SYOK

LALU ARIES FAHROZI

DEFINISI

suatu syndroma dimana perfusi jaringan tidak adekwat, akibat dari ketidak mampuan sistim sirkulasi untuk mensuplai oksigen

Jika sel tidak menerima oksigen yang cukup atau tidak bisa menggunakan oksigen dengan baik maka terjadilah metabolisme
Syok pada awalnya terjadi pada tingkat sellular (mikrosirkulasi) , kemudian berkembang ke tingkat jaringan ,tingkat organ / multiple (MOD) dan pada akhirnya menyebabkan kematian

A. Glycolisis, metabolisme anaerob (tanpa oksigen),menghasilkan

B. Metabolisme aerobik lewat

siklus Crebb / asam cytric

asam piruvat dipecah

asam piruvat--- asam laktat

dengan sedikit energy (2ATP) +

menjadi H2O dan CO2 +

energi tinggi (36 ATP) + panas

panas (32 Kcal)

(417 Kcal)

Metabolisme Anaerobik, apa yang terjadi ?

Oksigenasi sel Tidak adekwat

Inadequate Energy Production

Anaerobic Metabolism

Lactic Acid Production

Metabolic Failure

Cell Death!

Metabolic Acidosis

Penyebab:
Keadaan apapun yang membuat/mempengaruhi kemampuan sistim sirkulasi untuk menyalurkan oksigen ( mikrosirkulasi )

Komponen pada sisitim sirkulasi :

1. Jantung --- sebagai pompa.

2. Darah + plasma----- sebagai pembawa oksigen ( + nutrisi ) 3. Pembuluh darah ---- sebagai wadah.
jika terjadi suatu masalah pada ke 3 komponen tersebut, maka akan menyebabkan perfusi jaringan terganggu / tidak adekwat

Komponen sistim sikulasi

Jantung

Sebagai pompa , memompa darah dari sistim vena ke paru untuk oksigenisasi, dan memompakan darah yang teroksigenisasi lewat arteri ke jaringan periperal. Stroke Volume / isi volume sekuncup dipengaruhi : 1. Preload = jumlah darah yang diterima jantung selama diastole 2. Contractility = kekuatan kontraksi otot jantung Hukum Frank starling 3. Afterload = tahananan terhadap kontraksi ventrikel.

Hukum Frank-Starling
peregangan serabut miokardium selama diastole melalui peningkatan volume akhir diastole akan meningkatkan kontraksi pada saat sistole

- Contractility : dipengaruhi oleh hormon epineprin dan norepineprin.

-Cardiac Out-put (CO) : jumlah darah yang dipompa kan

jantung selama 1 menit. Cardiac Output = Stroke Volume X denyut 1 menit.(HR)

-Tekanan darah : tahanan dari pembuluh peripheral yang

harus dilawan jantung ketika memompa darah. tekanan darah = Cardiac Output X PVR/SVR

Darah
Darah : berisi sel darah (ery,leu, platelets ) plasma, oksigen transports, CO,nutrisi,hormon, zat sisa dan panas harus dalam keadaan cukup. - berkurangnya volume : pendarahan, dehidrasi dsb. Menyebabkan syok

Pembuluh darah.

Dibawah pengaruh outonom. Kebocoran = gangguan perfusi.

RESPON TUBUH TERHADAP SYOK / KOMPENSASI

Normal compensation includes:

Progressive vasoconstriction Increased blood flow to major organs Increased cardiac output Increased respiratory rate and volume Decreased urine output

Renin-Angiotensin-Aldosterone
Plasma volume
Detected by

&/Or

Kidney (juxtaglomerular apparatus)

Releases

[Na+]
Via ACE (Angiotensin Converting Enzyme)

Renin
Converts

Angiotensin II Angiotensin I

Angiotensinogen

Renin-AngiotensinAldosterone
vasoconstriction Angiotensin II thirst ADH (anti-diuretic hormone) Adrenal cortex
Releases

PVR

Fluid volume

BP!

Aldosterone

Na+ reabsorption

Cellular Response to Shock

O2 use
Anaerobic metabolism ATP synthesis Na+ Pump Function

Tissue perfusion
Stimulation of clotting cascade & inflammatory response

Impaired cellular metabolism

Impaired glucose usage

Intracellular Na+ & water

Cellular edema Vascular volume

TAHAP-TAHAP SYOK

SYOK TERKOMPENSASI SYOK TIDAK TERKOMPENSASI SYOK YANG IRREVERSIBLE

Compensated Shock
Defense mechanisms are successful in maintaining perfusion Presentation
Tachycardia Decreased skin perfusion Altered mental status

Uncompenstated Shock
Defense mechanisms begin to fail Presentation
Hypotension Prolonged Cap refill Marked increase in heart rate Rapid, thready pulse Agitation, restlessness, confusion

Irreversible Shock
Complete failure of compensatory mechanisms Death even in presence of resuscitation

SHOCK CLASSIFICATION (FCCS, 2001)

. HYPOVOLUMIC SHOCK: blood loss, git loss, third space loss

-CARDIOGENIC SHOCK
-OBSTRUCTIVE SHOCK: cardiac tamponade, pulmonary embolism

-DISTRIBUTIVE SHOCK: anaphylactic,neurogenic,

acut adrenal insufficiency

Hypovolemic Shock
Penyebab : kehilangan cairan intravascular Internal atau external hemorrhage. Trauma. Dehydration. Plasma loss from burns. Excessive sweating. Diabetic ketoacidosis with resultant osmotic diuresis.

Tanda dan gejala shok

-Penurunan kesadaran :
-Nadi : mula-mula meningkat, sampai tak teraba

-Hypoperfusi : Capillary refill memanjang, acral dingin / basah.

-Produksi urine menurun < 0.5 1ml/kg/jam. -Tekanan darah mula-mula normal, kemudian menurun.

-Dysarithmia

MANAGEMEN SYOK HIPOVOLUMIK

-AIRWAY

-BREATHING
-CIRCULATION AND HEMORRHAGE CONTROL

-SHOCK POSITION
-REPLACE BLOOD LOSS -STOP / MINIMIZE THE BLEEDING PROCESS

AIRWAY
Open airway : head tilt & chin lift , modification
jaw trust(trauma) Secure airway: Oro-pharingeal , naso-pharyngeal . ETT

Control secret : Rigid suction cateter ( Yangkeur ) for Trauma Px

BREATHING
AIR
pO2 150

20,9% O2 + 80% N2

ALVEOLI
pO2 120

16% 02 + 80% N2 + 4% CO2

DARAH
pO2 100 Hypoxia = paO2 < 90mmhg Terapi Oksigen = meningkatkan paO2 dengan cara meningkatkan pO2 Udara

Onloading Oxygen in Lungs

pH 7.45
Remember: CO2 [H+]
oxyhemeglobin

pH 7.4

deoxyhemeglobin

pH shifts curve to left onloading in lungs

Pressure

Offloading Oxygen in Tissues

pH 7.4
Remember: CO2 [H+]
oxyhemeglobin

pH 7.35

deoxyhemeglobin

pH shifts curve to right offloading to tissues

Pressure

Shock Position

Live both foods

If necessary up both arm

auto-transfusion
300-500 cc

HYPOVOLUMIC SHOCK
SHOCK POSITION 2 LARGE I.V CATHETER LINE ( 14,16G ) TAKEN BLOOD SAMPLE RINGER LAKTAT 1000 CC

PERFUSION WARM,DRY,RED PULSE < 100 BP-SIST >100

POOR PERFUSION,BPSIST<100, PULSE<100

ADD RL UNTIL 3-4 X EBF

SLOW

BLOOD IF READY

Hemodilution technic
Estimate Wieght : 60 kg Estimate Blood volume: 70 ml/kg x 60 = 4200 ml Estimate blood loss : ---- % EBV = ml

BP-sist Pulse perfus

120 80 warm

100 100 pale

-15%EBV

<90 >120 cold

<60-70 >140/weak Cold&wet

-30%EBV Normo volume -50%EBV

EBL

600

1200

2000 ml

Infusion

1200-2000 2500-5000

4000-8000ml

End-point of fluid resuscitation

-perfusion back to normal

-BP (sistole) about 90 100 mmhg

-Urine production 0,5 1 ml/kgBW/hour

NOT normal BP ---- re-bleeding risk !

Cardiogenic shock

The heart loses its ability to supply all body parts with blood. Usually the result of left ventricular failure secondary to acute myocardial infarction or CHF. Many patients will have normal blood pressures.

Cardiogenic Shock
R.A.S. Activation
CO

Catecholamine Release

Volume/ Preload

Myocardial O2 demand

SVR
O2 supply

Impaired myocardial function

Dyspnea

Peripheral & pulmonary edema

Tanda dan Gejala

Edema paru akut : Difficulty breathing. As fluid levels rise, wheezes, crackles, or rales may be heard. There may be a productive cough with white or pink-tinged foamy sputum. Cyanosis, altered mentation, and oliguria.

MANAGEMENT OF CARDIOGENIC SHOCK

-AIRWAY

-BREATHING
-CIRCULATION AND

CARDIAC IMPROVING & MONITORING UP POSITION +

+ KEEP WARM

-HEAD&SHOULDER

-IV.LINE WITH MINIMAL FLUID

-VASOPRESSOR , INOTROPIC AND DIURETIC -----

MAYBE NEEDED

DISTRIBUTIVE SHOCK

NEUROGENIC SHOCK ANAPHYLAKTIC SHOCK SEPTIC SHOCK

Neurogenic Shock
Results from injury to brain or spinal cord causing an interruption of nerve impulses to the arteries. The arteries dilate causing relative hypovolemia. Sympathetic impulses to the adrenal glands are lost, preventing the release of catecholamines with their compensatory effects.

Neurogenic Shock
Sympathetic Tone Or Parasympathetic Tone
Vascular Tone

Tissue perfusion

Massive Vasodilation

Cardiac Output

SVR & Preload

TANDA &GEJALA
Warm, dry, red skin. Tekanan Darah rendah Bradycardia

Penatalaksanaan
Airway control. Maintain body temperature. Immobilization of patient. Consider other possible causes of shock. IV access and medications that increase peripheral vascular resistance.

Anaphylactic Shock
A severe immune response to a foreign substance. Signs and symptoms most often occur within a minute, but can take up to an hour. The most rapid reactions are in response to injected substances:
Penicillin injections. Bees, wasps, hornets.

Anaphylactic Shock

Container failure Massive & systemic allergic reaction Large release of histamine Increases membrane permeability & vasodilation

Tanda & Gejala

Because immune responses can affect different body systems, signs and symptoms vary widely:
Skin:
Flushing, itching, hives, swelling, cyanosis.

Respiratory system:
Breathing difficulty, sneezing, coughing, wheezing, stridor, laryngeal edema, laryngospasm.

Tanda &Gejala
Cardiovascular system:
Vasodilation, increased heart rate, decreased blood pressure.

Gastrointestinal system:
Nausea, vomiting, abdominal cramping, diarrhea.

Nervous system:
Altered mental status, dizziness, headache, seizures, tearing.

Penatalaksanaan

Airway protection, may include endotracheal intubation. Establish an IV of crystalloid solution. Pharmacological intervention:
Epinephrine, antihistamines, corticosteroids, vasopressors, inhaled beta agonists.

Septic Shock

An infection that enters the bloodstream and is carried throughout the body. The toxins released overcome the compensatory mechanisms. Can cause the dysfunction of an organ system or result in multiple organ dysfunction syndrome.

Tanda & Gejala

The signs and symptoms are progressive. Increased to low blood pressure. High fever, no fever, or hypothermic. Skin flushed, pale, or cyanotic. Difficulty breathing and altered lung sounds. Altered mental status.

PENATALAKSANAAN

Airway control. Support brething if necessary IV of crystalloid solution. Dopamine to support blood pressure. Monitor heart rhythm.

KESIMPULAN

SHOCK ADALAH SYNDROMA KARENA TIDAK ADEKUATNYA PERFUSI JARINGAN SEHINGGA MENGURANGI SUPLAI OKSIGEN DAN NUTRISI YANG DIBUTUHKAN PROSES METABOLISME TUBUH. ORGAN TUBUH AKAN BEREAKSI TERHADAP SHOCK SEBAGAI MEKANISME KOMPENSASI, BILA GAGAL AKAN TERJADI ISKEMIK VASKULER, KEGAGALAN FUNGSI ORGAN DAN AKHIRNYA KEMATIAN

SEMOGA BERMANFAAT