monitoring shock

8/9/2019 Monitoring Shock

1/24

MONITORING

OFHEMORRHAGIC SHOCK

BASRUL HANAFI

SUB DIVISION DIGESTIVE, DEPARTMENT OF SURGERY

HASAN SADIKIN HOSPITALBANDUNG


2/24

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


3/24

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


4/24

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 @


5/24

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@


6/24

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 )


7/24

Aerobic Metabolisms


8/24

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


9/24

Anaerobic Metabolisms


10/24


11/24

Cell injuryCell injury necrosisnecrosis


12/24


13/24

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


14/24


15/24

Pathophysiologic of !"SPathophysiologic of !"SMicrocirculatory Arrest TheoryMicrocirculatory Arrest Theory

Multiple Organ Failure, Pathophysiology, Prevention, and Therapy (Baue, 2


16/24

#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


17/24

!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


18/24

Microcirculatory SystemMicrocirculatory System


19/24

Rheology of ErythrocyRheology of Erythrocy


20/24

!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


21/24

Microcirculatory SystemMicrocirculatory System


22/24

Rheology of ErythrocyRheology of Erythrocy


23/24


24/24

monitoring shock

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