuous
cardiac monitoring. Additionally, fluid and
electrolyte balance should be monitored.
• Chelation – Dimercaprol and DMSA
Botulinum Toxin
Treatment
Monitoring
• Pulse oximetry
• Spirometry
• ABG
• Ventilation, perfusion, upper airway integrity
Antitoxin
• Equine serum heptavalen botulism antitoxin à children >1 year old and adult
• Human-derived botulism immune globin à 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
Acetaminophen Intoxication
Minimum toxic doses of acetaminophen à adult: 7.5 g – 10 g; children 150 mg/kg; 200
mg/kg in healthy children
• Phase 1 (0.5-24 h) à asymptomatic, anorexia, nausea or vomiting, and malaise, pallor, diaphoresis, fatigue
• Phase 2 (18-72 h) à RUQ pain and tenderness, tachycardia and hypotension (indicate volume losses), oliguria
• Phase 3 (72-96h) à jaundice, coagulopathy, hypoglycemia, encephalopathy, acute renal failure in some critically ill
patients, death from multiorgan may occur
• Phase 4 (4d-3w) à resolution of symptoms and complete resolution of organ failure
Diagnosis
Management