PENYEGARAN  

PENANGANAN GAWAT DARURAT

DI RSU CARUBAN KAB. MADIUN 

diklat RSU Caruban

Module
Day 2b
2b_Circulation 1
Diagnosis and Understanding of
Circulation emergencies

2b_Circulation 2
 Circulation

• Jantung = pompa
• Pembuluh darah = pipa
jantung
• Darah = isi pipa

pembuluh
darah darah
2b_Circulation 3
 LEFT

RIGHT

CO = HR x SV
2b_Circulation 4
 Sirkulasi darah
• Cardiac Output = CO = volume darah yang
dipompa jantung satu menit
• Stroke Volume = SV = volume darah yang
dipompa jantung satu kali
• Heart rate = HR = denyut jantung per menit

• CO = HR x SV

2b_Circulation 5
 Cardiac output

Jantung
=
Pembuluh pompa
darah =
pipa
Darah
=
isi pipa
Venous return

Venous return = VR = 5 lpm

Cardiac output = CO = 5 lpm

2b_Circulation 6
 Krisis sirkulasi
• Hipovolemia : • Shock hipovolemik
– perdarahan
– muntaber
• Gagal jantung / sirkulasi • Shock kardiogenik
– decomp. cordis
– infark miokard luas
• Anafilaksis, Cedera spinal,
Sepsis • Shock distributif
• Pericardial tamponade,
• Shock obstruktif
tension pneumothorax
2b_Circulation 7
 Cardiac output 

Jantung
=
Pembuluh pompa
darah =
pipa
Darah
=
isi pipa
Venous return 

Perdarahan  Masalah pada isi pipa

2b_Circulation 8
 Cardiac output 
perdarahan
multi-trauma
muntaber
peritonitis Jantung
=
Pembuluh pompa
darah =
pipa
Darah 
=
isi pipa
Venous return 

Perdarahan  Masalah pada isi pipa

Rx :
- (hentikan perdarahan)
- posisi shock
- isi kembali volume yg hilang
2b_Circulation 9
 vasodilatasi
Cardiac output 
Anafilaksis
Anestesia SAB/peridural
Anestesia inhalasi
Jantung
=
pompa
Pembuluh
 darah =
Relative
Hypo- pipa
Darah volemia
=
isi pipa

Venous return 
Masalah pada pipa
Rx :
- beri vaso-pressor / vaso-constrictor
- isi kembali volume yang “hilang”
2b_Circulation 10
 Cardiac output 
RHF
Edema tungkai
Ascites
hepatomegali
Pleural effusion
Jantung
=
LHF
Edema paru Pembuluh pompa
edema
darah = Decomp cordis
pipa Myocardiopathy
Darah Cardiogenic shock
=
isi pipa
Venous return
tertahan
Masalah pada pompa
Rx : obat inotropik (+) :
- Lasix / frusemide  membuang edema
- dopamin/dobutamin
- adrenalin menaikkan kontraksi
- digitalis miokard
2b_Circulation 11
- amrinone
Edema paru karena
decomp cordis kiri
2b_Circulation 12
 100% NORMAL
Cardiac Output

HIPOTENSI

50% SHOCK
Hipoksia, acidosis

20% CARDIAC ARREST

Anoksia, sel otak mati

2b_Circulation 13
Shock = gangguan oksigenasi jaringan / sel

Ventilasi & distribusi

O2
udara Difusi
alveoli
Sirkulasi
kapiler
paru Sirkulasi
arterial
Difusi
kapiler
SHOCK jaringan
O2
intra-sel

2b_Circulation 14
 Transport oksigen

• CaO2 = arterial oxygen content =

Oksigen terikat Hb + Oksigen larut plasma
• CaO2 = (Hb x SaO2 x 1.3) + (pO2 x 0.003)
• CaO2 = (15 x 100% x 1.3) + (100 x 0.003) = 21
ml O2 /100ml darah
• CO = Cardiac Output = 5 Liter
• Available oxygen = CaO2 x CO = 21 x 50
• 1050 ml O2 tersedia setiap menit
– Pada keadaan basal, terpakai 225-250 ml/menit
2b_Circulation 16
 Shock menyebabkan:
• Aliran darah yang membawa oksigen ke jaringan
berkurang
• Oksigen di jaringan berkurang, metabolisme sel
menjadi an-aerobik
• Terjadi kekurangan ATP di dalam sel
• Terbentuklah dan tertimbunlah di jaringan
– asam laktat
– sampah metabolisme,
– toksin, radikal bebas dll
2b_Circulation 17
 aerobic
w/ O2
GLUCOSE CO2 + H2O + 38 ATP
ENERGY
AN-aerobic DEBT
wo/ O2
LACTIC ACID + 2 ATP

Lactic acidosis

ENERGY DEBT = OXYGEN DEBT

fatal if > 150 ml/kg
High lactic acid = high O2 debt = high mortality
2b_Circulation 18
 Tanda Shock (1)

Gangguan Perfusi Perifer

• Raba telapak tangan

– Hangat, Kering, Merah : NORMAL

– Dingin, Basah, Pucat : SHOCK
• Tekan - lepas ujung kuku / telapak tangan
– Merah kembali < 2 detik : NORMAL
– Merah kembali > 2 detik : SHOCK

– Bandingkan dengan tangan pemeriksa

2b_Circulation 19
 SIRKULASI NORMAL

• Perfusi perifer  hangat, kering

• Warna akral  pink / merah muda
Perfusi
• Capillary refill  < 2 detik, bandingkan
waktu shock
dengan tangan pemeriksa
Dingin
Basah
Pucat

Hangat
Kering
2b_Circulation 20
Merah
 Otak dan Jantung
NORMAL

Kulit, otot, ginjal, viscera

normal

Otak dan Jantung

SHOCK

Kulit, otot, ginjal, viscera

Selective
vasoconstriction ischemia
2b_Circulation 21
 Tanda Shock (2)
Gangguan Perfusi Splanchnic
• Renal Blood Flow turun

– GFR turun, produksi urine turun

• Perfusi usus turun

– ischemia usus, bacterial translocation (kuman
lumen usus masuk sirkulasi sistemik)

2b_Circulation 22
 Tanda Shock (3)

NADI MENINGKAT
• raba nadi radialis

– nadi < 100 : NORMAL

– > 100 : SHOCK

2b_Circulation 23
 Tanda Shock (4)

TEKANAN DARAH MENURUN

• Ukur dengan tensimeter

– Sistolik > 100 : NORMAL
– < 90-100 : SHOCK
• Raba nadi untuk memperkirakan tensi
– Nadi radialis teraba = sistolik  80
– Nadi brachialis teraba = sistolik  70
– Nadi carotis teraba = sistolik  60
2b_Circulation 24
 Jenis shock

1. Hypovolemic:
kehilangan volume darah
2. Cardiogenic:
gangguan kerja jantung
3. Obstructive:
gangguan aliran darah masuk
dan keluar jantung
4. Distributive:
gangguan distribusi darah
di perifer
2b_Circulation Shoemaker,1992
25
 Pastikan, korban sadar atau tidak waktu
disapa
• Pasien sadar
– raba nadi radialis
• shock ?
– evaluasi perfusi
– ukur tek darah
Bebaskan jalan nafas
Look – listen - feel
Bila tdak nafas _ beri nafas
Baru  raba carotis
• Pasien tak sadar
– raba nadi carotis
• cardiac arrest ?

• Ada nadi carotis • Tidak ada nadi carotis

– raba nadi radialis
• shock ?
Resusitasi
– evaluasi perfusi
– ukur tek darah
Jantung Paru
2b_Circulation 26
 Tempat palpasi
arteria

carotis

brachialis

radialis

femoralis
2b_Circulation 27
 Cara mencari nadi carotis
|
raba trachea
|
tarik jari ke lateral
(2 cm)

2b_Circulation 28
Posisi shock

ANGKAT 300 - 500 cc darah

KEDUA TUNGKAI dari kaki pindah ke
sirkulasi sentral

2b_Circulation 29
Shock, First Aid,  Update Date: 4/30/2004  
Call 911 for immediate medical help.
Check the person's airway, breathing, and circulation. If necessary, begin
rescue breathing and CPR.
Even if the person is able to breathe on his or her own, continue to check
rate of breathing at least every 5 minutes until help arrives.
If the person is conscious and DOES NOT have an injury to the head, leg,
neck, or spine, place the person in the shock position.
Lay the person on the back and elevate the legs about 12 inches.
DO NOT elevate the head. If raising the legs will cause pain or potential
harm, leave the person lying flat.
Give appropriate first aid for any wounds, injuries, or illnesses.
Keep the person warm and comfortable. Loosen tight clothing.

2b_Circulation 30
 Shock, Last Updated: October 19, 2004
Author: Adam Schwarz, MD, Clinical Associate Professor, Department
of Pediatrics, University of Arizona School of Medicine; Director of
Education Program, Division of Pediatric Critical Care, Phoenix
Children's Hospital
Initial treatment
Regardless of the cause of shock, the ABCs must be evaluated and
stabilized immediately. Do not delay this initial stabilization for further
workup and imaging studies. The patient's airway must be patent, and the
patient must be adequately oxygenated and ventilated. Initially, administer
100% supplemental oxygen at a high flow rate. If the patient is in
respiratory distress, consider intubating and providing mechanical
ventilation.
Stabilizing the airway and providing mechanical ventilation may relieve the
patient's metabolic work of breathing and facilitate elimination of carbon
dioxide, improving the coexistent metabolic acidosis. Once the airway has
been stabilized, if necessary, and adequate ventilation and administration
of oxygen have been ensured, immediately place attention on improving
circulation and systemic oxygen delivery (DO2). Circulatory improvement
is achieved via volume expansion and, if necessary, pharmacologic
therapy with vasopressors and cardiac inotropic agents, as indicated. 31
2b_Circulation
 John P Pryor, MD, Instructor, Department of Surgery, Division of
Trauma and Surgical Critical Care, Hospital of the University of
Pennsylvania

Shock, Hemorrhagic, Last Updated: November 11, 2004

Crystalloid is the first fluid of choice for resuscitation.
Immediately administer 2 L of isotonic sodium chloride solution
or lactated Ringer solution in response to shock from blood
loss. Fluid administration should continue until the patient's
hemodynamics become stabilized. Because crystalloids quickly
leak from the vascular space, 3 L of fluid need to be
administered to raise the intravascular volume by 1 L.
Alternatively, colloids restore volume in a 1:1 ratio. Currently
available colloids include human albumin, hydroxy-ethyl starch
products.
PRBCs should be transfused if the patient remains unstable
after 2000 mL of crystalloid resuscitation. Administer 2 U rapidly
and note the response. For patients with active bleeding,
several units of blood may be necessary.
2b_Circulation 32
 Shock, Hypovolemic, Last Updated:July 12, 2006
Author: Paul Kolecki, MD, Director of Emergency Medicine Student
Education, Assistant Professor, Department of Emergency Medicine,
Thomas Jefferson University

Emergency Department Care: Three goals exist in the treatment of the patient
with hypovolemic shock as follows: (1) maximize oxygen delivery - completed by
ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and
restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.

Maximizing oxygen delivery

The patient's airway should be assessed immediately upon arrival and
stabilized if necessary. High-flow supplemental oxygen should be
administered to all patients, and ventilatory support should be given, if
needed.
Two large bore IV lines should be started.
The position of the patient can be used to improve circulation;
one example is raising the hypotensive patient's legs while
fluid is being given.
Another example of useful positioning is rolling a hypotensive gravid patient
with trauma onto her left side which displaces the fetus from the inferior vena
2b_Circulation 33
cava and increases circulation.
The Merck Manual of Diagnosis and Therapy   
Section 16. Cardiovascular Disorders  Chapter 204.
Shock (1995-2005)

First aid involves keeping the patient warm, with the legs
raised slightly to improve venous return.
Hemorrhage should be stopped, airway and ventilation checked,
and respiratory assistance given if necessary.
Nothing should be given by mouth, and the patient's head should be
turned to avoid aspiration if emesis occurs.
Because tissue hypoperfusion makes absorption unreliable, all
drugs should be given IV if possible.
Although cerebral hypoperfusion may cause anxiety, sedatives or
tranquilizers should not be given.

2b_Circulation 34
 Mengapa posisi shock,
mengapa tidak langsung pasang infus ?

• Kita hidup di Indonesia, bukan di negara 911

dimana 10 menit ambulans datang membawa infus
• Dengan angkat tungkai, darah kembali mengisi.
Vena tangan yang tadinya kolaps (hilang), jadi
terisi lagi, memudahkan memasang infus
• Tungkai bisa tahan tanpa aliran darah untuk waktu
lama. Sementara darah yang ada dipakai untuk
mengaliri otak, jantung, ginjal, usus dll

2b_Circulation 35
Hypovolemic shock, hemorrhagic shock

2b_Circulation 36
 Circulation
mengatasi perdarahan

• Hentikan perdarahan
• Posisi shock
• Pasang infus besar x 2
• Ambil sampel darah
– u/ darah donor dan periksa Hb
• Beri infus cairan, 1000 ml cepat

2b_Circulation 37
 Menghentikan perdarahan
prioritas utama

Gunakan sarung tangan / lapis plastik

Perdarahan 20 cc / menit = 1200 cc / jam

2b_Circulation 38
 Bebat tekan

Gunakan 2 gulung kasa

atau elastic / compression bandage

2b_Circulation 39
Bebat tekan mengurangi perdarahan

2b_Circulation 40
• Darah terus mengalir karena bebat tidak efektif

2b_Circulation 41
 Menghentikan perdarahan
prioritas utama

• Tekan sumber perdarahan

• Bebat tekan pada seluruh
ekstremitas yang luka
• Pasang tampon subfasia
(gauze pack)
• Hindari tourniquet
(tourniquet = usaha terakhir)

2b_Circulation 42
 Pasang infusi pada vena besar
1. Vena cubiti, basilica

2. Vena jugularis ext

(posisi kepala-leher
tetap in-line)

3. Vena saphena magna

? 2b_Circulation 43
 Tempat punksi
vena
jugularis
subclavia

basilica

vena lengan
lainnya

2b_Circulation 44
 Pasien berdarah
perkirakan volume yang hilang
|
posisi shock
pasang infus jarum besar
ambil sample darah u/ cari donor
|
infusi RL 1000 (+ 1000 lagi)

Perfusi HKM Perfusi jelek,

nadi < 100 nadi >100, T-sist <100
T-sist > 100 |
| tambah RL lagi
Lambatkan infusi sampai 2-4 x vol. perdarahan
2b_Circulation 45
 Infusi cairan
• Cairan kristaloid atau koloid
• Kristaloid
– RL, NaCl 0.9%, RA  2-4x EBL
– NaCl 5% atau 7.5%  1/3 - 1/5x EBL
• Koloid
– gelatin  2x EBL
– dextran, HES  1x EBL

2b_Circulation 46
 Perdarahan & tanda-tandanya
(korban dewasa)

• Bleeding < 750 ml 750-1500 ml > 1500 ml

• Cap. refill normal memanjang memanjang
• Nadi < 100 > 100 > 120
• Tek sistolik normal normal menurun
• Nafas normal 20-30 > 30-40
• Kesadaran normal gelisah / gelisah/coma

“normal” hipotensi shock

2b_Circulation 47
 Konsep terapi perdarahan

infusi RL
sampai
normovolemia
Hb
turun

perdarahan
hentikan
2b_Circulation 48
 Hasil terapi infusi
• Sirkulasi membaik lalu stabil
– good response, normovolemia
• Sirkulasi membaik lalu merosot lagi
– transient response, masih hipovolemia,
ada perdarahan berlanjut
• Sirkulasi tidak membaik
– no response, masih tetap hipovolemia

2b_Circulation 49
infus intra-osseus di tibia

2b_Circulation 50
 Infus intra-osseus
• Jalur sementara sampai infus intravena
dapat dipasang.
• Infusi cairan dan obat-obat boleh masuk
intra-osseus
• Yang tidak boleh masuk lewat intra-osseus
– Natrium bicarbonat
– Transfusi ?

2b_Circulation 51
waspada & cari lokasi perdarahan

• Cedera intra-abdominal
• Cedera dada
• Patah tulang panjang
• Patah tulang pinggul /
retroperitoneal
• Luka tusuk / tembus
• Luka kulit kepala

2b_Circulation 52
 ?

2b_Circulation 53
 Circulation skill 1
• Identification of radial – brachial – femoral
and carotid pulse
• Evaluation and measurement of perfusion,
pulse rate, blood pressure
• Evaluation of jugular vein filling

2b_Circulation (peer, on table) 54

Circulation skill 2

• IV access
• Intra-osseus

(arm iv simulator, on table) 55

2b_Circulation
 Circulation Skill 3

• Compression bandage
• Shock position

2b_Circulation
(peer, on the floor) 56
 Jenis shock
• Hypovolemic:
kehilangan volume darah
• Cardiogenic:
gangguan kerja jantung
• Obstructive:
gangguan aliran darah masuk
dan keluar jantung
• Distributive:
gangguan distribusi darah
di perifer
Shoemaker,1992
2b_Circulation 57
 Gangguan kerja jantung
• Contractility turun
– Cardio-myopathy, cardiac failure, infark luas
– Beta-blocker, High dose Ca-blocker
– High Spinal anesth, Deep general anesth
• Gangguan irama (arrhythmia)
– Severe bradycardia
• AV block, sinus brady
– Severe tachycardia
• SVT, AF rapid, VT
• Gangguan katub
– severe stenosis
– severe regurgitation
2b_Circulation 58
 Gangguan Contractility

• Contractility turun • Obat inotropik (+)

– Cardio-myopathy, – digitalis
cardiac failure, – dopamin / dobutamin
infark luas – amrinone

– Beta-blocker,
High dose Ca-blocker
– High Spinal anesth, – Dopamin, ephedrin,
adrenalin, nor-adrenalin
Deep general anesth

2b_Circulation 59
 Case scenario on hemorrhagic case
(plenary)

• Seorang wanita 20 th nyeri perut mendadak,

dan datang di RS dengan telapak tangan
dingin, nadi lemah 120 per menit, tekanan
darah 80/60.
• Seorang laki trauma abdomen, sadar,
telapak tangan dingin, pucat, nadi lemah,
140 per menit, tekanan darah 90/60

2b_Circulation 60
 Tanda-tanda klinis
• Sesak nafas, tachypnea • X-ray
• JVP di leher meningkat – edema paru
• Ronchi tersebar seluruh paru – cardiomegali
yang berpindah ke bagian • CVP meningkat
dada yang dibawah – right ventricle failure
• Batuk, pink frothy sputum • PCWP meningkat
• Tachycardia, irama gallop – left ventricle failure
• Oliguria • Gas darah
• Hepar membesar – asidosis metabolik

2b_Circulation 61
 Terapi dengan obat-obat inotropik (+)

• Dopamin 3-15 • Adrenalin 10-100

microgram/kg/menit nanogram/kg/menit
– dosis > 10 micro – efek tachycardia lebih
menyebabkan
tinggi dp Nor-adrenalin
vasokonstriksi dan
tachycardia
• Dobutamin 3-15 • Nor-Adrenalin 10-100
microgram/kg/menit nanogram/kg/menit
– diikuti vasodilatasi
sehingga MAP turun

2b_Circulation 62
 Gangguan irama jantung

• Atropin 0.5 mg iv diulang tiap

• Severe bradycardia 3 menit sampai nadi > 60 atau
– AV block, sinus brady dosis mencapai 3 mg
• Orciprenalin /Alupent bisa
dicoba, tetapi mudah PVC

2b_Circulation 63
 Gangguan irama jantung

• Severe tachycardia • Amiodarone

• Beta-blocker : Propanolol
– SVT, AF rapid
• Ca-blocker : verapamil, diltiazem
• Adenosine (efek singkat)
• Digitalis (onset lambat)
• Synchronized DC 50-150 Joules

• Severe tachycardia • Amiodarone 50-150 mg iv

– Multiple PVC, VT • Lidocain 1-2 mg/kg
• Beta-blocker : Propanolol
• Ca-blocker : verapamil, diltiazem
• VT pulseless : DC 360 Joules64
2b_Circulation