MANAJEMEN SYOK

Oleh:
Ns.Sidik Awaludin, M.Kep., Sp. Kep., MB
Sidik Awaludin
Alamat: Griya Satria Purwokerto Identitas Diri
Pendidikan : Sp.Kep.MB (KKV) 2011 (FIK-UI)
Certified Cardiology (USA)
Certified Andvance Cardiac Life Support (AHA)
Certified Basic-Advance Wound Therapist
Certified Of Hypnotist (IBH)
Contact: WA:081901405785 pin:54E0CE7E
Riwayat pekerjaan
Perawat Jakarta Islamic Hospital
Perawat ICU RSISA Semarang
Staff Pengajar PSIK UNDIP di Bagian Kep. Dewasa
(2008-2013)
Staff Pengajar FIKES UNSOED (Cardiovascular
Nursing) (2014-Sekarang)
Dosen Tidak Tetap di beberapa PT Kep. Jakarta ,
Malang, Bekasi &Surakarta
Trainer Critical Care, ECG, BTCLS, ACLS, Disaster
Management, Physical assessment.
Wound Care Therapist
Hypno Nursing Practitioner
CEO Accurate Solution Institute of Java
Konsultan Pengembangan Mutu Internal
Pendidikan Keperawatan Indonesia
Asesor BAN PT/ LAM PT Kes (2014-skrg)
 Learning Objectives
Setelah mengikuti perkuliahan ini mahasiswa
diharapkan mampu:
Menjelaskan pengertian syok
Menyebutkan klasifikasi syok
Menjelaskan syok hipovolemik dan syok
anafilaktik

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 SYOK
Definisi :
Syok adalah suatu kondisi komplek yang mengancam jiwa
ditandai dengan tidak adekuatnya aliran darah ke jaringan dan
sel-sel tubuh
Syok adalah keadaan sindroma gangguan perfusi ke jaringan
yang menyeluruh sehingga tidak terpenuhinya kebutuhan
metabolisme jaringan
Shock is defined as an inadequate perfusion to the tissue of the body,
or in other words, the body is not getting enough oxygen to feed it self.
Dax & Hermey (2000) shock is a clinical syndrome characterized by
an inadequate supply of oxygen and nutrients to cell from impaired
tissue perfusion.

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CLASSIFICATION OF SHOCK
Eight Types of Shock (
www.alpharubicon.com/med/shockpalehorse.htm-17k
)

Medical-Surgical Nursing: Assessment and

Management of Clinical Problem, Sharon Mantik
Lewis, 5th edition, page 1867): (1) vascular tone
(distributive shock), (2) the ability of the heart to
pump (cardiogenic shock), (3) intravascular volume
(hypovolemic shock).

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 CLASSIFICATION OF SHOCK
Eight Types of Shock
www.alpharubicon.com/med/shockpalehorse.htm-17
k

1.Respiratory Shock
2.Hemorrhagic shock
3.Hypovolemic Shock
4.Cardiogenic Shock

6
CLASSIFICATION OF SHOCK
5. Neurogenic Shock
6. Anaphylactic Shock
7. Septic Shock
8. Metabolic Shock

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 CLASSIFICATION OF SHOCK

Lewis (2000)
SHOCK

DISTRIBUTIVE HYPOVOLEMI
SHOCK C SHOCK
CARDIOGENIC
SHOCK
Septic Neurogenic Anaphylactic
shock shock shock

8
CLASSIFICATION OF SHOCK
Hypovolemic Shock
blood VOLUME problem

Cardiogenic Shock
blood PUMP problem
Distributive Shock
[septic;anaphylactic;neurogenic]
blood VESSEL problem

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CAUSES OF SHOCK

10
Causes of shock

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 Causes of shock
DISTRIBUTIVE
SHOCK

ANAPHYLACTIC SEPTIC NEUROGENIC

SHOCK: severe SHOCK: SHOCK: SPINAL
hypersensitivity INFECTION INJURY, SPINAL
reaction e.g: ANESTHESIA
Contrastmedia,
drug,

12
How Shock Can Affect The Body
Initial stage - tissues are under perfused,
decreased O2 increased anaerobic metabolism, lactic
acid is building
Compensatory stage - Reversible. SNS
activated by low O2, 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
13
 OVERALL MANAGEMENT
STRATEGIES OF SHOCK:GOAL
TO RESTORE NORMAL TISSUE PERFUSION
Blood pressure
Pulse
Respirations
Skin Appearance
Sensorium
Urine output (30-50 cc per hour)
Hemoglobin 8-10 gm or Hematocrit 24-30

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 OVERALL MANAGEMENT
STRATEGIES OF SHOCK
Surgery: immediate vs. delayed vs. none
Establish airway and deliver O2
Insert 2 large bore IVs with relatively short
length of tubing; infuse Normal saline or Lactated
Ringers
Treat mechanical causes of shock if they are
present: Tension pneumothorax, Pericardial
tamponade, Exsanguinating hemorrhage

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 OVERALL MANAGEMENT
STRATEGIES OF SHOCK
While inserting IVs, draw blood for laboratories and
for blood typing
Relieve pain with IV narcotics
Blood transfusion: think twice
Vasopressors
Antibiotics

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OVERALL MANAGEMENT
STRATEGIES OF SHOCK
Maintenance IV fluids
Inotropic support
Early removal of septic focus (i.e. dead
bowel or large abscess) or other definitive
surgery

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 Syok Hipovolemik
Syok Hipovolemik
syok akibat volume intravaskuler yang
berkurang
Paling mudah dan banyak ditemukan
dan paling mudah diatasi

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sidik/fikes/2016 19
 Faktor yang penting diperhatikan dalam syok
adalah hipoperfusi dan hipoksia jaringan.
tidak sama dengan hipotensi

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Tekanan darah rendah shock

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paradigma
Bila ada pasien tekanan darah turun maka
akan diguyur
Tidak memperhatikan jenis syok
Tidak memperhatikan jenis cairan

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Jenis-jenis Penggolongan Syok
1. Hipovolemik
2. Kardiogenik
3. Distributif
4. Obstruktif

dikaitkandengan
dikaitkan dengankardiak
kardiakoutput
output

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CARDIAC OUTPUT
Cardiac Output (CO) = curah jantung
Rumus : SV (Stroke Volume) x Frekuensi
SV = isi sekuncup
dipengaruhi
Preload (beban awal)
Afterload (beban akhir)
Kontraktilitas (kemampuan otot jantung)
Frekuensi : jumlah denyut nadi permenit

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 PENURUNAN VOLUME
CAIRAN INTRAVASKULER

PENURUNAN ARUS BALIK

PEMBULUH DARAH VENA / PRE LOAD

PENURUNAN ISI SEKUNCUP

(STROKE VOLUME )

PENURUNAN CURAH JANTUNG

(CARDIAC OUTPUT )

PENURUNAN PERFUSI Gangguan

JARINGAN Metabolisme Sel

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 Penyebab syok hipovolemia
Penyebab ABSOLUTE
Trauma
Pembedahan
1 Kehilangan Darah Perdarahan Gastro Intestinal

Luka bakar
2 Kehilangan Plasma Lesi yang luas

Muntah Hebat
Diare
3 Kehilangan cairan tubuh yang lain Diuresis berlebihan

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 Penyebab syok hipovolemia
Penyebab Relatif
Peningkatan permeabilitas membran
Sepsis
Anaphilaktik
Luka bakar
Penurunan tekanan osmotik kolloid
penurunan natrium darah
Hypopituarism

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 PENGKAJIAN
Gejala dan tanda tanda syok
Tanda dan gejala sangat berkait dengan
terjadinya kegagalan perfusi efektif ke jaringan
sehingga terjadi penurunan transport oksigen
ke daerah kapiler
berbeda berdasarkan derajat shock
(Lynne A Thelan, et.all)

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DERAJAT KEHILANGAN CAIRAN
Derajat I Setara sampai dengan 750cc
Kehilangan s/d 15%

Derajat II Antara 750 s/d 1500 cc

15% - 30%

Derajat III Antara 1500 s/d 2000 cc

30% - 40 %

Derajat IV Kehilangan lebih dari 2000 cc

Lebih dari 40 %

sidik/fikes/2016 (Lynne A Thelan, et.all)29

TANDA DAN GEJALA
Keadaan umum lemah
Kulit dingin dan basah
Kesadaran menurun
Kualitatif : Somnolent Koma
Kuantitatif : GCS < 15
Penurunan jumlah urin
Normal 1-2 cc/kgBB/jam

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TANDA DAN GEJALA
Gangguan peristaltik
Vena perifer tak tampak / kollaps
Awalnya pernafasan hiperventilasi
dilanjutkan takipnoe
Tanda asidosis metabolik (s/d metabolisme
anaerob)

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2. Mengapa cairan itu diberikan ?

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 Terapi
Terapi cairan
cairan dalam
dalamjumlah
jumlah banyak
banyak diberikan
diberikan
dalam
dalamwaktu
waktu singkat,
singkat, untuk
untuk mengatasi
mengatasi gangguan
gangguan akut
akut
yg
yg dalam
dalamwaktu
waktu singkat
singkat dapat
dapat menyebabkan
menyebabkan kematian
kematian
((Eddy
EddyRaharjo,
Raharjo,2004)
2004)

Definitions
Definitions of of Fluid
Fluid Resuscitation
Resuscitation on on the
theWeb:
Web:
Occurs
Occurs when
when large
large amounts
amounts ofof fluid
fluid are
are removed
removed in in
required
required treatment
treatment time,
time, and
and patient
patient develops
develops very
very lowlow
blood
blood pressure.
pressure. IfIf severe
severe then
then intravenous
intravenous fluid
fluid isis given
given
to
to raise
raise blood
blood pressure
pressure
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 RESUSITASI RUMATAN

Kristaloid Koloid Elektrolit Nutrisi

Mengganti 1. Kebutuhan normal

kehilangan akut (IWL + urin+ feses)
(hemorrhage, GI loss)sidik/fikes/20162. Dukungan nutrisi 34
3. Pengaruh pemberian cairan
kepada pasien

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sidik/fikes/2016 36
Tekanan Osmolaritas

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TONISITAS / OSMOLARITAS
CAIRAN INTRAVENA

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Tekanan Osmolaritas

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Efek pemberian Cairan Isotonik

240-340 mOmsm

Blood vessel
Normal cellsidik/fikes/2016 40
 How hypotonic solution affect cells
< 240 mOsm

Blood vessel
Normal cell
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How hypertonic solution affect cells
> 340 mOsm

Blood vessel
Normal cell
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 Isotonic infusion

*Ringers acetate
*Ringers lactate
*Normal saline

Replace acute/
increases ECF abnormal
loss

ICF ISF Plasma

800 ml sidik/fikes/2016
200 ml 43
 Hypotonic infusion

*5% dextrose

Replace Normal
increases ICF > ECF loss (IWL + urine)

ICF ISF Plasma

660 ml 255 ml 85 ml
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Solution Example
Isotonic RL (275 mOsm/L)
Ringers ( 275 mOsm/L)
NaCl 0,9% (308 mOsm/L)
D5% (260 mOsm/L)
5% albumin (308 mOsm/L)
Heas (310 mOsm/L)

Hypotonic Half-normal saline (154 mOsm/L)

0.33% sodium chloride ( 103mOsm/L)
Dextrose 2.5% in water (126 mOSm/L)

Hypertonic Dextrose 5% in half normal saline (406 mOsm/L)

Dextrose 5% in normal saline (560 mOsm/L)
Ringer Dextose 5% (575 mOsm/L)
Na Cl 3% ( 1.025 mOsm/L)
25% albumin (1500 mOsm/L)
7.5% sodium chloride (2400 mOsm/L)
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4. Memberikan cairan dengan
aman
Ikut memastikan kebutuhan resusitasi
Water Chalenge Test
Memberikan dengan metode dan alat yang
benar

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Hal Penting !
Untuk infus cepat siapkan kanula
ukuran besar (16, 14, 12 gauges )
Hindari untuk menyarankan pemasangan
central line sebagai pilihan pertama
Pemilihan cairan yang tepat kristaloid vs koloid
Disesuaikan untuk setiap pasien
Penilaian kontinyu respon terhadap terapi
Kehadiran dokter
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PENGGUNAAN JARUM IV

Nomor Penggunaan Considerations

Large adolescents or adult Very painful insertion
14 Trauma
Rapid infusion of fluids and or blood & Requires very large vein
blood products

Adolescent & adult Painful insertion

16 Trauma
Infusion of large volume of fluids Require large vein
Infusion of blood & blood product

Older children, adolescent & adult Mildly painful insertion

18 Fluid resucitation
Infusion of blood, blood compenents & Viscous solution Requires decent sized vein
Obstetric patients

Children, adolescent & adults Commonly used

20 Suitable for most infusions, KVO lines
Infusion of blood or blood compenents Slower to infuse large amounts of fluid

Infants, toddlers, children, adolescent & adults Easier to insert in small, thin, fragile
22 Suitable for most infusions veins
Use with slower flow rates
Difficult to insert into tough skin

Neonates, infants, toddlers Flow rate would be very slow

24
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5. Pemantauan dan Evaluasi
Pemantauan ditujukan pada dua pokok
utama
1. Evalusi terhadap target resusitasi

2. Pemantauan terhadap efek samping

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 Evalusi terhadap target resusitasi
Target resusitasi adalah mencukupi cardiac
output
Tingkat kesadaran
Fungsi respirasi
Fungsi saluran cerna
Fungsi saluran kemih
Tekanan darah dan nadi

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 Pemantauan terhadap efek samping :
Kelebihan cairan
Edema paru ------ ronkhi basah

Edema perifer

Sehubungan dengan tehnik infus

Ekstra vasasi

Plebitis

Trombus

adanya udara

Sehubungan dengan reaksi

Menggigil ---- demam

Reaksi anafilaksis

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6. DOKUMENTASI

Tanda dan gejala klinis

Hasil pemeriksaan laboratorium
Intervensi :
A - B - C
Pemberian cairan (kolaborasi); jenis, volume, respon
Pengkajian ulang setelah fluid challenges :
Monitor hemodinamik
Hasil laboratorium
Obat-obat yang diberikan
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Anaphilactic Shock
 Anaphylactic Shock
Risk factors for fatal anaphylaxis
Poorly controlled asthma
Previous anaphylaxis
Reoccurrence rates
40-60% for insect stings
20-40% for radiocontrast agents
10-20% for penicillin
Most common causes
Antibiotics
Insects
Food
 Anaphylactic Shock
Anaphylaxis a severe systemic
hypersensitivity reaction characterized by
multisystem involvement
IgE mediated
Anaphylactoid reaction clinically
indistinguishable from anaphylaxis, do not
require a sensitizing exposure
Not IgE mediated
 Anaphylactic Shock
Mild, localized urticaria can progress to full anaphylaxis
Symptoms usually begin within 60 minutes of exposure
Faster the onset of symptoms = more severe reaction
Biphasic phenomenon occurs in up to 20% of patients
Symptoms return 3-4 hours after initial reaction has cleared
A lump in my throat and hoarseness heralds life-
threatening laryngeal edema
 SYMPTOMS

First- Pruritus, flushing, urticaria appear

Next- Throat fullness, anxiety, chest

tightness, shortness of breath and
lightheadedness

Finally- Altered mental status, respiratory

distress and circulatory collapse
 Anaphylactic Shock- Treatment
ABCs
Angioedema and respiratory compromise require
immediate intubation
IV, cardiac monitor, pulse oximetry
IVFs, oxygen
Epinephrine
Second line
Corticosteriods
 Anaphylactic Shock- Treatment
Epinephrine
0.3 mg IM of 1:1000

Repeat every 5-10 min as needed

Caution with patients taking beta blockers-

can cause severe hypertension due to

unopposed alpha stimulation
For CV collapse, 1 mg IV of 1:10,000

If refractory, start IV drip

Terima kasih

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