Bls,Shock,Fluid Therapy

7/28/2019 Bls,Shock,Fluid Therapy

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LIFE THREAT

Dimana saja!!

Kapan saja!!

Pada siapa saja!!


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Life Threat

Orang sehat

TRAUMA/PENYAKIT MENDADAK

TERANCAM JIWA

PENYELAMATAN


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.


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SIAPA MENOLONG??

ORANG AWAM

AWAM KHUSUS : SATPAM

LIFE GUARDS

TENAGA AMBULANS

PERAWAT UMUM

PERAWAT KHUSUS (ICU)

MAHASISWA FK, DOKTER, DOKTERGIGI

DOKTER SPESIALIS


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Basic Life Support

LANGKAH:

Airway management

Breathing support

Circulation support

LEVEL OF COMPETENCE

* mampu mengerjakan

o diajarkan teorinya

x tidak diajarkan


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BASIS CRANIIatap nasopharynxtulang tipis mudah patah

ARAH TUBE

naso-pharyngeal

CRICOTHYROIDOTOMY

Plica vocalis


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Cause of Airway Obstruction


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Recognition of airway obstruction

Movement of chest and abdomen

Exhalation air : --

Retraction : suprasternal intercostal

epigastrium

Cyanotic


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Airway Management

Without Device

With Devices


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Suspect neck trauma

Jaw thrust


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2. Head tilt & chin lift


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Airway

Equipment


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Oropharyngeal airway


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Nasopharyngeal tube insertion

1.


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Trachea Intubation


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Mask Ventilation


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.


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SHOCK

Inadequate tissue perfusion along with

cellular hypoxia and oxygen debt, which

results in cellular dysfunction and is caused

by inadequate systemic oxygen delivery orimpairment of cellular oxygen uptake.


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Stages of Shock

1. A nonprogressive stage (compensated)

in which the normal circulatory mechanismseventually cause full recovery without help fromoutside therapy

2. Aprogressive stage, in which, withouttherapy, the shock become steadily worse until

death.

3. An irreversible stage


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EVALUATION OF SYMPTOMS

HISTORY

In hypovolemic shock : blood loss, trauma,

fluid losses, dehydration, third spacing orother fluid losses.


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History

In adult drop Systolic BP > 40 mmHgsignificant hypotension


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General Symptoms of Shock

CNS changes

*Confusion, coma, combative behavior,

agitation, stupor

Skin changes

*Cool, clammy, warm, diaphoresis

Cardiovascular

*Increase or decrease heart rate,

arrhythmia, angina, low high or normal

cardiac output, changes in pulmonary pressure


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General symptoms of shock

Pulmonary

*Increased RR, increase or decrease in

end- tidal CO2, decrease O2 saturation,

increased pulmonary pressures,

respiratory failure, decreased tidal volume,

decreased FRC

RENAL

*Decreased urine output, elevation in BUN andcreatinine levels, change in urine electrolyte levels


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Common effects of shock on organs

Systemic: Capillary leak, formation of micro

vascular shunts, cytokine release

Cardiovascular: circulatory failure,

depression of cardiovascular function, arrhythmia

Haematologic : bone marrow suppression,

coagulopathy, DIC, platelet

dysfunction


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. Hepatic : liver insufficiency, elevation of

liver enzyme levels, coagulopathy

Neuroendocrine: change in mental status,

adrenal suppression, insulin

resistance, thyroid dysfunction

Renal : renal insufficiency, change in urine

electrolyte levels, elevation of BUN

and creatinine levels

Cellular : cell-to-cell dehiscence, cellular

swelling, mitochondrial dysfunction,

cellular leak


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Hypovolemic shock

Cause :depletion of fluid in the intravascularspace (hemorrhage, vomiting, diarrhea,dehydration, capillary leak or a combination)

SIRS capillary leak Findings : decreased CO, decreased PCWP,

increase SVR

Echo :decreased right-sided filling, decreasedstroke volume, increase aortic diameter


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Perdarahan

Kehilangan akut darah dari sistim sirkulasi

Estimated blood volume /EBV:

* Adult : 7% BW male 70 ml/kg female 65 ml/kg

*Children : 8-9% BW


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The Role of Fluids

Optimal organ function requires the two-

way movement of substrates and cell

products between the circulatory system and

the cells themselves.


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Classification of infusion fluids

1.Dextrose/glukose/fruktose solution

2.Crystalloid : Resuscitation fluid (Ringer

laktat, Ringer asetat)

Maintenance fluid:

Kaen 3A, Kaen 3B, Kaen MG3

Tutofusin OPS

3.Colloid : Dextran 40 ,70, Gelatin, Hydroxy ethyl-starch, artificial blood


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Infusion fluids

4.Parenteral nutrition : carbohydrate,

protein/amino acids

lipid,

combination

Triofusin, Triofusin E-1000, Aminofusin,

Aminoleban, Lipovenous

5.Blood products : albumin, FFP, SPPS, cryoprecipitate


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Crystalloid

Expand the plasma volume by about 200 ml

per-liter infused diluting circulating proteins,plasma COP

Potentially harmful interstitial overhydration

Crystalloid need to be administered at volumes 3to 5-folds greater than of (isooncotic) colloids

to achieve comparable plasma volumes andresuscitation endpoints

I f i


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Infusion management:

A rational strategy Two different therapies for two different diagnosis

fluid substitution and fluid resuscitation.

The basis considerations:

1.Save the endothelial glycocalyx from degradation due tohyperinfusion

2.Substitute fluid loss or dehydration using crystalloidinfusions

3.Replace volume loss or hypovolemia with colloidal

tetrastarch solutions until normalization ofthe circulatingblood volume


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Colloid

The intravascular COP after colloid infusion is influencedby baseline COP, the degree of hemodilution and the COPof the infused volume and its plasma retention, determinedby the molecular weight distribution.

Albumin solutions are monodisperse (MW of 69 kDa) Gelatins are polydisperse and in excess of 75% of the

molecules are to be smaller than the renal threshold of 30

kDa.


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Colloid Hydroxy-ethyl-starch solutions is very polydisperse,

defined by degree of substitution and by MW.

The greater of degree of substitution the greaterthe resistance of degradation prolongs theeffectiveness of HES as a plasma expander

Colloid with a low COP50/COP10 ratio will be lostmore rapidly from intravascular space

The resulting sealing effect may attenuate fluidextravasation independently of the COP by albumin.


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increases ICF > ECFincreases ICF > ECF

ICF ISF PlasmaICF ISF Plasma

Replace Normalloss (IWL + urine)

Replace Normalloss (IWL + urine)

Hypotonic infusionHypotonic infusion

5% dextrose 5% dextrose

85 ml85 ml255 ml255 ml660 ml660 ml

Cairan


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increases ECFincreases ECF

ICF ISF PlasmaICF ISF Plasma

Replace acute/abnormalloss

Replace acute/abnormalloss

Infus IsotonicInfus Isotonic

800 ml 200 ml

Ringers acetate Ringers lactate Normal saline

Ringers acetate

Ringers lactate Normal saline

RL 2liter/15 menit


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Perdarahan

Mulai segera resusitasi cairan agressif:

Rule 3:1 untuk perdarahan akut

Pengobatan disesuaikan dengan respon

pasien pada terapi awal

T d d h


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Tanda perdarahan

Klas I (BB 70 Kg) -----------------------------------------------------------

Perdarahan ml sampai 750

Perdarahan (%BV) sampai 15%

Nadi < 100

Tensi Normal

Tek Nadi (mmHg) Normal atau naik

Nafas 14 - 20

Urine ml/jam > 30

SSP/status mental sedikit Cemas Penggantian cairan Kristaloid

(hukum 3:1)

T d d h


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Tanda perdarahan

Klas II

----------------------------------------------------------- Perdarahan ml 750-1500

Perdarahan (%BV) 15-30%

Nadi >100

Tensi Normal Tek Nadi (mmHg) Turun

Nafas 20-30

Urine ml/jam 20-30

SSP/status mental Cemas sedang

Penggantian cairan Kristaloid

(hukum 3:1)

T d d h


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Tanda perdarahan

Klas III

----------------------------------------------------------- Perdarahan ml 1500-2000

Perdarahan (%BV) 30-40%

Nadi > 120

Tensi Turun Tek Nadi (mmHg) Turun

Nafas 30-40

Urine ml/jam 5-15

SSP/status mental Cemas gelisah

Penggantian cairan Kristaloid & darah

(hukum 3:1)


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Perdarahan bermakna

perlu konsultasi BEDAH

.


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Keputusan Pengobatan

Respon pasien pada resusitasi cairan

merupakan penentu terapi berikutnya

INGAT

Bedakan antara hemodinamik stabil danhemodinamiknormal


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Keputusan Terapi

Respon cepat

*< 20% perdarahan

*Stabil : respon pada penggantian cairan

*Lanjutkan monitor

*Evaluasi dan konsultasi bedah


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Keputusan Terapi

Respon transient

20-40% perdarahan

Tidak stabil : memburuk setelah terapi cairan

awal

Lanjutkan cairan dan darah

Evaluasi dan konsultasi bedah

Perdarahan berlanjut : operasi


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Keputusan terapi

Tak ada respon (minimal)

> 40% perdarahan

Tak ada respon pada terapi cairan

Singkirkan kemungkinan shock

non- hemorrhagik

Operasi segera


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Diagnosis & pengobatan

Pitfalls *Tensi tidak sama dengan cardiac output

*Umur

*Atlit

*Hipotermi

*Pengobatan

*Pacu-jantung


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Differential Diagnosis

Distributive shock

Hypovolemic shock

Obstructive shock

Cardiogenic shock


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DD

Hypovolemic shock

Dehydration (low fluid intake, diarrhea, bowel

obstruction, sweating or diabetes insipidus)

Diuresis (diuretics, hyperglycemia)

Capillary leak and third spacing (burns, sepsis,

pancreatitis, surgical stress)

Hemorrhage (trauma , GIT bleeding, fractures,

vascular injuries, ectopic pregnancy, etc)

Anemia


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Management and Therapy

The basic goal of shock therapy is the restorationof effective perfusion to vital organs and tissuebefore the onset of cellular injury.

Basic resuscitation :

1.Rapid placement of a large- bore i.v line or ahigh-flow central line as a route for fluidresuscitation

2. Secure the airway and on mechanical ventilationif necessary high-flow oxygenation oxygensaturation > 92% & PaO2 > 60

Put 3.Foley catheter


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Fluid resuscitation

2/3 crystalloid + 1/3 colloid Loss of blood volume:

> 25% erythrocyte concentration

> 60% 4 erythrocyte concentration + FFP

> 80% polytransfusion + AT < 50.000

+ thrombocyte Massive red blood cell transfusion microfilter


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. Diagnose and treat underlying causeconcomittantly.


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G l l f t f h k ti t


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General goals for support of shock patients

Hemodynamic support

MAP > 60-65 mmHg

PCWP= 15-18 mmHg

Cardiac index > 2.1 L/min per m2 of body surfacearea for cardiogenic and obstructive shock

Cardiac index > 4.0 L/min per m2 body surface

area for septic, traumatic, or hemorrhagic shock


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A Fluid Challenge

A diagnostic intervention designed to givean indication of whether a patient with

hemodynamic compromise will benefit from

further fluid replacement To administer a pre-determined volume of iv

fluid over a short period of time while

measuring a change in the patientscardiovascular parameters


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The aim:

To differentiate hypovolemia, or relative

hypovolemia, which might improve with

further fluid, from cardiac failure or a fullintravascular volume in which case further fluid

will not improve things and may cause

deterioration


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Indication fluid challenge

Cardiac index 120 bpm

Oliguria (urine output < 25-30 ml/hr)

Lactic acidosis

Oxygen delivery < 600 ml/min/m2

Cool extremities

The need for vasoactive drug

Pulmonary arteri occlusive pressure (PAOP) < 18 mmHg


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The Surviving Sepsis Resuscitation Bundlerecommends: 1000 ml crystalloid or 300-500 mlof colloid over 30 minutes.

In ICU : 250 ml colloid run 5-10 minutes

Protocol


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Protocol

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CVP PAOP ACTIONmmHg mmHg

-----------------------------------------------------------------------------------------------------

During fluid challenge increase > 5 Increase > 7 Stop infusion,

WAIT & reassess

Following fluid challenge increase 3-5 Increase 3-7 WAIT & reassess

Following fluid challenge increase < 3 Increase < 3 Safe to repeat fluid

bolus if indicated

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Balans Cairan

Tiap pemberian cairan harus dibuat balanscairan: tiap 6 atau 8 jam, dihitung total tiap 24

jam.

Semua cairan masuk dihitung: oral dan infus

Setiap cairan keluar dihitung: urine,

muntah/NGT, diare, drain, IWL (insensibel

water loss)


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Fluid resuscitation in traumatic shock:

1. ABC

2. Restored tissue oxygenation

3. Avoid / prevent tissue injury

4. Monitor vital sign

5. Collaboration to allied surgeon

Bls,Shock,Fluid Therapy

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