1

PELATIHAN RESUSITASIPELATIHAN RESUSITASI

PEDIATRIK TAHAP LANJUTPEDIATRIK TAHAP LANJUT

S Y O KS Y O K

KOMISI RESUSITASI PEDIATRIKKOMISI RESUSITASI PEDIATRIK

UKK PEDIATRI GAWAT DARURAT IDAIUKK PEDIATRI GAWAT DARURAT IDAI

APRCAPRC

2

DEFINISI SYOKDEFINISI SYOK  

SINDROM KLINIS AKIBAT KEGAGALAN SISTEM SINDROM KLINIS AKIBAT KEGAGALAN SISTEM

SIRKULASI UNTUK MENCUKUPI :SIRKULASI UNTUK MENCUKUPI :

   NUTRISINUTRISI PASOKANPASOKAN METABOLISMEMETABOLISME OKSIGENOKSIGEN UTILISASIUTILISASI JARINGAN TUBUHJARINGAN TUBUH

  FASE: FASE: KOMPENSASIKOMPENSASI

DEKOMPENSASIDEKOMPENSASIIREVERSIBELIREVERSIBEL DEFISIENSI O2 DEFISIENSI O2

SELULERSELULER

3

Etiologi SyokEtiologi Syok

TypeType Primary InsultPrimary Insult Common CausesCommon CausesHypovolemicHypovolemic Decreased circulatingDecreased circulating Dehydration, hemorrhage,Dehydration, hemorrhage,

blood volblood vol capilarry leakscapilarry leaksDistributiveDistributive Vasodilation -> venousVasodilation -> venous Sepsis, anaphylaxis,Sepsis, anaphylaxis,

pooling -> decreased preloadpooling -> decreased preload drug intoxication,drug intoxication,spinal cord injuryspinal cord injury

ObstructiveObstructive Obstruction of cardiacObstruction of cardiac Cardiac tamponade, tensionCardiac tamponade, tensionfilling/out flowfilling/out flow pneumothoracx, pulmonary pneumothoracx, pulmonary

embolusembolusCardiogenicCardiogenic Decreased contractilityDecreased contractility Congenital heart disease,Congenital heart disease,

myocarditis, dysritmiamyocarditis, dysritmiaDissociativeDissociative O2 not released fromO2 not released from CO poisoning,CO poisoning,

hemoglobinhemoglobin methemoglobinemiamethemoglobinemia

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FUNGSI SISTEM SIRKULASIFUNGSI SISTEM SIRKULASI   JANTUNGJANTUNG CURAH JANTUNGCURAH JANTUNG

METABOLISMEMETABOLISME PEMB. DARAHPEMB. DARAH ALIRAN DARAHALIRAN DARAH ADEKUATADEKUAT JARINGANJARINGAN VOL. DARAHVOL. DARAH O2 DELIVERYO2 DELIVERY

  

METABOLITMETABOLIT

  

ELIMINASIELIMINASI

DI ORGAN DI ORGAN PEMBUANGANPEMBUANGAN

DO2 DO2 = CO x CaO2= CO x CaO2CaO2 CaO2 = (1,34 x Hb x sat O2) + (0,003 x PaO2)= (1,34 x Hb x sat O2) + (0,003 x PaO2)

5

Pengaturan curah jantung dan tekanan darahPengaturan curah jantung dan tekanan darah

PreloadPreload ContractilityContractilityAfterloadAfterload

  

   Heart rateHeart rate Stroke volumeStroke volume

    

Cardiac outputCardiac output Systemic vascular resistanceSystemic vascular resistance

   Blood pressureBlood pressure

6

7

Distribution of CO & VO2 Distribution of CO & VO2 in a Healthy Resting Normal Subjectin a Healthy Resting Normal Subject

% Total% Total AVDO2AVDO2 % Total% TotalOrganOrgan COCO vol %vol % VO2VO2GI tract and liverGI tract and liver 2424 4.14.1 2525Skeletal muscleSkeletal muscle 2121 8.08.0 3030KidneyKidney 1919 1.31.3 7 7BrainBrain 1313 6.36.3 2020SkinSkin 9 9 1.01.0 2 2HeartHeart 4 4 11.411.4 1111Other organsOther organs 1010 3.03.0 5 5

Adapted from Wade OL, Bishop JM: Cardiac output and regional blood flow, Oxford, Blackwell, 1962Adapted from Wade OL, Bishop JM: Cardiac output and regional blood flow, Oxford, Blackwell, 1962

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Extracel. FluidExtracel. Fluid Low Output Cardiac FailureLow Output Cardiac Failure Intra vasc. Vol. due toIntra vasc. Vol. due to VolumeVolume Pericardial TamponadePericardial Tamponade Oncotic PressureOncotic Pressure

Constrictive PericarditisConstrictive Pericarditis Capillary PermeabilityCapillary Permeability

CARDIAC OUTPUTCARDIAC OUTPUT

Activation receptor of ventricular & arterialActivation receptor of ventricular & arterial

Non-osmoticNon-osmotic Stimulation ofStimulation of Activation of theActivation of theVasopressinVasopressin Sympathetic NervousSympathetic Nervous Renin-Angiotensin- Renin-Angiotensin-StimulationStimulation SystemSystem Aldosterone SystemAldosterone System

RENAL WATERRENAL WATER PERIPHERAL & RENALPERIPHERAL & RENAL RENAL SODIUMRENAL SODIUM RETENTIONRETENTION ARTERIAL VASC. RESISTANCEARTERIAL VASC. RESISTANCE RETENTIONRETENTION

MAINTENANCE OF EFFECTIVEMAINTENANCE OF EFFECTIVE

ARTERIAL BLOOD VOLUMEARTERIAL BLOOD VOLUME

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FRANK STARLING`S LAWFRANK STARLING`S LAW

SYMPATHOMIMETIC SYMPATHOMIMETIC AMINESAMINES

XANTHINESXANTHINES

GLUCAGONGLUCAGON

CARDIAC GLYCOSIDESCARDIAC GLYCOSIDES

HYPOXEMIAHYPOXEMIA

ACIDOSISACIDOSIS

HYPOGLYCEMIAHYPOGLYCEMIA

ENDOTOXEMIAENDOTOXEMIA

DRUG TOXICITYDRUG TOXICITY

VOLUME INFUSIONVOLUME INFUSION

STR

OKE

VO

LUM

EST

RO

KE V

OLU

ME

44

22

33

11

55

00 55 1010

CENTRAL VENOUS PRESSURE (Toor)CENTRAL VENOUS PRESSURE (Toor)

A

DD

BB

CC

POSITIVEPOSITIVEINOTROPYINOTROPY

NEGATIVENEGATIVEINOTROPYINOTROPY

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Oxyhem

og

lob

in s

atu

rati

on

Oxyhem

og

lob

in s

atu

rati

on

HH++

2,3-DPG2,3-DPGCOCO22

PiPi

HH++

2,3-DPG2,3-DPGCOCO22

PiPi

PaOPaO22

The Oxygen-hemoglobin Dissociation CurveThe Oxygen-hemoglobin Dissociation Curve

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ShockShock

HypotensionHypotension

PreloadPreload

Cellular Cellular hypoxiahypoxia

Intravasculer volumeIntravasculer volume Myocardial contractility Myocardial contractility

Anaerobic metabolismAnaerobic metabolism

Membrane permeabilityMembrane permeability

Metabolic by-products:Metabolic by-products:

- lactic acid- lactic acid

- myocardial depressant factor- myocardial depressant factor

- endogeneous catecholamines- endogeneous catecholamines

- adenine nucleotides- adenine nucleotides

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STADIUM SYOKSTADIUM SYOK

KOMPENSASIKOMPENSASI

DEKOMPENSASIDEKOMPENSASI

IREVERSIBEL (PRETERMINAL)IREVERSIBEL (PRETERMINAL)

PERJALANAN KLINIS PERJALANAN KLINIS BERSIFAT PROGRESIFBERSIFAT PROGRESIF

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FASE I: KOMPENSASIFASE I: KOMPENSASI

KOMPENSASI TEMPORERKOMPENSASI TEMPORER

SIMPATIS, SIMPATIS, SVR, SVR, TEKANAN NADI TEKANAN NADI

DISTRIBUSI SELEKTIF ALIRAN DARAHDISTRIBUSI SELEKTIF ALIRAN DARAH

RETENSI NA & AIRRETENSI NA & AIR

KLINIS : KLINIS : * TAKHIKARDIA* TAKHIKARDIA* GADUH GELISAH* GADUH GELISAH

* KULIT PUCAT DINGIN * KULIT PUCAT DINGIN * PENGISIAN KAPILER >> * PENGISIAN KAPILER >>

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FASE 2: DEKOMPENSASIFASE 2: DEKOMPENSASI KOMPENSASI MULAI GAGALKOMPENSASI MULAI GAGAL HIPOPERFUSI HIPOPERFUSI HIPOKSIA JAR. HIPOKSIA JAR. METAB. ANAEROBIK METAB. ANAEROBIK

GGN. METAB. SELULER GGN. METAB. SELULER PELEPASAN MEDIATOR : PELEPASAN MEDIATOR : * VASODILATASI* VASODILATASI

* PERMEABILITAS * PERMEABILITAS * DEPRESI MIOKARD * DEPRESI MIOKARD * GGN KOAGULASI * GGN KOAGULASI

KLINIS : KLINIS : TAKHIKARDIA TAKHIKARDIA TEKANAN DARAH TEKANAN DARAH TAKIPNU TAKIPNU PERFUSI PERIFER PERFUSI PERIFER

ASIDOSIS (+)ASIDOSIS (+) OLIGURI (+) OLIGURI (+) TINGKAT KESADARAN TINGKAT KESADARAN

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FASE 3: IREVERSIBELFASE 3: IREVERSIBEL KOMPENSASI GAGALKOMPENSASI GAGAL CADANGAN ENERGI TUBUH CADANGAN ENERGI TUBUH KERUSAKAN/KEMATIAN SELKERUSAKAN/KEMATIAN SEL DISFUNGSI ORGAN DISFUNGSI ORGAN

MULTIPELMULTIPEL KLINIS : KLINIS : * T.D TAK TERUKUR* T.D TAK TERUKUR * NADI TAK TERABA* NADI TAK TERABA

* TINGKAT KESADARAN* TINGKAT KESADARAN * ANURIA (+)* ANURIA (+)* GAGAL MULTI ORGAN * GAGAL MULTI ORGAN DAN KEMATIAN DAN KEMATIAN

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Manifestasi Klinis SyokManifestasi Klinis Syok

Clinical SignsClinical Signs CompensatedCompensated UncompensatedUncompensated IrreversibleIrreversible

Blood loss (%)Blood loss (%) Up to 25Up to 25 25 - 4025 - 40 > 40> 40

Heart rate Heart rate Tachycardia + Tachycardia + Tachycardia ++ Tachycardia ++ Tachy/bradycardiaTachy/bradycardia

Systolic BPSystolic BP NN N or falling N or falling PlummetingPlummeting

Pulse volumePulse volume N/ N/ + + ++ ++

Capillary refill Capillary refill N/ N/ + + ++ ++

SkinSkin Cool, pale Cool, pale Cold, mottled Cold, mottled Cold, deathly paleCold, deathly pale

Respiratory rateRespiratory rate Tachypnoea + Tachypnoea + Tachypnoea ++Tachypnoea ++ Sighing rsp.Sighing rsp.

Mental stateMental state Mild agitationMild agitation Lethargic Lethargic Reacts only to painReacts only to pain

UncooperativeUncooperative or unresponsiveor unresponsive

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GANGGUAN PERFUSI PERIFERGANGGUAN PERFUSI PERIFER CORE > PERIFER TEMP. ~ > 2CORE > PERIFER TEMP. ~ > 2O O CC CAPILLARY REFILL >> : CAPILLARY REFILL >> :

* NAIL BED PRESS* NAIL BED PRESS * BLANCHING SKIN TEST* BLANCHING SKIN TEST

PRODUKSI URIN PRODUKSI URIN (N) (N) BAYI BAYI = 2 ml/kg/jam= 2 ml/kg/jam

ANAKANAK = 1 ml/kg/jam= 1 ml/kg/jam

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TATALAKSANA RESUSITASI TATALAKSANA RESUSITASI SYOKSYOK

RESUSITASI AWALRESUSITASI AWAL OKSIGEN 100% + VENTILATORY SUPPORTOKSIGEN 100% + VENTILATORY SUPPORT PASANG AKSES VASKULER (90 DETIK)PASANG AKSES VASKULER (90 DETIK) FLUID CHALLENGE (20 ml/kg BB)FLUID CHALLENGE (20 ml/kg BB)

SECEPATNYA < 10 MENITSECEPATNYA < 10 MENIT DPT DIULANGI 2-3 KALIDPT DIULANGI 2-3 KALI KRISTALOID/KOLOIDKRISTALOID/KOLOID

PEMANTAUAN AWALPEMANTAUAN AWAL RESPON THD FLUID CHALLENGERESPON THD FLUID CHALLENGE PANTAU PROD. URIN (KATETER)PANTAU PROD. URIN (KATETER) STAT. LAB/PENUNJANGSTAT. LAB/PENUNJANG

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MonitoringMonitoring State of consiousness-Glasgow Coma ScaleState of consiousness-Glasgow Coma Scale Respiratory rate and characterRespiratory rate and character Cardiovascular parametersCardiovascular parameters

Skin and core temperature differenceSkin and core temperature difference Pulse rate and volumePulse rate and volume Blood pressureBlood pressure Capillary perfusion timeCapillary perfusion time Central venous pressure - should be monitored in a Central venous pressure - should be monitored in a

patient where there has been poor response to fluid patient where there has been poor response to fluid therapy or with established shock. therapy or with established shock.

Urinary output - urine bag, or preferably catheter; Urinary output - urine bag, or preferably catheter; output should be 1-2 ml/kg body weightoutput should be 1-2 ml/kg body weight

Pulse oximetryPulse oximetry

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RESUSITASI LANJUTRESUSITASI LANJUT

BILA FLUID CHALLENGE NON BILA FLUID CHALLENGE NON RESPONSIVERESPONSIVE

INTUBASI & VENT. MEKANIKINTUBASI & VENT. MEKANIK PASANG CVP & LOADING HATI-HATIPASANG CVP & LOADING HATI-HATI KOREKSI EFEK INOTROPIK NEGATIFKOREKSI EFEK INOTROPIK NEGATIF

Hb < 5 g/dl Hb < 5 g/dl PRC 10 ml/kg BB (Ht 40-50 vol %) PRC 10 ml/kg BB (Ht 40-50 vol %)

OBAT INOTROPIKOBAT INOTROPIK

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PEMANTAUAN LANJUTPEMANTAUAN LANJUT CARI PENYEBAB SYOK (CXR, KONSULTASI)CARI PENYEBAB SYOK (CXR, KONSULTASI) EVALUASI FUNGSI SIST. ORGAN LAIN : EVALUASI FUNGSI SIST. ORGAN LAIN :

ATN/PRE RENAL FAILUREATN/PRE RENAL FAILURE ARDSARDS CARDIAC FUNCTIONCARDIAC FUNCTION GGN. KOAGULASI/DICGGN. KOAGULASI/DIC ORGAN-ORGAN LAINORGAN-ORGAN LAIN

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CHILD IN SHOCKCHILD IN SHOCK    

(1) (1) OXYGEN OXYGEN (2) CRYSTALLOID(2) CRYSTALLOID 20 ml/kg)20 ml/kg)

   IMPROVEMENTIMPROVEMENT

NO IMPROVEMENTNO IMPROVEMENT      

NO IMPROVEMENTNO IMPROVEMENT (3) CRYSTALLOID (3) CRYSTALLOID - INCREASE MABP - INCREASE MABP (20 ml/kg)(20 ml/kg) - NORMALIZATION HR- NORMALIZATION HR

- IMPROVED PERFUSION- IMPROVED PERFUSION - URINE OUTPUT > 1 ml/kg/hr- URINE OUTPUT > 1 ml/kg/hr

URINARY CATHETERURINARY CATHETER  

ESTABLISH CVPESTABLISH CVP ESTABLISH ETIOLOGYESTABLISH ETIOLOGY,,OOBSERVATIONBSERVATION

  CVP < 5 TorrCVP < 5 Torr CVP > 5 Torr CVP > 5 Torr    CRYSTALLOID INFUSIONCRYSTALLOID INFUSION NO IMPROVEMENT NO IMPROVEMENT UNTIL CVP - 5 TorrUNTIL CVP - 5 Torr   IMPROVEMENTIMPROVEMENT ABG, HT, NaK, GLUC Ca, ABG, HT, NaK, GLUC Ca,

SWAN GANZ CATHETERSWAN GANZ CATHETER  ESTABLISH ETIOLOGYESTABLISH ETIOLOGY CO, RAP, PAP, POAPCO, RAP, PAP, POAPCONFIRM SOURCECONFIRM SOURCE OF FLUID LOSSOF FLUID LOSS

CENTRAL VENOUS PRESSUREST

ROKE

VO

LUM

E

1. CORRECT ACIDOSIS

2. Co. GLUCOSE

3. INTROPIC SUPPORT

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Stadium syok septik dan manifestasi klinisStadium syok septik dan manifestasi klinis

StadiumStadium Tanda KlinisTanda Klinis Gang fisiologisGang fisiologis BiokimiawiBiokimiawi

Warm ShockWarm Shock perfusi perifer (N) perfusi perifer (N) Smv O Smv O22 hipokarbiahipokarbia(Hiperdinamik)(Hiperdinamik) kulit hangat keringkulit hangat kering VO VO22 hopoxiahopoxia

HR HR nadi bounding nadi bounding CO CO kadar laktat kadar laktat suhu / (tak stabil) suhu / (tak stabil) SVR SVR hiperglikemiahiperglikemiaRR RR , gg. kesadaran, gg. kesadaran

Cold ShockCold Shock sianosis sianosis CO CO hipoxiahipoxia(Hipodinamik)(Hipodinamik) kulit dingin lembabkulit dingin lembab SVR SVR asidosis metabasidosis metab

nadi kecil, lemah nadi kecil, lemah CVP CVP koagulopatikoagulopatiHR HR , Oliguria, Oliguria Smv O Smv O22 hipoglikemihipoglikemishallow breathing shallow breathing pe pe kesadaran kesadaran

MOSFMOSF bergantung sistem bergantung sistem KomaKoma sesuai sesuai yang terkenayang terkena ARDS, CHF, RFARDS, CHF, RF jenisjenis

GI bleeding/DIC GI bleeding/DIC organ failureorgan failure

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TATALAKSANA SYOK SEPTIKTATALAKSANA SYOK SEPTIK AB BROAD SPECTRUMAB BROAD SPECTRUM SESUAI KULTUR SESUAI KULTUR RESUSITASI CAIRAN : KOLOID/KRISTALOIDRESUSITASI CAIRAN : KOLOID/KRISTALOID OBAT INOTROPIK : OBAT INOTROPIK : DOBUTAMIN + DOPAMINDOBUTAMIN + DOPAMIN

ISOPRENALIN/ADRENALINISOPRENALIN/ADRENALIN

SVR SVR VASODILATASI PERIFER VASODILATASI PERIFER KOREKSI : KOREKSI : - HIPO/HIPERGLIKEMI - HIPO/HIPERGLIKEMI

- ASAM BASA- ASAM BASA- ELEKTROLIT- ELEKTROLIT

25

TATALAKSANA SYOK TATALAKSANA SYOK ANAFILAKTIKANAFILAKTIK

STOP ALERGEN PENYEBAB + ADRENALIN (IM)STOP ALERGEN PENYEBAB + ADRENALIN (IM) AIR WAY & RESPIRATION ADEKUATAIR WAY & RESPIRATION ADEKUAT

WHEEZINGWHEEZING NEBULASI ADRENALIN/SALBUTAMOL NEBULASI ADRENALIN/SALBUTAMOL OBSTRUKSIOBSTRUKSI INTUBASI/SURGICAL AIRWAY INTUBASI/SURGICAL AIRWAY

SIRKULASI & HEMODINAMIKSIRKULASI & HEMODINAMIK VASOPRESOR VASOPRESOR : ADRENALIN (10 : ADRENALIN (10 g/kg BB)g/kg BB) FLUID LOADING FLUID LOADING : KRISTALOID (20 ml/kg BB/IV-IO): KRISTALOID (20 ml/kg BB/IV-IO)

RE ASSESSMENT ABC RESUSITASIRE ASSESSMENT ABC RESUSITASI WHEEZING (+)WHEEZING (+) NEBULASI SALBUTAMOL NEBULASI SALBUTAMOL

BILA PERLU BILA PERLU (+) HIDROKORTISON (IV)(+) HIDROKORTISON (IV) (+) AMINOPILIN/SALBUTAMOL (+) AMINOPILIN/SALBUTAMOL

DRIPDRIP SYOK BERLANJUT : SYOK BERLANJUT : KOLOID + INOTROPIKKOLOID + INOTROPIK

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TATALAKSANA SYOK TATALAKSANA SYOK KARDIOGENIKKARDIOGENIK

OKSIGENASI ADEKUATOKSIGENASI ADEKUAT KOREKSI GGN ASAM BASA & ELEKTROLITKOREKSI GGN ASAM BASA & ELEKTROLIT KURANGI RASA SAKIT & ANSIETAS KURANGI RASA SAKIT & ANSIETAS ATASI DISRITMIA JANTUNGATASI DISRITMIA JANTUNG KELEBIHAN PRELOADKELEBIHAN PRELOAD : : DIURETIKADIURETIKA

KONTRAKTILITAS:KONTRAKTILITAS: FLUID CHALLENGE SESUAI CVP/POAPFLUID CHALLENGE SESUAI CVP/POAP OBAT OBAT

INOTROPIK (+)INOTROPIK (+)

BEBAN AFTERLOAD (SVR BEBAN AFTERLOAD (SVR ) : ) : VASODILATORVASODILATOR

KOREKSI PENYEBAB PRIMERKOREKSI PENYEBAB PRIMER

27

Key points in managementKey points in management Remember BP and pulse are unreliable indicators Remember BP and pulse are unreliable indicators

in early septic shockin early septic shock Look for minor degrees of mental impairment Look for minor degrees of mental impairment

(anxiety, restlessness)(anxiety, restlessness) Do not delay treatment, try to prevent the onset of Do not delay treatment, try to prevent the onset of

hypotension, metabolic acidosis, and hypoxiahypotension, metabolic acidosis, and hypoxia Give adequate fluids early in treatment, especially Give adequate fluids early in treatment, especially

colloidscolloids Do not use inotropic agents until the patient has Do not use inotropic agents until the patient has

received adequate fluid therapyreceived adequate fluid therapy Monitor blood glucose, gases, and pH, and treat Monitor blood glucose, gases, and pH, and treat

appropriatelyappropriately

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SEQUENCE OF THERAPEUTIC MANEUVERS SEQUENCE OF THERAPEUTIC MANEUVERS (VIPPS)(VIPPS)

PriorityPriority MnemonicMnemonic TherapyTherapy Purpose Purpose

11 VV VentilateVentilate Adequate O2&CO2Adequate O2&CO2exchangeexchange

22 II InfuseInfuse Vascular AccessVascular AccessBlood, fluid &Blood, fluid &electrolite balanceelectrolite balance

33 PP PumpPump Restoration cardiacRestoration cardiacperformanceperformance

44 PP PharmacologicPharmacologic Improved perfusionImproved perfusionby vasoactive agentsby vasoactive agents

55 SS Specific/Specific/ Medical & surgicalMedical & surgicalSurgicalSurgical management of management of

primary causesprimary causes