DIANOSIS DAN RESUSITASI PADA

PASIEN SYOK PERDARAHAN &

SYOK DEHIDRASI
Oleh
Soraya Febriananda
Pembimbing
dr. Rapto Hardian, Sp.An
FISIOLOGI DASAR JANTUNG

American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors, student course manual
Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
DEFINISI SYOK
Gangguan sirkulasi yang ditandai dengan
kolapsnya hemodinamik tubuh berupa perfusi yang
tidak adekuat pada kulit, ginjal dan sistem saraf
pusat.

American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors, student course manual
Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
KLASIFIKASI SYOK

Syok Hipovolemik

Syok Kardiogenik

Syok Distributif

Syok Obstruktif
 SYOK HIPOVOLEMIK
Kehilangan volume intravaskular yang bersirkulasi dan penurunan
cardiac preload
Loss of blood Loss of Fluid and
(hemorrhagic shock) electrolyte
External hemorrhage - External
Trauma
Vomiting
Gastrointestinal tract
bleeding Diarrhea

Internal hemorrhage - Internal (third-spacing)

Hematoma Pacreatitis
Hemothorax or Ascites
hemoperitoneum Bowel obstruction
Loss of plasma
(luka bakar)

American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors, student course manual
Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
PENILAIAN AWAL PASIEN
Denyut Nadi

Laju Pernapasan

Perfusi Kulit

Tekanan Nadi
American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors, student course manual
Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
Pathophysiology of Shock Hypovolemi
Volume loss
Autonomic tone Fluid shifts from extracellular to
Catecholamine release intravascular

survival Venous capacitance Partial restoration of intravascular

Heart rate volume
Intervention / stabilization
Maintenance of perfusion

Blood flow shunted to vital

organs (heart,lung,brain)
Continued volume loss
Cellular hypoxia /
anaerobic metabolism

ATP production / lactic acidosis

PATHOPHYSIO, CONTN Cellular hypoxia /
anaerobic metabolism

13/07/2017
Survival / delayed
morbidity / mortality ATP production / lactic acidosis

Intervention / stabilization Cellular

function
impaired
Continued volume loss
Membrane porosity
Lysozymal leakage
Movement of fluid
from intravascular Cellular autodigestion
to interstitial spaces
Irreversible
shock
intervention 8
No. intervention
DEATH
THE GOLDEN HOUR
is the time in which resuscitation of severely
injured patients must begin to achieve maximal
survive
R. Adams Cowley, MD

The lethal factor in shock is inadequate cellular oxygen delivery, leads

to irreversible anoxic cellular injury that kills a critical mass of cells

Hasanul, 2009
 THE GOLDEN HOUR
Probability of Survival R. Adams Cowley, MD

100
80
% survival
60
40
20

0 minutes
30 60 90
Survival is related to severity and
duration

Hasanul, 2009
SYOK HEMORAGIK
Perdarahan adalah kehilangan volume darah
sirkulasi secara akut.
Estimated Blood Volume (EBV):
Dewasa: 65-70 ml/kg BB
Anak: 80-90 ml/kg BB
Kehilangan darah yang mencapai 25% EBV akan
menyebabkan pasien jatuh dalam syok.
 DERAJAT SYOK
Sign & symptom Class I
PERDARAHAN
Class II Class III Class IV

Blood loss (mL) Up to 750 750-1500 1500-2000 >2000

%Blood volume Up to 15 15-30 30-40 >40

Pulse rate <100 >100 >120 >140

Blood pressure N N

Capillary refill N
RR N 20-30 30-40 >35
Urinary output >30 20-30 5-15 Negligible
(ml/hr)
Mental status Mild anxiety Anxiety Confused Lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid + Crystalloid +
blood blood
American College of Surgeons Committee on Trauma. Advanced trauma life supports for doctors, student course manual Ed. 8th.Chicago: American College of Surgeons Committee on Trauma, 2008.
PERUBAHAN DALAM SYSTEMIC OXYGEN DELIVERY
AKIBAT SYOK PERDARAHAN
PENATALAKSANAAN SYOK HEMORAGIK
Airway and Breathing
Circulation Bleeding Control
Disability Pemeriksaan Neurologi
Exposure Pemeriksaan Lengkap
Dilatasi Lambung Dekompresi
Pemasangan Kateter Urin
FLUID MANAGEMENT

INTRAVASCULAR VOLUME

HEMODYNAMIC MECHANISM
PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

SYSTEMIC VASCULAR
CARDIAC OUTPUT
RESISTANCE

BLOOD PRESSURE Tissue Perfusion

Hasanul, 2006
KRISTALLOID 3:1
KOLOID, HES 1:1
GELATIN 1.5 : 1
DARAH 1:1
PENGGANTIAN DARAH
Mengembalikan kapasitas angkut oksigen di
dalam volume intravaskuler.

Whole Blood = 6 x BB x Hb
Whole Blood = 6 x BB x Hb
American Soc of Anesthesiologists 1996
Hb 7-15

End-1
POLA KERJA PENANGANAN SHOCK PERDARAHAN
Penderita datang dengan
perdarahan

Pasang infus jarum kaliber Ukur tekanan darah, hitung nadi,

besar (16G, 18G), ambil nilai perfusi, produksi urine
sample darah

Tentukan estimasi jumlah

perdarahan, minta darah
Guyur cepat Ringer Laktat atau NaCl
0.9% [hangat, 390C] 3x prakiraan lost-
EVALUASI
volume [1-2 liter]
 RESPON AWAL TERHADAP RESUSITASI CAIRAN
TRANSIENT
RAPID RESPONSE NO RESPONSE
RESPONSE
Vital Sign Return to Normal Transient improvement, Remain abnormal
recurrent of BP and
HR

Estimated blood loss Minimal (10%-20%) Moderate and ongoing Severe (>40%)
(20%-40%)

Need for more Low High High

crystalloid
Need for blood Low Moderate to high Immediate
Blood preparation Type and cross match Type-specific Emergency blood
release
Need for operative Possibly Likely Highly likely
intervention
TANDA HEMODINAMIK MEMBAIK
Perfusimembaik (akral teraba hangat)
Nadi <100 x/menit

MAP > 65 - 95

Produksi urine 0,5 1 cc/kgBB/jam

SYOK DEHIDRASI
ETIOLOGI
Gastrointestinal losses
Vomiting
Diarrhea
Urinary losses
Diabetic ketoacidosis
Diabetes insipidus
Adrenal insufficiency
Diuretic usage
Decreased intake
Stomatitis, pharyngitis
Anorexia, fluid deprivation
Translocation of body fluids
Small bowel obstruction
Peritonitis
Acute pancreatitis
Burns
Ascites
Nephrotic syndrome
DERAJAT SYOK DEHIDRASI

Mild < 5% Moderate 5-10% Severe >10%

Pulse rate N
Blood pressure N N
Respiratory rate N N Rapid
Capillary return <2 seconds 3-4 seconds >5 seconds
Urine Output N Negligible/absent
Mucous membran Moist Dry Parched
CNS/mental status N/restless Drowsy Lethargic/comatose

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

PRODUKSI URIN
Pemantau aliran darah ginjal

Dewasa : Anak :
0,5 1
ml/kg/jam ml/kg/jam

Bayi :
2 ml/kg/jam

27
ESTIMASI CAIRAN
RUMATAN/MAINTENANCE

Weight Rate

For the first 10 kg 4 ml/kg/h

For the next 10-20 kg Add 2 ml/kg/h

For each kg above 20 kg Add 1 ml/kg/h

 MANAJEMEN SYOK DEHIDRASI

Klasifikasi Ringan atau Sedang Berat atau Syok

Pemberian Dibagi rata dalam Tahap I (rehidrasi cepat) :

Cairan 24 jam 20-40 cc/KgBB/1-2 jam
Defisit 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
TERIMA KASIH