Post on 07-Aug-2018
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REFERAT
SHOCK
Pembimbing: dr. Horry H, SpAn
Oleh: Vita Delia – !"#$##
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LATAR BELAKANG
• Shock hipoper%&'i padam<iorgan(") 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<iorgan 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<iorgan %ail&re