DIANOSIS DAN RESUSITASI

PADA PASIEN SYOK

PERDARAHAN & SYOK
DEHIDRASI
Oleh
Devvista Sari
(I1A010020)
Pembimbing
dr.Mahendratama, Sp.An
FISIOLOGI DASAR JANTUNG

American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors,
student course manual Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
DEFINISI SYOK
Gangguan sirkulasi yang ditandai dengan
kolapsnya hemodinamik tubuh berupa perfusi
yang tidak adekuat pada kulit, ginjal dan
sistem saraf pusat.

American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors,
student course manual Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
KLASIFIKASI SYOK
Syok
 Syok hipovolemik
Kehilangan volume intravaskular yang bersirkulasi dan
penurunan cardiac preload
Loss of blood Loss of Fluid and
(hemorrhagic shock) electrolyte
External hemorrhage
Trauma - External
Gastrointestinal tract Vomiting

bleeding Diarrhea

Internal hemorrhage - Internal (third-spacing)

Hematoma Pacreatitis
Hemothorax or Ascites
hemoperitoneum Bowel obstruction
Loss of plasma
(luka bakar)

American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors,
student course manual Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
PENILAIAN AWAL PASIEN
Denyut

American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors,
student course manual Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
 Pathophysiology of Shock
Hypovolemi
Volume loss
Autonomic tone Fluid shifts from extracellular to
Catecholamine release intravascular

survival Partial restoration of

Venous
capacitance intravascular volume
Heart rate
Intervention / stabilization

Maintenance of perfusion

Blood flow shunted to

vital organs
(heart,lung,brain)
Continued volume loss
Cellular hypoxia /
anaerobic metabolism

ATP production / lactic

acidosis
PATHOPHYSIO, CONTN Cellular hypoxia /
anaerobic metabolism

Survival / delayed
morbidity / mortality
ATP production / lactic
acidosis

Intervention / stabilization Cellular

function
impaired

Continued volume
loss
Membrane
porosity
Lysozymal
Movement of leakage
fluid from Cellular
intravascular autodigestion
to interstitial
Irreversibl spaces
e shock
intervention
No. intervention

DEATH 5/23/17 8
The Golden Hour
is the time in which resuscitation of severely
injured patients must begin to achieve
maximal survive
R. Adams Cowley, MD

The lethal factor in shock is inadequate cellular

oxygen delivery, leads to irreversible anoxic cellular
injury that kills a critical mass of cells

Hasanul, 2009
 THE GOLDEN HOUR
Probability of R. Adams Cowley, MD
Survival
100

80
%
survival
60

40

20

0 minutes
30 60 90
Survival is related to severity and
duration

Hasanul, 2009
SYOK HEMORAGIK
Perdarahan adalah kehilangan volume darah
sirkulasi secara akut.
Estimated Blood Volume (EBV):
Dewasa: 65-70 ml/kg BB
Anak: 80-90 ml/kg BB
Kehilangan darah yang mencapai 25% EBV akan
menyebabkan pasien jatuh dalam syok.
 DERAJAT SYOK PERDARAHAN
Sign & Class I Class II Class III Class IV
symptom
Blood loss Up to 750 750-1500 1500-2000 >2000
(mL)
%Blood Up to 15 15-30 30-40 >40
volume
Pulse rate <100 >100 >120 >140
Blood N N
pressure
Capillary refill N
RR N 20-30 30-40 >35
Urinary >30 20-30 5-15 Negligible
output (ml/hr)
Mental status Mild anxiety Anxiety Confused Lethargic
Fluid Crystalloid Crystalloid Crystalloid + Crystalloid +
replacement blood blood
American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors, student course manual Ed. 8 th.Chicago: American College of Surgeons
Committee on Trauma, 2008.
Perubahan Dalam Systemic Oxygen Delivery
Akibat Syok Perdarahan
PENATALAKSANAAN SYOK HEMORAGIK

Airway and Breathing

Circulation Bleeding Control
Disability Pemeriksaan Neurologi
Exposure Pemeriksaan Lengkap
Dilatasi Lambung Dekompresi
Pemasangan Kateter Urin
FLUID MANAGEMENT

INTRAVASCULAR VOLUME

HEMODYNAMIC MECHANISM
PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

SYSTEMIC VASCULAR
CARDIAC OUTPUT RESISTANCE

BLOOD PRESSURE Tissue Perfusion

Hasanul, 2006
Kristalloid 3:1
Koloid, HES 1:1
Gelatin 1.5 : 1
Darah 1:1
PENGGANTIAN DARAH
Mengembalikan kapasitas angkut oksigen di
dalam volume intravaskuler.

Whole Blood = 6 x BB x Hb

Whole Blood = 6 x BB x Hb
American Soc of Anesthesiologists 1996
Hb 7-15

End-1
Pola kerja penanganan shock
perdarahan
Penderita datang
dengan perdarahan

Pasang infus jarum Ukur tekanan darah, hitung

kaliber besar (16G, nadi, nilai perfusi, produksi
18G), ambil sample urine
darah

Tentukan estimasi jumlah

perdarahan, minta darah

Guyur cepat Ringer Laktat atau

NaCl 0.9% [hangat, 390C] 3x
prakiraan lost-volume [1-2 liter] EVALUAS
I
 RESPON AWAL TERHADAP RESUSITASI CAIRAN

RAPID TRANSIENT NO
RESPONSE RESPONSE RESPONSE
Vital Sign Return to Transient Remain
Normal improvement, abnormal
recurrent of
BP and HR
Estimated Minimal (10%- Moderate and Severe (>40%)
blood loss 20%) ongoing (20%-
40%)
Need for more Low High High
crystalloid
Need for blood Low Moderate to Immediate
high
Blood Type and cross Type-specific Emergency
preparation match blood release
Need for Possibly Likely Highly likely
operative
TANDA HEMODINAMIK MEMBAIK
Perfusi membaik (akral teraba hangat)
Nadi <100 x/menit
MAP > 65 - 95
Produksi urine 0,5 1 cc/kgBB/jam
SYOK DEHIDRASI
ETIOLOGI
Gastrointestinal losses
Vomiting
Diarrhea

Urinary losses
Diabetic ketoacidosis
Diabetes insipidus
Adrenal insufficiency
Diuretic usage

Decreased intake
Stomatitis, pharyngitis
Anorexia, fluid deprivation

Translocation of body fluids

Small bowel obstruction
Peritonitis
Acute pancreatitis
Burns
Ascites
Nephrotic syndrome
DERAJAT SYOK DEHIDRASI

Moderate 5- Severe
Mild < 5%
10% >10%
Pulse rate N
Blood N N
pressure
Respiratory N N Rapid
rate
Capillary <2 seconds 3-4 seconds >5 seconds
return
Urine Output N Negligible/abs
ent
5%Mucous Moist
dehydration = loss Dry
of 5 ml of fluid per 100 g bodyParched
weight or 50 ml
membran
per kg
PRODUKSI URIN
Pemantau aliran darah ginjal
Anak

27
Estimasi Cairan
Rumatan/Maintenance

Weight Rate

For the first 10 kg 4 ml/kg/h

For the next 10-20 kg Add 2 ml/kg/h

For each kg above 20 kg Add 1 ml/kg/h

 MANAJEMEN SYOK DEHIDRASI

Klasifikasi Ringan atau Sedang Berat atau Syok

Pemberian
Cairan Dibagi rata Tahap I (rehidrasi cepat) :
Defisit dalam 24 jam 20-40 cc/KgBB/1-2 jam
Tahap II :
sisa defisit 6 jam
sisanya 16-17 jam

MONITOR
PERUBAHAN :
-Gx Klinis
-Hematokrit
-Plasma elektrolit
-CVP
+ Maintenance
Contoh:

Pasien pria, BB 50 kg, mengalami dehidrasi

moderate (dehidrasi 5%)
Jawab:
Estimated Fluid Therapy

5% dehydration= 50 x 50 = 2500 ml/ 24 h

= 105 ml/h
Maintenance = 40+20+ 30 = 90 ml/h
Rehydration + maintenance = 195 ml/h
TERIMA KASIH