monitoring shock
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MONITORING
OFHEMORRHAGIC SHOCK
BASRUL HANAFI
SUB DIVISION DIGESTIVE, DEPARTMENT OF SURGERY
HASAN SADIKIN HOSPITALBANDUNG
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Ilustrasi kasus IIlustrasi kasus I((sesungguhnya terjadi disesungguhnya terjadi di
RSHS)RSHS)Jam 03.00 RSHS : Laki-laki, 18 th, ketabrak motorJam 03.00 RSHS : Laki-laki, 18 th, ketabrak motor
AA:clear with c-spine control;:clear with c-spine control; BB:8!"mnt #$S ki%ka;:8!"mnt #$S ki%ka; CC:& 130"'0,:& 130"'0,
( 110!"mnt( 110!"mnt
DD:)*S 1+. lab: Hb , Ht 1/, rin eritrosit penh.:)*S 1+. lab: Hb , Ht 1/, rin eritrosit penh.Time Elapse 32 JAM03.00 07.00
MAP=80
FAST ulg
KoleksiCairan
!up"ur
gin#al
kanan.
CT
S$an%
!up"ur&epar
'
gin#al
kanan
0(.00 )0.00
*perasi Pasien sesak
+ema"o"&ora,
CTT %-ara& 300 $$
MAP=80
P*- P*- 808.00
Trans/usi ) lau
-i !S Suang
MAP =(0
FAST
koleksi
Cairan 1
Pulang-Hidup
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Ilustrasi kasus IIIlustrasi kasus II(sesungguhnya terjadi di(sesungguhnya terjadi di
RSHS)RSHS)Jam 3.30 RSHS : Laki-laki, 30 th, motor tabrakan 2n mobil 1+Jam 3.30 RSHS : Laki-laki, 30 th, motor tabrakan 2n mobil 1+
mnt lalmnt lal
AA:clear:clear BB:!"mnt #$S ki%ka;:!"mnt #$S ki%ka; CC:& 10"0, ( /!"mnt:& 10"0, ( /!"mnt
DD:)*S 1. lab: Hb 1 :)*S 1. lab: Hb 1 ) Mn"0).00 02.30
T8040
MAP 3+ 3.8
CT J 2.44
T540
MAP 48+ 3.8
*perasi
0 Mn"
03.00 04.00
T)2080
MAP (3+ 5.(
6CS )0
Kes Turun
MAP (CT )5.30
-n/ark
Cereri
uas
6CS 4
P*- -s")).00
T )40(0 MAP )07
2l ! - !p" impaC9Ce: Kep !gnFr
inear Temp
6CS )4
T(040
MAP 7+ (.2
Konsul
en %;as
siapkan
*P
NC Butuh
Konf D/
CT ke RSB,
Overname
23.30
Koma
SABWater
Shed
nfark
!o"t
#R n$
% &r '2
Time Elapse
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DiskusiDiskusi
4ass 5 :4ass 5 : 6alapn &rama hebat, &ime 7llapse6alapn &rama hebat, &ime 7llapse
9am 3/, tapi 9am 3/, tapi ti2ak shock beratti2ak shock berat
p tertn2a
se2ikit krn bth 4on?rmasi Renal 2nse2ikit krn bth 4on?rmasi Renal 2n
*&, post op keranan rawat, ti2ak*&, post op keranan rawat, ti2akpernah shock @
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DiskusiDiskusi
4ass 55 :4ass 55 : @ask RS seera, shock rinan@ask RS seera, shock rinan 6alapn 2ilakkan ressitasi6alapn 2ilakkan ressitasi, transient, transient
responsrespons, ressitasi secara be2ah terlambat, ressitasi secara be2ah terlambat2ilakkan2ilakkan (time elapse > 2 hours)(time elapse > 2 hours)
Sempat 5skaemik *erebral sekitar 3 9amSempat 5skaemik *erebral sekitar 3 9am@
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MOFTRAUMA, SHOCK(
SIRS INFECTION
A )SSN*#+NK BTWNTRA-)A AND )-+T!+ OR*AN
A+-R
Trauma led to MOF asa result of unsuspected or
uncontrolled infection, and an intraa!dominal
a!scess "as most fre#uentl$ incriminated as t%e
tri&&erFr$ 'E, (earlstein ), Fulton R), (ol* HC+ Multiple s$stem or&an
failure t%e role of uncontrolled infection+Arch Surg-./01--2-3450+
T%ecomple6 of SIRS and MOF after trauma
does not re#uire a focus of infection for its
persistence+
Faist E, 7aue AE, 'ittmer H, He!erer 8+ Multiple or&an failure
in pol$trauma patients+ J Trauma-./3193::2/:+
If an intraa!dominala!scess "as found its
draina&e, did not al"a$s result in t%e
re;ersal of MOF+
Norton )
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Aerobic Metabolisms
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Cellular metabolism in theCellular metabolism in the
shock stateshock state
Respiratory
Enzyme
Chain
Citric
Acid
Cycle
Glycolysis8lucose ($ru;ate
)actate
NA'=
NA'(H
ANAERO!"ANAERO!"
AERO!"AERO!"
CO9
O6$&en
9AT(
34AT(
H9O
NA'=
NA'(H
NAD!& N1otnamde Adenne Dnu1eotdeNAD!& N1otnamde Adenne Dnu1eotde
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Anaerobic Metabolisms
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Cell injuryCell injury necrosisnecrosis
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NA'(=
O9 O9
NA'(H
Selectins
Inte&rins
Rollin& Ad%esion Transmi&ration
NA'(H
o6idase
R
E
(
E
RF
U
S
I
O
N
TISSUE
NONO
OONO#ERO$%N!TR!TE#ERO$%N!TR!TE
O9
)Ar& = iNOS
(roduction of ROS in endot%elium and neutrop%ils
EN'OTHE)
>ESSE)
'NA Strand 7rea*s'NA Strand 7rea*s
O9
H$po6ant%ine = ?O ?ant%ine
PARS ActivationCytochrome c release Apoptosis
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Pathophysiologic of !"SPathophysiologic of !"SMicrocirculatory Arrest TheoryMicrocirculatory Arrest Theory
Multiple Organ Failure, Pathophysiology, Prevention, and Therapy (Baue, 2
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#orrelation bet$een#orrelation bet$eenInsults andInsults and
Physiological "erangementPhysiological "erangement$ith$ithSIRS,SIRS,
!"S, !%, and "eath!"S, !%, and "eath (Baue, !!!)(Baue, !!!)
Common Pathway to Death
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!nitial
physiologiccondition
!! stst !nitial "tages!nitial "tages
O# PhysiologicO# Physiologic
$erangement$erangement
%&"%&"%ardiovascular%ardiovascular
'ormonal'ormonal
MetabolicMetabolic
!mmune system!mmune system
and mediatorsand mediators
&e)*uilibrium+
!! nd or rd etc
(&e "tages o(&e "tages o
physiologicphysiologic$erangement$erangement
$eath "e*uels
Philosophy ofPhilosophy ofPhysiologicPhysiologic
DerangementDerangement
2ndHIT
Goals
DirectedResuscitation
Supportive Th/1stHIT
Insult/Injury
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Microcirculatory SystemMicrocirculatory System
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Rheology of ErythrocyRheology of Erythrocy
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!nitial
physiologiccondition
!! stst !nitial "tages!nitial "tages
O# PhysiologicO# Physiologic
$erangement$erangement
%&"%&"%ardiovascular%ardiovascular
'ormonal'ormonal
MetabolicMetabolic
!mmune system!mmune system
and mediatorsand mediators
&e)*uilibrium+
!! nd or rd etc
(&e "tages o(&e "tages o
physiologicphysiologic$erangement$erangement
$eath "e*uels
Philosophy ofPhilosophy ofPhysiologicPhysiologic
DerangementDerangement
2ndHIT
Goals
DirectedResuscitation
Supportive Th/1stHIT
Insult/Injury
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Microcirculatory SystemMicrocirculatory System
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Rheology of ErythrocyRheology of Erythrocy
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