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Rabu, 23 Agustus 2017

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SKILL LAB

SHOCK

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Oleh:
Desi Suryani Dewi, S.Ked.
132011101102

Pembimbing:
dr. Dwi Ariyanti, Sp.JP

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Shock is an acute clinical syndrome initiated by
ineffective perfusion, resulting in severe
dysfunction of organs vital to survival.

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NUMBER OF PATIENTS = 43

10 14 20 13 6
100
% MORTALITY RATE

80 Arterial blood lactate determinations in 63


patients in shock, measured
60 PERBANDINGAN
When the patients were initially seen and
before treatmentUMUM was begun
40 This value was of prognostic, whereas a
similar plot of initial blood
20 Preassure vs. Mortality was not

<13 13-40 41-80 81-120 >120

INITIAL ARTERIAL LACTATE mgm %


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Golden hour. Probability of survival from posttraumatic shock

100
Percent
survival
80

60

40

20

0
0 30 60 90

Minutes
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From: Stene JK, Grande CM, Gieseke A, 1991
UNSUR2 PEMBEDA PADA SHOCK UNSUR YANG
SAMA PADA
SYOK
SYOK SYOK SYOK SYOK - COMMON
HIPOVOLEMIA KARDIOGENIK ANAFILACTIC SEPTIK TERMINAL
- PERDARAHAN PATH WAY
- KEHILANGAN
CAIRAN

GANGGUAN PENURUNAN PENURUNAN VASODILATASI GANGGUAN GANGGUAN PADA


UTAMA VOLUME` DAYA POMPA PERFUSI &
DARAH JANTUNG OKSIGENASI

MEKANISME VOLUME DAYA POMPA PEMBULUH PERFUSI &


FISIOLOGI DARAH JANTUNG DARAH OKSIGENASI
DASAR JARINGAN /
SEL

ARAH UTAMA PENGGAN- PENINGKATAN PENGEMBALIAN PERBAIKAN


PENGELO TIAN DAYA POMPA TONUS PEMBU - PERFUSI /
LAAN VOLUME JANTUNG LUH DARAH OKSIGENASI
OBAT :2 OBAT2
- INOTROPIK VASO AKTIF
- ANTI ARITMIK
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Type of Shock

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CELLULAR / METABOLIC
RECOGNITION OF SHOCK STATE
RESPONSE

Tachycardia Blood Loss


Vasoconstriction
Inadequate
Cardiac Out Put Perfusion

Narrow Pulse Pressure Cell injury


Further volume
MAP alteration
Membrane changes
Blood Flow
Fluid disturbance
change
Anaerobic
Caution : Compensatory Mechanism metabolism
Further circulation Organ Lactic
changes dysfunction acid
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PERTOLONGAN PADA SYOK PENDEKATAN Treatment of Shock
TERPADU BERORIENTASI FUNGSI / SISTIM

1. TAHAP PERTAMA / TAHAP SEGERA Goal: Restore perfusion


BERIKAN LIFE SUPPORT
(BANTUAN HIDUP, RESUSITASI STABILISASI) Method: Depends on
type of Shock
PARU Basically 2 kinds:
JAN Hypovolemic
O2 TUNG (hemorrhagic, septic,
neurogen.)
Cardiogenic
(Impedence or primary
AIRWAY CIRCULATION Cardiac Failure)
(A) BREATHING (C)
(B) BRAIN
2. TAHAP KEDUA
TETAPKAN DIAGNOSA DAN TERAPI DEFENITIF
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Resuscitation Fluids Outcome Resusitasi Cairan
Blood Tekanan darah mendekati 120/80 atau
Lactated Ringers HR menurun dari kondisi syok
MAP (Mean Arterial Pressure) 65
Normal Saline
mmHg
Colloids Urine output 0,5 mL/kg/jam
Hypertonic Saline Status mental normal
Blood Substitutes

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Aetiology and
pathophysiology

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SHOCK

Hypovolemic shock
absolute hypovolemia due to significant Septic shock
intravascular fluid depletion : internal or By complex mechanism, often including
external haemorage, dehydration, plasma vasodilatation, heart failure and absolute
leaks. hypovolemia
Relative hypovolemia due to vaodilatation
without concomitant increase in intravascular
volume: anaphylactic reaction, acute
Cardiogenic shock
haemolysis Decrease of cardiac output: direct injury to the
myocardium and indirect mechanism

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Clinical features
Sign common to most form of shock:
Pallor, mottle skin, cold extremities, sweating and thirst
Rapid and weak pulse often only detected on major arteries (femoral or
carotid)
Low BP, narrow pulse preasure, BP sometimes undetectable
CRT > 2 second
Cyanosis, dyspnoe are often present in varying degrees depending on the
mechanism
Consciousness usually maintained (more rapidly altered in children, but
anxiety, confusion, agitation or apathy are common
Oliguria or anuria
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Sign specific to the mechanism of shock

Hypovolaemic shock Anaphylactic shock


The common sign of shock Significant and sudden drop in
listed above are typical of BP
hypovolaemic shock
Tachycardia
Dont underestimated
Frequent cutaneus sign: rash,
hypovolemia. Sign of
urticaria, angiderma
shock may not become
evident untul a 50% loss Respiratory sign: dyspnoea,
of blood volume in adults. bronchospasm

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Sign specific to the mechanism of shock

Septic shock Cardiogenic shock


High fever or hypothermia Respiratory sign of left ventricular
(<36 Celcius), rigors, failure (acute pulmonary oedema)
confusion are dominant: tachypnoe,
BP may be initially crepitation on auscultation
maintenained, but rapidly, Sign of right ventricular failure:
same pattern as for raised jugular venous pressure,
hypovolaemic shock hepatojugular reflux, sometimes
alone, more often associated with
signs of left ventricular failure
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Management

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In all cases
Emergency: immediate attention to the patient
Warm the patient, lay him flat, elevate legs (except in respiratory distress,
acute pulmonary oedema)
Insert a peripheral IV line using a large calibre catheter (16G in adults). If
no IV access, use intraosseous route
Oxygen theraphy, assited ventilation in the event of repiratory distress
Assited ventilation and external cardiac compression in the event of
cardiac arrest
Intensive monitoring: conciousness, pulse, BP, CRT, respiratory rate,
hourly urinary output (insert a urinary catheter) and skin mottling
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Management according to the cause

Haemorrhage
Control bleeding (compression, torniquet, surgical haemostasis
Determine blood group
Priority: restore vascular volume as quickly as possible. Insert 2
peripheral IV lines (catheters 16G in adults). RL or 0.9% NaCl: replace
3 times the estimated lossess and/or plasma subtitute: replace 1.5
times the estimated losses
Transfuse: classically once estimated blood loss represents
approximately 30 to 40% of blood volume (25% in children). The
blood must be tested (HIV, hepatitis B and C, syphilis, etc) refer to the
MSF handbook, blood transfusion.
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OUTLINE

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Management according to the cause

Severe acute dehydration due to bacterial/viral gastroesnteritis


Urgently restore circulating volume using IV bolus therapy:
RL or 0.9% NaCl:
Children <2 months: 10 ml/kg over 15 minutes. Repeat (up to 3 times) if
sign of shock persist.
Children 2-59 months: 20 ml/kg over 15 minutes. Repeat (up to 3 times)
if sign of shock persist
Children > 5 years and adults: 30 mg/kgBB over 30 minutes. Repeat
once if signs of shock persist.
Then replace the remaining volume deficit using continous infusion until
signs of dehydration resolve (typically 70 ml/kg over 3 hours)
Closely monitor the patient, be careful to avoid fluid overload in young
children and elderly patient
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Management according to the cause

Severe Anaphylactic Reaction


Determine the causal agent and remove it, e.g. stop ongoing
injections or infusions, but if in place, maintain the IV line
Admister ephinephrine (adrenaline) IM, into the antero-lateral tight,
in the event of hypotension, pharyngolaryngeal oedema, or
breathing difficulties:
Use undilutes solution (1:1000=1 mg/ml) and a 1 ml syringe
graduated in 0,01 ml:
Children under 6 years: 0,15 ml
Children from 6-12 years: 0,3 ml
Children over 12 years and adults: 0,5 ml
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Management according to the cause

In children, if 1 ml syringe is not available, use a diluted solution, i.e.


add 1 mg epinephrine to 9 ml of 0,9% NaCl to obtain a 0,1 mg/ml
solution (1:10000):
Children under 6 years: 1,5 ml
Children from 6 to 12 years: 3 ml
At the same time, administer rapidly RL or 0,9% NaCl : 1 liter in adults
(maximum rate); 20 ml/kg in children, to be repeated if necessary. If
there is no clinical improvement, repeat IM epinephrine every 5 to 15
minutes.

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Management according to the cause

In shock persist after 3 IM injections, administration of IV epinephrine at a


constant rate by a syringe pump is necessary:
Use diluted solution, i.e. add 1 mg epinephrine (1:1000) to 9 ml of 0,9% NaCl to
obtain a 0,1 mg/ml solution (1:10000):
Children: 0,1 mg to 1 microgram/kg/minute
Adult: 0,05 to o,5 microgram/kg/minute
Corticosteroid have no effect in the acute phase. However, they must be given
once the patient is stabilized to prevent recurrence in the short term:
Hydrocortisone hemisuccinate IV or IM
Children: 1 to 5 mg/kg/24 hours in 2 or 3 injections
Adult: 200 mg every 4 hours
In patients with bronchospasm, epinephrine is usually effective. If the spasm
persist give 10 puff of inhaled salbutamol
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Management according to the cause

Septic Shock
Vascular fluid replacement with RL or 0,9% NaCl or plasma subtitute.
Use of vasoconstrictors:
Dopamine IV at a constant rate by syringe pump: 10 to 20
micrograms/kg/minute or if not available epinephrin IV at a constant
rate by syringe pump: use diluted solution, i.e. add 1 mg epinephrine
(1:1000) to 9 ml of 0,9% NaCl to obtain a 0,1 mg/ml solution
(1:10000). Start with 0,1 microgram/kg/minute. Increase the dose
progressively until a clinical improvement is seen.

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Management according to the cause
Look for the origin of infection (abscess; ENT, pulmonary, digestive,
gynaecological orurological infection etc) antibiotic therapy according
to the origin of infection:

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Management according to the cause

Ampicillin IV
Children and adults: 150 to 200 mg/kg/day in 3 injections (every 8
hours)

Cloxacin IV infusion (60 minutes)


Children over 1 month: 200 mg/kg/day in divided doses (every 6
hours); max 8 g/day
Adults: 12 g/day in 4 divided doses (every 6 hours)

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Management according to the cause

Amoxicillin/clavulanic acid (co- Ceftriaxon slow IV


amoxiclav) Children: 100 mg/kg as a single
Slow IV injection (3 minutes) or IV
infusion (30 minutes) injection
Children less than 3 months: 100 Adults: 2 g once daily
mg/kg/day in 2 divided doses (every
12 hours) Ciprofloxacin PO (by NGT)
Children > 3 months and < 40 kg: Children: 15 to 30 mg/kg/day in
150 mg/kg/day in divided 3 doses
(every 8hours); max 6 g/day divided doses
Children 40 kg and adults: 6 g/day Adults 1.5 g/day in divided doses
in 3 divided doses (every 8 hours)
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Management according to the cause

Gentamisin IM or slow IV (3 minutes) or infusion (30 minutes)


Children > 1 month and adult: 6 mg/kg once daily

Metronidazole IV infusion (30 minutes)


Children over 1 month: 30 mg/kg/day in 3 divided doses (every 8
hours); max 1.5 g/day
Adults: 1,5 g/day in 3 divided doses (every 8 hours)

Corticosteroids not recommended, the adverse effect outweigh the


benefits
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Management according to the cause

Cardiogenic Shock Acute left heart failure with pulmonary


oedema
The objective is to restore In the event of worsening sign with
efficient cardiac output. The vascular collapse, use a strong inotrope:
treatment of cardiogenic Dopamine IV at a contan rate by syringe
shock depends on its pump: 3 to 10 microgram/kg/minute
mechanism Once the haemodinamic situation allows
(normal BP, reduction in the signs of
peripheral circulatory failure), nitrates or
morphine may be cautiously introduced.
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Management according to the cause

Digoxin should no longer be used for cardiogenic shock, except in the


rare cases when a supraventricular tachycardia has been diagnosed
by ECG. Correct hypoxia before using digoxin.
Digoxin slow IV
Children: one injection of 0,010 mg/kg (10 microgram/kg), to be
repeated up to 4 times/24 hours if necessary
Adults: one injection of 0,25 to 0,5 mg, then 0,25 mg 3 or 4
times/hours if necessary.

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Management according to the cause

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TERIMA KASIH

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IVF
ISF ICF

Perdarahan

ICF

IVF ISF

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ECF SHIFT

IVF
ISF ICF

Perdarahan
Squesterasi

IVF
ISF ICF

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Management according to the cause

Cardiac tamponade: restricted cardiac filling as a result of


haemopericardium or pericarditis. Requires immediate pericardial
tap after restoration of circulating volume.

Tension pnemothorax: drainage of the pneumothorax

Symptomatic pulmonary embolism: treat with an anticoagulant in a


hospital setting.

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