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 cellullar injury that kills a critical mass of cells

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THE GOLDEN HOUR

Probability of Survival
R. Adams Cowley, MD

100

80
60 40 20 0

% survival

30

60

90

minutes

Survival is related to severity and duration

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OXYGEN TRANSPORT DO2 = CaO2 x CO VO2 = [CaO2-CvO2] x CO

CaO2 = SaO2 x Hb x 1.34 CvO2 = SvO2 x Hb x 1.34 SHOCK,
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DO2 < VO2

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PRE-LOAD

CONTRACTILITY

AFTER-LOAD

STROKE VOLUME

HEART-RATE

CARDIAC OUTPUT

TOTAL PERIPHERAL RESISTANCE

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BLOOD PRESSURE
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PERDARAHAN

HILANG VOLUME HILANG ERITROSIT

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SHOCK

B1, B2,

nafas sesak, RR , cuping hidung

HR , nadi halus cepat, TD. N/ Pulse-press. , perfusi dingin, pucat, basah, capill.refill > 2 det., lactic-acid
anxious, confused, lethargy urine out-put , <0.5 ml/kg/jam, pekat

B3, B4,

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Estimated Fluid and Blood Losses Based on Patients Initial Presentation

Class I
Blood-Loss[ml] Blood-loss [%BV] Pulse-Rate [x/min.] Blood-Pressure Pulse-Pressure Respiratory Rate Urine out-put [ml/hour] Mental status/CNS ->750 ->15% <100 Normal N or increased 14-20 >30 Slightly anxious

Class II
750-1500 15-30% >100 Normal Decreased 20-30 20-30 Midly anxious

Class III Class IV

1500-2000 30-40% >120 Decreased Decreased 30-35 5-15 Anxious and confused >2000 >40% >140 Decreased Decreased >35 Negligible Confused and lethargic

BV = 70 ml/kg
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FLUID REPLACEMENT 3 : 1 Rule

Class I Class II Class III Crystalloid Crystalloid + Colloid ? Crystalloid +Colloid, Blood Crystalloid +Colloid, Blood
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Class IV
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Pola kerja penanganan shock perdarahan

Hasanul, 2003

Penderita datang dengan perdarahan Pasang infus jarum kaliber besar (16G, 18G), ambil sample darah Ukur tekanan darah, hitung nadi, nilai perfusi, produksi urine

Tentukan estimasi jumlah perdarahan, minta darah Guyur cepat Ringer Laktat atau NaCl 0.9% [hangat, 390C] 3x prakiraan lost-volume [1-2 liter]

evaluasi
9

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Management selanjutnya

Rapid response, perdarahan <20% Transient response, perdarahan 20-40% BV ongoing loss resusitasi tdk adekwat RL, NaCl 0.9%, Kolloid, Darah ? Minimal, no response Tindakan bedah segera Transfusi darah
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Efek volume infus 1 L cairan Kolloid pada kompartement tubuh [BB,70kg]

Laruta n
Albumin-5%
PPF [Plasma Protein Fraction-5%] Gelafundin Haemacel Dextran-40 Dextran-70 Expafusin

Vol. plasma
1000
1000 1000 700 1600 1300 1000

Vol. interstetial
-300 -260 -130 -

Vol.intrasel
-340 -170 -

Haes-steril-6%
Haes-steril-10%
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1000
1450

-450

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TRANSIENT RESPONSE, DARAH BELUM DATANG,

KOLLOID
1:1

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Transfusi,
Target
Rule of - 5

7 - 9g%

ml Whole-Blood = 5 x delta Hb x BB
contoh:

BB 60 kg, Hb 6g%, WB yang dibutuhkan = 5 x 3 x 60

= 900 ml
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= 4 bag [unit]

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14

Transient response, darah belum datang.

Perdarahan pada

Usia tua Ibu hamil Pasca bedah major (reseksianastomose) Varices esofagus Anak-anak

Plasmanate
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(1:1)

15

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Plasma Protein Fraction ( PPF-5%), Plasmanate

100 ml Plasmanate
Mengandung :

4.4gr Human Albumin 0.6gr alfa dan beta globulin 0.05 gr gamma globulin Natrium 145mEq/L Kalium 0.25 mEq/l Chlorida 100 mEq/L
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17