Professional Documents
Culture Documents
SYOK
KOMISI RESUSITASI PEDIATRIK
UKK PEDIATRI GAWAT DARURAT
IDAI
APRC
DEFINISI SYOK
SINDROM KLINIS AKIBAT KEGAGALAN
SISTEM
SIRKULASI UNTUK MENCUKUPI :
NUTRISI PASOKAN
METABOLISME
OKSIGEN UTILISASI JARINGAN TUBUH
FASE: KOMPENSASI
DEKOMPENSASI
IREVERSIBEL
DEFISIENSI O2 SELULER
Etiologi Syok
Type
Primary Insult
Common Causes
Hypovolemic
Decreased circulating
blood vol
Vasodilation -> venous
pooling -> decreased preload
Obstruction of cardiac
Dehydration, hemorrhage,
capilarry leaks
Sepsis, anaphylaxis,
drug intoxication,
spinal cord injury
Cardiac tamponade,
filling/out flow
pneumothoracx,
Distributive
Obstructive
tension
pulmonary
Cardiogenic
Decreased contractility
Dissociative
embolus
Congenital heart disease,
myocarditis, dysritmia
CO poisoning,
methemoglobinemia
METABOLIT
DO2 = CO x CaO2
CaO2 = (1,34 x Hb x sat O2) + (0,003 x PaO2)
JARINGAN
Preload
Contractility
Heart rate
Stroke volume
Blood pressure
Afterload
Adapted from Wade OL, Bishop JM: Cardiac output and regional blood flow, Oxford, Blackwell, 1
Extracel. Fluid
Low Output Cardiac Failure
Volume Pericardial Tamponade Oncotic Pressure
CARDIAC OUTPUT
Non-osmotic
Vasopressin
Stimulation
RENAL WATER
RETENTION
MAINTENANCE OF EFFECTIVE
ARTERIAL BLOOD VOLUME
Renin-AngiotensinAldosterone System
RENAL SODIUM
RETENTION
STROKE VOLU ME
SYMPATHOMIMETIC
AMINES
XANTHINES
POSITIVE
GLUCAGON
INOTROPY
CARDIAC GLYCOSIDES
4
D
3
HYPOXEMIA
ACIDOSIS
HYPOGLYCEMIA
ENDOTOXEMIA
2
DRUG TOXICITY
C
B
NEGATIVE
INOTROPY
A
VOLUME INFUSION
0
10
Oxyhemoglobin saturation
H+
2,3-DPG
CO2
Pi
H+
2,3-DPG
CO2
Pi
PaO2
Shock
Hypotension
Preload
Intravasculer volume
Myocardial contractility
Anaerobic metabolism
Membrane permeability
Cellular hypoxia
Metabolic by-products:
- lactic acid
- myocardial depressant factor
- endogeneous catecholamines
- adenine nucleotides
STADIUM SYOK
KOMPENSASI
DEKOMPENSASI
IREVERSIBEL (PRETERMINAL)
PERJALANAN KLINIS BERSIFAT
PROGRESIF
FASE I: KOMPENSASI
KOMPENSASI TEMPORER
SIMPATIS, SVR, TEKANAN NADI
DISTRIBUSI SELEKTIF ALIRAN DARAH
RETENSI NA & AIR
KLINIS :
* TAKHIKARDIA
* GADUH GELISAH
* KULIT PUCAT DINGIN
* PENGISIAN KAPILER >>
FASE 2: DEKOMPENSASI
KOMPENSASI MULAI GAGAL
HIPOPERFUSI HIPOKSIA JAR. METAB.
ANAEROBIK
GGN. METAB. SELULER
PELEPASAN MEDIATOR : * VASODILATASI
* PERMEABILITAS
* DEPRESI MIOKARD
* GGN KOAGULASI
KLINIS :
TAKHIKARDIA
TEKANAN DARAH TAKIPNU
PERFUSI PERIFER ASIDOSIS (+) OLIGURI (+)
TINGKAT KESADARAN
FASE 3: IREVERSIBEL
KOMPENSASI GAGAL
CADANGAN ENERGI TUBUH
KERUSAKAN/KEMATIAN SEL DISFUNGSI
ORGAN
MULTIPEL
KLINIS : * T.D TAK TERUKUR * NADI TAK TERABA
* TINGKAT KESADARAN * ANURIA (+)
* GAGAL MULTI ORGAN
DAN KEMATIAN
Compensated Uncompensated
Up to 25
25 - 40
Irreversible
> 40
Heart rate
Tachycardia + Tachycardia ++
Tachy/bradycardia
Systolic BP N N or falling
Plummeting
Pulse volume N/
+ ++
Capillary refill
N/
+ ++
Skin
Cool, pale Cold, mottled
Cold, deathly pale
Respiratory rate Tachypnoea + Tachypnoea ++
Sighing rsp.
Mental state
Mild agitation Lethargic Reacts only to pain
Uncooperative or unresponsive
GANGGUAN PERFUSI
PERIFER
CORE > PERIFER TEMP. ~ > 2O C
CAPILLARY REFILL >> :
* NAIL BED PRESS
* BLANCHING SKIN TEST
PRODUKSI URIN
(N) BAYI = 2 ml/kg/jam
ANAK = 1 ml/kg/jam
TATALAKSANA RESUSITASI
SYOK
RESUSITASI AWAL
OKSIGEN 100% + VENTILATORY SUPPORT
PASANG AKSES VASKULER (90 DETIK)
FLUID CHALLENGE (20 ml/kg BB)
SECEPATNYA < 10 MENIT
DPT DIULANGI 2-3 KALI
KRISTALOID/KOLOID
PEMANTAUAN AWAL
RESPON THD FLUID CHALLENGE
PANTAU PROD. URIN (KATETER)
STAT. LAB/PENUNJANG
Monitoring
State of consiousness-Glasgow Coma Scale
Respiratory rate and character
Cardiovascular parameters
RESUSITASI LANJUT
BILA FLUID CHALLENGE NON
RESPONSIVE
INTUBASI & VENT. MEKANIK
PASANG CVP & LOADING HATI-HATI
KOREKSI EFEK INOTROPIK NEGATIF
Hb < 5 g/dl PRC 10 ml/kg BB (Ht 40-50
vol %)
OBAT INOTROPIK
PEMANTAUAN LANJUT
CARI PENYEBAB SYOK (CXR,
KONSULTASI)
EVALUASI FUNGSI SIST. ORGAN LAIN :
ATN/PRE RENAL FAILURE
ARDS
CARDIAC FUNCTION
GGN. KOAGULASI/DIC
ORGAN-ORGAN LAIN
CHILD IN SHOCK
(1) OXYGEN
(2) CRYSTALLOID
20 ml/kg)
NO IMPROVEMENT
NO IMPROVEMENT
URINARY CATHETER
(3) CRYSTALLOID
- INCREASE MABP
(20 ml/kg)
- NORMALIZATION HR
- IMPROVED PERFUSION
- URINE OUTPUT > 1 ml/kg/hr
ESTABLISH CVP
CRYSTALLOID INFUSION
UNTIL CVP - 5 Torr
IMPROVEMENT
ESTABLISH ETIOLOGY
CONFIRM SOURCE
OF FLUID LOSS
IMPROVEMENT
ESTABLISH ETIOLOGY,
ETIOLOGY,
OBSERVATION
CVP > 5 Torr
NO IMPROVEMENT
STROKE VOLUME
1. CORRECT
ACIDOSIS
2. Co. GLUCOSE
3. INTROPIC
SUPPORT
Stop
pemberian
Stadium
Warm Shock
perfusi perifer (N)
Smv O2
(Hiperdinamik)kulit hangat kering
VO2
HR nadi bounding
CO
suhu / (tak stabil)
SVR
RR , gg. kesadaran
hipokarbia
hopoxia
kadar laktat
hiperglikemia
Cold Shock
sianosis
(Hipodinamik) kulit dingin lembab
nadi kecil, lemah
HR , Oliguria
shallow breathing
pe kesadaran
hipoxia
asidosis metab
koagulopati
hipoglikemi
MOSF
failure
Tanda Klinis
bergantung sistem
yang terkena
Gang fisiologis
CO
SVR
CVP
Smv O2
Biokimiawi
Koma
susai
ARDS, CHF, RF
GI bleeding/DIC
jenis
organ
TATALAKSANA SYOK
ANAFILAKTIK
STOP ALERGEN PENYEBAB + ADRENALIN (IM)
AIR WAY & RESPIRATION ADEKUAT
WHEEZING NEBULASI
ADRENALIN/SALBUTAMOL
OBSTRUKSI INTUBASI/SURGICAL AIRWAY
SIRKULASI & HEMODINAMIK
VASO PRESOR
: ADRENALIN (10 g/kg BB)
FLUID LOADING
: KRISTALOID (20 ml/kg
BB/IV-IO)
RE ASSESSMENT ABC RESUSITASI
WHEEZING (+)
NEBULASI SALBUTAMOL
BILA PERLU
(+) HIDROKORTISON (IV)
(+) AMINOPILIN/SALBUTAMOL DRIP
SYOK BERLANJUT :
KOLOID + INOTROPIK
TATALAKSANA SYOK
KARDIOGENIK
OKSIGENISASI ADEKUAT
KOREKSI GGN ASAM BASA & ELEKTROLIT
KURANGI RASA SAKIT & ANSIETAS
ATASI DISRITMIA JANTUNG
KELEBIHAN PRELOAD : DIURETIKA
KONTRAKTILITAS:FLUID CHALLENGE SESUAI
CVP/POAP
OBAT INOTROPIK (+)
Key points in
management
Remember BP and pulse are unreliable
indicators in early septic shock
Look for minor degrees of mental impairment
(anxiety, restlessness)
Do not delay treatment, try to prevent the onset
of hypotension, metabolic acidosis, and hypoxia
Give adequate fluids early in treatment,
especially colloids
Do not use inotropic agents until the patient has
received adequate fluid therapy
Monitor blood glucose, gases, and pH, and treat
appropriately
Pediatric Shock
Introduction
Shock is a syndrome that results
from inadequate oxygen delivery to
meet metabolic demands
DO2 < VO2
Untreated this leads to metabolic
acidosis, organ dysfunction and
death
Oxygen Delivery
Oxygen delivery = Cardiac Output x
Arterial Oxygen Content
(DO2 = CO x CaO2)
Stages of Shock
Compensated
Uncompensated
Irreversible
Compensatory
Mechanisms
Baroreceptors
Chemoreceptors
Compensatory Mechanisms
(cont)
Renin-angiotensin system
Decreased perfusion to the kidney leads to
renin secretion. Renin is eventually
converted to Anigiotensin II leading to
vasoconstriction and aldosterone release.
Aldosterone leads to sodium and water
reabsorption
Humoral responses
catecholamine release leading to increased
contractility and vasoconstriction.
Autotransfusion
Reabsorption of interstitial fluid.
Clinical Presentation
Early diagnosis requires a
index of suspicion
high
Hemodynamic Response to
Hemorrhage
% of
Vasc Resistance
Control
100
Blood Pressure
Cardiac Output
25%
50%
% Plasma Loss
medical history
heart disease
surgeries
steroid use
medical problems
Brief history of present
illness
exposures
Distributive
Analphylactic
Neurogenic
Septic
Cardiogenic
Myocardial
Dysrrhythmia
CHD-(duct
dependant)
Obstructive
Pneumo,
Tamponade,
Dissection
Dissociative
Heat, CO, Cyanide
Endocrine
Neonate in Shock:
Include in differential:
Congenital adrenal hyperplasia
Inborn errors of metabolism
Obstructive left sided cardiac
lesions:
Aortic stenosis
Hypoplastic left heart syndrome
Coarctation of the aorta
Interrupted aortic arch
Outcome of Pediatric
Shock
Chang 1999
2 2 S h o c k K id s
1 1 S e p t ic
7 H y p o v o l e m ic
4 C a r d i o g e n ic
8 2 % D ie d
0 % D ie d
7 5 % D ie d
Management-General
Goal: increase oxygen delivery and
decrease oxygen demand:
Oxygen
Fluid
Temperature control
Antibiotics
Correct metabolic abnormalities
Inotropes
Management-General
(cont)
Airway
If not protected or unable to be
maintained, intubate.
Breathing
Always give 100% oxygen to start
Sat monitor
Circulation
Establish IV access rapidly
CR monitor and frequent BP
Management-General
(cont)
Laboratory studies:
ABG
Blood sugar
Electrolytes
CBC
PT/PTT
Type and cross
Cultures
Management-Volume
Expansion
Optimize preload
NS or RL
Except for myocardial failure use 1020cc/kg aliquots q 2-10 minutes
At 40-60cc/kg reassess and consider:
ongoing losses, adrenal, intestinal
ischemia, obstructive shock. Get CXR.
Consider colloid
Further fluid therapy guided by
response, labs, possibly CVP, CXR
Fluid
Fluid in
in early
early septic
septic shock
shock
Carcillo,
Carcillo, et
et al,
al, JAMA,
JAMA, 1991
1991
Group
1
Group
2
Group
3
(n = 14)
(n = 11)
(n = 9)
Hypovolemic
at 6 hours
-Deaths
Not
hypovolemic
at 6 hours
-Deaths
Total deaths
Management - Cardiotonics
I
Lack of history of fluid losses, history of
heart disease, hepatomegaly, rales,
cardiomegaly and failure to improve
perfusion with adequate oxygenation,
ventilation, heart rate, and volume
expansion suggests a cardiogenic or
distributive component.
Prior to introduction of cardiotonics, the
goals of therapy and criteria for
monitoring of endpoint should be
established
Management - Cardiotonics
II
Epinephrine
0.05-1.5 ug/kg/min
increase HR, SVR,
contractility
End point: adequate BP;
acceptable tachycardia
Norepinephrine
0.05-1.0 ug/kg/min
Increase SVR
End point: adequate BP
Dopamine
2-20 ug/kg/min
Lower doses,
increases renal and
splanchnic blood
flow, & contractility.
Higher doses
increases HR and
SVR
End Point: Improved
perfusion, BP, Urine
Management - Cardiotonics
III
Dobutamine
1-20 ug/kg/min
increases
contractility, may
reduce SVR, PVR
End Point: Improved
perfusion, may
decrease BP
Prostaglandin E1
0.05-0.1 ug/kg/min
maintains patency
of ductus
Hypovolemic Shock
Most common form of shock worldwide
Results in decreased circulating
blood volume, decrease in prelaod,
decreased stroke volume and
resultant decrease in C.O.
Etiology: Hemorrhage, renal and/or
GI fluid losses, capillary leak
syndromes
Hypovolemic Shock
Clinically, history of
vomiting/diarrhea or trauma/blood
loss
Signs of dehydration: mucous
membranes, tears, skin turgor
Hypotension, tachycardia without
signs of congestive heart failure
Hemorrhagic Shock
Most common cause of shock in
the United States (due to trauma)
Patients present with an obvious
history (but in child abuse history
may be misleading)
Site of blood loss obvious or
concealed (liver,
spleen,intracranial, GI)
Hypotension, tachycardia and
Hypovolemic/Hemorrhagic
Shock: Therapy
Always begin with ABCs
Replace circulating blood volume
rapidly: start with
crystalloid/colloid
Blood products as soon as
available for hemorrhagic shock
(Type and Cross with first blood
draw)
Replace ongoing fluid/blood losses
Septic Shock
SIRS/Sepsis/Septic shock
Mediator release:
exogenous & endogenous
Maldistribution
Cardiac
of blood flow
dysfunction
Imbalance of
oxygen
supply and
demand
Alterations in
metabolism
Cardiogenic Shock
Etiology:
Dysrhythmias
Infection
Metabolic
Obstructive
Drug intoxication
Congenital heart disease
Trauma
History
PE:
Enlarged liver
Gallop rhythm
Murmur
Rales
CXR:
Enlarged heart, pulmonary venous congestion
Correct dysrhymias
Optimize preload
Improve contractility
Reduce afterload
Minimize cardiac work:
Distributive Shock
Due to an abnormality in vascular tone
leading to peripheral pooling of blood
with a relative hypovolemia.
Etiology
Anaphylaxis
Drug toxicity
Neurologic injury
Early sepsis
Management
Fluid
Treat underlying cause
Obstructive Shock
Dissociative Shock
Hemodynamic Variables
in Different Shock States
Hypovolemi
c
Cardiogeni
c
Obstructive
Distributiv
e
Septic:
Early
Septic:
Late
CO
SVR
MAP
Or
Or
Or
Or
Or
Wedg
e
Or
CVP
Or
or
Final Thoughts
Recognize compensated shock quickly- have a
high index of suspicion, remember tachycardia is
first sign. Hypotension is late and ominous.
Gain access quickly- if necessary use an IO line.
Administer adequate amounts of fluid rapidly.
Remember ongoing losses.
Correct electrloytes and glucose problems quickly.
If the patient is not responding the way you think
he should, broaden your differential, think about
different types of shock.
Figure 1.
Hgb
CaO2
A-a gradient
DPG
Acid-Base Balance
Blockers
Competitors
Temperature
Influenced By
Oxygenation
DO2
Influenced By
Drugs
Conduction System
HR
CO
EDV
SV
CVP
Venous Volume
Venous Tone
Ventricular
Compliance
Influenced By
ESV
Contractility
Influenced By
Afterload
Temperature
Drugs
Metabolic Milieu
Ions
Acid Base
Temperature
Drugs
Toxins
Blockers
Competitors
Autonomic Tone