Dr. Az Rifki, SpAn.

KIC
Departemen Anestesiologi dan Reanimasi
RSI Siti Rahmah/FK-FKG Universitas Baiturrahmah
Padang

Diagnosa dan Penaganan Syok 1

Pokok Bahaasan
n Definisi Syok

n Pembagian / Penyebab Syok

n Gejala dan tanda

n Prinsip penanganan jenis-jenis Syok

Diagnosa dan Penaganan Syok 2

 Definisi
• Gangguan sistem sirkulasi yang
menyebabkan tidak adekuatnya perfusi dan
oksigenasi jaringan

• Klinis :
– Sindroma : lemah, pucat, dingin, vena
permukaan colaps, perubahan mental dan
berkurangnya prod. urin

Diagnosa dan Penaganan Syok 3

 Definisi

• Hipotensi
– Tekanan Darah Sistolik < 90 mmHg
– Tekanan Darah Sistolik berkurang > 40 mmHg
• Hipoperfusi
– Perubahan status mental
– Oliguria
– Asidosis laktat

Diagnosa dan Penaganan Syok 4

 Tanda dan gejala syok
• Sistem Kardiovaskuler
– Gangguan sirkulasi
• Pucat, dingin, sianosis
• Vena perifer kolaps
– Nadi cepat dan halus
– Tekanan darah rendah – kurang bisa jadi pegangan
– Vena jugularis – penting.
– CVP

Diagnosa dan Penaganan Syok 5

 Tanda dan gejala syok
• Sistem Respirasi
– Nafas cepat dan dangkal
• Sistem susunan saraf pusat
– Perubahan mental / kesadaran
• Sistem saluran cerna
– Mual dan muntah
• Sistem saluran kencing
– Produksi urin < ½ cc/kg/jam

Diagnosa dan Penaganan Syok 6

 Perfusi normal

• Pompa jantung

• Volume sirkulasi

• Tahanan pembuluh darah

perifer

Diagnosa dan Penaganan Syok 7

Perfusion is Perfusion
accomplished by heart,
vessels and blood
working together.
The components of the
Cardiovascular System
are Interdependent.
If one component
malfunctions, the other
components
compensate to return
the blood pressure to
normal.
 Normal Compensation for Low Volume of
Fluids (Hypovolemia)
During Bleeding or
Dehydration (volume Heart Rate
of fluid in vessels falls): Increases

Heart Rate Increases

Blood vessels and Increased
capillary sphincters Vasoconstrictio
tighten up n
(vasoconstrict)

All to maintain blood Dehydration or Blood Loss

pressure and tissue and causing Hypovolemia
organ perfusion.
Hypotension is a sign of
cardiovascular insufficiency.
In shock, there is insufficient
pressure to maintain tissue perfusion.
At least one of the
components of the CVS
has malfunctioned and
the others have failed to
compensate.
 What causes Shock?
Problems with the Heart
itself (Cardiogenic)
Loss of fluids
(Hypovolemic)
Problems with the
Vascular System
(Distributive)
Conditions blocking flow
to/ from the Heart
(Extra Cardiac
Obstructive)
 Classification of Shock
Hypovolemic Cardiogenic
Hemorrhagic
Myopathic (ie. Ischemic)
Non-hemorrhagic
Mechanical (ie. Valvular)
Arrhytmic
Distributive Obstructive
Septic
Massive PE
Adrenal crisis
Tension Pneumothorax
Neurogenic (Spinal
Cardiac tamponade
shock)
Constrictive pericarditis
Anaphylactic
 Gambaran hemodinamik Syok
Jenis Syok PAOP Cardiac SVR
Output
Kardiogenik   
Hipovolemik   
Distributif  / nl  / nl /  
Obstruktif
Tamponade   
Jantung
Emboli Paru  / nl  

Diagnosa dan Penaganan Syok

13
 Cardiogenic Shock
(Problems with the Pump itself:
The Heart Muscle)

If the heart muscle is damaged, it can not

pump effectively.
Normal compensatory mechanisms can
make the situation worse.
Pump failure can cause fluid to back up
into the lungs, resulting in Pulmonary
edema
Pulmonary edema leads to impaired
ventilation
Diagnosa Syok Kardiogenik

• Cardiac Output berkurang

• LV filling pressure meningkat

• SVR meningkat

Diagnosa dan Penaganan Syok 15

 Hypovolemic Shock
Results from fluid loss
(dehydration) or blood loss
(hemorrhagic)
Hemorrhagic shock is the
most common cause of shock
after an injury
Hemorrhage can be both
external and internal bleeding
 Hypovolemic Shock
Some Blood Facts

A 70kg man (150 lbs) has a circulating volume of

approximately 5 Liters
Loss of 15-30% blood (750ml-1.5L) causes tachycardia
and decreasead pulse pressure Fractured tibia or
humerus may be associated with 750ml of blood loss
Loss of 30-40% (1.5L-2L) consistently drops systolic
blood pressure and usually requires a blood transfusion.
Femur fracture may lose 1.5L blood
More than 40% (>2L) is immediately life-threatening
Pelvic fractures may bleed several liters.
 Hypovolemic Shock

Severe thermal burns cause

body fluid loss
Pre-existing dehydration
aggravates shock
Diagnosa Syok Hipovolemik

• Cardiac Output berkurang

• LV filling pressure berkurang

• SVR meningkat

Diagnosa dan Penaganan Syok 19

 Distributive Shock
Due to poor vessel function: a
problem with abnormally dilated
vessels.
Blood vessels are normally kept in
a state of tonic vasoconstriction,
maintained by the interaction
between special pressure receptors
in vessel walls and the autonomic
nervous system. (tonic vasoconstriction)
NORMAL
 Distributive Shock
Injury, toxins, medications and
chemicals may reverse normal
tonic vasoconstriction and the
blood vessels dilate and the
patient becomes hypotensive.
NORMAL ABNORMAL

Blood Vessels
(tonic vasoconstriction) (vasodilation)
Types of Distributive Shock

Septic Shock
Neurogenic Shock
Anaphylactic Shock
(Drugs, Chemicals,
Toxins)
 Distributive Shock (Septic Shock)

Occurs when an infection enters the

bloodstream and travels throughout the
body.
Toxins released from infectious
organisms override compensatory
mechanisms.
A number of physiological upsets
contribute to dilation of blood vessels,
hypotension and inadequate perfusion.
 Distributive Shock (Neurogenic Shock)

Cervical spinal cord injury can interrupt the normal

control of the Autonomic Nervous System (blocks
sympathetic nerves).
Blood vessels dilate, the size of the vascular
system increases, and blood can not fill the
enlarged system
Classic Picture:
Warm, flushed, dry skin,
Low blood pressure,
Normal or slow (bradycardia) heart rate
 Distributive Shock (Anaphylactic
Shock)
Systemic allergic reaction involving
the whole body
Body mast cells release chemicals
and histamines which cause
vasodilation
Onset is acute, manifestations vary
from mild to rapidly fatal
Stings from bees, wasps, hornets are
most common
Diagnosa Syok Distributif

• Cardiac Output normal atau meningkat

• LV filling pressure normal atau rendah

• SVR berkurang

Diagnosa dan Penaganan Syok 26

 Extracardiac Obstructive Shock
(or anything that prevents blood flow
into or out of the heart)
Pericardial Tamponade (build up of fluid
in the membrane surrounding the heart)
Massive Pulmonary Embolism
(blockage of blood flow to the lungs by blood
clot, gas bubble, tissue or other object)
Tension Pneumothorax (an expanding
air collection outside the lung which causes
lung collapse and places pressure on heart
and blood vessels)
 Diagnosa Syok Obstruktif

• Cardiac Output berkurang

• LV filling pressure bervariasi

• SVR meningkat

Diagnosa dan Penaganan Syok 28

 Hipotensi
• Biasanya (tidak selalu) cardiac output
berkurang, kecuali Sepsis berat
• Tidak selalu berarti syok
• Hipertensi bisa CO rendah dan
hipoperfusi organ (Gagal Jantung)
• Penting pemeriksaan fisik

Diagnosa dan Penaganan Syok 29

 PRINCIPLES OF MANAGEMENT

 identify cause
 establish adequate ventilation and
oxygenation
 restore optimum intravascular volume
 maintain adequate cardiac output and
renal perfusion
 maintain optimum internal metabolic
environment

Diagnosa dan Penaganan Syok 30

 Penanganan Syok
 Prinsip dasar
 Meningkatkan O2 delivery
 Cara
 resusitasi cairan
 meningkatkan kontraktilitas jantung
 meningkatkan SVR
 Memperbaiki kelainan irama
 Optimalisasi O2 content darah
 Pasang kateter urin
The goal of all treatment is to maintain adequate
tissue perfusion and treat the underlying cause

Diagnosa dan Penaganan Syok 31

 Treatment of Cardiogenic Shock

 Determinants of Myocardial Oxygen

Consumption
I. Heart rate
II. Contractility
III. Preload
IV. Afterload

Diagnosa dan Penaganan Syok 32

 Treatment
 Broadly based on four methods
 (a) increasing contractility
 (b) altering preload and afterload
 (c) controlling arrhythmias.

Diagnosa dan Penaganan Syok 33

 Treatment
 Increasing Contractility
 The three drugs commonly used to
increase cardiac contractility are
dobutamine, dopamine, noradrenalin
and isoproterenol.
 Reducing Preload and Afterload
 Diuretics may be used as an adjuvant in
the treatment of cardiogenic shock but
not as a primary agent.
 vasodilator therapy may be added to
reduce preload and afterload, thereby
enhancing cardiac output and reducing
myocardial oxygen needs
Diagnosa dan Penaganan Syok 34
 Treatment
Common Drugs for Arrhythmias

 Supraventricular  Ventricular ectopy

tachycardia  Lidocaine
 Digitalis  Procainamide
 Verapamil
 Bretylium
 Propanolol
 Quinidine
 Procainamide
 Quinidine

Diagnosa dan Penaganan Syok 35

 Penanganan Syok
Hipovolemik
• Mengembalikan volume intravaskuler
– Tekanan Darah
– Nadi
– Perfusi organ
• Pilihan cairan
– Kristaloid
– Koloid
– PRC

Diagnosa dan Penaganan Syok 36

 Treatment
 Impaired perfusion secondary to
reduced volume
 restore volume
 Restoration of circulating volume can be
achieved by the infusion of 3 mL of
balanced electrolyte solution for each
milliliter of blood lost.
 Fluids are infused through two large-
bore intravenous lines

Diagnosa dan Penaganan Syok 37

 Treatment
 Administration of supplemental
oxygen
 Control bleeding
 Foley catheter to monitor renal
function
 establishment of urine output at
approximately 50 cc/hr for the adult

Diagnosa dan Penaganan Syok 38

Penanganan Syok Distributif
Syok Septik
I. Correct primary process
A. Antibiotics
B. Drainage

II. Resuscitation
A. Ventilatory support and 02, as needed
B. Fluids
C. Inotropes
D. Vasodilators or vasopressors

Diagnosa dan Penaganan Syok 39

 Resuscitation
 increase vascular volume
 crystalloid solutions are preferred for raising
intravascular volume

 severe acidosis may impair cardiac function

if the arterial pH is < 7. 1, bicarbonate may
be required.
 Dopamine in doses of 5 to 15 ug/kg/min
seems ideal for improving myocardial
contractility and cardiac output in
hypotensive vasodilated patients.
Diagnosa dan Penaganan Syok 40
Penanganan Syok Distributif

• Syok Anafilaktik
– Epinephrine SQ
– Resusitasi cairan
– Epinephrine IV

Diagnosa dan Penaganan Syok 41

 Terapi Cairan
• Mengganti volume intravaskuler

• Menentukan status volume cairan pasien

– Vena leher

– Auskultasi paru

– CVP

Diagnosa dan Penaganan Syok 42

 Resusitasi Cairan
• Koreksi hipotensi
• Turunkan HR
• Koreksi hipoperfusi
– Oliguria
– Perubahan status mental
– Asidosis laktat

• Pantau perburukkan oksigenasi

Diagnosa dan Penaganan Syok 43

Prioritas dalam Terapi Cairan
 EMERJENSI :
 VOLUME INTRAVASKULAR
 CURAH JANTUNG
 PERFUSI ORGAN VITAL
 SUB-EMERJENSI :
 INTERSTITIAL
 INTRASEL
 TANDA-TANDA VITAL
 PROD. URIN

Diagnosa dan Penaganan Syok 44

 Jenis Cairan
 Kristaloid
 Ringer Laktat / Ringer Asetat
 Normal Saline
 Koloid
 Hetastarch
 Albumin 5%
 PRC
 Meningkatkan kapasitas angkutan O2
 Fresh-frozen plasma
 Tidak diindikasikan untuk mengganti volume

Diagnosa dan Penaganan Syok 45

 Penanganan Syok
Obstruktif
• Atasi obstruksi
– Perikardiosentesis
– Needle torakostomi
• Resusitasi cairan
• Hindari pemakaian Diuretika
• Peran inotropik dan vasopresor :
minimal

Diagnosa dan Penaganan Syok 46

 Gagal Jantung Kiri dengan
Hemodinamik Stabil
• Cardiac Output rendah
• Tekanan Darah Normal /
meningkat
• Hipoksemia
• Penanganan
– Kurangi preload
– Kurangi afterload
Diagnosa dan Penaganan Syok 47
Inotropik dan Vasopresor
n Dopamine
u Dosis rendah (2-3 g/kg/min)
F Inotropik, kronotropik, renal efek

u Dosisi menengah (4-10 g/kg/min)

F Inotropik

u Dosis besar (> 10 g/kg/min)

F Vasokonstriksi

Diagnosa dan Penaganan Syok 48

Inotropik dan Vasopresor
n Dobutamine (5-20 g/kg/min)
u -Adrenergic agonist
u Inotropik, kronotropik
n Norepinephrine
u Efek -Adrenergic
u Inotropik, kronotropik
u Kombinasi dengan dosis rendah Dopamine

Diagnosa dan Penaganan Syok 49

Inotropik dan Vasopresor

n Epinephrine

u  dan  adrenergic

u Inotropik dan kronotropik kuat

u Meningkatkan “myocardial O2 demand”

Diagnosa dan Penaganan Syok 50

 Terapi Syok

• Mengurangi O2 demand
– Intubasi
– Sedasi
– Analgesi
– Atasi demam

Diagnosa dan Penaganan Syok 51

 Terapi Syok

• Meningkatkan O2 delivery
(Hb x 1.34 x SaO2) x CO x 10

– Naikkan Cardiac Output

– Naikkan Hb

– Naikkan saturasi oxyhemoglobine

Diagnosa dan Penaganan Syok 52

 TREATMENT CONCEPT OF SHOCK
ENHANCING PERFUSION / OXYGEN DELIVERY

DO2 = CO x CaO2

Cardiac Arterial O2
output content

Oxygen delivery/DO2 = HR X SV X Hb X S02 X 1.39 + 0.03 X paO2

Inotropes Transfuse
Fluids Partially
dependent on
FIO2 and
pulmonary
status

Diagnosa dan Penaganan Syok 53

 Cardiogenic Distributive
Shock Shock

Inotropes
Vasopressor ( NE,PE,ADR,Dop)
(Dob,Dop,Adr,Amr)

Release Pipe = Vascular Blood Pressure

Pump =
tamponade,etc
Heart

Obstructive Cardiac Output x SVR

Shock

Volume =
Blood

Hypovolemic
Fluids Shock

Diagnosa dan Penaganan Syok 54

Target Terapi Syok
n Hb  10 g%
n Saturasi  92%
n Cardiac index 2.5-4.5 L/min/m2
n PAOP 12-15 mmHg
n PAOP lebih tinggi pada syok kardiogenik

Diagnosa dan Penaganan Syok 55

Oliguria
n Tanda hipoperfusi
n Dewasa
u Urine output < 0.5 ml/kg/jam untuk  2 jam
n Penyebab
u Prerenal
u Renal
u Postrenal

Diagnosa dan Penaganan Syok 56

 Evaluasi Oliguria
• Riwayat dan pemeriksaan fisik
• Evaluasi laboratorium
– BUN
– Creatinine
– BD urine
– Osmolalitas urine
– Sodium urine

Diagnosa dan Penaganan Syok 57

Evaluasi Oliguria

Test Laboratorium Prerenal ATN

Ratio BUN / Creatinin > 20 10 - 20
BD urine > 1.020 < 1.010
Osmolalitas urine (mOsm/L) > 500 < 350
Sodium urine (mEq/L) < 20 > 40
Fraksi ekskresi sodium (%) <1 >2

Diagnosa dan Penaganan Syok 58

 Kesimpulan
• Syok : gangguan aliran darah ke organ
yang tidak mencukupi kebutuhan
oksigenasi jaringan
• Gambaran hemodinamik dapat
membantu menegakkan diagnosa dan
penanggulangan Syok
• Hipotensi biasanya (tidak selalu)
menunjukkan CO berkurang (kecuali
Sepsis berat). Hipertensi bisa dengan CO
rendah (Gagal Jantung)

Diagnosa dan Penaganan Syok 59

 Kesimpulan

• Penanggulangan Syok dilakukan dengan

meningkatkan CO dan TD dengan
kombinasi pemberian cairan,
meningkatkan kontraksi jantung dengan
inotropik dan meningkatkan SVR dengan
vasopresor
• Bila Gagal Jantung dengan CO rendah, N/
TD dan Hipoksemia, diatasi dengan
pengurangan preload dan afterload
Diagnosa dan Penaganan Syok 60
 Kesimpulan

• Pengurangan Preload dan afterload pada

gagal jantung yang hipotensi
• Target terapi hipovolemik syok :
menstabilkan TD, Nadi dan perfusi organ
(prod. Urin adekuat)
• Terapi awal Septik Syok : optimalisasi vol.
Intravaskuler
• Optimalisasi Vol. Intravaskuler vital pada
obstruksi syok
Diagnosa dan Penaganan Syok 61
 Kesimpulan
• Bersihnya lapangan paru dan vena leher yang
kosong menunjukkan masih perlunya tambahan
resusitasi cairan pada pasien hipotensi
• Target pertama resusitasi cairan adalah koreksi
hipotensi, baru kemudian menurunkan frekuensi
nadi dan koreksi gangguan perfusi. Penting monitor
prod. Urin
• Dobutamin harus diberikan hati-hati pada pasien
hipotensi, terutama bila penggantian volume
Intravaskuler belum adekuat.
• Volume intravaskuler harus optimal sebelum
pemberian loop diuretik pada pasien oliguria

Diagnosa dan Penaganan Syok 62