Kuliah Bidan - syok Hipovolemik
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Transcript of Kuliah Bidan - syok Hipovolemik
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HYPOVOLEMIC SHOCK
AND RESUSCITATION
Asri Prameswari, dr., SpPD
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SHOCK AND RESUSCITATION
GOAL: UNDERSTAND THE PATHOPHYSIOLOGY OF SHOCK AND IT’S
TREATMENT
Objectives:
Be able to categorize types of shock
Understand mechanisms of adapting to volume
loss of blood loss
Demonstrate shock treatment:
lines, sites, types of fluid
End points of resuscitationComplications of treatment
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TYPES OF SHOCK
“Classic” Blalock 1937
Hematogenic
Neurogenic Vasogenic
Cardiogenic
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CLASSIFICATION OF SHOCK
Low Cardiac Output states
Hypovolemic shock
volume loss
Internal volume loss
Cardiac shock
Impaired inflow
Primary pump dysfunction
Impaired outflow
Low peripheral resistance states
Neurogenic shock
Loss of sympathetic tone
Vasogenic Shock
Septic
Anaphylactic
Carrico: ACS Early Care of the Injured Patient 4th Ed.
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HYPOVOLEMIC SHOCK
Definition:
Reduction in intravascular volume leading to
insufficient oxygen delivery to cells
(mitochondria)
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HYPOVOLEMIC SHOCKReduced intravascular volume?
No oxygen delivery!
No aerobic metabolism!
Then…
Metabolic acidosis (lactic acid production)
Endoplasmic recticulum swelling
Mitochondrial damage
Cell Death!
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THE CIRCULATORY SYSTEM
Components:
Heart (pump)
Blood Vessels Blood
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CIRCULATION SCHEMATIC
The Pump (heart)
2 sided
Anatomically looksparallel, BUT:
Physiologically and
in Actuality
Supplies 2 systems
connected in series
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Right Side
Compliant, flexible
Low pressure,variable volume
Left Side
Stiff, strong
High pressure, fixedvolume
The Heart:
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THE CIRCULATORY SYSTEM
Multiple Parallel Circuits Organized teleologically:
Prioritized supply
Closest circuits getsupplied first andforemost Coronaries, Brain,
Kidneys
Distal circuits getshut down whenvolume low Gut/Muscle, Skin
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CIRCULATORY CONTROL MECHANISMS
Closest, fastest
Carotid Bodies (Baroreceptors)
Stimulate Sympathetic Nervous System
Mid-level
Kidneys- Juxtaglomerular Apparatus
Sense low flow and stimulate Renin resulting in vasoconstriction (splancnic)
Down-line
Adrenal Cortex
Senses need for more Sodium and Fluid Re-absorbtion to deal with upright
posture volume needs
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HYPOVOLEMIC SHOCK
Vascular compartments:
TBW (60% of IBW)
Total Body Water
ICW (40%) ECW (20%)
Intracellular Water Extracellular Water
Interstitium Plasma
(1/3) (2/3)
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HYPOVOLEMIC SHOCK
Loss of circulating blood volume (Plasma)
Normal Blood Volume:- 7% IBW in adults
- 9% IBW in kids
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ACUTE VOLUME LOSS
Shock - Classes:
I 0-15% blood loss
II 15-30% blood lossIII 30-40% blood loss
IV >40% blood loss
SHOCK
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TREATMENT OF SHOCK
Recognize Type of Shock If definite pump failure and cardiogenic shock institute cardiac
protocols
Otherwise: 2 large bore, upper extremity lines and:
Volume
Volume
Volume
When in doubt, try a little more volume
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TREATMENT OF SHOCK
Goal: Restore perfusion
Method: Depends on type of Shock
Basically 2 kinds:
Hypovolemic (hemorrhagic, septic,
neurogen.)
Cardiogenic (Impedence or primary
Cardiac Failure)
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TREATMENT OF SHOCK
Prioritized approach
Must address and treat sequentially:
PRELOAD
AFTERLOAD PUMP
QUESTIONs:
What type of fluid
How Much End Point of Resuscitation
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HYPOVOLEMICSHOCK
Management:
ABCs of trauma (AIRWAY is always first!)
Control hemorrhage
Obtain IV access and resuscitate with fluids and blood
2 liters crystalloid for adults
20 cc/kg crystalloid x 2 for kids
Blood vs. Crystalloid??
Long term critical care management
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HYPOVOLEMIC SHOCK
Your management goals AFTER securing the ABCs:
STOP THE BLEEDING!
RESTORE VOLUME!
CORRECT ANY ELECTROLYTE/ACID-BASEDISTURBANCES!
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TREATMENT: HEMORRHAGIC SHOCK
Large bore access
2 upper extremity IVs
16 gauge or larger
Bolus therapy
20 cc/kg
Adults- 2 liters
Monitor Effect
Repeat if necessary
After 2nd bolus: need blood
10cc/kg
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END POINTS OF RESUSCITATION:
Restoration of normal vital signs Adequate Urine output
0.5 - 1.0 cc/kg/hr
Tissue Oxygenation measurement
Adequate Cardiac Index Normalization of Oxygen delivery
Normal Serum Lactate levels
none proven helpful, some deleterious
Englehart; Curr Op Crit Care; Vol 12(6), Dec 06, p 579-574
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BLOOD TRANSFUSION
Blood Banks safer
Some risk unavoidable
New viruses are inevitable
False negative screeningtests
Time for cross-matchdelays Rx
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TRY OUT
Wanita 50 tahun datang ke UGD dengan pucat,menggigil, lemah dangelisah
Diare 2 hari, muntah >10kali, isi cairan warnacoklat dan kuning berair
Ada riwayat flek-flek vagina
sejak 3 bulan, dicurigaitumor kandungan
Apa yang anda
lakukan?
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DISKUSI
Anamnesa : brp lama flek?Banyak? Hari? Banyak?
Tensi 60/palpasi
Nadi 66 kali, lemah, reguler
Suhu 38 RR 30 reguler
KU gelisah
Kesadaran GCS 446
Urine -
Sat oksigen 65% Akral dingin
CRT >3dtk
Pain score
Infus RL 100cc
Oksigen masker
Lapor
Resusitasi 20cc/kg–
ceknadi 5 menit stlh resusitasi
Pasang NGT –hematemesis +
Kateter urine pekat 10cc
Cek GDS cito
Rawat intensif
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SUMMARY
The Circulation is a Circuit
Volume is most often the answer
Lactated Ringers still the standard
More is better than less, maybe Better Indicators & Endpoints of Resuscitation
Shock and Resuscitation: