RESUSITASI CAIRAN DAN

DARAH PADA TRAUMA

TRAUMA

Blood loss:
– Trauma: blunt and penetrating
– BLOOD YOU SEE
– BLOOD YOU DON’T SEE
Perdarahan  hipovolume  oksigenasi sel
turun - shock (+)

Masalah :
- Pada waktu yang tidak lama
jumlah cairan intravaskuler berkurang.
- Jumlah cairan di interstitiel & intrasel
tetap.
 BODY FLUIDS
COMPARTEMENT
40
%

20
%

Acute
Bleeding

INTRA CELL INTERSITIELINTRAVASCULAR

 BODY FLUIDS
COMPARTEMENT
CRITICALLY ILL PATIENTS
40
%
PERCENT
OF BODY
WEIGHT

THIRD
20
% SPACE

INTRA CELL INTERSITIELINTRAVASCULAR

Metabolisme
Metabolisme Anaerobik,
Anaerobik, apa
apa yang
yang terjadi
terjadi ??

Oksigenasi
Oksigenasisel
sel
Tidak
Tidakadekwat
adekwat

Inadequate
Inadequate Anaerobic
Anaerobic Lactic
LacticAcid
Acid
Energy
Energy Metabolism
Metabolism Production
Production
Production
Production

Metabolic
Metabolic Metabolic
Metabolic
Cell
CellDeath!
Death!
Failure
Failure Acidosis
Acidosis
 Cellular
Cellular Response
Response to
to Shock
Shock
OO22 Tissue
Tissue Impaired
Impairedcellular
cellular
use
use perfusion
perfusion metabolism
metabolism

Anaerobic
Anaerobic Stimulation
Stimulationof of Impaired
Impaired
metabolism
metabolism clotting
clottingcascade
cascade& & glucose
glucose
inflammatory
inflammatory usage
usage
response
response
ATP
ATP
synthesis
synthesis
Intracellular Na
Intracellular Na
++

&
&water
water Cellular
Na
Na+Pump
+
Pump Cellularedema
edema
Function Vascular
Vascularvolume
volume
Function
 Stages of Shock
 Initial stage - tissues are under perfused, decreased CO, increased
anaerobic metabolism, lactic acid is building
 Compensatory stage - Reversible. SNS activated by low CO,
attempting to compensate for the decrease tissue perfusion.
 Progressive stage - Failing compensatory mechanisms: profound
vasoconstriction from the SNS ISCHEMIA Lactic acid production
is high metabolic acidosis
 Irreversible or refractory stage - Cellular necrosis and Multiple Organ
Dysfunction Syndrome may occur
DEATH IS IMMINENT!!!!
 HAL YANG PERLU DIINGAT !!
1. VOLUME DARAH EFEKTIF(Effective blood
volume/flow)
– ♂ 70 – 75 cc/kgBB
– ♀ 60 – 65 cc/kgBB
– Anak2 90 – 100 cc/kgBB

2. 15 % EBV/F hilang  hypoxia (+)  nadi

meningkat
3. 25 % EBV/F hilang  syok.
 KRITERIA PERDARAHAN

• Tanda TS I TS II TS III
-------------------------------------------------------
Sesak - + ++
Tensi N Trn t’ trkr
Nadi Cpt sgt Cpt t’ trb
Urine N Olig. U An. U
Kesdrn N Dis. O t’ sdr
Gas Drh:PO2 N Trn Trn
PCO2 N Trn T/N
CVP N Rdh Sgt Rdh
--------------------------------------------------------
Blood loss 10 % 30 % > 50 %
 Initial Management Hypovolemic Shock
Management goal: Restore circulating volume, tissue
perfusion, & correct cause:
• Early Recognition- Do not relay on BP! (30% fld loss)
• Control hemorrhage
• Restore circulating volume
• Optimize oxygen delivery
• Vasoconstrictor if BP still low after volume loading
 Penanganan spesifik bervariasi
tergantung situasi
• Perdarahan External yang dapat
dikontrol
• Perdarahan External yang tak
dapat dikontrol
• Perdarahan Internal
Fluid And Blood Resuscitation
 Fluid and Blood Resuscitation
• Terapi cairan  terapi AWAL pada kondisi
penurunan intravaskular dengan Hipoperfusi dan
penurunan fungsi organ
• Perdarahan akut merupakan faktor penyebab utama
• TARGET  normovolum
• Namun ada kontroversi utk pemberian cairan masif
akibat perdarahan
• TUJUAN memberikan volume intravaskular yang
cukup sehingga perfusi jaringan terpenuhi untuk sel
tubuh
 Management

• Initial therapy:
1. Airway-breathing management
2. Adequate ventilation
3. Controll bleeding
4. Control cervical
5. Obtain 2 large bore IV’s
6. Fluid resuscitation
 Management Cont: fluid resucitation

1. Restoring intravascular volume sufficiently

to reverse systemic hypoperfusion
2. Maintaining adequate oxygen-carrying
capacity so that tissue oxygen delivery
meets critical tissue oxygen demand.
3. Limiting ongoing loss of circulating RBC’s.
Place foley cath to monitor urinary output.
 Fluid Resuscitation
• Currently there is controversy concerning
normotensive vs hypotensive
resuscitation.
• The goal of hypotensive resuscitation is to
provide sufficient fluid to maintain vital
organ perfusion and avoid cardiovascular
collapse while keeping arterial BP
relatively low (MAP of 60).
 Fluid Resuscitation Cont.

• Currently there still is controversy

concerning crystalloids vs colloids for
use in resuscitation.
• The cost of colloids greatly out
weights that of crystalloids causing
most to use the later.
Isotonic Crystalloid Solution

• Comprised mainly of normal saline and

lactated Ringer’s.
• Crystalloids are hypo-oncotic because of
there lack of protein.
• Therefore most of the fluid given will
shift into the extravascular space instead
of the intravascular or interstitial space.
Isotonic Crystalloid Solution Cont.

• This is the physiologic basis for the 3:1

ratio for isotonic crystalloid volume
replacement.
• Therefore for every amount of blood
lost 3 times that amount is needed to
replace intravascular volume using
crystalloids.
Isotonic Crystalloid Solution Cont.

• Concerns have been raised about each fluid.

1. Infusing large volumes using either
causes increased neutrophil activation.
2. LR also increases cytokine release and
may increase lactic acidosis in large
amounts.
3, NS exacerbates intracellular potassium
depletion and causes hypochloremic
acidosis.
 Osmal. Glucose Na+ Cl- K+
Ca+ Lactate
• 5% D/W 278 50g/l 0 0 0 0
0
• 10%D/W 556 100g/l 0 0 0 0
0
• .45% NS 154 0 77 77 0 0
0
• .9% NS 308 0 154 154 0 0
0
• LR 274 0 130 109 4 1.5
28
• Na, Cl, K, Ca, and lactate are measured in mmol/liter.
 Colloid Resuscitation

• Colloids have larger molecular weight

particles with plasma oncotic pressures
similar to normal plasma proteins.
• With this it would be thought colloids
would be more effective at restoring
circulating blood volume compared to
crystalloid solutions.
 Colloid Resuscitation Cont.

• However, in a systematic review of the use of

albumin in critically ill patients found an
increase relative risk of death, as compared to
the use of crystalloids.
• Given the much greater cost of colloid
products, there is no clear basis for the choice
of these agents over crystalloids for
resuscitation.
 Blood Transfusion
• Remember there are no clear parameters for
transfusions.
• It is generally accepted that a patient in
shock not responding to 2-3 liters of
crystalloids will need a blood transfusion
• This however leads to a large area of
hemoglobin between 6-10.
• Remember blood is the ideal resuscitation
agent.
 Challenge to Modern Transfusion
Medicine
1. Can we prevent disease transmission in
blood transfusion?
2. Which patients must have transfusion and
which must not ?
3. Which blood components must be
replaced accordingly ?
4. In emergency, to save lives, what are the
rules ?
 Nilai ambang kritis komponen darah tidak sama, maka
untuk perdarahan tidak selalu perlu
transfusi whole blood
• Volume darah efektif (EBV) • Diganti segera
– normal 70 cc/kg BB RL/NaCl atau
– nilai ambang kritis sisa 70% PS/HES
• Hb
• Diganti PRC / WB
– normal 12-15 gm/dl
– nilai ambang kritis 5-8 gm/dl
• Trombosit
• Diganti TC jika BT
> 3 menit
– normal 300-400,000
– nilai ambang krtis 50,000
 DALAM KEGAWATDARURATAN

• Jangan sampai pasien meninggal karena tidak

ada golongan ABO yang sama
• Apa lagi, jangan sampai pasien meninggal karena
tidak ada golongan Rhesus yang sama
• Yang dibutuhkan adalah golongan darah yang
kompatibel, tidak harus golongan darah yang
sama
• Jangan sampai pasien shock lama karena
menunggu transfusi. Terapi cairan dengan
RL / NaCl dan Plasma Substitute / HES adalah
penyelamat nyawa
 PEMBERIAN TRANSFUSI DARAH

• Hb normal adalah 12-15

• Hb optimal adalah 8-10
• Hb batas survival adalah 4-5
• Pasien berdarah harus diganti volume (H2O+Na)
dulu setelah itu baru transfusi jika nilai Hb turun
jauh dibawah nilai optimal
• Target Hb setelah transfusi adalah batas optimal
 PEMBERIAN PRODUCT DARAH

Nilai ambang kritis komponen darah tidak sama, maka untuk

perdarahan tidak selalu perlu transfusi whole blood
•Hb
– normal 12-15 gm/dl
– nilai ambang kritis 5-8 gm/dl
•Volume darah efektif (EBV)
– normal 70 cc/kg BB
– nilai ambang kritis sisa 70%
•- Plasma protein
– albumin normal 3.5-4.5 gm/dl
– nilai ambang kritis 1.5-2.0 gm/dl
•- Trombosit
– normal 300-400,000
– nilai ambang krtis 50,000
 Transfusi trombosit diperlukan
jika

• Pasien pembedahan / trauma

– Ada perdarahan
– trombosit < 50,000
• Pasien DHD / Demam berdarah Dengue
– Ada perdarahan
– trombosit < 20,000
– Bleeding Time > 3 menit
 Evaluasi klinis kegawatan

• S  anatomi
• O  fisiologi  TTV - nadi
- akral
- GCS
- RR
- TD
-Titik akhir resusitasi ditentukan berdasarkan kombinasi data
laboratorium dan tanda-tanda fisiologis.
-Pembacaan tingkat hemoglobin diketahui tidak akurat
selama fase
akut .
Titik akhir resusitasi
- Tekanan darah normal,
- Menurunnya denyut jantung,
- Urin output yang cukup (≥ 30 mL/jam),
- (CVP) normal.
- Mengevaluasi oksigenasi jaringan termasuk defisit basa,
bikarbonat dan laktat. Semua ini menilai glikolisis anaerobik.
. Defisit basa menetap - resusitasi tidak mencukupi.