Shock & Treatment Conceptgvg

7/26/2019 Shock & Treatment Conceptgvg

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SHOCK DAN KONSEPTERAPI

Yohanes WH George


2/41

Memahami peran jantng! stats "o#meMemahami peran jantng! stats "o#me

intra"as$#ar %an tahanan pemh %arahintra"as$#ar %an tahanan pemh %arahsistemi$ %a#am mempertahan$an te$anansistemi$ %a#am mempertahan$an te$anan

%arah%arah

'e#ajar mengenai $#asi(i$asi sho)$'e#ajar mengenai $#asi(i$asi sho)$

Memahami etio#ogi %an patogenesis %ari sho)$Memahami etio#ogi %an patogenesis %ari sho)$

Mamp men%iagnosis %an meren)ana$anMamp men%iagnosis %an meren)ana$an

terapi *ang a%e$at pa%a masing+masing tipeterapi *ang a%e$at pa%a masing+masing tipesho)$sho)$

O',EKTI-O',EKTI-


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DE-INISIDE-INISI

IT IS NOT LOW BLOOD PRESSURE!!!

IT IS HYPOPERFUSION..

Gangguan dari perfusi jaringan yang terjadi akibat adanyaketidakseimbangan antara suplai oksigen ke sel dengan

kebutuhan oksigen dari sel tersebut.

Semua jenis shock mengakibatkan gangguan pada perfusi

jaringan yang selanjutnya berkembang menjadi gagalsirkulasi akut atau disebut juga sindrom shock


4/41

TIPE. SHOCK/TIPE. SHOCK/

T*pe o( Sho)$ C#ini)a# )ases Primar* me)hanism

Hypovolemic

Volume loEo"e#ou $loo%&pl'm'& (ui% o)elec*)oly*e lo

+')%io"e#icPump ,'ilu)e

-yoc')%i'l i#,')c*io#&c')%i'c '))y*mi'&

e')* ,'ilu)e

Di*)i$u*ive

I#c)e'e% ve#ouc'p'ci*'#ce o)')*e)iove#ou

u#*i#"

Sep*ic oc/& pi#'loc/& 'u*o#omic$loc/'%e& %)u"ove)%oe

O$*)uc*ive

E*)'1c')%i'c

o$*)uc*io# o, $loo%(o2

Ve#' c'v'l

o$*)uc*io#& c')%i'c*'mpo#'%e&pulmo#')y em$olim&'o)*ic comp)eio# o)%iec*io#

/MORE THAN ONE TYPE MAY 'E PRESENT/MORE THAN ONE TYPE MAY 'E PRESENT


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01 HYPO2O3EMIC SHOCK01 HYPO2O3EMIC SHOCK

DECREASE IN INTRA2ASC43AR'3OOD 2O34ME

DECREASE IN CARDIAC O4TP4T

AND TISS4E PER-4SION

Hemorrhage

2omiting

Diarrhea

-#i% se5estration

Intraluminal bowel obstruction

Intraperitoneal pancreatitis

Interstitial - burns


6/41

HYPO2O3EMIC SHOCKHYPO2O3EMIC SHOCK01 DECREASE IN INTRA2ASC43AR

'3OOD 2O34ME

.1 '3OOD DI2ERTED -ROM SKIN TO

MAINTAIN ORGAN PER-4SION

Pa#e an% )oo# s$in

Postra# h*potension an% ta)h*)ar%ia

61 '3OOD DI2ERTED PRE-ERENTIA33Y

TO HEART AND 'RAIN

Thirst! o#igria

Ta)h*)ar%ia

3a&i#e oo% pressre


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71 END+STAGE SHOCK

'ra%*)ar%iaArr*thmias

Death

81 DECREASED '3OOD -3OW TO'RAIN AND HEART

Rest#ess! agitate%! )on(se%

H*potension

Ta)h*)ar%ia

Ta)h*pnea

HYPO2O3EMIC SHOCKHYPO2O3EMIC SHOCK


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C3INICA3 -INDINGS

H*potension

Ta)h*)ar%iaTa)h*pnea

O#igria

//%isten%e% ne)$ "eins//

DECREASED CARDIAC -4NCTIONDe)rease% "entri)#ar (n)tion

MIPeri)ari%a# tampona%e

Tension pnemothora9

In(e)ti"e )ar%ia) )ontra)tion

Arrh*thmias

.1 CARDIOGENIC SHOCK.1 CARDIOGENIC SHOCK


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61 SEPTIC SHOCK61 SEPTIC SHOCKSE2ERE IN-ECTION W RE3EASE O-

MICRO'IA3 PROD4CTSRe#ease o( "asoa)ti"e me%iators

HYPERDYNAMIC STATEPeriphera# "aso%i#ation

In)rease% )ar%ia) otpt

-e"er! ta)h*)ar%ia! ta)h*pnea! :arm s$in

MAINTENANCE O-

INTRA2ASC43AR 2O34MEH*per%*nami) sho)$

-AI34RE TO MAINTAIN

INTRA2ASC43AR 2O34MEH*po%*nami) sho)$

Coo# s$in! ta)h*)ar%ia! h*potension!

o#igria


10/41

C3INICA3 -INDINGS

'ra%*)ar%ia

Mi#% h*potension-#at ne)$ "eins

RED4CED 2ASOMOTOR TONE -ROM3OSS O- SYMPTATHETIC

INNER2ATIONSpinal cord trauma

Spinal anesthesia

Acute gastric dilatation

81 NE4ROGENIC SHOCK81 NE4ROGENIC SHOCK


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HEMODYNAMIC


12/41

RightAtrim

Right

"entri)#e

P

#mona#arter*

3e(t

"entri)#e

P#mona#

"ein

3ng

3e(t atrim

S2R ;

'#oo%Press

re

Aorta

organ

S*stemi)

2as)#ar

Resistan)e


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PATHOGENESIS O- SHOCK


14/41


15/41

Cardiac utput ! S"#

Pipe$ "ascularPmp ;

%eart

2o#me$

&lood

%ypo'olemic

Shock

Cardiogenic

Shock(istributi'e

Shock

Inotropes

)(ob*(op*Adr*Amr+ "asopressor ) ,**A(#*(op+

/luids

bstructi'e

Shock

#elease

tamponade*etc&lood ressure


16/41

PATO-ISIO3OGI DARI RESPONPATO-ISIO3OGI DARI RESPONT4'4H TERHADAP SHOCKT4'4H TERHADAP SHOCK

Respon Neroen%o$rinRespon Neroen%o$rin

Respon Hemo%*nami$Respon Hemo%*nami$

Respon Meta&o#i)Respon Meta&o#i)


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HYPO2O3EMIAHYPO2O3EMIA

R atrimR atrim#o:+pressre stret)h#o:+pressre stret)h

re)eptorsre)eptors

AortaEpinephrine


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RESPON HEMODYNAMICRESPON HEMODYNAMIC0ekanisme untuk memperbaiki keseimbangan0ekanisme untuk memperbaiki keseimbangan

kardio'askularkardio'askular

Re%istri&si a#iran %arahRe%istri&si a#iran %arah

Pening$atan @)ar%ia) otptPening$atan @)ar%ia) otpt

Memper&ai$i "o#me intra"as$#arMemper&ai$i "o#me intra"as$#ar


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STIM43ASI NE4ROENDOKRINSTIM43ASI NE4ROENDOKRIN

HYPOTENSIONHYPOTENSION

'3OOD -3OW PROTECTED'3OOD -3OW PROTECTED

HeartHeart'rain'rain

A%rena#


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CARDIAC O4TP4T ;CARDIAC O4TP4T ; HR B S2HR B S2

S*mpatheti) n1 s*stemS*mpatheti) n1 s*stemCate)ho#amine re#easeCate)ho#amine re#ease

In)rease ED2 "iaIn)rease ED2 "ia?"enoconstriction"enoconstriction

Arteriolar constrictionArteriolar constriction#enal reabsorption#enal reabsorption

In)rease%In)rease%)ontra)ti#it*)ontra)ti#it*

3imite% to 0 &eats


21/41

Memper&ai$i "o#me %arahMemper&ai$i "o#me %arah

Trans)api##ar* re(i## phaseTrans)api##ar* re(i## phase4. (ecreased capillary pressure caused by hypotension4. (ecreased capillary pressure caused by hypotension

5. Sympathetic increase in precapillary arteriolar constriction5. Sympathetic increase in precapillary arteriolar constriction

(ecrease capillary hydrostatic pressure promotes passage of(ecrease capillary hydrostatic pressure promotes passage offluid from interstitium to intra'ascular spacefluid from interstitium to intra'ascular space

P#asma protein restittion phaseP#asma protein restittion phaseIncreased plasma osmolarity due toIncreased plasma osmolarity due to mainlymainlyhepatic release ofhepatic release ofglucose* pyru'ate* amino acids* etc.glucose* pyru'ate* amino acids* etc.

Increased interstitial osmolarityIncreased interstitial osmolarity

Increased interstitial 'olume and pressureIncreased interstitial 'olume and pressure

1ranscapillary mo'ement of albumin into intra'ascular space1ranscapillary mo'ement of albumin into intra'ascular space


22/41

RESPON HEMODYNAMIKRESPON HEMODYNAMIK2eno)onstri)tion2eno)onstri)tion

Sympathetic n. system )S,S+Sympathetic n. system )S,S+Catecholamines )CA+Catecholamines )CA+Angiotensin II )A1II+Angiotensin II )A1II+

A(%A(%

Re%)e% "enosRe%)e% "enos)apa)itan)e)apa)itan)e

Arterio#ar )onstri)tionArterio#ar )onstri)tionS,S* CA* A1II* A(%S,S* CA* A1II* A(%

De)rease% )api##ar* PDe)rease% )api##ar* P

-#i% shi(t (rom interstitim into-#i% shi(t (rom interstitim into"as)#ar )ompartment"as)#ar )ompartment

In)rease% %ista# tarIn)rease% %ista# tarrea&sorptionrea&sorption

A#%osterone! ADHA#%osterone! ADH

In)rease% pro9ima# tarIn)rease% pro9ima# tarrea&sorptionrea&sorptionSNS! CA! ATIISNS! CA! ATII

In)rease% m*o)ar%ia#In)rease% m*o)ar%ia#)ontra)ti#it*)ontra)ti#it*

SNS! CASNS! CA

Restoration o(Restoration o(oo% "o#meoo% "o#me

In)rease%In)rease%"entri)#ar"entri)#ar

(i##ing P(i##ing P

In)rease% "entri)#arIn)rease% "entri)#areje)tion (ra)tioneje)tion (ra)tion

S2S2

COCO

'P'PIn)rease% heart rateIn)rease% heart rateSNS! CASNS! CA

In)rease% S2R %e toIn)rease% S2R %e toarterio#ar )onstr)tionarterio#ar )onstr)tion

SNS! CA! ATII! ADHSNS! CA! ATII! ADH

S2R


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24/41

RESPON META'O3IKRESPON META'O3IK

H*perg#*)emiaH*perg#*)emia

Mo&i#isasi #ema$Mo&i#isasi #ema$

Kata&o#isme


25/41


'rea$%o:n o('rea$%o:n o(s$e#eta# ms)#es$e#eta# ms)#e

into a1a1into a1a1

Con"ersionCon"ersiono( a1a1 too( a1a1 tog#)oseg#)ose

Re#ease o(?Re#ease o(?Cate)ho#aminesCate)ho#amines

Cortiso#Cortiso#G#)agonG#)agonGro:th hormoneGro:th hormone

Impaire%Impaire%periphera#periphera#

g#)ose pta$eg#)ose pta$e

HYPERG3YCEMIAHYPERG3YCEMIA

G#*)ogenG#*)ogen&rea$%o:n&rea$%o:n


26/41


De)rease% oo%De)rease% oo%"o#me"o#me

De)rease% CODe)rease% CO

Ce###ar h*poper(sion an% h*po9iaCe###ar h*poper(sion an% h*po9ia

Anaero&i) g#*)o#*sisAnaero&i) g#*)o#*sisP*r"ate )on"erte% to #a)ti) a)i%P*r"ate )on"erte% to #a)ti) a)i%

META'O3IC ACIDOSISMETA'O3IC ACIDOSIS


27/41

Re#ease o(?Re#ease o(?

Cate)ho#aminesCate)ho#aminesCortiso#Cortiso#G#)agonG#)agon

3IPO3YSIS3IPO3YSIS

INCREASE IN P3ASMA -REEINCREASE IN P3ASMA -REE-ATTY ACIDS-ATTY ACIDS



28/41

E-EK SHOCK PADA TINGKATAN SE3E-EK SHOCK PADA TINGKATAN SE3

HYPOBIAHYPOBIA

3OW+-3OW!3OW+-3OW!POOR PER-4SIONPOOR PER-4SION

ANAERO'ICMETA'O3ISM

ACIDOSIS

DECREASED CE3343ARENERGY E--ICIENCY


29/41

Glucose breakdown. (A) Stage one, glycolysis, is anaerobic (does

not require oxygen). It yields pyruvic acid, with toxic byproducts

such as lactic acid, and very little energy. (!) Stage two is aerobic

(requires oxygen). In a process called the "rebs or citric acid

cycle, pyruvic acid is degraded into carbon dioxide and water,

which produces a #uch higher yield o$ energy.


30/41

CE33 MEM'RANE -AI34RE?DIRECT

ndoto!inComplement

INDIRECT/ailure to maintain normal ,a6* 76or Ca56gradient(ecreased o!idati'e phosphorylation

OSMOTICGRADIENT

Water entr*into )e##

CE3343AREDEMA

IMPAIREDINTRACE3343AR

META'O3ISM

CE33

DEATH

Naentr*into )e##

E-EK SHOCK PADA TINGKATAN SE3E-EK SHOCK PADA TINGKATAN SE3


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Ki%ne*Ki%ne*liguric renal failureliguric renal failure%igh output renal failure%igh output renal failure

3i"er3i"er3i'er failure3i'er failure

GI tra)tGI tra)t /ailure of intestinal barrier )sepsis* bleeding+/ailure of intestinal barrier )sepsis* bleeding+

3ng3ngCapillary leak associated with or caused by sepsis andCapillary leak associated with or caused by sepsis andinfectioninfection

E-EK SHOCK PADA TINGKATANE-EK SHOCK PADA TINGKATANORGANORGAN

DIAGNOSIS STAT4S SHOCKDIAGNOSIS STAT4S SHOCK


32/41

DIAGNOSIS STAT4S SHOCKDIAGNOSIS STAT4S SHOCK'ERDASARKAN PARAMETER'ERDASARKAN PARAMETER

HEMODYNAMIKHEMODYNAMIK

TYPE

H*po"o#emi)

Car%iogeni)

Septi)

Tramati)

Nerogeni)

H*poa%rena#

C2P or

PCWP

De)rease%

In)rease%

De)rease% or

in)rease%

De)rease%

De)rease%

De)rease% or

in)rease%

Car%ia)

Otpt

De)rease%

De)rease%

In)rease%

De)rease% or

in)rease%

De)rease%

De)rease% or

in)rease%

S2R

In)rease%

Norma# or

In)rease%

De)rease%

De)rease% or

in)rease%

De)rease%

De)rease% or

in)rease%

1,SI, ,201%#A81,SI, ,201%#A8


33/41

1,SI, ,201%#A81,SI, ,201%#A8


34/41

PRINSIP RES4SITASIPRINSIP RES4SITASI

Mempertahan$an "enti#asiMempertahan$an "enti#asi

Mening$at$an per(siMening$at$an per(si

Terapi pen*e&a&Terapi pen*e&a&


35/41

MAINTAIN 2ENTI3ATIONMAINTAIN 2ENTI3ATIONIn)rease% o9*genIn)rease% o9*gen

%eman%%eman%

H*per"enti#ationH*per"enti#ation

Respirator* (ai#reRespirator* (ai#reRespirator* a)i%osis! #etharg*+)oma! h*po9iaRespirator* a)i%osis! #etharg*+)oma! h*po9ia

Espe)ia##* in?Espe)ia##* in?

SepsisSepsisH*po"o#emiaH*po"o#emia

TramaTrama

Respirator* (atigeDi"ersi oo% (#o: (rom

"ita# organ

Organ injr*

TREATMENT O- RESPIRATORY -AI34RETREATMENT O- RESPIRATORY -AI34RE


36/41

H*po"o#emia =oo% #oss>H*po"o#emia =oo% #oss>

De)rease% CODe)rease% CO

De)rease% o9*gen %e#i"er*! in)rease%De)rease% o9*gen %e#i"er*! in)rease%

o9*gen re5iremento9*gen re5irement

Meta&o#i) a)i%osis! h*po9emiaMeta&o#i) a)i%osis! h*po9emia ta)h*pneata)h*pnea

TREATMENT?TREATMENT?Primar* ress)itationPrimar* ress)itationO9*genO9*gen

Me)hani)a# "enti#ation i( nee%e%Me)hani)a# "enti#ation i( nee%e%

TREATMENT O- RESPIRATORY -AI34RETREATMENT O- RESPIRATORY -AI34RE

TREATMENT CONCEPT O- SHOCKTREATMENT CONCEPT O- SHOCK


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TREATMENT CONCEPT O- SHOCKTREATMENT CONCEPT O- SHOCK

ENHANCING PER-4SION < OBYGEN DE3I2ERYENHANCING PER-4SION < OBYGEN DE3I2ERY

O9*gen %e#i"er*


38/41

OBYGEN CONS4MPTION < DE3I2ERY AND SHOCK

2O.))


39/41

TimeTime

sr"i"a#sr"i"a#

-ast rate-ast rate

S#o: rateS#o: rate

NoneNone

Ress)itationRess)itation

RES4SCITATIONRES4SCITATION,( /# S(,( /# S(


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S4MMARYS4MMARY

Sho)$ is an a#tere% state o( tisseSho)$ is an a#tere% state o( tisseper(sion se"ere enogh to in%)eper(sion se"ere enogh to in%)e%erangements in norma# )e###ar (n)tion%erangements in norma# )e###ar (n)tion

Neroen%o)rine! hemo%*nami) an%Neroen%o)rine! hemo%*nami) an%meta&o#i) )hanges :or$ together tometa&o#i) )hanges :or$ together to

restore per(sionrestore per(sion

Sho)$ has man* )ases an% o(ten ma* &eSho)$ has man* )ases an% o(ten ma* &e%iagnose% sing simp#e )#ini)a# in%i)ators%iagnose% sing simp#e )#ini)a# in%i)ators

Treatment o( sho)$ is primari#* (o)se%Treatment o( sho)$ is primari#* (o)se%on restoring tisse per(sion an% o9*genon restoring tisse per(sion an% o9*gen%e#i"er* :hi#e e#iminating the )ase%e#i"er* :hi#e e#iminating the )ase


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Shock & Treatment Conceptgvg