Syok
Merupakan sindrom multifaktorial hipoperfusi jaringan perifer dan sentral hipoksia seluler dan disfungsi organ multipel. Perfusi menurun secara sistemik dengan gejala yg jelas hipotensi Prognosis: derajat syok, durasi, organ yang terpengaruh, disfungsi organ sebelumnya
Patofisiologi
perfusi jaringan
Diagnosis
Heart rate: takikardi bradikardi BP: Hipotensi severe volume loss and shock Temp: hypothermia severe hypovolemic and septic shock Urin output: early guide of hypovolemia and end organ response (renal) to shock. Delayed vital sign Pulse oxymetry early indicator of hypoxemia, invalid in hypothermic patient
Vital Sign
Arterial catheter Central venous catheter Pulmonary arterial catheter help guide aggressive resuscitation
Cardiac preload
Cardiac output cardiac function, measured by PAC Systemic vascular resistance index (SVRI)
Hemodynamic variables
Measured variable Systolic blood pressure (SBP) Diastolic blood pressure (DBP) Systolic pulmonary blood pressure (PAS) Diastolic pulmonary blood pressure (PAD) Pulmonary artery occlusion pressure (PAOP) Central venous pressure (CVP) Heart Rate (HR) Cardiac output (CO) Right ventricular ejection fraction (RVEF) Unit mmHg mmHg mmHg mmHg mmHg mmHg Beats/min L/min Fraction Normal Range 90-140 60-90 15-30 4-12 2-12 0-8 50-100 4-6 0,4-0,6
Calculated variable
Mean arterial pressure (MAP) Mean pulmonary artery pressure (MPAP) Cardiac index (CI) Stroke volume (SV) Stroke volume index (SVI)
Unit
mmHg mmHg L/min/m2 ML/beat mL/beat/m2
Normal range
70-105 9-16 2,8-4,2 Varies 30-65
Dynes
Sec/cm-5 g m/m2 g m/m2 mL/m2 m2
1.600-2.400
250-340 45-62 7-12 60-100 varies
The amount of base required to titrate whole blood to a normal pH Elevated base deficit severity of shock
Intramucosal pH monitoring
The mesenteric organ will have earlier and greater hypoperfusion than other organ system Gastric tonometry early indicator of hypoperfusion
Syok hipovolemik
Kehilangan volume intravaskular yang bersirkulasi dan penurunan cardiac preload
Mental status
Fluid replacement
Mild anxiety
Crystalloid
Anxiety
Crystalloid
Confused
Crystalloid + blood
Lethargic
Crystalloid + blood
Syok hipovolemik
Rapid infusion of multiple liters of crystalloid Large-bore venous access and central access is needed If haemorrhage shock after 2-3 liters of fluid blood is transfused + source of bleeding needs to be controlled Vasoconstrictor rarely needed
An initial, warmed fluid bolus is given as rapidly as possible. The usual dose is 1-2 liters for an adult and 20 ml/kg for a pediatric patient. 3-for-1 rule replace each mililiter of blood loss with 3 mL of crystalloid fluid Assess the patients response to fluid resuscitation
Minimal (10%20%)
Severe (>40%)
Low
Low
High
Moderate to high Type-specific Likely
High
Immediate Emergency blood release Highly likely
Blood preparation Type and cross match Need for operative intervention Possibly
Grades of dehydration
Mild < 5% Pulse rate Blood pressure Respiratory rate Capillary return Urine Output CNS/mental status N N N <2 seconds N N/restless Moderate 510% N N 3-4 seconds Dry Drowsy Severe >10% Rapid >5 seconds Negligible/absent Parched Lethargic/comato se
Klasifikasi
Tahap I (rehidrasi cepat) : 20-40 cc/KgBB/1-2 jam Tahap II : sisa defisit 6 jam sisanya 16-17 jam
+ Maintenance
Contoh:
Pasien pria, BB 50 kg, mengalami dehidrasi moderate (dehidrasi 5%) Jawab: Estimated Fluid Therapy 5% dehydration= 50 x 50 = 2500 ml/ 24 h = 105 ml/h Maintenance = 40+20+ 30 = 90 ml/h Rehydration + maintenance = 195 ml/h
Syok Obstruktif
Disebabkan oleh obstruksi mekanis thd cardiac output dgn penurunan perfusi sistemik Penyebab: a. Cardiac tamponade b. Tension pneumothorax c. Emboli paru masif d. Emboli udara
Tanda: distensi vena jugularis, muffled heart sound (tamponade), suara nafas unilateral (pneumothorax) Tx: memaksimalkan preload dan mengatasi obstruksi
Syok obstruktif
Penyebab harus diidentifikasi dan ditangani secepatnya: a. Pericardiocentesis/ pericardiotomy cardiac tamponade b. Needle decompression/ tube thoracostomy tension pneumothorax c. Ventilatory and cardiac support
Syok kardiogenik
Disebabkan karena kegagalan pompa Penyebab: extensive myocardial infarction (>>), reduced contractility (cardiomyopathy, sepsis induced) aortic stenosis, mitral stenosis, atrial myxoma, acute valvular failure, and cardiac dysrythmias. Tx: memaksimalkan preload dan kerja jantung, menurunkan after load.
Syok kardiogenik
Optimize preload with infusion of fluids Optimize contractility with inotropes Adjust afterload to maximize CO Diuresis indicated in patient with heart failure PAC guide therapy Identifiy and treat the underlying cause
Syok distributif
Disebabkan oleh vasodilatasi sistemik krn penyebab yg muncul (infeksi, anafilaksis) hipoperfusi sistemik dan atau cardiac output. Syok distributif ditingkatkan oleh respon inflamasi Terjadi hipoksia seluler karena gangguan fungsi mitokondria. Penyebab lain: anaphylaxis, severe trauma, severe liver dysfunction, and neurogenic shock.
Neurogenic shock trauma MS servikal disertai hilangnya tonus simpatis vaskuler. Gejala: hipotensi, bradikardi, ekstremitas hangat Tx: volume dan vasokonstriktor
Syok anafilaksis
Anafilaksis: reaksi alergi yg berat terhadap rangsangan apapun, onset mendadak (<24 jam), melibatkan 1 atau lebih sistem tubuh dan memiliki gejala antara lain bengkak, flushing, gatal, angioedema, stridor, wheezing, sesak, mual, diare atau syok.
Sepsis