Dr.devi-syok Diagnosis & Penanganannya
-
Upload
tyahudisaputri -
Category
Documents
-
view
228 -
download
0
Transcript of Dr.devi-syok Diagnosis & Penanganannya
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
1/63
SYOK DIAGNOSIS &
PENANGANANNYA
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
2/63
DESKRIPSI SYOKSuplai aliran darah ke jaringan inadekuatKebutuhan nutrien tidak terpenuhi
Hasil metabolisme (toxic) tidak dapat dikeluarkan
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
3/63
PatofisiologiFase awal pemeliharaan curah jantung
Rllasee katkolamin irama jantung naik (HR ),kontraktilitas naikStimulasi simpatis resistensi vaskuler sistemik naik(SVR), tekanan arteri naik (arterial pressure ) Venokonstriksi preload
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
4/63
Bledsoe et al., Essentials of Paramedic Care:Division 1II 2006 by Pearson Education, Inc. Upper SaddleRiver, NJ
Vena Cavaand
Systemic Veins
Aortaand
Systemic Arteries
SystemicCapillaries
Pulmonary Arteries
LUNGS
Pulmonary Veins
Right Atrium
Right Ventricle
Left Atrium
Left Ventricle
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
5/63
Patofisiologi (lanjutan)Fase lanjut mekanisme kompensasi gagal
Penurunan curah jantung (CO), penurunan tekananarteriMikrosirkulasi sludging (tersumbat)
Disfungsi selulerPenurunan delivery oksigen dan substrat energi
anaerob, asidosis sistemik (depresi otot polos danmiokard), gagal organSyok irreversibel
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
6/63
PATHOPHYSIOLOGY OF SHOCKSYNDROME
Cells switch from aerobic to anaerobic metabolismlactic acid production
Cell function ceases & swellsmembrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impairedmitochondria damage
cell death
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
7/63
Kriteria diagnosisVital signsHypotensive < 90 mmHgMAP < 60 mmHgTachycardia : Weak and Thready pulseTachypneic -blow off CO2 R espiratoryalkalosis
Mental status : (LOC) restless, irritable, apprehensive unresponsive, painful stimuli only
Decreased Urine output
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
8/63
Shock Do you remember how to
quickly estimate bloodpressure by pulse?
60
80
70
90
If you palpate a pulse, you know SBP is at
least this number
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
9/63
Etiology of circulatory shock
1. Hypovolemic - intravascular fluid volume losshemorrhage, fluid depletion or
sequestration
2. Cardiogenic - impairment of heart pumpmyopathic lesions : myocardialinfarction, cardiomyopathiesdysrhythmias
obstructive and regurgitant lesions ofintracardial blood flow mechanics
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
10/63
3. Obstructive - factors extrinsic to cardiac valves andmyocardium
v. cava obstruction, pericardialtamponade,pulmonary embolism,coarctation of aorta
4. Distributive - pathologic redistribution of intravascularfluid volumesepticaemia : endotoxic, secondary tospecific infectionanaphylactic
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
11/63
NORMAL
1. HYPOVOLEMIC 2. CARDIOGENIC
3. DISTRIBUTIVE
High Resistance 4. OBSTRUCTIVELow Resistance
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
12/63
Goals of Treatment
ABCDE A irway
control work of Breathing optimize Circulation assure adequate oxygen Delivery achieve End points of resuscitation
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
13/63
What Type of Shock is This?Laki-laki, 20 th, dibawakeUGD post KLL ,tampak jejas di pelvis,hipotensi, takikardi,afebris, akral dingin
Types of Shock Hypovolemic
Septic Cardiogenic Anaphylactic Neurogenic ObstructiveHypovolemic Shock
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
14/63
Hypovolemic Shock
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
15/63
Hypovolemic Shock Non-hemorrhagic Vomiting Diarrhea Bowel obstruction, pancreatitis Burns Neglect, environmental (dehydration)
Hemorrhagic GI bleed Trauma Massive hemoptysis AAA rupture Ectopic pregnancy, post-partum bleeding
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
16/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
17/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
18/63
Hypovolemic Shock ABCs Establish 2 large bore IVs or a central line
Crystalloids Normal Saline or Lactate Ringers Up to 3 liters
Transfuse
O negative or cross matched Control any bleeding Arrange definitive treatment
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
19/63
Evaluation of Hypovolemic Shock CBC ABG/lactate
Electrolytes BUN, Creatinine Coagulation studies
Type and cross-match
As indicated CXR
Pelvic x-ray Abd/pelvis CT Chest CT GI endoscopy
Bronchoscopy Vascular radiology
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
20/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
21/63
What Type of Shock is This? An 81 yo F resident of a nursing
home presents to the ED withaltered mental status. She is febrile
to 39.4, hypotensive with a widenedpulse pressure, tachycardic, with warm extremities
Types of Shock Hypovolemic
Septic Cardiogenic Anaphylactic Neurogenic ObstructiveSeptic
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
22/63
Septic Shock
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
23/63
Sepsis Two or more of SIRS criteria Temp > 38 or < 36 C HR > 90 RR > 20 WBC > 12,000 or < 4,000
Plus the presumed existence of infection Blood pressure can be normal!
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
24/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
25/63
Sepsis
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
26/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
27/63
Septic Shock Clinical signs: Hyperthermia or hypothermia Tachycardia Wide pulse pressure Low blood pressure (SBP
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
28/63
Ancillary Studies Cardiac monitor Pulse oximetry
CBC, Chem 7, coags, LFTs, lipase, UA ABG with lactate Blood culture x 2, urine culture CXR Foley catheter (why do you need this?)
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
29/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
30/63
Persistent Hypotension If no response after 2-3 L IVF, start a vasopressor(norepinephrine, dopamine, etc) and titrate toeffect
Goal: MAP > 60 Consider adrenal insufficiency: hydrocortisone 100
mg IV
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
31/63
Treatment Algorithm
Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med. 2001:345:1368-1377.
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
32/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
33/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
34/63
Cardiogenic Shock Signs:
Cool, mottled skin
Tachypnea Hypotension Altered mental status Narrowed pulse pressure Rales, murmur
Defined as: SBP < 90 mmHg
CI < 2.2 L/m/m 2 PCWP > 18 mmHg
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
35/63
Etiologies What are some causes of cardiogenic shock?
AMI
Sepsis Myocarditis Myocardial contusion Aortic or mitral stenosis, HCM Acute aortic insufficiency
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
36/63
Pathophysiology of Cardiogenic Shock
Often after ischemia, loss of LV function Lose 40% of LV clinical shock ensues
CO reduction = lactic acidosis, hypoxia Stroke volume is reduced
Tachycardia develops as compensation Ischemia and infarction worsens
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
37/63
Ancillary Tests EKG CXR
CBC, Chem 10, cardiac enzymes, coagulation studies Echocardiogram
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
38/63
Treatment of Cardiogenic Shock Goals- Airway stability and improving
myocardial pump function
Cardiac monitor, pulse oximetry Supplemental oxygen, IV access Intubation will decrease preload and result
in hypotension Be prepared to give fluid bolus
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
39/63
Treatment of Cardiogenic Shock AMI Aspirin, beta blocker, morphine, heparin If no pulmonary edema, IV fluid challenge If pulmonary edema
Dopamine will HR and thus cardiac work Dobutamine May drop blood pressure Combination therapy may be more effective
PCI or thrombolytics RV infarct
Fluids and Dobutamine (no NTG) Acute mitral regurgitation or VSD
Pressors (Dobutamine and Nitroprusside)
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
40/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
41/63
Anaphalactic Shock
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
42/63
Anaphylactic Shock Anaphylaxis a severe systemic
hypersensitivity reaction characterized by
multisystem involvement IgE mediated
Anaphylactoid reaction clinically
indistinguishable from anaphylaxis, do notrequire a sensitizing exposure Not IgE mediated
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
43/63
Anaphylactic Shock What are some symptoms of anaphylaxis?
First- Pruritus, flushing, urticaria appear
Next- Throat fullness, anxiety, chest tightness,shortness of breath and lightheadedness
Finally- Altered mental status, respiratorydistress and circulatory collapse
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
44/63
Anaphylactic Shock Risk factors for fatal anaphylaxis Poorly controlled asthma Previous anaphylaxis
Reoccurrence rates 40-60% for insect stings 20-40% for radiocontrast agents 10-20% for penicillin
Most common causes Antibiotics Insects Food
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
45/63
Anaphylactic Shock Mild, localized urticaria can progress to full anaphylaxis Symptoms usually begin within 60 minutes of exposure
Faster the onset of symptoms = more severe reaction Biphasic phenomenon occurs in up to 20% of patients
Symptoms return 3-4 hours after initial reaction has cleared
A lump in my throat and hoarseness heralds life -
threatening laryngeal edema
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
46/63
Anaphylactic Shock- Diagnosis Clinical diagnosis
Defined by airway compromise, hypotension, or
involvement of cutaneous, respiratory, or GIsystems Look for exposure to drug, food, or insect Labs have no role
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
47/63
Anaphylactic Shock- Treatment ABCs
Angioedema and respiratory compromise requireimmediate intubation
IV, cardiac monitor, pulse oximetry IVFs, oxygen Epinephrine
Second line Corticosteriods H1 and H2 blockers
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
48/63
Anaphylactic Shock- Treatment Epinephrine
0.3 mg IM of 1:1000 (epi-pen) Repeat every 5-10 min as needed Caution with patients taking beta blockers- can cause severe
hypertension due to unopposed alpha stimulation For CV collapse, 1 mg IV of 1:10,000 If refractory, start IV drip
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
49/63
Anaphylactic Shock - Treatment Corticosteroids Methylprednisolone 125 mg IV Prednisone 60 mg PO
Antihistamines H1 blocker- Diphenhydramine 25-50 mg IV H2 blocker- Ranitidine 50 mg IV
Bronchodilators Albuterol nebulizer Atrovent nebulizer Magnesium sulfate 2 g IV over 20 minutes
Glucagon For patients taking beta blockers and with refractory hypotension 1 mg IV q5 minutes until hypotension resolves
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
50/63
Anaphylactic Shock - Disposition All patients who receive epinephrine should be
observed for 4-6 hours If symptom free, discharge home If on beta blockers or h/o severe reaction in past,
consider admission
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
51/63
What Type of Shock is This? Laki-laki, 41 th dibawake UGD setelah terjatuhdari lantai 4 mengeluhkeempat ektremitastidak dapat digerakkandan baal. PFhypotensive,bradycardic, ektremitashangat
Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic ObstructiveNeurogenic
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
52/63
Neurogenic Shock
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
53/63
Neurogenic Shock Occurs after acute spinal cord injury Sympathetic outflow is disrupted leaving
unopposed vagal tone Results in hypotension and bradycardia Spinal shock- temporary loss of spinal reflex
activity below a total or near total spinal cordinjury (not the same as neurogenic shock, theterms are not interchangeable)
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
54/63
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
55/63
Neurogenic Shock- Treatment A,B,Cs Remember c-spine precautions
Fluid resuscitation Keep MAP at 85-90 mm Hg for first 7 days Thought to minimize secondary cord injury If crystalloid is insufficient use vasopressors
Search for other causes of hypotension
For bradycardia Atropine Pacemaker
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
56/63
Neurogenic Shock- Treatment Methylprednisolone Used only for blunt spinal cord injury High dose therapy for 23 hours Must be started within 8 hours Controversial- Risk for infection, GI bleed
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
57/63
What Type of Shock is This? A 24 yo M presents to the
ED after an MVC c/o chestpain and difficultybreathing. On PE, you notethe pt to be tachycardic,hypotensive, hypoxic, and with decreased breath
sounds on left
Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic ObstructiveObstructive
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
58/63
Obstructive Shock
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
59/63
Obstructive Shock Tension pneumothorax Air trapped in pleural space with 1 way valve,
air/pressure builds up Mediastinum shifted impeding venous return Chest pain, SOB, decreased breath sounds No tests needed!
Rx: Needle decompression, chest tube
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
60/63
Obstructive Shock Cardiac tamponade Blood in pericardial sac prevents venous return to and
contraction of heart Related to trauma, pericarditis, MI Becks triad: hypotension, muffled heart sounds, JVD Diagnosis: large heart CXR, echo Rx: Pericardiocentisis
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
61/63
Obstructive Shock Pulmonary embolism Virscow triad: hypercoaguable, venous injury, venostasis Signs: Tachypnea, tachycardia, hypoxia Low risk: D-dimer Higher risk: CT chest or VQ scan Rx: Heparin, consider thrombolytics
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
62/63
Obstructive Shock Aortic stenosis Resistance to systolic ejection causes decreased cardiac
function Chest pain with syncope Systolic ejection murmur Diagnosed with echo Vasodilators (NTG) will drop pressure! Rx: Valve surgery
HYPOVOLEMICEXTRACARDIAC
CARDIOGENIC DISTRIBUTIVE
-
8/10/2019 Dr.devi-syok Diagnosis & Penanganannya
63/63
HYPOVOLEMIC Obstruction CARDIOGENIC DISTRIBUTIVE
Fluid loss,
hemorrhage
e.g., Pericardial
tamponadeMyocardialinjury ornecrosis
Decreasedsystemicvascularresistance
Myocardiacdysfunction
Reducedsystolic performance
Reducedfilling
Low cardiacoutput
Reducedpreload
Decreased arterialpressure
Shock
Multiple organ
High or normalcardiac output
Maldistributionof blood flow in