Syok

M. Hafidz Azhari Humairah Ayun Puji lestari Coni Senopadang

Pembimbing: dr Rapto Hardian, Sp.An

Syok
Merupakan sindrom multifaktorial hipoperfusi jaringan perifer dan sentral hipoksia seluler dan disfungsi organ multipel. Perfusi menurun secara sistemik dengan gejala yg jelas hipotensi Prognosis: derajat syok, durasi, organ yang terpengaruh, disfungsi organ sebelumnya

Patofisiologi
perfusi jaringan

shock Hipoksia seluler

Hipoksia seluler permeabilitas vaskuler radikal super oksida respon inflamasi kerusakan sel lebih lanjut kerusakan multiorgan

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 of hypoxemia, invalid in hypothermic patient

Vital Sign

Invasive hemodynamic monitoring

Arterial catheter Central venous catheter Pulmonary arterial catheter help guide aggressive resuscitation

Cardiac preload

Left ventricular end-diastolic volume Pulmonary artery occlusion pressure

Cardiac flow variable

Cardiac output cardiac function, measured by PAC Systemic vascular resistance index (SVRI)

Hemodynamic variables
Measured variable Systolic blood pressure (SBP) Diastolic blood pressure (DBP) Systolic pulmonary blood pressure (PAS) Diastolic pulmonary blood pressure (PAD) Pulmonary artery occlusion pressure (PAOP) Central venous pressure (CVP) Heart Rate (HR) Cardiac output (CO) Right ventricular ejection fraction (RVEF) Unit mmHg mmHg mmHg mmHg mmHg mmHg Beats/min L/min Fraction Normal Range 90-140 60-90 15-30 4-12 2-12 0-8 50-100 4-6 0,4-0,6

Calculated variable
Mean arterial pressure (MAP) Mean pulmonary artery pressure (MPAP) Cardiac index (CI) Stroke volume (SV) Stroke volume index (SVI)

Unit
mmHg mmHg L/min/m2 ML/beat mL/beat/m2

Normal range
70-105 9-16 2,8-4,2 Varies 30-65

Systemic vascular resistance index (SVRI)

Pulmonary vascular resistance index (PVRI) Left ventricular stroke work index (LVSWI) Right ventricular stroke work index (RVSWI) Right ventricular end-diastolic work index (RVEDWI) Body surface area (BSA)

Dynes
Sec/cm-5 g m/m2 g m/m2 mL/m2 m2

1.600-2.400
250-340 45-62 7-12 60-100 varies

Resuscitation end point

Lactic acid production Base deficit
Cellular hypoxia anaerobic metabolism lactic acid >> severity of shock Rate of clearance of lactate better marker of adequate resuscitation

The amount of base required to titrate whole blood to a normal pH Elevated base deficit severity of shock

Intramucosal pH monitoring

The mesenteric organ will have earlier and greater hypoperfusion than other organ system Gastric tonometry early indicator of hypoperfusion

Syok hipovolemik
Kehilangan volume intravaskular yang bersirkulasi dan penurunan cardiac preload

Loss of blood (hemorrhagic shock)

External hemorrhage Trauma Gastrointestinal tract bleeding Internal hemorrhage Hematoma Hemothorax or hemoperitoneum

Loss of Fluid and electrolyte

- External
Vomiting Diarrhea - Internal (third-spacing) Pacreatitis Ascites Bowel obstruction

Loss of plasma (luka bakar)

Grades of hypovolemic shock

Sign & symptom Blood loss (mL) %Blood volume Pulse rate Blood pressure RR Urinary output (ml/hr) Class I Up to 750 Up to 15 <100 N Class II 750-1500 15-30 >100 N 20-30 20-30 Class III 1500-2000 30-40 >120 30-40 5-15 Class IV >2000 >40 >140 >35 Negligible

Capillary refill N N >30

Mental status
Fluid replacement

Mild anxiety
Crystalloid

Anxiety
Crystalloid

Confused
Crystalloid + blood

Lethargic
Crystalloid + blood

Syok hipovolemik
Rapid infusion of multiple liters of crystalloid Large-bore venous access and central access is needed If haemorrhage shock after 2-3 liters of fluid blood is transfused + source of bleeding needs to be controlled Vasoconstrictor rarely needed

An initial, warmed fluid bolus is given as rapidly as possible. The usual dose is 1-2 liters for an adult and 20 ml/kg for a pediatric patient. 3-for-1 rule replace each mililiter of blood loss with 3 mL of crystalloid fluid Assess the patients response to fluid resuscitation

Response to Initial Fluid Resuscitation

Rapid Response Vital Sign Return to Normal Transient Response Transient improvement, recurrent of BP and HR Moderate and ongoing (20%40%) No Response Remain abnormal

Estimated blood loss

Minimal (10%20%)

Severe (>40%)

Need for more crystalloid

Need for blood

Low
Low

High
Moderate to high Type-specific Likely

High
Immediate Emergency blood release Highly likely

Blood preparation Type and cross match Need for operative intervention Possibly

Grades of dehydration
Mild < 5% Pulse rate Blood pressure Respiratory rate Capillary return Urine Output CNS/mental status N N N <2 seconds N N/restless Moderate 510% N N 3-4 seconds Dry Drowsy Severe >10% Rapid >5 seconds Negligible/absent Parched Lethargic/comato se

Mucous membran Moist

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

Estimating Maintenance Fluid Requirement

Weight For the first 10 kg For the next 10-20 kg For each kg above 20 kg Rate 4 ml/kg/h Add 2 ml/kg/h Add 1 ml/kg/h

Klasifikasi

Ringan atau Sedang

Berat atau Syok

Pemberian Cairan Defisit

Dibagi rata dlm 24 jam

Tahap I (rehidrasi cepat) : 20-40 cc/KgBB/1-2 jam Tahap II : sisa defisit 6 jam sisanya 16-17 jam

PERUBAHAN : -Gx Klinis -Hematokrit -Plasma elektrolit -CVP

+ Maintenance

Contoh:
Pasien pria, BB 50 kg, mengalami dehidrasi moderate (dehidrasi 5%) Jawab: Estimated Fluid Therapy 5% dehydration= 50 x 50 = 2500 ml/ 24 h = 105 ml/h Maintenance = 40+20+ 30 = 90 ml/h Rehydration + maintenance = 195 ml/h

Syok Obstruktif
Disebabkan oleh obstruksi mekanis thd cardiac output dgn penurunan perfusi sistemik Penyebab: a. Cardiac tamponade b. 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

Syok obstruktif
Penyebab harus diidentifikasi dan ditangani secepatnya: a. Pericardiocentesis/ pericardiotomy cardiac tamponade b. Needle decompression/ tube thoracostomy tension pneumothorax c. Ventilatory and cardiac support

Syok kardiogenik
Disebabkan karena kegagalan pompa Penyebab: extensive myocardial infarction (>>), reduced contractility (cardiomyopathy, sepsis induced) aortic stenosis, mitral stenosis, atrial myxoma, acute valvular failure, and cardiac dysrythmias. Tx: memaksimalkan preload dan kerja jantung, menurunkan after load.

Syok kardiogenik
Optimize preload with infusion of fluids Optimize contractility with inotropes Adjust afterload to maximize CO Diuresis indicated in patient with heart failure PAC guide therapy Identifiy and treat the underlying cause

Syok distributif
Disebabkan oleh vasodilatasi sistemik krn penyebab yg muncul (infeksi, anafilaksis) hipoperfusi sistemik dan atau cardiac output. Syok distributif ditingkatkan oleh respon inflamasi Terjadi hipoksia seluler karena gangguan fungsi mitokondria. Penyebab lain: anaphylaxis, severe trauma, severe liver dysfunction, and neurogenic shock.

 Neurogenic shock trauma MS servikal disertai hilangnya tonus simpatis vaskuler. Gejala: hipotensi, bradikardi, ekstremitas hangat Tx: volume dan vasokonstriktor

Syok anafilaksis
Anafilaksis: reaksi alergi yg berat terhadap rangsangan apapun, onset mendadak (<24 jam), melibatkan 1 atau lebih sistem tubuh dan memiliki gejala antara lain bengkak, flushing, gatal, angioedema, stridor, wheezing, sesak, mual, diare atau syok.

Sepsis

Pediatric septic shock