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SHOCK

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Defnisi

Clinical syndrome caused by

hemodynamic and metabolic disturbance

characterized by failure of the circulatory

system to maintain adequate perfusion to

vital body organs

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Etiologi

Extensive myocardial inarction or pulmonary

embolism cardiogenic shock

Sepsis caused by bacteria uncontrolled septic

shock

asomotor tone inade!uate neurogenic shock

Due to an immune response anaphylactic shock

"assive bleeding# trauma# severe burns

hypovolemic shock

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Shock criteria

TD sistolik

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S!*C S3(.S

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4ase of shock

Compensation Decompensation

irreversible

5lood loss 678 p to )% )% : ;0 # ;0

Cardiac rate Tachycardia Tachycardia Tachycardia ,bradycardia

1ulse pressure . , decreased Decreased Decreased

Capillary re=l . , increased 3ncreased 3ncreased

Skin Cold+ pale Cold+ mottled 5lue pale

"" Tachypnoea Tachypnoea Sighing

raspirationConsciousnesslevel

>gitation Cooperation "espons to painor no respons

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Dari ? C@S Di=culty? >ssesmentA Dalam ? Tasker "C+ BcClure "+

>cerini C+ editorA *Eford !andbook of 1aediatricsA Fdisi $A 3tali?*Eford niversity 1ress+ )00'A

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!ypovolemic ShockDeGnition?

"eduction in intravascular volumeleading to insu=cient oEygendelivery to cells 6mitochondria8

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Hemorrhagic hypovolemia

Thorax

Pulmonary parenchymal trauma

Pulmonary vascular injury

Intercostal vascular injury

Aortic disruption

Massive hemoptysis

Abdomen/pelvis/retroperitoneum

Solid organ injuries (liver, spleen, idney!

"ascular (trauma, aneurysmal rupture!

#astrointestinal hemorrhage (esophageal varices, ulcers, vascular anomalies, etc$!

#ynecologic disorders (ruptured ectopic pregnancy,peripartum hemorrhage abnormal uterine bleeding,ovarian cystrupture!

%rthopedic

Pelvic &racture

'arge bone &ractures

Multiple &ractures

xtremity and sin sur&ace

Major vascular injuries 'arge so&t tissue injuries

Nonhemorrhagic hypovolemia

#astrointestinal disorders) vomiting, diarrhea, ascites

*urns

nvironmental exposure or neglect

+enal salt asting

FT3**(3

Tintinalli's Emergency Medicine-Section .) Shoc-hapter 01$ 2luid and *lood +esuscitation-

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!emorrhage Shock

>n acute loss of circulating bloodvolume

The normal adult blood volume approEimately 7 of body Ieight

The blood volume for a child '7 297 of body Ieight 6'0 : 90 ml,kg8

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$%&'(&) * +,- vol.

Darah/

SED(&') +,01,- vol.

Darah/

2E$(3) 4 1,- vol.

Darah/

Fkstremitas dinginSama+ di 68

takikardia

Sama+ di 68hemodinamik tak

stabil

C"T Takipnea Takikardi berge-ala

Diaporesis *liguria !ipotensi

@ena kolaps !ipotensi ortostatik1erubahankesadaran

Cemas

(e-ala linis Syok!ipovolemik

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Diagnosis !emorrhage shock basedof >TS

C>SS 3 C>SS 33 C>SS 333 C>SS 3@

5lood loss6m8

p to %0 %0: $%00 $%00 : )000 # )000

5lood loss67 8

p to $% $% : &0 &0 : ;0 # ;0

5loodpressure

. . Decreased Decreased

1ulsepressure

. ,increased

Decreased Decreased Decreased

1ulse rate J $00 $00 2 $)0 $)0 2 $;0 # $;0"espiratoryrate

$; : )0 )0 : &0 &0 : ;0 # &%

rine output6m,hr8

# &0 )0 : &0 % : )0 .egligible

C.S , mentalstatus SlightlyanEious BildlyanEious >nEious+confused Confused+lethargic

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FLects of !emorrhagicShock

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!ypovolemic Shock

Mour management goals >4TF" securing the>5Cs?

ST*1 T!F 5FFD3.(N

"FST*"F @*BFN

C*""FCT >.M FFCT"*MTF,>C3D25>SFD3ST"5>.CFSN

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!ypovolemic Shock@olume "esuscitation O Phat are my

goalsQ

$A "apid "esponder (ive %00cc2$ iter crystalloid rapid

improvement of 51,!",rine output

< )07 blood loss

Surgery consult

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!ypovolemic Shock@olume "esuscitation O Phat are my

goalsQ

)ATransient "esponder (ive %00cc2$ iter crystalloid improves

brieRy then deteriorates

)02;07 blood loss Continue crystalloid infusion ,2 5lood

Surgery consult

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!ypovolemic Shock@olume "esuscitation O Phat are my

goalsQ

&A .on "esponder (ive ) iters crystalloid, ) units 5lood

no response

# ;07 blood loss

ST>T Surgery consultN

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!ypovolemic Shock3s my volume resuscitation

adequate,inadequateQ

rine output@ital signsSkin perfusion

1ulse *Eimetry>cidemiaQQ

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"esponses to 3nitial 4luid"esuscitation

$apid$esponse

3ransient$esponse

"inimal or noresponse

@ital sign "eturn to normal Transientimprovement+recurrence of

decreased 51 andincreased !T

"emain abnormal

Fstimatedblood loss

Binimal 6$07 2)078

Boderate andongoing 6)07 2;078

Severe 6# ;078

.eed for morecrystalloid oI !igh !igh

.eed for blood oI Boderate to high 3mmediate

5loodpreparation

Type andcrossmatch

Type speciGc Fmergency bloodrelease

.eed foroperative 1ossibly ikely !ighly likely

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Cardiogenic Shock

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"isk 4actors

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Ftiology

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Ftiology

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Signs and Symptoms

.eck?ugular venous distention

Cardiac?

3schemic chest pain Systolic apical bloIing murmur

(allop rhythm? S& reRects severe myocardial dysfunction

S; is present in '07 patients in sinus rhythm Iith>B3

Systolic click? Suggests rupture of the chordae tendinae

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Signs and Symptoms

>5Cs and vital signs? 1atent airIay 6early8

abored breathing and tachypnea 6early8respiratory failure 6late8

DiLuse crackles or Iheezing

!ypoEia

!ypotension?

Systolic blood pressure

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Signs and Symptoms

(eneral? Cyanosis

1allor

Diaphoresis

Dulled sensorium

Decrease in body temperature

rine RoI of less than )0 m,h

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Signs and Symptoms

>bdominal? Fpigastric pain

.ausea and vomiting

.eurologic? *btundation

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; 1otential Therapies

1ressors

3ntra2aortic 5alloon 1ump 63>518

4ibrinolytics "evascularization? C>5(,1C3

"efractory shock? ventricular assistdevice+ cardiac transplantation

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DiLerentiating Types of Shock

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SE53%C SHOCK

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Syok Septik

S%$S 6Systemic 3nRammatory "esponse Syndrome8

-ikamencakup ) keadaan berikut ?suhu # &'oC atau < &/oCfrekuensi -antung # 90E,mnt

frekuensi napas # )0E,mnt atau 1aC*) < &)mm!g

leukosit darah # $)A000,mm&+ < ;00,mm& atau batang #$07

Sepsis keadaan klinis berkaitan dengan infeksi danmanifestasi S3"S

Sepsis berat

sepsis yang disertai dengan disfungsi organ+hipoperfusi , hipotensi termasuk asidosis laktat+ oliguria+ danpenurunan kesadaranA

Sepsis dengan hipotensi sepsis dengan TD sistolik dministration of epinephrine

3f possible set tourniquets proEimal to thein-ection site and relaE every $0 minutes

System *herapy

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System *herapy

respiratorysystem

%oal' .aintain an ade/uate airwayepinephrineLaryngeal edematracheostomy

%i)ing oxygenLower airway obstructionbronchodilators 0salbutamol or 1beta*1 agonists in Na!l 2#34 with nebulized or aminophyllinewere diluted and 12 cc of 54 dextrose or sodium chloride 2#34

!ardi)ascularystem

ymptoms of hypotension and shock if not managed withintra)enous fluids epinephrine 02#34 Na!l crystalloid orcolloid plasma, dextran6xygen and gi)ing Na bicarbonate 0metabolic acidosis7!8Pmonitoring needs fluids and a)oid excess fluid, and

used for drug deli)ery when the leak can stimulate thesurrounding tissue9lood Pressure)asopressor not resol)ed throughintra)enous infusionepinephrine :':222 in 152 ml of dextrose or :5*;2 microdrip cral+ skin turgor+ and urine output to

assess response to therapyA

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SHOCK O2S3$7C3%E

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O2S3$7C3%E SHOCK

*bstructive shock is a form ofcardiogenic shock caused bymechanical di=culties in circulation+

Ihich causes decreased C*+ notprimary heart failure

Ftiology such as pulmonary

embolism or tension pneumothoraE

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5harmacologic shock Supportive therapy

Decontamination of overdoses Iith charcoal

3notropic agents as needed

Drug speciGc antidotes

&eurogenic shock Supportive therapy

Traction K fracture stabilization Corticosteroids