Penderita wanita 22 th, + 70 kg masuk IRD karena

kecelakaan sepeda motor. Patah tulang paha terbuka

dan ada jejas di abdomen.Wanita tersebut juga hamil 8
bulan, keluar perdarahan pervaginam. Nafas 36x/mnt,
nadi 128 x/mnt, tensi 70/50. Tangan pucat dan dingin,
hanya ada respon dengan stimulasi nyeri. Dilaporkan
oleh petugas ambulan 118, keadaan sekarang ini
seperti waktu di TKP. Selama perjalanan ke IRD, di
ambulan diberikan Ringer Lactate 2 liter cepat, tensi
pernah naik 90/60 dan nadi 120x/mnt

Apakah penderita shock

Macam shock, penyebab, & patofisiologinya
Klasifikasi derajat shock
Bagaimana tindakan pertolongan awal
Bagaimana respon thd pemberian cairan
Bagaimana monitoringnya dan evaluasinya
1
 SHOCK

Inadequate organ perfusion and tissue

oxygenation

2
 NUMBER OF PATIENTS = 43

10 14 20 13 6
100
% MORTALITY RATE
80

60

40

20

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

INITIAL ARTERIAL LACTATE mgm %

Arterial blood lactate determinations in 63 patients in shock, measured

When the patients were initially seen and before treatment was begun
This value was of prognostic, whereas a similar plot of initial blood
Preassure vs. Mortality was not
3
 THE PATIENTS IN SHOCK
+
+ DIED
160

140 SURVIVED

120 +
+ + +
100

80

60
+
40

20

7.1 7.2 7.3 7,4 7,5 7,6

ARTERIAL pH
A summary of 32 in whom serial measurements of arterial blood lactate
reflect prognosis. In patents (represented by the broken lines) the lactate
rose and all patients died. In 22 patients (respresented by the solid lines)
the lactate dropped quickly to normal and all survived 4
Bagan 4
Golden hour. Probability of survival from posttraumatic shock

100
Percent
survival
80

60

40

20

0
0 30 60 90

Minutes
From: Stene JK, Grande CM, Gieseke A, 1991 5
 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

6
Bagan 6
 PERTOLONGAN PADA SYOK PENDEKATAN TERPADU
BERORIENTASI FUNGSI / SISTIM

1. TAHAP PERTAMA / TAHAP SEGERA

BERIKAN LIFE SUPPORT
(BANTUAN HIDUP, RESUSITASI STABILISASI)

PARU
JAN
O2 TUNG

AIRWAY CIRCULATION
(A) BREATHING (C)
(B) BRAIN
2. TAHAP KEDUA
TETAPKAN DIAGNOSA DAN TERAPI DEFENITIF
7
Bagan 9
PARADIGMA : PADA SYOK KARENA PERDARAHAN PERFUSI
DAN OKSIGENASI JARINGAN DAPAT DIPERBAIKI
DENGAN TERAPI CAIRAN (HEMODILUSI) UNTUK
MENGEMBALIKAN VOLUME DARAH DAN
MENINGKATKAN CARDIAC OUTPUT (1964)

TEMUAN PADA PENELITIAN (BAIK PADA BINATANG MAUPUN

PADA MANUSIA)
PADA PERDARAHAN TERJADI 3 TAHAP PENYEMBUHAN :
1. TAHAP VASOKONSTRIKSI
- REDISTRIBUSI PROTEKTIV
2. TAHAP HEMODILUSI
3. TAHAP PRODUKSI ERITROSIT

PERBAIKAN PERFUSI DAN OKSIGENASI JARINGAN DAPAT

DILAKUKAN DENGAN TERAPI CAIRAN / HEMODILUSI
UNTUK MEMPERCEPAT TAHAP HEMODILUSI

8
LANDASAN PEMIKIRAN HEMODILUSI ATAU TERAPI CAIRAN

OKSIGEN = CARDIAC OUTPUT X SATURASI Hb% X Hb % X 1,34

TERSEDIA (1) (2) (3)

FUNGSI FUNGSI FUNGSI

SIRKULASI PERNAFASAN DAYA ANGKUT
OKSIGEN
(RUMUS DARI NUNN)

9
 PENGGUNAAN = CARDIAC X ISI O2 ISI O2
OKSIGEN OUTPUT DARAH DARAH
ARTERI VENA

DALAM KEADAAN NORMAL Hb 15 G %

PENGGUNAAN O2 250 ml/mnt = 5000 X (20 ml/100 15 ml/100)

DALAM KEADAAN HEMODILUSI
SETELAH PERDARAHAN
MISAL Hb 7,5 G % (50% HARGA NORMAL)

PENGGUNAAN O2 250 ml/me = (2X5000)X(10ml/100 7,5 ml/100)

ISI O2 DARAH ARTERI TINGGAL 50% 10 ml/100
ISI O2 DARAH VENA 7,5 ml/100
PENGGUNAAN O2 PER 100 ml DARAH 2,5 ml/100
PENGGUNAAN O2 DAPAT TETAP
DIPERTAHANKAN 250 ml/me DENGAN MENAIKKAN
CARDIAC OUPUT 2 X MENJADI 10000 ml/me

KENAIKAN CARDIAC OUTPUT, DIMUNGKINKAN APABILA VOLUME

DARAH KEMBALI NORMAL DENGAN TERAPI CAIRAN 10
 PERTOLONGAN PADA SYOK PENDEKATAN TERPADU
BERORIENTASI FUNGSI / SISTIM

1. TAHAP PERTAMA / TAHAP SEGERA

BERIKAN LIFE SUPPORT
(BANTUAN HIDUP, RESUSITASI STABILISASI)

PARU
JAN
O2 TUNG

AIRWAY CIRCULATION
(A) BREATHING (C)
(B) BRAIN
2. TAHAP KEDUA
TETAPKAN DIAGNOSA DAN TERAPI DEFENITIF
11
Bagan 9
MODEL PENDEKATAN TERPADU
BERORIENTASI SISTIM / FUNGSI

PENYEBAB

PERDARAHAN
POST PARTUM GANGGUAN
SISTIM / FUNGSI OBGIN
PECAHNYA
VARICESS EVOPHAGUS SYOK PERTAMA KEDUA PENY.
KARENA LIFE SUPPORT DIAGNOSA DALAM
FRAKTUR FEMUR PERDA - DAN
TERBUKA RAHAN PENGGANTIAN TERAPI BEDAH
VOLUME DEFENITIV

ORIENTASI FUNGSI /
SISTIM

12
Bagan 10
 IMMEDIATE : CNS injury or heart
and great vessel injury
50
EARLY : Major hemorrhage
40
LATE : Infection and
30 multiorgan failure

20

10

0
0 1 2 3 4hr 1,2 5,6 weeks

Time ofter injury

Trimodal distribution of deaths (from Trankey DD:

Sci Am 249 : 28: 35, 1983)

Bagan 12
 PRIMARY CARA
PREVENTION TERBAIK
HILANGKAN RESIKO

PENDEKATAN
KOMPREHENSIV SECONDARY CARA KEDUA
PADA SHOCK PREVENTION TERBAIK
DIAGNOSA &
TERAPI DINI

TERTIARY CARA
PREVENTION TERAKHIR
LIMIT THE DAMAGE

14
Bagan 13
Hershey / Lillehei (1964)

15
16
 RECOGNITION OF SHOCK STATE

Tachycardia
Vasoconstriction
Cardiac Out Put
Narrow Pulse Pressure
MAP
Blood Flow

Caution : Compensatory Mechanism

17
18
 PITFALL IN SHOCK RECOGNITION

Extremes of age
Athletes
Pregnancy
Medications
Hematocrit / hemoglobin concentration

19
 HCT : 45% HCT : 27% HCT : 45%

4 Plasma

HCT : 45%
Liters 3

2
Cells

Acute 1 hour Saline Whole Blood

Hemorrhage later

Resuscitation
20
IVF ISF ICF

Perdarahan

ICF

IVF ISF

21
 ECF SHIFT

IVF ISF ICF

Perdarahan
Squesterasi

IVF ISF ICF

22
 MILD HEMORRHAGE
(<15% BV)

Stage I : vasoconstriction
Stage II
II a : Transcapillary refill ISF IVF
II b : Activation Reninangiotensin aldosteron
Sodium + water retension

Stage III : Erythrocyte production

23
CELLULAR / METABOLIC RESPONSE
Blood Loss

Inadequate
Perfusion

Cell injury
Further volume
alteration
Membrane changes

Fluid disturbance
change
Anaerobic
metabolism
Further circulation Organ Lactic
changes dysfunction acid
24
 HEMORRHAGIC SHOCK

Most common
Loss of circulating blood volume
Normal blood volume:
Adult : 6-7% of ideal weight
Child : 8-9% of ideal weight

25
 ASSESSMENT & MANAGEMENT

Airway and Breathing:

Oxygenate and ventilate
PaO2 > 80 mmHg
SaO2 > 95%

Circulation
Assess (Class I, II, III, IV)
Control Haemorrhage
Prompt Treatment

26
 ASSESSMENT & MANAGEMENT

Disability cerebral perfusion

Exposure / Environment
Associated injuries
Prevent hypothermia

Gastric and bladder decompression

Urinary output

27
 CLASSIFICATION OF HEMORRHAGE

Class I IV
Not absolute
Only a clinical guide
Subsequent treatment determined by patient
response

28
 Table 1. ESTIMATED FLUID AND BLOOD LOSSES *)
Based on Patients Initial Presentation
(For a 70 kg man)
CLASS I CLASS II CLASS III CLASS IV

Blood Loss (mL) Up to 750 750 1500 1500 2000 > 2000

Blood Loss
Up to 15% 15 30 % 30 40 % > 40 %
(% Blood Vol)

Pulse Rate < 100 > 100 > 120 > 140

Blood Pressure Normal Normal

Pulse Pressure Normal or

Respiratory Rate 14 20 20 30 30 40 > 35

Urinary Output (ml/hr) > 30 20 30 5 15 Negligible

Anxious, Confiused,
CNS / Mental Status Slightly anxious Mildly anxious
confused lethargic

Fluid Replacement (3:1 Crystalloid and Crystalloid and

Crystalloid Crystalloid 29
Rule) blood blood
 MANAGEMENT VASCULAR ACCESS

2 large-caliber peripheral IVs

Central access
Femoral
Jugular
Subclavian

Intraosseous
Obtain blood for crossmatch

30
 Short Catheter

200

Flow rate Short Catheter

(mL/min)

100

Diameter 14 ga 16 ga 16 ga 16 ga

Length 2 in 2 in 5,5 in 12 in
31
32
 MANAGEMENT FLUID THERAPY

Warmed crystalloid solution

Rapid fluid bolus

Adult : 2 liters Ringers Lactate
Child : 20 ml/kg Ringers Lactate

Monitor response to initial therapy

33
 THERAPEUTIC DECISIONS

Patient response determines subsequent therapy

Hemodynamically normal vs hemodinamically
stable
Recognize need to resuscitate in operating room

34
 Table 2. RESPONSES TO INITIAL FLUID RESUSCITATION *)

Rapid Transient No
Response Response Response
Transient improve-
Vital Signs Return to normal ment; recurrence of Remain abnormal
BP and HR

Minimal Moderate and ongoing

Estimated Blood loss Severe (>40%)
(10-20%) (20-40%)

Need for more

Low High High
Crystalloid

Need for Blood Low Moderate to high Immediate

Emergency blood
Blood Preparation Type and crossmatch Type specific
release
Need for Operative
Possibly Likely Highly likely
Intervension
Early Presence of
Yes Yes Yes
Surgeon

*) 2000 ml RL solution in adults, 20 ml/Kg RL bolus in children over 10-15 min 35

 VOLUME REPLACEMENT

Warmed fluids
Crossmatch, PRBC
Type-specific
Type O, Rh-negative
Autotransfusion
Coagulopathy

36
 Catheter Dimension
16 gauge diameter
100 2 inches in length

Flow rate
(mL/min)

50

Water 5% Whole Packed

Albumin Blood RBCs

37
 REEVALUATE ORGAN PERFUSION

MONITOR :
Vital signs
CNS Status
Skin perfusion
Urinary output
Pulse oximetry
End Tidal CO2
Oxygen Extraction
Acid base
38
 RESUSCITATION / EVALUATION

Urinary output :
Adults : 0,5 ml/kg/hour
Child : 1 ml/kg/hour
Infant : 2 ml/kg/hour
Inadequate output suggests inadequate
resuscitation

39
 30

20
ET CO2
(mmHg)

10

1 2 3 4 5
Volume Infused (Liters)

40
 SaO2 SvO2 SaO2 SvO2

Normal > 95% > 65% 20 30 %

Hypovolemia > 95% 50 65 % 30 50 %

Hypovolemic shock > 95% < 50 % > 50 %

41
 AVOIDING COMPLICATION

Fluid overload
Invasive monitoring (ICU)
CVP
Pulmonary artery catheter

Other problems :
Resuscitation induced haemorrhage
Post resuscitation injury
No Reflow phenomenon
Reperfusion injury

42
 CVP CATHETER

Catheter in Right atrium

Via :
Vena cubiti
Vena subclavia
Vena jugularis interna
Vena femoralis

43
 CVP MONITORING

Monitors right hearts ability to accept

fluid load
CVP level vs actual blood volume
Low / declining : Replace fluids
Elevated : adequate fluids,
hypervolemia, cardiothoracic problem
Elective, monitoring line

44
45
46
47
 FLUID CHALLENGE TEST
( Rule 2 5 )

CVP

< 8 cm H2O 8-14 cm H2O > 14 cm H2O

RL 200 cc/10 mnt RL 100 cc/10 mnt RL 50 cc/10 mnt

Kenaikan C V P

< 2 cm H2O 2-5 cm H2O > 5 cm H2O

Ulang Tunggu 10 menit STOP

< 2 cm H2O 2-5 cm H2O 48

49
 SHOCK MANAGEMENT

Recoqnize inadequate organ perfusion and

oxygenation

Identify the cause :

Haemorrhage
Non haemorrhage

Treatment
Stop the cause / bleeding
Restore volume and perfusion

50
 5% 15 % 40 %

IVF ISF ICF

Na Na K
D5% Koloid

IVF ISF ICF IVF ISF ICF

RL / NS

IVF ISF ICF

51
 IVF ISF ICF

Non
Perdarahan

IVF
ICF
ISF

IVF ICF
ISF 52
 ASSESSMENT & MANAGEMENT

Recognize shock
Stop the bleeding !
Resplenish intravascular volume
Restore organ perfussion

53
 THERAPEUTIC DECISIONS
Rapid Response

< 20% blood loss

Responds to fluid replacement
Surgical consultation, evaluation
Continue to monitor

54
 THERAPEUTIC DECISIONS
Transient Response

20% - 40% blood loss

Deteriorates after initial fluods
Surgical consultation, evaluation
Continued fluids plus blood
Continued hemorrhage Operation

55
 THERAPEUTIC DECISIONS
Minimal to No Response

>40% blood loss

No response to fluid resuscitation
Immediate surgical consultation
Exclude non hemorrhagic shock
Immediate operation

56
57
58
59
60
61
62
63