Kuliah Bidan - syok Hipovolemik

8/18/2019 Kuliah Bidan - syok Hipovolemik

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HYPOVOLEMIC SHOCK

AND RESUSCITATION

Asri Prameswari, dr., SpPD


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SHOCK AND RESUSCITATION

GOAL: UNDERSTAND THE PATHOPHYSIOLOGY OF SHOCK AND IT’S

TREATMENT

Objectives:

Be able to categorize types of shock

Understand mechanisms of adapting to volume

loss of blood loss

Demonstrate shock treatment:

lines, sites, types of fluid

End points of resuscitationComplications of treatment


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TYPES OF SHOCK

“Classic” Blalock 1937

Hematogenic

Neurogenic Vasogenic

Cardiogenic


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CLASSIFICATION OF SHOCK

Low Cardiac Output states

Hypovolemic shock

volume loss

Internal volume loss

Cardiac shock

Impaired inflow

Primary pump dysfunction

Impaired outflow

Low peripheral resistance states

Neurogenic shock

Loss of sympathetic tone

Vasogenic Shock

Septic

Anaphylactic

Carrico: ACS Early Care of the Injured Patient 4th Ed.


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HYPOVOLEMIC SHOCK

Definition:

Reduction in intravascular volume leading to

insufficient oxygen delivery to cells

(mitochondria)


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HYPOVOLEMIC SHOCKReduced intravascular volume?

No oxygen delivery!

No aerobic metabolism!

Then…

Metabolic acidosis (lactic acid production)

Endoplasmic recticulum swelling

Mitochondrial damage

Cell Death!


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THE CIRCULATORY SYSTEM

Components:

Heart (pump)

Blood Vessels Blood


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CIRCULATION SCHEMATIC

The Pump (heart)

2 sided

Anatomically looksparallel, BUT:

Physiologically and

in Actuality

Supplies 2 systems

connected in series


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Right Side

Compliant, flexible

Low pressure,variable volume

Left Side

Stiff, strong

High pressure, fixedvolume

The Heart:


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THE CIRCULATORY SYSTEM

Multiple Parallel Circuits Organized teleologically:

Prioritized supply

Closest circuits getsupplied first andforemost Coronaries, Brain,

Kidneys

Distal circuits getshut down whenvolume low Gut/Muscle, Skin


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CIRCULATORY CONTROL MECHANISMS

Closest, fastest

Carotid Bodies (Baroreceptors)

Stimulate Sympathetic Nervous System

Mid-level

Kidneys- Juxtaglomerular Apparatus

Sense low flow and stimulate Renin resulting in vasoconstriction (splancnic)

Down-line

Adrenal Cortex

Senses need for more Sodium and Fluid Re-absorbtion to deal with upright

posture volume needs


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HYPOVOLEMIC SHOCK

Vascular compartments:

TBW (60% of IBW)

Total Body Water

ICW (40%) ECW (20%)

Intracellular Water Extracellular Water

Interstitium Plasma

(1/3) (2/3)


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HYPOVOLEMIC SHOCK

Loss of circulating blood volume (Plasma)

Normal Blood Volume:- 7% IBW in adults

- 9% IBW in kids


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ACUTE VOLUME LOSS

Shock - Classes:

I 0-15% blood loss

II 15-30% blood lossIII 30-40% blood loss

IV >40% blood loss

SHOCK


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TREATMENT OF SHOCK

Recognize Type of Shock If definite pump failure and cardiogenic shock institute cardiac

protocols

Otherwise: 2 large bore, upper extremity lines and:

Volume

Volume

Volume

When in doubt, try a little more volume


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TREATMENT OF SHOCK

Goal: Restore perfusion

Method: Depends on type of Shock

Basically 2 kinds:

Hypovolemic (hemorrhagic, septic,

neurogen.)

Cardiogenic (Impedence or primary

Cardiac Failure)


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TREATMENT OF SHOCK

Prioritized approach

Must address and treat sequentially:

PRELOAD

AFTERLOAD PUMP

QUESTIONs:

What type of fluid

How Much End Point of Resuscitation


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HYPOVOLEMICSHOCK

Management:

ABCs of trauma (AIRWAY is always first!)

Control hemorrhage

Obtain IV access and resuscitate with fluids and blood

2 liters crystalloid for adults

20 cc/kg crystalloid x 2 for kids

Blood vs. Crystalloid??

Long term critical care management


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HYPOVOLEMIC SHOCK

Your management goals AFTER securing the ABCs:

STOP THE BLEEDING!

RESTORE VOLUME!

CORRECT ANY ELECTROLYTE/ACID-BASEDISTURBANCES!


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TREATMENT: HEMORRHAGIC SHOCK

Large bore access

2 upper extremity IVs

16 gauge or larger

Bolus therapy

20 cc/kg

Adults- 2 liters

Monitor Effect

Repeat if necessary

After 2nd bolus: need blood

10cc/kg


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END POINTS OF RESUSCITATION:

Restoration of normal vital signs Adequate Urine output

0.5 - 1.0 cc/kg/hr

Tissue Oxygenation measurement

Adequate Cardiac Index Normalization of Oxygen delivery

Normal Serum Lactate levels

none proven helpful, some deleterious

Englehart; Curr Op Crit Care; Vol 12(6), Dec 06, p 579-574


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BLOOD TRANSFUSION

Blood Banks safer

Some risk unavoidable

New viruses are inevitable

False negative screeningtests

Time for cross-matchdelays Rx


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TRY OUT

Wanita 50 tahun datang ke UGD dengan pucat,menggigil, lemah dangelisah

Diare 2 hari, muntah >10kali, isi cairan warnacoklat dan kuning berair

Ada riwayat flek-flek vagina

sejak 3 bulan, dicurigaitumor kandungan

Apa yang anda

lakukan?


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DISKUSI

Anamnesa : brp lama flek?Banyak? Hari? Banyak?

Tensi 60/palpasi

Nadi 66 kali, lemah, reguler

Suhu 38 RR 30 reguler

KU gelisah

Kesadaran GCS 446

Urine -

Sat oksigen 65% Akral dingin

CRT >3dtk

Pain score

Infus RL 100cc

Oksigen masker

Lapor

Resusitasi 20cc/kg–

ceknadi 5 menit stlh resusitasi

Pasang NGT –hematemesis +

Kateter urine pekat 10cc

Cek GDS cito

Rawat intensif


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SUMMARY

The Circulation is a Circuit

Volume is most often the answer

Lactated Ringers still the standard

More is better than less, maybe Better Indicators & Endpoints of Resuscitation

Shock and Resuscitation:

Documents

Kuliah Bidan - syok Hipovolemik