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SyokM. Hafidz Azhari

Humairah

Ayun Puji lestari

Coni Senopadang

Pembimbing: dr Rapto Hardian, Sp.An

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Syok

Merupakan sindrom multifaktorialhipoperfusi jaringan perifer dan sentralhipoksia seluler dan disfungsi organ multipel.

Perfusi menurun secara sistemik dengan gejalayg jelas hipotensi

Prognosis: derajat syok, durasi, organ yangterpengaruh, disfungsi organ sebelumnya

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Patofisiologi

Hipoksia

seluler

shock

perfusi

jaringan

Hipoksia seluler permeabilitasvaskuler radikal super oksidarespon inflamasi kerusakan sellebih lanjut kerusakan multi-organ

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Diagnosis

Heart rate: takikardi bradikardi BP: Hipotensi severe volume loss and

shock Temp: hypothermia severe hypovolemic

and septic shock Urin output: early guide of hypovolemia and

end organ response (renal) to shock.Delayed vital sign

Pulse oxymetry early indicator ofhypoxemia, invalid in hypothermic patient

Vital

Sign

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Cardiac outputcardiac function,measured by PAC

Systemic vascularresistance index(SVRI)

Cardiacflow

variable

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Hemodynamic variablesMeasured variable Unit Normal

Range

Systolic blood pressure (SBP) mmHg 90-140

Diastolic blood pressure (DBP) mmHg 60-90

Systolic pulmonary blood pressure (PAS) mmHg 15-30

Diastolic pulmonary blood pressure (PAD) mmHg 4-12

Pulmonary artery occlusion pressure (PAOP) mmHg 2-12

Central venous pressure (CVP) mmHg 0-8

Heart Rate (HR) Beats/min 50-100

Cardiac output (CO) L/min 4-6

Right ventricular ejection fraction (RVEF) Fraction 0,4-0,6

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Calculated variable Unit Normal range

Mean arterial pressure (MAP) mmHg 70-105

Mean pulmonary artery pressure(MPAP)

mmHg 9-16

Cardiac index (CI) L/min/m2 2,8-4,2

Stroke volume (SV) ML/beat Varies

Stroke volume index (SVI) mL/beat/m2 30-65

Systemic vascular resistance index(SVRI)

Dynes 1.600-2.400

Pulmonary vascular resistance index(PVRI)

Sec/cm-5 250-340

Left ventricular stroke work index

(LVSWI)

g m/m2 45-62

Right ventricular stroke work index(RVSWI)

g m/m2 7-12

Right ventricular end-diastolic workindex (RVEDWI)

mL/m2 60-100

Body surface area (BSA) m2 varies

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Resuscitation end point

Cellular hypoxia anaerobic metabolism lacticacid >> severity of shock

Rate of clearance of lactate better marker ofadequate resuscitation

Lactic acid

production

The amount of base required to titrate whole bloodto a normal pH

Elevated base deficit severity of shockBase deficit

The mesenteric organ will have earlier and greaterhypoperfusion than other organ system

Gastric tonometry early indicator ofhypoperfusion

IntramucosalpH monitoring

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Syok hipovolemik

Loss of blood(hemorrhagic shock)

External hemorrhage Trauma

Gastrointestinal tractbleeding

Internal hemorrhage

Hematoma Hemothorax or

hemoperitoneum

Loss of plasma

(luka bakar)

Loss of Fluid andelectrolyte

- External Vomiting

Diarrhea

- Internal (third-spacing)

Pacreatitis

Ascites

Bowel obstruction

Kehilangan volume intravaskular yang bersirkulasi dan penurunancardiac preload

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Grades of hypovolemic shock

Sign &symptom

Class I Class II Class III Class IV

Blood loss(mL)

Up to 750 750-1500 1500-2000 >2000

%Bloodvolume

Up to 15 15-30 30-40 >40

Pulse rate 100 >120 >140

Bloodpressure

N N

Capillary refill N

RR N 20-30 30-40 >35Urinaryoutput(ml/hr)

>30 20-30 5-15 Negligible

Mental status Mild anxiety Anxiety Confused Lethargic

Fluidreplacement

Crystalloid Crystalloid Crystalloid +blood

Crystalloid +blood

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Syok hipovolemik

Rapid infusion of multiple liters of crystalloid

Large-bore venous access and central access isneeded

If haemorrhage shock after 2-3 liters of fluid blood is transfused + source of bleeding needs

to be controlled Vasoconstrictor rarely needed

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An initial,warmed fluidbolus is given asrapidly as possible. The usual dose is 1-2 liters

for an adult and 20 ml/kg for a pediatricpatient.

3-for-1 rule replace each mililiter of blood

loss with 3 mL of crystalloid fluid Assess the patients response to fluidresuscitation

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Response to Initial Fluid ResuscitationRapidResponse

TransientResponse

No Response

Vital Sign Return to Normal Transientimprovement,recurrent of BPand HR

Remain abnormal

Estimated bloodloss

Minimal (10%-20%)

Moderate andongoing (20%-40%)

Severe (>40%)

Need for morecrystalloid

Low High High

Need for blood Low Moderate to high Immediate

Blood preparation Type and crossmatch

Type-specific Emergency bloodrelease

Need foroperative

intervention

Possibly Likely Highly likely

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Grades of dehydrationMild < 5% Moderate 5-

10%Severe >10%

Pulse rate N

Blood pressure N N

Respiratory rate N N Rapid

Capillary return 5 seconds

Urine Output N Negligible/absent

Mucous membran Moist Dry Parched

CNS/mentalstatus

N/restless Drowsy Lethargic/comatose

5% dehydration = loss of 5 ml of fluid per 100 g body weight or 50 ml per kg

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Estimating Maintenance FluidRequirementWeight 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

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Ringanatau

Sedang

Beratatau

Syok

Dibagi rata

dlm 24 jam

PERUBAHAN :

-Gx Klinis

-Hematokrit

-Plasma elektrolit

-CVP

Tahap I (rehidrasi cepat) :

20-40 cc/KgBB/1-2 jam

Tahap II :

sisa defisit 6 jam sisanya 16-17 jam

Klasifikasi

Pemberian

Cairan

Defisit

+ Maintenance

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Contoh:

Pasien pria, BB 50 kg, mengalami dehidrasimoderate (dehidrasi 5%)

Jawab:

Estimated Fluid Therapy

5% dehydration= 50 x 50 = 2500 ml/ 24 h = 105

ml/hMaintenance = 40+20+ 30 = 90 ml/h

Rehydration + maintenance = 195 ml/h

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Syok Obstruktif

Disebabkan oleh obstruksi mekanis thd cardiac outputdgn penurunan perfusi sistemik

Penyebab:

a. Cardiac tamponadeb. Tension pneumothorax

c. Emboli paru masif

d. Emboli udara

Tanda: distensi vena jugularis, muffled heart sound(tamponade), suara nafas unilateral (pneumothorax)

Tx: memaksimalkan preload dan mengatasi obstruksi

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Syok obstruktif

Penyebab harus diidentifikasi dan ditanganisecepatnya:

a. Pericardiocentesis/ pericardiotomy cardiactamponade

b. Needle decompression/ tube thoracostomy

tension pneumothoraxc. Ventilatory and cardiac support

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Syok kardiogenik

Disebabkan karena kegagalan pompa

Penyebab: extensive myocardial infarction (>>),reduced contractility (cardiomyopathy, sepsisinduced) aortic stenosis, mitral stenosis, atrialmyxoma, acute valvular failure, and cardiac

dysrythmias. Tx: memaksimalkan preload dan kerja jantung,menurunkan after load.

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Syok kardiogenik

Optimize preload with infusion of fluids

Optimize contractility with inotropes

Adjust afterload to maximize CO

Diuresis indicated in patient with heartfailure

PAC guide therapy Identifiy and treat the underlying cause

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Syok distributif

Disebabkan oleh vasodilatasi sistemik krnpenyebab yg muncul (infeksi, anafilaksis)

hipoperfusi sistemik dan atau cardiac output. Syok distributif ditingkatkan oleh respon

inflamasi

Terjadi hipoksia seluler karena gangguan fungsimitokondria.

Penyebab lain: anaphylaxis, severe trauma,severe liver dysfunction, and neurogenic shock.

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Neurogenic shock trauma MS servikal disertaihilangnya tonus simpatis vaskuler.

Gejala: hipotensi, bradikardi, ekstremitas hangat

Tx: volume dan vasokonstriktor

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Syok anafilaksis Anafilaksis: reaksi alergi yg berat terhadap

rangsangan apapun, onset mendadak (

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Sepsis

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P di t i ti h k

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Pediatric septic shock

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