Presentasi Shock

8/20/2019 Presentasi Shock

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REFERAT

SHOCK

Pembimbing: dr. Horry H, SpAn

Oleh: Vita Delia – !"#$##


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LATAR BELAKANG

• Shock hipoper%&'i padam&ltiorgan(") a'd%a.

• Tipe: – hipo*olemi+, +ardiogeni+, 'epti+,

anala+ti+, ne&rogeni+, endo+rinologi+

– Dapat ter-adi o*erlap

• Diagno'a 'r +lini' parameterhemodinami+


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• /P 0 1O 2 SVR ↓ ↓ /P 3↓ ↓ 1O 4 ↓ ↓ SVR

• 1O men&r&n a+ral dingin, ap rell lambat

• 1O nai+ a+ral hangat, ap rell epat

• 5ngat6 – Pada indi*id& +ondi'i 'ehat b' terdapat /P rendah

– Pada indi*id& 'ho+ dapat ter-adi /P 'i'toli+ normaloleh +arena ton&' 'impati' berlebihan

– Seda'i menyebab+an hipoten'i

• 7ompli+a'i 8ODS death


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EP5DE85O9O5

• Tida+ dapat dipa'ti+an parametertida+ 'en'iti%; deni'i tida+ denit

• /P 'i'toli+


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ET5O9O5 ? T5PE

• Sho+ hipo*olemi+

• Sho+ +ardiogeni+

• Sho+ *a'ogeni+: – Sho+ 'epti – Sho+ anala+ti+

– Sho+ ne&rogeni+

• Sho+ hipoadrenal


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Shock hipovolemik – penurunan venous returnen!an "un!si #antun! $an! normal7ehilangan darah:

-Perdarahan tra&mati'o Hemotora+', Hemoperitone&m, Fra+t&r Bpel*i',

%em&rC- Perdarahan non tra&mati'

o 5 /leeding, AAA r&pt&re, etopi pregnany

7ehilangan *ol&me pla'ma:- 9&+a ba+ar, ET, 8&ntah, Diare, Hipero'molar,

A'ite', Dehidra'i, 7ehamilan, Di&reti, Diabete'

in'ipid&'

Pening+atan te+anan atri&m +anan – hipo*olemi+'entral:- Heart ompre''ion

- Te+anan intratora+' tinggi


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Shock Kario!enik – penurunan "un!si #antun!

5n%ar+ mio+ardi&m a+&t5n%ar+ *entri+el +anan ata& +iri7ardiomiopati tahap a+hirAritmia

R&pt&r 'ept&m4dinding -ant&ngReg&rgita'i +at&pSteno'i' +at&pDi'%&ng'i ata& r&pt&r otot papillary

Shock septic – hipotensi en!an penin!katanCO5n%e+'i ba+teri – gram B?C5n%e+'i %&ngi – ?"

5m&no'&pre'i


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Shock ana%laktik

Rea+'i alergi obatRea+'i alergi ma+ananRea+'i *enomRea+'i non?im&nologi+ Brea+'i anala+toidC

Shock neuro!enik Tra&ma med&lla 'pinali'E%e+ 'amping ane'te'ia 'pinal ata& regional

Tra&ma +epala

Shock hipoarenal5n'&'ien'i adrenalAtro +elen-ar adrenal8eta'ta'i'


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PATOF5S5O9O5

.

8etaboli'me anaerobi+

Sem&a tipe 'ho+ hipoper%&'i

9a+tat a'ido'i' 8ediatorinammatori+

hipo+'ia

5n-&ri'el

Di'%&ng'i m&ltiorgan 8ODS

re'pon inamatori+'i'temi+


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Re'pon 5namatori+

• Ter-adi pada 'ho+, mi'. Sho+ 'epti+

• Sebali+nya 'ho+ merang'angre'pon inamatori+ me+ani'meischemic-reperfusion injury


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Re'pon 8i+ro'ir+&la'i

Diameter

arteriole


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Re'pon 'el


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Re'pon e&roendo+rin

• 1erebral blood o=


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• Stre'' pengel&aran A1TH orti'ol I gl&o'e inta+e,Igl&+oneogene'i',lipoli'i'

• l&+agon Igl&+oneogene'i' di hepar GIgl&+o'a darah

• ReninI AT 5 AT 55 *a'o+on'tri+tor poten – Aldo'teronI a reab'I

– Va'opre''inI H#O reab'I

J Re'pon hormonal &t+ pertahanan *ol&medarah


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Re'pon 7ardio*a'+&lar

• /P 0 1O 2 SVR

SV 2 HR

• SV 3 preload, a%terload, +ontra+tilita'• Hipo*olemi+ preload *entri+el SV

– 7ompen'a'i: HRI Bterbata'C

• Sep'i', 85, A, hipoten'i

+ontra+tilita'

• SVRI1O

• SVR1OI B'ho+ 'epti+C


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Re'pon P&lmoner

• Hipo+'ia hiper*entila'i al+alo'i're'piratori+, FR1 atele+ta'i'

• 9e&+o'it 8ediator inamatori+ diarteri p&lmoner A95 G ARDS

• 7er-a organ perna%a'anI +eb&t&han O#I


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Re'pon Renal

• Hipoper%&'i renal FR

• Arteriol a%eren *a'o+on'tri+'i ton&' 'impati'I, adrenergi+I,angioten'inI

• Renal i'+emi+ ATN edema ob'tr&+'i t&b&l&' renal

• Di'%&ng'i renal 'i'temb&Kera'ido'i' metaboli+ ma+inb&r&+


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Re'pon 8etaboli+

• angg&an metaboli'me +arbohidrat,lipid, protein

• 8etaboli'me anaerobi+ la+tatII

• 9a+tat memprod&+'i gl&+o'a drhepar

• 9ipogene'i'I hipertrigli'erid

• 7ataboli'me proteinI atro otot


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ELA9A 7955S

• Hipoten'i

• Tahyardia

• Tahypnea• Hipertermia4hipotermia

• Te+anan p&l'a'i

• A+ral dingin4hangat• Olig&ria


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Sho+ Hipo*olemi+Kelas I Kelas II Kelas III Kelas IV

Perdarahan (ml) Hingga 750 750-1500 1500-2000 >2000

% KehilanganVolume Darah

Hingga 15% 15-30% 30-40% >40%

Nadi 140

Tekanan Darah Normal Normal Menurun Menurun

Frekuensi Nafas 14-20 20-30 30-40 >35

Tekanan Pulsasi Normal /meningkat

Menurun Menurun Menurun

Urin Output >30 20-30 5-15 -tatus !ental eli!a"

!angatringan

eli!a"ringan

eli!a" #etargik

"ekomendasi

resusitasi

$ri!taloi $ri!taloi $ri!taloi &

ara"

$ri!taloi &

ara"


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Sho+ 7ardiogeni+

• Angina

• Di'pnea

• Palor

• Dia%ore'i'

• /radi+ardia Bapabila '&dah beratC

• Te+anan p&l'a'i 'empit B


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• 9ab: le&+o'ito'i', pening+atan /N G+reatinin, la+tat a'ido'i', 178/,troponin 5 G T

• E7 abnormal

• 1he't ?Ray: +ardiomegali

• Ehoardiography: reg&rgita'i,ardia tamponade, P emboli


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Sho+ Septi+

• Febri'4hipotermi

• A+ral hangat

• 9ab: 9e&+o'ito'i', ne&tropeni, PTprolonged, trombo'itopeni,hipergli+emi, bilir&binemia, al+alin%o'%ata'e mening+at


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Sho+ Anala+ti+• e-ala +ardio*a'+&lar:

– Hipoten'i B


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Sho+ e&rogeni+

• Pen&r&nan +e'adaran

• Hipoten'i

• Tahyardia4bradyardia• Di'%&ng'i 'impati' pooling darahpd *ena

• A+ral hangat

• 1T48R5: %ra+t&r, de+ompre'i


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Sho+ Hipoadrenal

• Hipoten'i

• SVR dan 1O

• Diagno'i': – Sedang dalam 'tre'4penya+it

a+&t4opera'i mayor

– Pema+aian 'teroid +roni'

– A1TH 'tim&lation te't


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ho#kKardiogenik

ho#k hipo$olemik ho#k septikho#k

anafilaktik

ho#khipo

adrenal"ingan edang &erat 'O 'O

Perfusiperifer

'u(at 'u(at 'u(at 'u(at 'u(atNormal/keme-ra"an

Normal/kemera"an

Normal/kemera"an

UrineOutput

↓↓ ↓↓ N ↓↓ ↓↓ ↓↓ ↓↓ ↓↓

Nadi )) )) N N )) )) )) ↓↓tatus!ental

eli!a" eli!a" Normal Hau! eli!a" eli!a" eli!a" eli!a"

Vena *ugularis

*i!ten!i *i!ten!i +ata +ata +ata +ata +ata +ata

'ardia#

Inde+

↓↓ ↓↓ ↓↓ ↓↓ ↓↓ )) ↓↓ ↓↓

Tekananatrium,

$entrikel)) )) ↓↓ ↓↓ ↓↓ )) ↓↓ ↓↓

V" )) )) )) )) )) ↓↓ ↓↓ ↓↓


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D5AOS5S


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TATA9A7SAA

• S&r*ey a=al :

–Air=ay

–/reathing –1ir&lation

–Dr&g'


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Airway

'nikasi 'ntu(asi paa Shock

Hipo+'emia7egagalan Ventila'iHipoper%&'i organ *italon?ompo'menti'

Tahypnea Q>4menit ata& bradypnea berat

Pengg&naan otot a'e'ori' +eti+a re'pira'i


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Penilaian Hemodinami+Pa'ien

• A+'e' intra*ena peri%er

• 1V1 BEarly Goal-Directed Therapy C

• 7ateter &rin

• OT4T

• 8onitor pa'ien: O# Sat, /P, E7

• 7ateter arteri peri%er

/P G 1O lbha+&rat, A/


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Breathing

• Ventila'i me+ani+ 'eda'i Grela+'an otot – +eb&t&han O# 'i'tem re'p

– Veno&' ret&rn Iairan

• Vol&m tidal @?ml4+g

– 8enegah hipoten'i

– 8enegah ventilator-induced lung injury


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Circulation

• Re'&'ita'i 'eepatnya meminimali'ir S5RS – Time is tissue

• A+'e' 5V # +ateter &+&ran be'ar B"@?"C

– Pd ana+ Bbila '&'ahC intrao'eo&'

• Proto+ol Early Goal-Directed Therapy


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Early oal?Direted Therapy


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Re'&'ita'i Terapi 1airan

• " 9iter B#ml4+g pada ana+?ana+C.$ S dalam " menit

• E%e+ -ang+a pende+ – benet: hiperten'i, te+anan p&l'a'i I,

HR

– +ompli+a'i: LVP I, edema p&lmoner

• E%e+ B?C re'&'ita'i inade+&at


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• Sho+ +ardiogeni+: # ml 'etiap #menit

• Sho+ 'epti+: ml 'etiap M menit

• Sho+ perdarahan: -&mlah be'arhingga /P mening+at dan -ant&ngpen&h(")


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Early oal?Direted Therapy


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End-point Resuscitation

• Perbai+an 'tat&' mental

• HR, /P

• Sir+&la'i peri%er

• /a'e e2e'' G latate

• oal?direted approah

– Nrine o&tp&t Q . m94+g4hr

– 1VP ?"# mmHg – 8AP @ to $ mmHg

– 1entral *eno&' o2ygen onentration Q !


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Drugs

• Penyebab 'ho+ telah di+etah&idengan pa'ti tatala+'ana 'r lebih'pe'i+ G lebih optimal

• Sho+ 7ardiogeni+ – e di'%&ng'i +at&p, r&pt&r 'ept&m

opera'i repara'i – e 85 tromboli'i', angiopla'i, 1A/

– Aritmia obat anti?aritmi


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• Sho+ Perdarahan – 5ndi+a'i tran'%&'i berd'ar+an re'pon a=al

Respon CepatResponTransien

Responne!ati"*minimal

Tana+tana,ital 7embali ormal

Hipoten'i dan

tahyardiaber&lang

Tetap abnormal

Ban$akn$a-erarahan

Ringan B"?#C

Sedang B#?>C

/erat BQ>C

Ke(utuhan

cairan

Rendah Tinggi Tinggi

Ke(utuhantrans"usiarah

Rendah Sedang – tinggi Segera

-ersiapanarah

Tipe Gro''math

Tipe?'pe'i+ Darah dar&rat

'ntervensi 7em&ng+inan Diperl&+an Sangat


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• Septi+ 'ho+

– antibioti+ broad 'petr&m

– draina'e ab'e'

– protein 1 a+ti%

– 'teroid Bbagi pa'ien hipoadrenalC

• Sho+ ne&rogeni+

– ER ata& %enilepine%rin &t+ pertahan+anSVR G 8AP


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Sho+ anala+ti+

Epine"rin

./.000

Klo"enamin

Hirokortison

&e1asa 2anak 3.4tahun

. ml " mg # mg

Anak 5+.4

tahun.M ml mg "

Anak 5 (ln+5 thn

." ml#. mg

Anak 65

(ulan

#

g4+g #


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Progno'i'

• /ergant&ng pada +ondi'i +lini'pa'ien, penyebab, +ompli+a'i, dane%e+ti*ita' re'&'ita'i dini

• 8ortalita' 'ho+ +ardiogeni+ dan'ho+ 'epti+ tetap tinggi

• /a'e deit per'i'ten adanya

m&ltiorgan %ail&re

Presentasi Shock

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