13069744 Syok Pada Anak
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Transcript of 13069744 Syok Pada Anak
1
PELATIHAN RESUSITASIPELATIHAN RESUSITASI
PEDIATRIK TAHAP LANJUTPEDIATRIK TAHAP LANJUT
S Y O KS Y O K
KOMISI RESUSITASI PEDIATRIKKOMISI RESUSITASI PEDIATRIK
UKK PEDIATRI GAWAT DARURAT IDAIUKK PEDIATRI GAWAT DARURAT IDAI
APRCAPRC
2
DEFINISI SYOKDEFINISI SYOK
SINDROM KLINIS AKIBAT KEGAGALAN SISTEM SINDROM KLINIS AKIBAT KEGAGALAN SISTEM
SIRKULASI UNTUK MENCUKUPI :SIRKULASI UNTUK MENCUKUPI :
NUTRISINUTRISI PASOKANPASOKAN METABOLISMEMETABOLISME OKSIGENOKSIGEN UTILISASIUTILISASI JARINGAN JARINGAN
TUBUHTUBUH
FASE: FASE: KOMPENSASIKOMPENSASI
DEKOMPENSASIDEKOMPENSASIIREVERSIBELIREVERSIBEL DEFISIENSI O2 DEFISIENSI O2
SELULERSELULER
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Etiologi SyokEtiologi Syok
TypeType Primary InsultPrimary Insult Common CausesCommon Causes
HypovolemicHypovolemicDecreased circulatingDecreased circulating Dehydration, Dehydration, hemorrhage,hemorrhage,
blood volblood vol capilarry leakscapilarry leaks
DistributiveDistributive Vasodilation -> venousVasodilation -> venous Sepsis, anaphylaxis,Sepsis, anaphylaxis,pooling -> decreased preloadpooling -> decreased preload drug drug
intoxication,intoxication,spinal cord injuryspinal cord injury
ObstructiveObstructive Obstruction of cardiacObstruction of cardiac Cardiac tamponade, Cardiac tamponade, tensiontension
filling/out flowfilling/out flow pneumothoracx, pneumothoracx, pulmonary pulmonary
embolusembolus
CardiogenicCardiogenic Decreased contractilityDecreased contractility Congenital heart Congenital heart disease,disease,
myocarditis, dysritmiamyocarditis, dysritmia
DissociativeDissociative O2 not released fromO2 not released from CO poisoning,CO poisoning,hemoglobinhemoglobin methemoglobinemiamethemoglobinemia
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FUNGSI SISTEM SIRKULASIFUNGSI SISTEM SIRKULASI JANTUNGJANTUNG CURAH JANTUNGCURAH JANTUNG
METABOLISMEMETABOLISME PEMB. DARAHPEMB. DARAH ALIRAN DARAHALIRAN DARAH ADEKUATADEKUAT
JARINGANJARINGAN VOL. DARAHVOL. DARAH O2 DELIVERYO2 DELIVERY
METABOLITMETABOLIT
ELIMINASIELIMINASI
DI ORGAN DI ORGAN
PEMBUANGANPEMBUANGAN
DO2 DO2 = CO x CaO2= CO x CaO2CaO2 CaO2 = (1,34 x Hb x sat O2) + (0,003 x PaO2)= (1,34 x Hb x sat O2) + (0,003 x PaO2)
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Pengaturan curah jantung dan tekanan darahPengaturan curah jantung dan tekanan darah
PreloadPreload ContractilityContractilityAfterloadAfterload
Heart rateHeart rate Stroke volumeStroke volume
Cardiac outputCardiac output Systemic vascular resistanceSystemic vascular resistance
Blood pressureBlood pressure
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Distribution of CO & VO2 Distribution of CO & VO2 in a Healthy Resting Normal Subjectin a Healthy Resting Normal Subject
% Total% Total AVDO2AVDO2 % Total% TotalOrganOrgan COCO vol %vol % VO2VO2GI tract and liverGI tract and liver 2424 4.14.1 2525Skeletal muscleSkeletal muscle 2121 8.08.0 3030KidneyKidney 1919 1.31.3 7 7BrainBrain 1313 6.36.3 2020SkinSkin 9 9 1.01.0 2 2HeartHeart 4 4 11.411.4 1111Other organsOther organs 1010 3.03.0 5 5
Adapted from Wade OL, Bishop JM: Cardiac output and regional blood flow, Oxford, Blackwell, 1962Adapted from Wade OL, Bishop JM: Cardiac output and regional blood flow, Oxford, Blackwell, 1962
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Extracel. FluidExtracel. Fluid Low Output Cardiac FailureLow Output Cardiac FailureIntra vasc. Vol. due toIntra vasc. Vol. due to
VolumeVolume Pericardial TamponadePericardial TamponadeOncotic PressureOncotic Pressure
Constrictive PericarditisConstrictive PericarditisCapillary PermeabilityCapillary Permeability
CARDIAC OUTPUTCARDIAC OUTPUT
Activation receptor of ventricular & arterialActivation receptor of ventricular & arterial
Non-osmoticNon-osmotic Stimulation ofStimulation ofActivation of theActivation of the
VasopressinVasopressin Sympathetic NervousSympathetic Nervous Renin-Angiotensin- Renin-Angiotensin-StimulationStimulation SystemSystem
Aldosterone SystemAldosterone System
RENAL WATERRENAL WATER PERIPHERAL & RENALPERIPHERAL & RENAL RENAL SODIUMRENAL SODIUM
RETENTIONRETENTION ARTERIAL VASC. RESISTANCEARTERIAL VASC. RESISTANCE RETENTIONRETENTION
MAINTENANCE OF EFFECTIVEMAINTENANCE OF EFFECTIVE
ARTERIAL BLOOD VOLUMEARTERIAL BLOOD VOLUME
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FRANK STARLING`S LAWFRANK STARLING`S LAW
SYMPATHOMIMETIC SYMPATHOMIMETIC AMINESAMINES
XANTHINESXANTHINES
GLUCAGONGLUCAGON
CARDIAC GLYCOSIDESCARDIAC GLYCOSIDES
HYPOXEMIAHYPOXEMIA
ACIDOSISACIDOSIS
HYPOGLYCEMIAHYPOGLYCEMIA
ENDOTOXEMIAENDOTOXEMIA
DRUG TOXICITYDRUG TOXICITY
VOLUME VOLUME INFUSIONINFUSION
STR
OK
E V
OLU
ME
STR
OK
E V
OLU
ME
44
22
33
11
55
00 55 1010
CENTRAL VENOUS PRESSURE (Toor)CENTRAL VENOUS PRESSURE (Toor)
A
DD
BB
CC
POSITIVEPOSITIVEINOTROPYINOTROPY
NEGATIVENEGATIVEINOTROPYINOTROPY
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Oxyhem
og
lob
in s
atu
rati
on
Oxyhem
og
lob
in s
atu
rati
on
HH++
2,3-DPG2,3-DPGCOCO22
PiPi
HH++
2,3-DPG2,3-DPGCOCO22
PiPi
PaOPaO22
The Oxygen-hemoglobin Dissociation CurveThe Oxygen-hemoglobin Dissociation Curve
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ShockShock
HypotensionHypotension
PreloadPreload
Cellular hypoxiaCellular hypoxia
Intravasculer volumeIntravasculer volume Myocardial contractility Myocardial contractility
Anaerobic metabolismAnaerobic metabolism
Membrane permeabilityMembrane permeability
Metabolic by-Metabolic by-products:products:
- lactic acid- lactic acid
- myocardial - myocardial depressant factordepressant factor
- endogeneous - endogeneous catecholaminescatecholamines
- adenine - adenine nucleotidesnucleotides
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STADIUM SYOKSTADIUM SYOK
KOMPENSASIKOMPENSASI
DEKOMPENSASIDEKOMPENSASI
IREVERSIBEL (PRETERMINAL)IREVERSIBEL (PRETERMINAL)
PERJALANAN KLINIS PERJALANAN KLINIS BERSIFAT PROGRESIFBERSIFAT PROGRESIF
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FASE I: KOMPENSASIFASE I: KOMPENSASI
KOMPENSASI TEMPORERKOMPENSASI TEMPORER
SIMPATIS, SIMPATIS, SVR, SVR, TEKANAN NADI TEKANAN NADI
DISTRIBUSI SELEKTIF ALIRAN DARAHDISTRIBUSI SELEKTIF ALIRAN DARAH
RETENSI NA & AIRRETENSI NA & AIR
KLINIS : KLINIS : * TAKHIKARDIA* TAKHIKARDIA* GADUH GELISAH* GADUH GELISAH
* KULIT PUCAT DINGIN * KULIT PUCAT DINGIN * PENGISIAN KAPILER >> * PENGISIAN KAPILER >>
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FASE 2: DEKOMPENSASIFASE 2: DEKOMPENSASI KOMPENSASI MULAI GAGALKOMPENSASI MULAI GAGAL HIPOPERFUSI HIPOPERFUSI HIPOKSIA JAR. HIPOKSIA JAR. METAB. METAB.
ANAEROBIKANAEROBIK GGN. GGN. METAB. SELULERMETAB. SELULER
PELEPASAN MEDIATOR : PELEPASAN MEDIATOR : * VASODILATASI* VASODILATASI * *
PERMEABILITAS PERMEABILITAS * *
DEPRESI MIOKARD DEPRESI MIOKARD * *
GGN KOAGULASI GGN KOAGULASI
KLINIS : KLINIS : TAKHIKARDIA TAKHIKARDIA TEKANAN DARAH TEKANAN DARAH TAKIPNU TAKIPNU
PERFUSI PERIFER PERFUSI PERIFER ASIDOSIS (+)ASIDOSIS (+) OLIGURI (+) OLIGURI (+)
TINGKAT KESADARAN TINGKAT KESADARAN
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FASE 3: IREVERSIBELFASE 3: IREVERSIBEL KOMPENSASI GAGALKOMPENSASI GAGAL CADANGAN ENERGI TUBUH CADANGAN ENERGI TUBUH
KERUSAKAN/KEMATIAN SELKERUSAKAN/KEMATIAN SEL DISFUNGSI ORGAN DISFUNGSI ORGAN
MULTIPELMULTIPEL KLINIS : KLINIS : * T.D TAK TERUKUR* T.D TAK TERUKUR * NADI TAK TERABA* NADI TAK TERABA
* TINGKAT KESADARAN* TINGKAT KESADARAN * ANURIA (+)* ANURIA (+)* GAGAL MULTI ORGAN * GAGAL MULTI ORGAN DAN KEMATIAN DAN KEMATIAN
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Manifestasi Klinis SyokManifestasi Klinis Syok
Clinical SignsClinical Signs CompensatedCompensated UncompensatedUncompensated IrreversibleIrreversible
Blood loss (%)Blood loss (%) Up to 25Up to 25 25 - 4025 - 40 > 40> 40
Heart rate Heart rate Tachycardia + Tachycardia + Tachycardia ++ Tachycardia ++ Tachy/bradycardiaTachy/bradycardia
Systolic BPSystolic BP NN N or falling N or falling PlummetingPlummeting
Pulse volumePulse volume N/ N/ + + ++ ++
Capillary refill Capillary refill N/ N/ + + ++ ++
SkinSkin Cool, pale Cool, pale Cold, mottled Cold, mottled Cold, deathly paleCold, deathly pale
Respiratory rateRespiratory rate Tachypnoea + Tachypnoea + Tachypnoea ++Tachypnoea ++ Sighing Sighing rsp.rsp.
Mental stateMental state Mild agitationMild agitation Lethargic Lethargic Reacts only to painReacts only to pain
UncooperativeUncooperative or unresponsiveor unresponsive
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GANGGUAN PERFUSI PERIFERGANGGUAN PERFUSI PERIFER CORE > PERIFER TEMP. ~ > 2CORE > PERIFER TEMP. ~ > 2O O CC CAPILLARY REFILL >> : CAPILLARY REFILL >> :
* NAIL BED PRESS* NAIL BED PRESS * BLANCHING SKIN TEST* BLANCHING SKIN TEST
PRODUKSI URIN PRODUKSI URIN (N) (N) BAYI BAYI = 2 ml/kg/jam= 2 ml/kg/jam
ANAKANAK = 1 ml/kg/jam= 1 ml/kg/jam
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TATALAKSANA RESUSITASI TATALAKSANA RESUSITASI SYOKSYOK
RESUSITASI AWALRESUSITASI AWAL OKSIGEN 100% + VENTILATORY SUPPORTOKSIGEN 100% + VENTILATORY SUPPORT PASANG AKSES VASKULER (90 DETIK)PASANG AKSES VASKULER (90 DETIK) FLUID CHALLENGE (20 ml/kg BB)FLUID CHALLENGE (20 ml/kg BB)
SECEPATNYA < 10 MENITSECEPATNYA < 10 MENIT DPT DIULANGI 2-3 KALIDPT DIULANGI 2-3 KALI KRISTALOID/KOLOIDKRISTALOID/KOLOID
PEMANTAUAN AWALPEMANTAUAN AWAL RESPON THD FLUID CHALLENGERESPON THD FLUID CHALLENGE PANTAU PROD. URIN (KATETER)PANTAU PROD. URIN (KATETER) STAT. LAB/PENUNJANGSTAT. LAB/PENUNJANG
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MonitoringMonitoring State of consiousness-Glasgow Coma ScaleState of consiousness-Glasgow Coma Scale Respiratory rate and characterRespiratory rate and character Cardiovascular parametersCardiovascular parameters
Skin and core temperature differenceSkin and core temperature difference Pulse rate and volumePulse rate and volume Blood pressureBlood pressure Capillary perfusion timeCapillary perfusion time Central venous pressure - should be monitored in a Central venous pressure - should be monitored in a
patient where there has been poor response to fluid patient where there has been poor response to fluid therapy or with established shock. therapy or with established shock.
Urinary output - urine bag, or preferably Urinary output - urine bag, or preferably catheter; output should be 1-2 ml/kg body catheter; output should be 1-2 ml/kg body weightweight
Pulse oximetryPulse oximetry
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RESUSITASI LANJUTRESUSITASI LANJUT
BILA FLUID CHALLENGE NON BILA FLUID CHALLENGE NON RESPONSIVERESPONSIVE
INTUBASI & VENT. MEKANIKINTUBASI & VENT. MEKANIK PASANG CVP & LOADING HATI-HATIPASANG CVP & LOADING HATI-HATI KOREKSI EFEK INOTROPIK NEGATIFKOREKSI EFEK INOTROPIK NEGATIF
Hb < 5 g/dl Hb < 5 g/dl PRC 10 ml/kg BB (Ht 40-50 vol %) PRC 10 ml/kg BB (Ht 40-50 vol %)
OBAT INOTROPIKOBAT INOTROPIK
21
PEMANTAUAN LANJUTPEMANTAUAN LANJUT CARI PENYEBAB SYOK (CXR, KONSULTASI)CARI PENYEBAB SYOK (CXR, KONSULTASI) EVALUASI FUNGSI SIST. ORGAN LAIN : EVALUASI FUNGSI SIST. ORGAN LAIN :
ATN/PRE RENAL FAILUREATN/PRE RENAL FAILURE ARDSARDS CARDIAC FUNCTIONCARDIAC FUNCTION GGN. KOAGULASI/DICGGN. KOAGULASI/DIC ORGAN-ORGAN LAINORGAN-ORGAN LAIN
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CHILD IN SHOCK
(1) OXYGEN (2) CRYSTALLOID 20 ml/kg)
IMPROVEMENT
NO IMPROVEMENT
NO IMPROVEMENT (3) CRYSTALLOID - INCREASE MABP (20 ml/kg) - NORMALIZATION HR
- IMPROVED PERFUSION - URINE OUTPUT > 1 ml/kg/hr
URINARY CATHETER
ESTABLISH CVP ESTABLISH ETIOLOGY,OBSERVATION
CVP < 5 Torr CVP > 5 Torr CRYSTALLOID INFUSION NO IMPROVEMENT UNTIL CVP - 5 Torr IMPROVEMENT ABG, HT, NaK, GLUC Ca,
SWAN GANZ CATHETER ESTABLISH ETIOLOGY CO, RAP, PAP, POAPCONFIRM SOURCE OF FLUID LOSS
CENTRAL VENOUS PRESSURESTR
OK
E V
OLU
ME
1. CORRECT ACIDOSIS
2. Co. GLUCOSE
3. INTROPIC SUPPORT
23
Stadium syok septik dan manifestasi klinisStadium syok septik dan manifestasi klinis
StadiumStadium Tanda KlinisTanda Klinis Gang fisiologisGang fisiologis BiokimiawiBiokimiawi
Warm ShockWarm Shock perfusi perifer (N) perfusi perifer (N) Smv Smv OO22 hipokarbiahipokarbia
(Hiperdinamik)(Hiperdinamik) kulit hangat keringkulit hangat kering VO VO22
hopoxiahopoxiaHR HR nadi bounding nadi bounding CO CO kadar laktat kadar laktat
suhu / (tak stabil) suhu / (tak stabil) SVR SVR
hiperglikemiahiperglikemiaRR RR , gg. kesadaran, gg. kesadaran
Cold ShockCold Shock sianosis sianosis CO CO hipoxiahipoxia(Hipodinamik)(Hipodinamik) kulit dingin lembabkulit dingin lembab SVR SVR
asidosis metabasidosis metabnadi kecil, lemah nadi kecil, lemah CVP CVP
koagulopatikoagulopatiHR HR , Oliguria, Oliguria Smv O Smv O22 hipoglikemihipoglikemishallow breathing shallow breathing pe pe kesadaran kesadaran
MOSFMOSF bergantung sistem bergantung sistem KomaKoma sesuai sesuai yang terkenayang terkena
ARDS, CHF, RFARDS, CHF, RF jenisjenisGI bleeding/DIC GI bleeding/DIC organ failureorgan failure
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TATALAKSANA SYOK SEPTIKTATALAKSANA SYOK SEPTIK AB BROAD SPECTRUMAB BROAD SPECTRUM SESUAI KULTUR SESUAI KULTUR RESUSITASI CAIRAN : KOLOID/KRISTALOIDRESUSITASI CAIRAN : KOLOID/KRISTALOID OBAT INOTROPIK : OBAT INOTROPIK : DOBUTAMIN + DOPAMINDOBUTAMIN + DOPAMIN
ISOPRENALIN/ADRENALINISOPRENALIN/ADRENALIN
SVR SVR VASODILATASI PERIFER VASODILATASI PERIFER KOREKSI : KOREKSI : - HIPO/HIPERGLIKEMI - HIPO/HIPERGLIKEMI
- ASAM BASA- ASAM BASA- ELEKTROLIT- ELEKTROLIT
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TATALAKSANA SYOK TATALAKSANA SYOK ANAFILAKTIKANAFILAKTIK
STOP ALERGEN PENYEBAB + ADRENALIN (IM)STOP ALERGEN PENYEBAB + ADRENALIN (IM) AIR WAY & RESPIRATION ADEKUATAIR WAY & RESPIRATION ADEKUAT
WHEEZINGWHEEZING NEBULASI NEBULASI ADRENALIN/SALBUTAMOLADRENALIN/SALBUTAMOL
OBSTRUKSIOBSTRUKSI INTUBASI/SURGICAL AIRWAY INTUBASI/SURGICAL AIRWAY
SIRKULASI & HEMODINAMIKSIRKULASI & HEMODINAMIK VASOPRESOR VASOPRESOR : ADRENALIN (10 : ADRENALIN (10 µµg/kg BB)g/kg BB) FLUID LOADING FLUID LOADING : KRISTALOID (20 ml/kg BB/IV-IO): KRISTALOID (20 ml/kg BB/IV-IO)
RE ASSESSMENT ABC RESUSITASIRE ASSESSMENT ABC RESUSITASI WHEEZING (+)WHEEZING (+) NEBULASI SALBUTAMOL NEBULASI SALBUTAMOL
BILA PERLU BILA PERLU (+) HIDROKORTISON (IV)(+) HIDROKORTISON (IV) (+) AMINOPILIN/SALBUTAMOL (+) AMINOPILIN/SALBUTAMOL
DRIPDRIP SYOK BERLANJUT : SYOK BERLANJUT : KOLOID + INOTROPIKKOLOID + INOTROPIK
26
TATALAKSANA SYOK TATALAKSANA SYOK KARDIOGENIKKARDIOGENIK
OKSIGENASI ADEKUATOKSIGENASI ADEKUAT KOREKSI GGN ASAM BASA & ELEKTROLITKOREKSI GGN ASAM BASA & ELEKTROLIT KURANGI RASA SAKIT & ANSIETAS KURANGI RASA SAKIT & ANSIETAS ATASI DISRITMIA JANTUNGATASI DISRITMIA JANTUNG KELEBIHAN PRELOADKELEBIHAN PRELOAD : : DIURETIKADIURETIKA
KONTRAKTILITAS:KONTRAKTILITAS: FLUID CHALLENGE SESUAI FLUID CHALLENGE SESUAI CVP/POAPCVP/POAP
OBAT OBAT INOTROPIK (+)INOTROPIK (+)
BEBAN AFTERLOAD (SVR BEBAN AFTERLOAD (SVR ) : ) : VASODILATORVASODILATOR
KOREKSI PENYEBAB PRIMERKOREKSI PENYEBAB PRIMER
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Key points in managementKey points in management Remember BP and pulse are unreliable indicators Remember BP and pulse are unreliable indicators
in early septic shockin early septic shock Look for minor degrees of mental impairment Look for minor degrees of mental impairment
(anxiety, restlessness)(anxiety, restlessness) Do not delay treatment, try to prevent the onset Do not delay treatment, try to prevent the onset
of hypotension, metabolic acidosis, and hypoxiaof hypotension, metabolic acidosis, and hypoxia Give adequate fluids early in treatment, Give adequate fluids early in treatment,
especially colloidsespecially colloids Do not use inotropic agents until the patient has Do not use inotropic agents until the patient has
received adequate fluid therapyreceived adequate fluid therapy Monitor blood glucose, gases, and pH, and treat Monitor blood glucose, gases, and pH, and treat
appropriatelyappropriately
28
SEQUENCE OF THERAPEUTIC MANEUVERS SEQUENCE OF THERAPEUTIC MANEUVERS (VIPPS)(VIPPS)
PriorityPriority MnemonicMnemonic TherapyTherapy Purpose Purpose
11 VV VentilateVentilate Adequate O2&CO2Adequate O2&CO2exchangeexchange
22 II InfuseInfuse Vascular AccessVascular AccessBlood, fluid &Blood, fluid &electrolite balanceelectrolite balance
33 PP PumpPump Restoration cardiacRestoration cardiacperformanceperformance
44 PP PharmacologicPharmacologic Improved perfusionImproved perfusionby vasoactive agentsby vasoactive agents
55 SS Specific/Specific/ Medical & surgicalMedical & surgicalSurgicalSurgical management of management of
primary causesprimary causes