SHOCK HAEMORHAGIC

DAN KONSEP THERAPI

Ns. Sugiyono.S.Kep,CVRN, CH. CHt

 Tujuan Instruksional

Setelah menyelesaikan bab ini diharapakan peserta

dapat :
1. Dapat menjelaskan definisi syok
2. Dapat mengenali dengan cepat tanda – tanda
klinis syok hemorhagik
3. Mampu melakukan tindakan stabilisasi dan
resusitasi
4. Dapat membedakan penyebab syok
 DEFINISI
Gangguan dari perfusi jaringan yang terjadi akibat adanya
ketidakseimbangan antara suplai oksigen ke sel dengan
kebutuhan oksigen dari sel tersebut.
Semua jenis shock mengakibatkan gangguan pada perfusi
jaringan yang selanjutnya berkembang menjadi gagal
sirkulasi akut atau disebut juga sindrom shock

IT IS NOT LOW BLOOD PRESSURE !!!

IT IS HYPOPERFUSION…..
 TIPE2 SHOCK*
Type of Shock Clinical causes Primary mechanism

Exogenous blood,
Hypovolemic Volume loss plasma, fluid or
electrolyte loss

Myocardial infarction,
Cardiogenic Pump failure cardiac arrhythmias,
heart failure

Increased venous Septic shock, spinal

Distributive capacitance or shock, autonomic
arteriovenous shunting blockade, drug
overdose

Vena caval obstruction,

Extra-cardiac
Obstructive cardiac tamponade,
obstruction of blood
pulmonary embolism,
flow
aortic compression or
dissection

*MORE THAN ONE TYPE MAY BE PRESENT

 1. HYPOVOLEMIC SHOCK
DECREASE IN INTRAVASCULAR
BLOOD VOLUME

Hemorrhage
Vomiting
Diarrhea
Fluid sequestration
Intraluminal – bowel obstruction
Intraperitoneal – pancreatitis
Interstitial - burns

DECREASE IN CARDIAC OUTPUT

AND TISSUE PERFUSION
HYPOVOLEMIC SHOCK
1. DECREASE IN INTRAVASCULAR
BLOOD VOLUME

2. BLOOD DIVERTED FROM SKIN TO

MAINTAIN ORGAN PERFUSION
Pale and cool skin
Postural hypotension and tachycardia

3. BLOOD DIVERTED PREFERENTIALLY

TO HEART AND BRAIN

Thirst, oliguria
Tachycardia
Labile blood pressure
HYPOVOLEMIC SHOCK
4. DECREASED BLOOD FLOW TO
BRAIN AND HEART

Restless, agitated, confused

Hypotension
Tachycardia
Tachypnea

5. END-STAGE SHOCK

Bradycardia
Arrythmias
Death
2. CARDIOGENIC SHOCK
DECREASED CARDIAC FUNCTION
Decreased ventricular function
MI
Pericaridal tamponade
Tension pneumothorax

Infective cardiac contraction

Arrhythmias

CLINICAL FINDINGS

Hypotension
Tachycardia
Tachypnea
Oliguria
**distended neck veins**
 3. SEPTIC SHOCK
SEVERE INFECTION W RELEASE OF
MICROBIAL PRODUCTS
Release of vasoactive mediators

HYPERDYNAMIC STATE
Peripheral vasodilation
Increased cardiac output

Fever, tachycardia, tachypnea, warm skin

MAINTENANCE OF FAILURE TO MAINTAIN

INTRAVASCULAR VOLUME INTRAVASCULAR VOLUME
Hyperdynamic shock Hypodynamic shock

Cool skin, tachycardia, hypotension,

oliguria
4. NEUROGENIC SHOCK
REDUCED VASOMOTOR TONE FROM
LOSS OF SYMPTATHETIC
INNERVATION
Spinal cord trauma
Spinal anesthesia
Acute gastric dilatation

CLINICAL FINDINGS

Bradycardia
Mild hypotension
Flat neck veins
 Cardiogenic Distributive
Shock Shock
Inotropes
Vasopressor ( NE,PE,ADR,Dop)
(Dob,Dop,Adr,Amr)

Release Pump = Pipe = Vascular Blood Pressure

tamponade,etc
Heart

Obstructive Cardiac Output x SVR

Shock
Volume =
Blood

Hypovolemic
Fluids
Shock
 Derajat syok Perdarahan
Di bagi menjadi 4 Kelas Syok :

1. Kelas 1 : <15% vol.darah hilang

2. Kelas 2 : 15-30% vol.darah hilang
Tensi Normal

3. Kelas 3 : 30-40% vol.darah hilang Tensi 

4. Kelas 4 : > 40 % vol.darah hilang
Slightly Respiration
anxious 14-20/min

Urine
Heart rate
30 mL/hr <100/min □ BP

crystalloid
Mildly Respiration
anxious 20 –30/min
Heart rate
Urine
>100/min BP
20-30 mL/hr
↓Pulse
Crystalloid pressure
? blood
Confused,
Respirations
lethargic
>35/min
Urine Heart rate
negligible >140/min
 BP
Rapid fluid,
 Pulse
blood, operation
pressure
Sumber Perdarahan yg dpt
menyebabkan Syok Hemorhagik

 Luar / eksternal
 Dalam / Internal
1. Toraks
2. Abdomen
3. Pelvis
4. Tulang panjang / Femur
5. Retroperitoneal
2. Perbaikan Volume

 Infus 2 jalur dengan IV catheter pendek

 -besar (ukuran 14 – 16 G)
 Ambil contoh darah untuk crossmatch
 Cairan Ringer Lactat yang sudah
dihangatkan
 Tetesan cepat / guyur
Pemberian cairan dapat diulang

Posisi syok
 Akses Vena

a. Vena perifer
b. Vena perifer
(v. jugularis eksterna)
c. Vena Jugularis interna

d. Vena Subklavia
e. Intra-oseus
(bayi – anak di
bawah 6 th)

f. Vena seksi
Venous Cut-down
(VC) di depan
Malleolus medialis
Tdk di anjurkan pd
anak di bawah 6 th
g. Arteri / Vena Femoralis
3. Monitor syok

Monitor terhadap pemberian cairan,

meliputi :

 Perbaikan perfusi (akral hangat, nadi

lebih besar, kesadaran membaik, dsb)
 Pantau produksi urin, produksi urin normal :
Dewasa : 30-50 cc/jam atau 0.5 cc/KgBB
Anak : 1 cc /KgBB
Bayi : 2 cc /KgBB
Monitor Respon terhadap pemberian cairan :

 Baik artinya perdarahan terkontrol

 Sementara, perlu darah  OK sito
 Buruk / tidak ada respon (OK sangat sito)

Resusitasi A, B, C, D  Selesai dlm 10’

Monitor Respon terhadap pemberian cairan :

 Bila respon terhadap cairan tidak baik,

selalu pertimbangkan kemungkinan syok
non- hemoragik
 Bila respon buruk kemungkinan perdarahan
berlanjut, cari sumber perdarahan

Cari sumber perdarahan lain :

 Jika ada terapi stop perdarahan

 Jika tidak ada berarti non hemoragik,
terapi sesuai penyebab
PRINSIP RESUSITASI

 Mempertahankan ventilasi
 Meningkatkan perfusi
 Terapi penyebab
 MAINTAIN VENTILATION
Increased oxygen
Especially in: demand

Sepsis
Hypovolemia
Trauma Hyperventilation

Diversi blood flow from

Respiratory fatigue
vital organ

Respiratory failure Organ injury

Respiratory acidosis, lethargy-coma, hypoxia
TREATMENT OF RESPIRATORY FAILURE
Hypovolemia (blood loss)

Decreased CO

Decreased oxygen delivery, increased

oxygen requirement

Metabolic acidosis, hypoxemia tachypnea

TREATMENT:
Primary resuscitation
Oxygen
Mechanical ventilation if needed
 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 1.34 + Hb X paO2

Inotropes Transfuse
Fluids Partially
dependent on
FIO2 and
pulmonary
status
 RESUSCITATION
NEED FOR SPEED

Resuscitation

Fast rate
%
surviva
l Slow rate
None

Time
NURSING INTERVENTION OF
PATIENT WITH SHOCK

31
 INTRODUCTION

 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.

32
 CLASSIFICATION OF SHOCK

Eight Types of Shock

(www.alpharubicon.com/med/shockpaleh
orse.htm-17k)
1. Respiratory Shock
2. Hemorrhagic shock
3. Hypovolemic Shock
4. Cardiogenic Shock

33
 CLASSIFICATION OF SHOCK

5. Neurogenic Shock
6. Anaphylactic Shock
7. Septic Shock
8. Metabolic Shock

34
 CLASSIFICATION OF SHOCK
Lewis (2000):

SHOCK

DISTRIBUTIVE HYPOVOLEMIC
SHOCK SHOCK
CARDIOGENIC
SHOCK
Septic Neurogenic Anaphylactic
shock shock shock

35
 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

37
Causes of shock

38
 Causes of shock
DISTRIBUTIVE
SHOCK

ANAPHYLACTIC SEPTIC NEUROGENIC

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

39
 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

40
 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 Ringer’s
 Treat mechanical causes of shock if they are present
 Tension pneumothorax
 Pericardial tamponade
 Exsanguinating hemorrhage

41
 OVERALL MANAGEMENT
STRATEGIES OF SHOCK
 While inserting IVs, draw blood for
 Laboratories and for blood typing
 Relieve pain with IV narcotics
 Reassess
 Blood transfusion: think twice
 Vasopressors
 Antibiotics

42
 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

43
NURSING ASSESSMENT OF SHOCK
 General: normal, ↑ or ↓ temperature,bleeding external
 Neurology: consciousness,irritability, stupor, coma
 Respiratory: rapid, deep respiration
 Cardiovascular: tachycardia with weak
 GI: diminished or absent bowel sounds
 Cutaneous:warm, pale, cool, moist skin

44
 NURSING ASSESSMENT OF
SHOCK
 Urine: color, volume, specific gravity
 Diagnostic Procedure: electrolyte, Hb, Ht, leuko,
blood gas, creatinin, BUN, cardiac enzymes

45
 NURSING INTERVENTION
 Reduce anxiety
 Safety
 Monitor vitals closely
 Report changes to RN
 Intensive Care
 Vasopressors
 Fluids
 Hemodynamic Monitoring
 Support/ Family Support
 Prevent complications

46
 CONCLUSION
The definition of shock does not involve
low blood pressure, rapid pulse or cool
clammy skin - these are merely the signs.
Simply stated, shock results from
inadequate perfusion of the body’s cells
with oxygenated blood.
Shock can kill quickly and without warning.

47
 CONCLUSION

 There are 3 types of shock: cardiogenic, hypovolaemic

and distributive.

 Each of these has a different haemodynamic profile and

consequently a different management strategy.

 The prime objective of any of these strategies is to

return blood pressure to baseline, and maintain tissue
perfusion and oxygenation.

 Regular assessment and accurate monitoring of patients

most at risk of shock is crucial

 The nurse must ensure these skills are incorporated into

48or her daily practice.
his
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