Você está na página 1de 39

Shock Management

& Emergency Drugs


Ahmad Handayani, MD
DEFINISI
Gangguan dari perfusi jaringan yang terjadi
akibat adanya ketidakseimbangan antara
suplai oksigen ke sel dengan kebutuhan
oksigen dari sel tersebut.
Semua jenis shock mengakibatkan gangguan pada
perfusi jaringan yang selanjutnya berkembang
menjadi gagal sirkulasi akut atau disebut juga
sindrom shock

IT IS NOT LOW BLOOD PRESSURE !!!


IT IS HYPOPERFUSION…..
 Jadi diagnosis syok saat ini bukan
lagi berdasarkan TD semata,
melainkan syok adalah hipotensi
disertai tanda/gejala hipoperfusi.
 “Hipoperfusi dapat terjadi pada
keadaan TIDAK hipotensi”
 Hipotensi : Nilai TD sistolik
< 90 mmHg, atau penurunan TD
sistolik > 40 mmHg dari normal

 Hipoperfusi 
 Otak : Penurunan kesadaran
 Kulit : Akral Dingin
 Ginjal : Urine Output berkurang

Selanjutnya terjadi disfungsi


organ  kematian.
ETIOLOGY OF SHOCK
HYPOVOLEMIC
CARDIOGENIC
DISTRIBUTIVE :
NEUROGENIC
ANAPHYLACTIC
SEPTIC
OBSTRUCTIVE
TIPE - SHOCK*
Clinical Primary
Type of Shock
causes mechanism
Exogenous blood,
Hypovolemic Volume loss plasma, fluid or
electrolyte loss

Myocardial infarction,
Cardiogenic Pump failure cardiac arrhythmias,
heart failure

Increased venous Septic shock, spinal


Distributive capacitance or
arteriovenous shunting
shock, autonomic
blockade, drug
overdose

Vena caval obstruction,


Extra-cardiac
cardiac tamponade,
obstruction of blood
Obstructive flow
pulmonary embolism,
aortic compression or
dissection

*MORE THAN ONE TYPE MAY BE PRESENT


3 DASAR PENYEBAB PATOFISIOLOGI SYOK

CURAH JANTUNG MASALAH POMPA KARDIOGENIK-


ISKEMIK

VOLUME INTRAVASKULER MASALAH CAIRAN HIPOVOLEMIK

TAHANAN PEMB DRH MASALAH SALURAN / NEUROGENIK-


PERIFER PIPA SEPTIK-
ANAFILAKTIK
HYPOVOLEMIC SHOCK
PENYEBAB HIPOVOLEMIA

HEMORRHAGIC

NON - HEMORRHAGIC
HEMORRHAGIC

Trauma

Vascular

Gastrointestinal

Retro peritoneal

Obstetric and Gynecology


NON-HEMORRHAGIC
1. External Fluid Loss
Dehydration
Vomiting, Diarrhea
Polyuria
2. Interstitial Fluid Redistribution
Thermal injury
Trauma
Anaphylaxis
3. Increased Vascular Capacitance
Sepsis
Anaphylaxis
Toxins / Drugs
Head Injury
A 25 year old woman was admitted in the ER
She had given birth 2 hours ago helped by “dukun”
Is the uterine muscle contracted sufficiently ?
Is there no placenta remained inside ?
Is there no laceration in the birth canal ?
Is there no bleeding diathesis / coagulopathy ?
CARDIOGENIC SHOCK
 Sebab:
 Disritmia ; ( takiaritmi, bradiaritmi)
 “Pump failure”  akut MCI, kardiomiopati
 Disfungsi katup akut ; terutama lesi
regurgitasi
 Ruptur dinding ventrikel

 Karakteristik hemodinamik
  curah jantung
  tek pengisian vent kiri
  tahanan pemb darah sistemik
CARDIOGENIC SHOCK
Tujuan Utama Terapi: Memperbaiki fungsi
miokard
 Antiaritmi
 Inotropik : Dobutamin (ß1,ß2) - kontraksi 
 Vasopresor : Norepinephrin (a1,a2) – me 
diastolik pressure untuk perfusi koroner
 Kombinasi NE dan dopamin dosis tinggi jika
TD < 80 mmHg, tambahan dobutamin jika
TD sudah mulai stabil untuk mengganti
vasopresor
CARDIOGENIC SHOCK
DECREASED CARDIAC FUNCTION
Decreased ventricular function
MI
Pericaridal tamponade
Tension pneumothorax

Infective cardiac contraction


Arrhythmias

CLINICAL FINDINGS
Hypotension
Tachycardia
Tachypnea
Oliguria
**distended neck veins**
TENSION
PNEUMOTHORAX
DISTRIBUTIVE SHOCK

 Sebab :
 Tersering septik syok, anafilaksis,
neurogenik, obat vasodilator dan
insufisiensi adrenal akut.
 Gambaran hemodinamik :
 curah jantung normal / meningkat,
tahanan pemb.drh sistemik
rendah, tekanan pengisian
ventrikel kiri rendah/normal
SEPTIC SHOCK
SEVERE INFECTION W RELEASE OF
MICROBIAL PRODUCTS
Release of vasoactive mediators

HYPERDYNAMIC STATE
Peripheral vasodilation
Increased cardiac output
Fever, tachycardia, tachypnea, warm skin

MAINTENANCE OF FAILURE TO MAINTAIN


INTRAVASCULAR VOLUME INTRAVASCULAR VOLUME
Hyperdynamic shock Hypodynamic shock
Cool skin, tachycardia,
hypotension, oliguria
NEUROGENIC SHOCK

REDUCED VASOMOTOR TONE FROM


LOSS OF SYMPTATHETIC
INNERVATION

Spinal cord trauma


Spinal anesthesia
Acute gastric dilatation

CLINICAL FINDINGS

Bradycardia
Mild hypotension
Flat neck veins
HEMODYNAMIC
Lung

Pulmonal
vein
Left atrium

SVR =
Systemic

Blood Pressure
Vascular
Right
Left Resistance
Atrium
ventricle

Right
ventricle

organ
PATHOGENESIS OF
SHOCK
Cardiogenic Distributive
Shock Shock
Inotropes
Vasopressor ( NE,PE,ADR,Dop)
(Dob,Dop,Adr,Amr)

Release Blood Pressure


tamponade,etc
Pump =
CO SVR
Pipe = Vascular
Heart

Obstructive Cardiac Output x SVR


Shock
Volume =
BloodCVP

Hypovolemic
Fluids
Shock
DIAGNOSIS STATUS SHOCK
BERDASARKAN PARAMETER
HEMODYNAMIK
Cardiac
TYPE CVP or PCWP Output SVR

Hypovolemic Decreased Decreased Increased

Cardiogenic Increased Decreased Normal or


Increased

Septic Decreased or Increased Decreased


increased
Traumatic Decreased Decreased or Decreased or
increased increased
Neurogenic Decreased Decreased Decreased

Hypoadrenal Decreased or Decreased or Decreased or


increased increased increased
Kasus 1

 Seorang laki-laki, kecelakaan, trauma multiple.


Perdarahan hebat. TD 90/60 mmHg. Ditemukan
nilai CO 6 L/I, CVP 1 mmHg.
 Berapakah nilai SVR?

A. > 1200
B. 1020
C. 920
D. < 800
1

 Apakah Jenis Shock yang dialami?

A. Hipovolemik
B. Kardiogenik
C. Distributif (Septik)
Kasus 2

 Seorang laki-laki, gagal jantung setelah mengalami


sindroma koroner akut. TD 80/50 mmHg.
Ditemukan nilai CO 2 L/I, CVP 16 mmHg.
 Berapakah nilai SVR?

A. > 1200
B. 1020
C. 920
D. < 800
2

 Apakah Jenis Shock yang dialami?

A. Hipovolemik
B. Kardiogenik
C. Distributif (Septik)
Kasus 3

 Seorang laki-laki, infeksi berat karena DBD. TD


80/50 mmHg. Ditemukan nilai CO 5.5 L/I, CVP 8
mmHg.
 Berapakah nilai SVR?

A. > 1200
B. 1000
C. 920
D. < 800
3

 Apakah Jenis Shock yang dialami?

A. Hipovolemik
B. Kardiogenik
C. Distributif (Septik)
TREATMENT CONCEPT OF SHOCK

ENHANCING PERFUSION / OXYGEN DELIVERY

DO2 = CO x CaO2
Cardiac Arterial
output O2 content

Oxygen delivery/DO2 = HR X SV X Hb X S02 X 1.34 + Hb X


paO2

Inotropes Transfuse Partially


Fluids
dependent on
FIO2 and
pulmonary
status
SUMMARY
Shock is an altered state of tissue perfusion
severe enough to induce derangements in
normal cellular function
Shock has many causes and often may be
diagnosed using simple clinical indicators
Treatment of shock is primarily focused on
restoring tissue perfusion and oxygen delivery
while eliminating the cause

Você também pode gostar