pleno 2 kgd unfinished
TRANSCRIPT
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PEMICU 2
BLOK KEGAWATDARURATAN
MEDIK
KELOMPOK 22
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Kelompok 22
• Tutor: dr !muel
• A"##ot!:
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De$%"%t%o"
• A p&'(%olo#%)!l (t!te t&!t re(ult( %"%"!de*u!te or#!" per$u(%o" !"d t%((ueo+'#e"!t%o"
• Do,",!rd (p%r!l o$ %mp!%red per$u(%o"
le!d%"# to %mp!%red $u")t%o"
• Re(ult( %" mult%ple or#!" $!%lure !"d de!t&
Ghana Emergency MedicineCollaborative
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B!(%) P&'(%olo#'
• O+'#e" Del%-er' . CO + !rter%!l )o"te"t o$ O2
• C!rd%!) Output . /R + troke 0olume
• troke 0olume %( ! $u")t%o"
1 Prelo!d
1 A$terlo!d
1 M'o)!rd%!l Co"tr!)t%l%t'
Ghana Emergency MedicineCollaborative
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P!t&op&'(%olo#'
• Blood lo((
1 Rele!(e o$ e"do#e"ou( )!te)&ol!m%"e(
• I")re!(e )!rd%!) output 1 I")re!(e &e!rt r!te
1 0!(o)o"(tr%)t%o" o$ le(( -%t!l or#!"(
(k%"3 mu()le
Re(ult( %" &%#&er d%!(tol%) BP 4"!rro, PP5
• Co"t%"ue to per$u(e -%t!l or#!"( !( lo"# !(
po((%6le 46r!%"3 &e!rt3 k%d"e'5
Ghana Emergency MedicineCollaborative
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I"%t%!l P!t%e"t A((e((me"t
• Re)o#"%t%o" o$ &o)k
1 Cl%"%)!l (%#"( !"d ('mptom( depe"d(
o" t&e (e-er%t' o$ t&e (&o)k 1 E!rl' m!"%$e(t!t%o"( %")lude t!)&')!rd%!
!"d )ut!"eou( -!(o)o"(tr%)t%o"
Ghana Emergency MedicineCollaborative
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Cl%"%)!l P!t&op&'(%olo#' o$
&o)k• Ge"er!l 7 0%t!l (%#"(
• C!rd%o-!()ul!r8 t!)&')!rd%!
• k%"8 -!(o)o"(tr%)t%o" -(9 -!(od%l!t%o"• Re(p%r!tor'8 %")re!(ed RR
• Ur%"!r'8 de)re!(e ur%"e output
• Neurolo#%)8 )o"$u(%o"3 !#%t!t%o"• E+trem%t%e(8 )old -(9 ,!rm
Ghana Emergency MedicineCollaborative
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Cl%"%)!l E"dpo%"t( o$ &o)k
END-STAGE SHOCK
Bradycardia
Arrythmias
Death
DECREASED BLOOD FLOW TO BRAIN AND HEARTRe(tle((3 !#%t!ted3 )o"$u(ed3 let&!r#'
/'pote"(%o"
T!)&')!rd%!
T!)&'p"e!
Ghana Emergency MedicineCollaborative
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Cl!((%$'%"# &o)k
• /'po-olem%) 1 /emorr&!#%)
• D%(tr%6ut%-e 70!(o#e"%) 1 ep(%(3 A"!p&'l!)t%)
• C!rd%o#e"%)
• Neuro#e"%) 1 p%"!l )ord %"ur'
Ghana Emergency MedicineCollaborative
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&o)k T'pe( ; P&'(%olo#'
Shoc C!"#"CW" CO S!RI
/emorr&!#%) $ $ <
ept%) e%t&er % $
C!rd%o#e"%) < $ <
Neuro#e"%) $ $ $
/'po!dre"!l e%t&er $ $
A"!p&'l!)t%) $ $ $
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e-er%t' o$ &o)k
• Compe"(!ted (&o)k: p!t%e"t %( de-elop%"#
(&o)k 6ut 6od' (t%ll !6le to m!%"t!%" per$u(%o"9
• De)ompe"(!ted (&o)k: p!t%e"t de-eloped (&o)k6ut 6od' "o lo"#er )!" )ompe"(!te9
• Irre-er(%6le (&o)k: p!t%e"t de-eloped (&o)k 6ut6od' %( u"!6le to m!%"t!%" per$u(%o" to or#!"(9
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& i ( i Eti ) i
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&e'is syo (ea'isme Etio)o*i
Hi+o,o)emi
Pe"#ur!"#!" -olumed!r!& '!"#d%(e6!6k!" ole&
ke&%l!"#!" d!r!&3pl!(m!3 !t!u )!%r!"tu6u& '!"#!kut76!"'!k (ek!l% :=9Perd!r!&!"
29De&%dr!(% :• GIT• Pe"#u!p!"
=9 Perd!r!&!"ekter"!l7%"ter"!l
29 Mu"t!&3 d%!re
>9 Luk! 6!k!r?9 P!"kre!t%t%( 3 luk!
6!k!r
Kardio*e'i
Ke#!#!l!" pomp!
!"tu"# !k%6!tpe"uru"!"ko"tr!kt%l%t!( !"tu"#
=9 I"$!rk m%ok!rd
29 P!'!& !"tu"#
/%l!"#"'! to"u(
pem6ulu& d!r!& '!"#"orm!l (e&%" !
=9 ep(%(
29 A"!$%l!kt%$>9 Neuro e"%k
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Dera0at Syo
• Syo Ri'*a' "e'.r.'a' +er/.si ha'ya +ada 0ari'*a' da' or*a'
'o' ,ita) se+erti .)it1 )ema1 otot ra'*a1 da'
t.)a'*9 @!r%"#!" %"% rel!t%$ d!p!t &%dup le6%& l!m! de"#!"
per$u(% re"d!&3 t!"p! !d!"'! peru6!&!" !r%"#!"
'!"# me"et!p 4%rre-er(%6le59
Ke(!d!r!" t%d!k ter#!"##u3 produk(% ur%" "orm!l !t!u&!"'! (ed%k%t me"uru"3 !(%do(%( met!6ol%k t%d!k !d!
!t!u r%"#!"9
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• Syo Seda'* "er/.si e or*a' ,ita) se)ai' 0a't.'* da' ota
me'.r.' 2hati1 .s.s1 *i'0a)34
Or#!"8or#!" %"% t%d!k d!p!t me"toler!"(% &%poper$u(%le6%& l!m! (epert% p!d! lem!k3 kul%t d!" otot9
P!d! ke!d!!" %"% terd!p!t ol%#ur% 4ur%" kur!"# d!r% 3
m#7k#7!m5 d!" !(%do(%( met!6ol%k9 Ak!" tet!p%
ke(!d!r!" rel!t%$ m!(%& 6!%k9
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Syo Berat "er/.si e 0a't.'* da' ota tida ade.at9
Mek!"%(me kompe"(!(% ('ok 6er!k(% u"tuk
me"'ed%!k!" !l%r!" d!r!& ke du! or#!" -%t!l9 P!d! ('ok l!"ut ter!d% -!(oko"tr%k(% d% (emu!
pem6ulu& d!r!& l!%"9
Ter!d% ol%#ur% d!" !(%do(%( 6er!t3 #!"##u!"
ke(!d!r!" d!" t!"d!8t!"d! &%pok(%! !"tu"# 4EKG!6"orm!l3 )ur!& !"tu"# me"uru"59
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• De$%"%(% :
ter#!"##u"'! (%(tem (%rkul!(% !k%6!t d!r%
-olume d!r!& dlm pem6ulu& d!r!& '# 6er485
'ok /%po-olem%k
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Syo hi+o,o)emi
Perd!r!&!" /em!tom (u6k!p(ul!r &ep!r A"eur%(m! !ort! pe)!&Perd!r!&!" GITPerluk!!" 6er#!"d!
Ke&%l!"#!" pl!(m! Lu!k 6!k!r lu!(
P!"kre!t%t%(De(ku!m!(% kul%t%"drom Dump%"#
Ke&%l!"#!" )!%r!"
ek(tr!(eluler
Mu"t!&
De&%dr!(%D%!reTer!p% d%uret%k '!"# (!"#!t!#re(%$ D%!6ete( %"(%p%du(
I"((u$%e"(% !dre"!l
Et%olo#%
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P!to$%(%olo#%
• M%kro(%rkul!(% : MAP mm/# $( or#!" ter#!"##u
• Neuroe"dokr%" : 6!rore(eptor ; kemore(eptor
• K0 : pe"#%(%!" -e"tr%kel -olume (eku")up
4kompe"(!(% :
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Ge!l! Kl%"%(
• < ker! (%mp!t%(
• /%per-e"t%l!(%
• Pem6ulu& -e"! kol!p(• Pelep!(!" &ormo" (tre(
• Ek(p!"(% 6e(!r u"tuk pe"#%(%!" -olume
PD d#" )!%r!" %"ter(%(%!l3 %"tr!(elul!r • produk(% ur%"
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Ge!l! Kl%"%(
Ri'*a' 25678 ,o) darah3 Seda'*267-978 ,o) darah3 Berat 2:978 ,o) darah3
Ek(trem%t!( d%"#%" !m!3 d%t!m6!&: !m!3 d%t!m6!&:
W!ktu pe"#%(%!"k!p%ler me"%"#k!t
T!k%k!rd%! /emod%"!m%k t!k(t!6%l
D%!pore(%( T!k%p"e! T!k%k!rd%! 6er#e!l!
0e"! kol!p( Ol%#our%! /%pote"(%
Cem!( /%pote"(% orto(t!t%k Peru6!&!"ke(!d!r!"
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Kl!(%$%k!(%
&ttp:77,,,9(tud'6lue9)om7"ote(7"ote7"7(u=88(&o)k7de)k7>>HH=
http://www.studyblue.com/notes/note/n/su1-05-shock/deck/3390917http://www.studyblue.com/notes/note/n/su1-05-shock/deck/3390917
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D%!#"o(%(
• Ket%d!k(t!6%l!" &emod%"!m%k 7 !d!"'!
(um6er perd!r!&!"
• /t d% !,!l 6uk!" pe#!"#!"
• /%l!"#"'! pl!(m!3 t!"d! :
&emoko"(e"tr!(%
• /%l!"#"'! )!%r!" 6e6!( 3 t!"d! :&%per"!trem%!
P %k P k
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Pemer%k(!!" Pe"u"!"# 'ok
/%po-olem%k
A"!l%(! #!( d!r!& !rter%7 p!"elPe"uru"!" de$%(%t 6!(!
Pe"%"#k!t!" "%l!% l!kt!t
Mere$lek(%k!" !(%do(%( l!kt!t !k%6!t &%poper$u(%
Pemer%k(!!" l!6or!tor%um
o"o#r!$% !6dom%"!l ter$oku( u"tuk tr!um! 4AT3o)u(ed A6dom%"!l o"o#r!p&' $or Tr!um!5
L!-!(e per%to"e!l d%!#"o(t%k
CT ()!"
oto polo(
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T!"d! Per6!%k!" Ko"d%(% 'ok
• Pe"%"#k!t!" tek!"!" d!r!&
• Me"%"#k!tk!" t%"#k!t ke(!d!r!"
• Me"%"#k!tk!" per$u(% per%$er • Pe"uru"!" t!)&')!rd%!
• Pe"uru"!" l!kt!t
• p/ !(!m76!(! "orm!l
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DD
• 'ok k!rd%o#e"%k
!m!2 : CO ; kompe"(!(% (%mp!t%(
Bed! : d%(te"(% -9u#ul!r%(3 ro"k% ; #!llop>
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T!t!l!k(!"!
• Me"emp!tk!" p!(%e" d#" po(%(% k!k% le6%& t%"##%
• Me"!#! !lur per"!p!(!"
• Ber%k!" re(u(%t!(% )!%r!" %"tr! -e"!7 CVP 7
%"tr!rter%!l
C!%r!" : 28? L dlm 28> m"t
#!r!m %(oto"u( '# d%tete( )ep!t 4&!t%2 pd
!(%do(%( &%perklorem%!5 !t!u d#" RLme"##u"!k!" !rum %"$u( '# ter6e(!r 4kolo%d
6lm ter6ukt%5
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• K!teter Swan-Ganz
Pemer%k(!!" 6!% p!ru
Tuu!" : me"#et!&u% !p!k!& )!%r!" (ud!&)ukup meme"u&% ke6utu&!" u"tuk
me"%"#k!tk!" tek!"!" pe"#%(%!" -e"tr%kel
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• Tr!"($u(% d!r!&
1 /emod%"!m%k 6elum (t!6%l (etel!& pem6er%!"
)!%r!"
1 K!d!r /6 = #7dl
1 L!kuk!" cross-match (e6elum d%#u"!k!"
1 !"#!t d!rur!t : PRC t%pe d!r!& '# (e(u!% 7
O"e#!t%$
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• /%po-olem%! 6er!t ; 6erkep!"!"#!" : 1 Dop!m%" 7
1 0!(opre((%" 7
1 Do6ut!m%"9 1 NE %"$u( tdk 6erm!"$!!t
1 < MAP : N!lok(o" 6olu( >m)#7k& >8m"t
m)#7k# =!m d!l!m dek(tro( J
•ntuk kekuatan ventrikel•!ebutuhan vol"darah dicukupi
dahulu
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• Me"!#! (!lur!" per"!p!(!"
1 Ke6utu&!" O2 terpe"u&%
1 B%l! d%perluk!" l!kuk!" %"tu6!(%
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E!rl' Go!l D%re)ted Tre!tme"t
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Ter!p% /%po-olem%k pd A"!k
• lu%d 6olu( o$ 2 mL7k# o$ "orm!l (!l%"e or l!)t!ted R%"#er (olut%o"
(&ould 6e #%-e" r!p%dl'9
• I$ %t %( "ot po((%6le to %"(ert !" %"tr!-e"ou( )!t&eter %"to ! per%p&er!l
-e%" ,%t&%" H (e) or ,%t&%" t&ree !ttempt( %"tr!o((eou( "eedle
• C&%ldre" %" (e-ere &'po-olem%) 6olu(e( tot!l%"# 8 mL7k# ,%t&%"
t&e $%r(t =82 &r o$ pre(e"t!t%o"9• re(& $roe" pl!(m!3 !l6um%"3 ,&ole 6lood3 or p!)ked red 6lood
)ell(
• T&e u(e o$ de+tr!"( 4&'dro+'et&'l (t!r)&5 or #el!t%"( m!' 6e
%"d%)!ted %$ t&ere %( ! "eed to %")re!(e pl!(m! o")ot%) pre((ure 6ut
6lood )ompo"e"t t&er!p' )!""ot 6e !dm%"%(tered or %( %"e$$e)t%-e
485 : o(mot%) re"!l %"ur' !"d pred%(po(e( t&e p!t%e"t to !)ute re"!l
$!%lure
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• t%ll poor per$u(%o" !"d (&o)k -!(o!)t%-e !#e"t(
• O+'#e" del%-er' "eed "ot e+)eed 4(upr!"orm!l5 "orm!l
e+pe)t!t%o"( 4(uppl'8depe"de")'5
GOAL : re(tore o+'#e" del%-er' to -%t!l t%((ue(9
Impro-%"# o+'#e"8)!rr'%"# )!p!)%t' 4m!%"t!%" "orm!l
&em!to)r%t !t >8?J5
Impro-%"# o+'#e" (!tur!t%o" 4H8HHJ5 !"d P!o2 4%$
(e-erel' !"em%)5
E"&!")%"# ! depre((ed )!rd%!) output9 ,%t& d%re)t
t&er!p' 4!"t%)o"-ul(!"t(3 !"t%p'ret%) !#e"t(5
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Kompl%k!(%
• Keru(!k!" or#!" !k&%r !r!"# ter!d%d%6!"d%"#k!" ('ok (ept%k 7 tr!um!t%k
• B%(! ter!d% keru(!k!" or#!" d%
1 P 1 /!t%
1 G%"!l :
• Nekro(%( tu6ul!r !kut 4%"ter!k(% !"t!r ('ok3 (ep(%(3 o6t
"e$rotok(%k : !m%"o#l%ko(%d! ; med%! ko"tr!( !"#%o#r!$%5
• GGA : (#t !r!"# kr" )ep!t"'! pem6er%!" )!%r!"
pe"##!"t%
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Pro#"o(%(
• /!(%l ter#!"tu"# p!d! et%olo#% d!" pemul%&!" '!"# )ep!t
de"#!" per$u(% '!"# mem!d!%9
• D%l!kuk!" mo"%tor '!"# teru(8me"eru( ter&!d!p
ke)ukup!" re(u(%t!(% 4m%(!l"'! (t!6%l%(!(% TD3 per6!%k!"
t!k%k!rd%3 per$u(% '!"# 6!%k p!d! (!!t pemer%k(!!"3re(olu(% !(%do(%(3 produk(% ur%"e '!"# mem!d!%5
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Syok Septik
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Definisi
#Keadaan di mana terjadi penurunan tekanan darah
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Definition
#septic shock is a decrease in peripheral vascularresistance that occurs despite increased levels ofvasopressor catecholamines
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Etiology
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Epidemiology
#>200.000 death in US/year
#Sepsis-related incidence and mortality rates increase
with age and preexisting comorbidity
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Syok dan Mekanisme Hemodinamik
#Syok à gangguan hemodinamik à perfusi jaringantidak adekuat dan mengganggu metabolisme sel &
jaringan
#8 faktor hemodinamik yang berperan dalamterjadinya syok
# Volume intravaskular
# Jantung
# Resistensi vaskular
# Mikrosirkulasi & kapiler
# Resistensi venula
# Hubungan arteri vena tanpa memalui kapiler
# Volume sirkulasi sistemik
# Pembuluh darah
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Faktor hemodinamik yg berperan dalam terjadinya syok1.Volume intravaskular
-Mempertahankan tekanan & aliran balik vena ke jantung
2.Jantung
-Mempengaruhi sirkulasi hemodinamik (curah jantung,
frekuensi, irama, kontraktilitas, keseimbangan preload, afterload)3.Resistensi vaskular (Perbedaan tonus arteriol pada organàmaldistribusi volume darah à ketidakseimbangan suplai &oksigen)
4.Mikrosirkulasi & kapiler (transportasi cairan dan nutrisi)
-Gangguan sirkulasi mikrovaskular à gangguanmetabolisme sel
-Peningkatan permeabilitas kapiler à edema interstisial
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5.Resistensi Venula
- Peningkatan resistensi venula & tekanan hidrostatik àkeluarnya cairan intravaskular ke interstisial
6.Hubungan arteri vena tanpa kapiler àhipoksia & gangguantransport nutrisi
7.Penurunan tonus vena & peningkatan kapasitas vena àmempengaruhi volume sirkulasi sistemik
8.Patensi pembuluh darah-Obstruksi pembuluh darah à penurunan aliran balik vena
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&ttp:77,,,9"em9or#7do%7$ull7=9=7NE@Mr!=22>
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Neuro#e"%) &o)k
Ter!d% !k%6!t #!"##u!" p!d! !r!( (%mp!t%(
de(e"de" d% (er-%k!l !t!u tor!k!l !t!(
&%l!"#"'!to"u( -!(omotor d!" %"e-!r(% (%mp!t%( ke !"tu"#9
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Neuro#e"%) &o)k
#Causes$
%"Spinal cord in&ury
'"(egional anesthesia
)"Drugs
*"+eurological disorders
S ok
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SyokNeurogenik
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(a'i/estasi K)i'is
• /!mp%r (!m! de"#!" ('ok p!d! umum"'! tet!p%
p!d! ('ok "euro#e"%k terd!p!t t!"d! TD turu"3 /R
t%d!k 6ert!m6!& )ep!t3 6!&k!" d!p!t le6%& l!m6!t
46r!d%k!rd%5 k!d!"# d%(ert!% de"#!" !d!"'! de$%(%t
"eurolo#%( 6erup! *u!dr%ple#%! !t!u p!r!ple#%!9
• P!d! ke!d!!" l!"ut3 (e(ud!& p!(%e" me"!d%
t%d!k (!d!r "!d% 6ert!m6!& )ep!t
• Pe"#umpul!" d!r!& d% d!l!m !rter%ol3 k!p%ler d!"-e"! kul%t ter!(! !#!k &!"#!t d!" )ep!t
6er,!r"! kemer!&!"9
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Dia*'osis Ba'di'*
• (%"kop -!(o-!#!l
1Kedu!"'! (!m!8(!m! me"'e6!6k!" &%pote"(%
k!re"! ke#!#!l!" pu(!t pe"#!tur!" -!(omotor
tet!p% p!d! (%"kop -!(o-!#!l &!l %"% t%d!k(!mp!% me"'e6!6k!" %(kem%! !r%"#!"
me"'eluru& d!" me"%m6ulk!" #e!l! ('ok9
• ('ok (ept%k
• ('ok !"!$%l!k(%(
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"e'ata)asa'aa'
B!r%"#k!" p!(%e" de"#!" po(%(% kep!l!
le6%& re"d!& d!r% k!k% 4po(%(%
Tre"dele"6ur#59
Pert!&!"k!" !l!" "!$!( de"#!"mem6er%k!" ok(%#e"3 (e6!%k"'! de"#!"
me"##u"!k!" m!(ker9
P!d! p!(%e" de"#!" d%(tre(( re(p%r!(% d!"&%pote"(% '!"# 6er!t3 endotrachea! tube
d!" -e"t%l!tor mek!"%k
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Re(u(%t!(% )!%r!"
C!%r!" kr%(t!lo%d (epert% N!Cl 3HJ !t!u
R%"#er L!kt!t d%6er%k!" per %"$u( (e)!r!
)ep!t 28 )) 6olu( de"#!"
pe"#!,!(!" '!"# )erm!t ter&!d!p
tek!"!" d!r!&3 !kr!l3 tur#or kul%t3 d!" ur%"
output u"tuk me"%l!% re(po" ter&!d!pter!p%9
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B%l! tek!"!" d!r!& d!" per$u(% per%$er t%d!k (e#er! pul%&3
6er%k!" o6!t8o6!t -!(o!kt%$
Dop!m%"
Merup!k!" o6!t p%l%&!" pert!m!9 P!d! do(%( =
m)#7k#7me"%t3 6ere$ek (erup! de"#!" "orep%"e$r%"9 @!r!"#ter!d% t!k%k!rd%9
Norep%"e$r%"
E$ekt%$ %k! dop!m%" t%d!k !deku!t d!l!m me"!%kk!"
tek!"!" d!r!&9 Mo"%tor ter!d%"'! &%po-olem% !t!u )!rd%!) output '!"#
re"d!& %k! "orep%"e$r%" #!#!l d!l!m me"!%kk!" tek!"!"
d!r!& (e)!r! !deku!t9
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D%6er%k!" per %"$u(9
A,!(% pem6er%!" o6!t %"% p!d! ,!"%t! &!m%l3
k!re"! d!p!t me"%m6ulk!" ko"tr!k(% otot8otot
uteru(9
Ep%"e$r%"
Do6ut!m%"
Ber#u"! %k! tek!"!" d!r!& re"d!& '!"#
d%!k%6!tk!" ole& me"uru""'! )!rd%!) output9Do6ut!m%" d!p!t me"uru"k!" tek!"!" d!r!&
mel!lu% -!(od%l!t!(% per%$er
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Kompl%k!(%
• ARD
• G%"!l : ol%#our%!3 !otem%!3 prote%"ur%!3
• G!"##u!" ko!#ul!(% : trom6o(%tope"%!33
keru(!k!" e"dotel3 m%kro-!(kul!r
trom6o(%(
• Kelem!&!" motor%k 6!#%!" d%(t!l
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• Be"tuk d!r% ('ok k!rd%o#e"%k '!"# ter!d%
!k%6!t ke(uk!r!" mek!"%k pd (%rkul!(%3 '#
me"'e6!6k!" me"uru""'! CO3 6uk!"
ke#!#!l!" !"tu"# pr%mer
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Te"(%o" P"eumot&or!+
• redu)ed $%ll%"# o$ t&e r%#&t (%de o$ t&e &e!rt
$rom e%t&er %")re!(ed %"tr!pleur!l pre((ure
(e)o"d!r' to !%r !))umul!t%o"
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M!"%$e(t!t%o"(
• re(p%r!tor' d%(tre(( 4%" !" !,!ke p!t%e"t53
• &'pote"(%o"
• de)re!(d 6re!t& (ou"d(
• &'pert'mp!"' to per)u((%o"
• u#ul!r -e"ou( d%(te"t%o"
• (&%$t o$ med%!(t%"!l (tru)ture( to t&eu"!$$e)ted (%de ,%t& tr!)&e!l de-%!t%o"
-
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Tre!tme"t
• Pleur!l de)ompre((%o"
• C&e(t tu6e
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C!rd%!) T!mpo"!de
• %")re!(ed %"tr!per%)!rd%!l pre((ure
pre)lud%"# !tr%!l $%ll%"# (e)o"d!r' to 6lood
!))umul!t%o"
• !))umul!t%o" o$ 6lood ,%t&%" t&eper%)!rd%!l (!) 4Q2mL5
• u(u!ll' $rom pe"etr!t%"# tr!um! or )&ro"%)
med%)!l )o"d%t%o"( 4&e!rt $!%lure orurem%!5
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Tre!tme"t
• D+ : E)&o)!rd%o#r!p&' dete)t%"#
per%)!rd%!l $lu%d
• Per%)!rd%o)e"te(%( u"der ultr!(ou"d
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Cardiogenic ShockCardiogenic shock results ,rom lo- cardiacoutput due to myocardial pump ,ailure due to intrinsic myocardial damage.in,arction/0 ventricular arrhythmias0
e1trinsic compression .cardiactamponade/0 or out2o- obstruction .e"g"0pulmonary embolism/"
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Cardiogenic Shock3Cardiogenic shock is characteri4ed by
systemic hypoper,usion due to $
3Severe depression o, the cardiac inde156'"' .78min/8m'9 and sustained systolic
arterial hypotension .6:; mmHg/
3despite =/ ? %@
mmHg9
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Cardiogenic Shock3 Circulatory ,ailure cardiac dys,unc"
primary myocardial ,ailure mostcommon $ secondary to AM less,reBuent $ cardiomyopathy or myocarditis
or cardiac tamponade"
3 Shock is typically associated -ith ST
elevation M .STEM/ and is less common-ith nonST elevation M"
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Cardiogenic Shock
37V ,ailure accounts ,or @; o, thecases o, CS complicating acute M"
3(emainder $ Acute severe mitralregurgitation0 ventricular septalrupture0 predominant right
ventricular ,ailure0 and ,ree -allrupture or tamponade"
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F(elease o,in2ammatory cytokinesa,ter myocardialin,arction may lead toinducible nitrous o1ide
e1pression0 e1cess +0and inappropriatevasodilation"
A vicious spiral o,progressive myocardialdys,unction occurs that
ultimately results indeath i, it is notinterrupted"
C di i Sh k
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Cardiogenic Shock3 A systemic in2ammatory response
syndrome may accompany largein,arctions and shock in2ammatorycytokines0 inducible nitric o1ide synthase0
and e1cess nitric o1ide and pero1ynitritemay contribute to the genesis o, CS asthey do to other ,orms o, shock"
C di i Sh k
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Cardiogenic Shock
3Severe acidosis .pH 6 "'I/ reducesthe eJcacy o, endogenous ande1ogenously administered
catecholamines"3(e,ractory sustained ventricular or
atrial tachyarrhythmias can cause or
e1acerbate cardiogenic shock"
C di i Sh k
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Cardiogenic Shock
3'
8) patients -ith CS have 2o-limiting stenoses in ) ma&orcoronary arteries0 K '; $ le,t main
coronary artery stenosis"
C di i Sh k
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Cardiogenic Shock3 Shock is present on admission in only %8*
patients -ho develop CS complicating ML%8* develop it rapidly therea,ter0 -ithin h
o, M onset"
3 Another Buarter develop shock later on the
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Cli i l Ni di
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Clinical Nindings3 Most $ continuing chest pain and dyspnea0
appear pale0 apprehensive0 anddiaphoretic"
3 Mentation may be altered0 -ith
somnolence0 con,usion0 and agitation"3 The pulse is typically -eak and rapid0 o,ten
in the range o, :;O%%; beats8min0 or
severe bradycardia due to highgradeheart block may be present"
Cli i l Ni di
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Clinical Nindings3 Systolic blood pressure is reduced .6:;
mmHg/ -ith a narro- pulse pressure .6);mmHg/"
3 Tachypnea0 CheyneStokes respirations0
and &ugular venous distention may bepresent"
3 S% is usually so,t0 S) gallop may be
audible"
7 b t Ni di
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7aboratory Nindings3 =rior to support -ith supplemental '0
arterial blood gases $ hypo1emia andmetabolic acidosis0 compensated byrespiratory alkalosis"
3 Cardiac markers0 creatine phosphokinaseand its MP ,raction0 are markedly elevated0
as are troponins and T"
i Ni di
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maging Nindings3 Chest (oentgenogram $
3CQ( $ pulmonary vascular congestionand o,ten pulmonary edema0 may beabsent in up to a third o, patients"
3 The heart si4e is usually normal -hen CSresults ,rom a
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maging Nindings3
Echocardiogram $3Doppler $ a le,ttoright shunt inpatients -ith VS( and the severity
o, M( -hen the latter is present"
Cardiogenic Shock
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Cardiogenic Shock
3DiRerential Diagnoses $3Shock Secondary to (V n,arction
3Mitral (egurgitation
3Ventricular Septal (upture
3Nree >all (upture
3Acute Nulminant Myocarditis
0
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0!(opre((or(
"oreinehrine
/irst )i'e %( ! pote"t -!(o)o"(tr%)tor !"d %"otrop%)
(t%mul!"t t&!t %( u(e$ul $or p!t%e"t( ,%t& C
• e,er !d-er(e e-e"t(3 %")lud%"# !rr&'t&m%!(3
)omp!red to ! dop!m%"e r!"dom%ed tr%!l o$ p!t%e"t(
• t!rted !t ! do(e o$ 2 to ? #7m%" !"d t%tr!ted up,!rd
!( "e)e((!r'9
• I$ ('(tem%) per$u(%o" or ('(tol%) pre((ure )!""ot 6em!%"t!%"ed !t H mm/# ,%t& ! do(e o$ = #7m%"
#oamine : %"$u(%o" r!te o$ 21 #7k# per m%"3
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# # p 3
!"d t&e do(e %( %")re!(ed e-er' 21 m%" to
! m!+%mum o$ 21 #7k# per m%"
• lo, do(e( 4 2 #7k# per m%"5:d%l!te( t&e re"!l
-!()ul!r 6ed3 "ot 6ee" demo"(tr!ted
)o")lu(%-el'
• moder!te do(e( 421= #7k# per m%"5 :
po(%t%-e )&ro"otrop%) !"d %"otrop%) e$$e)t(
!( ! )o"(e*ue")e o$ 8!dre"er#%) re)eptor
(t%mul!t%o"9
• &%#&er do(e(: -!(o)o"(tr%)tor
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• #obutamine %( ! ('"t&et%)('mp!t&om%met%) !m%"e
1 lo, do(e( 429 #7k# per m%"5 :po(%t%-e
%"otrop%) !)t%o" !"d m%"%m!l po(%t%-e)&ro"otrop%) !)t%-%t'
1 &%#&er do(e(: moder!te )&ro"otrop%) !)t%-%t'
1 = #7k# per m%" : -!(od%l!t%"# !)t%-%t'pre)lude( %t( u(e ,&e" ! -!(o)o"(tr%)tor
e$$e)t %( re*u%red
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ANA"H
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Syo A'a/i)asis
A"!$%l!k(%( (u!tu (%"drom kl%"%k '!"# ter!d% !k%6!t re!k(%!ler#%k 4re!k(% %mu"olo#%(5 6er(%$!t (%(tem%k '!"# )ep!tme"#e"!% 6e6er!p! or#!"3 mel%put% :Re(p%r!(%%rkul!(%Per")er"!!"Kul%t3 dll%"drom ter(e6ut me"'e6!6k!" ('ok ('ok !"!$%l!k(%(
S d%t!"#!"% de"#!" )ep!t d!" tep!t KEMATIAN
Syo a'a/i)asis !d!l!& #!"##u!" per$u(% !r%"#!" !k%6!t!d!"'! re!k(% !"t%#e" !"t%6od% '!"# me"#elu!rk!" &%(t!m%"ede"#!" !k%6!t pe"%"#k!t!" perme!6%l%t!( mem6r!" k!p%ler d!"ter!d% d%l!t!(% !rter%ol! (e&%"##! -e"ou( retur" me"uru"
Re!k(% A"!$%l!kto%d No"8
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Re!k(% A"!$%l!kto%d No"8
Imu"olo#%k
• Re!k(% !"!$%l!k(%( S re!k(% %mu"olo#%k
• Mek!"%(me 6elum el!(
• Ge!l! . re!k(% %mu"olo#%( tet!p% le6%&r%"#!"
• Le6%& 6!"'!k d%temuk!" d%6!"d%"# de"#!"
re!k(% %mu"olo#%(
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I"(%de"( 'ok A"!$%l!k(%(
• !"#!t !r!"#
• D% Amer%k! :
1 ? 1 J #%#%t!" (er!"##! 1 2 1 ? J ko"tr!( r!d%o#r!$%
1 = 1 2 J pe"%(%l%" HJ $!t!l
Et%olo#% 'ok A"!$%l!k(%(
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Et%olo#% 'ok A"!$%l!k(%(
• G%#%t!" (er!"##!3
l!te+3 m!k!"!"3 dll
• A"t%6%ot%k : pe"%(%l%"
d!" (e$!lo(por%"• Ko"tr!( r!d%o#r!$%
• A"e(tet%k lok!l
• NAID
• Op%!te
• A(p%r%"
• Tu6o)ur!r%"
• M!""%tol
• De+tr!"
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M!"%$e(t!(% Kl%"%( 'ok
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'
A"!$%l!k(%(• Re!k(% Lok!l : B%!(!"'! &!"'! urt%k!r%! d!" edem!(etemp!t 3 t%d!k $!t!l• Re!k(% (%(tem%k : B%!(!"'! me"#e"!% (!lur!" "!p!(
6!# !t!( 3 (%(tem k!rd%o-!(kul!r3 GIT3 d!" kul%t3re!k(% ter(e6ut t%m6ul (e#er! !t!u > me"%t (etel!&
terp!p!r !"t%#e"!9R%"#!" : m!t! 6e"#k!k 3 &%du"# ter(um6!t 3 #!t!l8
#!t!l 3 6er(%"3 t%m6ul 2 !m (etel!& terp!p!r
69ed!"# : Bro"ko(p!(me3 edem! l!r%"# 3 mu!l 3mu"t!&
)9Ber!t : Bro"ko(p!(me3 edem! l!r%"# 3 (tr%dor 3 (e(!k"!p!( 3mu"t!&2 3 (%!"o(%( 3 &e"t% !"tu"# 3 d%($!#%! 3"'er% perut 3 ke!"# 3 &%pote"(% 3 !r%tm%! !"tu"# 3kom!
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A"!p&'l!)t%) (&o)k
-
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A"!p&'l!)t%) (&o)k
• A"!p&'l!)t%) A l%$e t&re!te"%"# ('"drome 4I#Emed%!ted5 )&!r!)ter%ed 6' mult%or#!"
%"-ol-eme"t !"d r!p%d o"(et
• A"!p&'l!)to%d re!)t%o"
A ('"drome )l%"%)!ll'(%m%l!r to !"!p&'l!+%( t&!t %( "ot med%!ted 6'
I#E
Et%olo#%
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#
R%(k !)tor(
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R%(k !)tor(
• E)o"om%) (t!tu( %" people o$ &%#&ere)o"om%) (t!tu(
• A#e ;(e+ ,ome" > 'e!r(
• e!(o" ummer ; e!rl' $!ll
P!t&op&'(%olo#'
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P!t&op&'(%olo#'
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Cl%"%)!l m!"%$e(t!t%o"(
-
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Cl%"%)!l m!"%$e(t!t%o"(
• O"e )!rd%"!l $e!ture o$ !" !"!p&'l!)t%) re!)t%o" r!p%d
o"(et
1 8> m%"ute( !$ter p!re"ter!l e+po(ure
1 2 &our( !$ter %"#e(t%o"
1 'mptom( )!" re(ol-e ; re)ur &our( l!ter 6%p&!(%)
!"!p&'l!+%(
• %r(t )l%"%)!l m!"%$e(t!t%o" prur%tu(3 urt%)!r%!3
!"#%oedem!3 $lu(&%"#
• ollo,ed 6' m%ld to (e-ere re(p%r!tor' d%(tre((
1 )ou#& )&e(t t%#&t"e((3 d'(p"e!3 ,&eee 46ro")&o(p!(m5
1 /o!r(e"e((3 T&ro!t t%#&t"e((3 od'"op&!#%! 4l!r'"#e!l
edem!7orop&!r'"#e!l !"#%oedem!5
• !t!l )!rd%o-!()ul!r )oll!p(e or re(p%r!tor' $!%lure
Cl%"%)!l m!"%$e(t!t%o"(
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Cl%"%)!l m!"%$e(t!t%o"(
-
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D%!#"o(%(
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D%!#"o(%(
• A"!p&'l!+%( %( &%#& l%kel' ,&e" !"' o'e o/ the/o))o=i'* three criteria /.)/i))ed :
>4 Ac.te o'set o/ a' i))'ess 4m%"ute( to (e-er!l
&our(5 ,%t& i',o),eme't o/ the si'1 m.cosa)
tiss.e1 or oth 4prur%tu(3 $lu(&%"#3 (,olle" l%p(8to"#ue8u-ul!3 #e"er!l%ed &%-e(5
AND AT LEAST ONE O T/E OLLOWING :
a3 Res+iratory com+romise 4d'(p"e!3 6ro)&o(p!(m3
(tr%dor3 redu)ed PE3 /'po+em%!53 Red.ced B" or associated sym+toms o/ e'd-
or*a' dys/.'ctio' 4)oll!p(e3 ('")ope3 %")o"t%"e")e5
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64 T=o or more o$ t&e $ollo,%"# occ.ri'* ra+id)y2mi'.tes to se,era) ho.rs3 a/ter e?+os.re to !
l%kel' !ller#e" $or t&!t p!t%e"t:
!5 I"-ol-eme"t o$ t&e (k%"8mu)o(!l t%((ue 4%t)&8$lu(&3
(,olle" l%p(8to"#ue8u-ul!3 #e"er!l%ed &%-e(565 Re(p%r!tor' )omprom%(e
)5 Redu)ed BP or !((o)%!ted ('mptom(
d5 Per(%(te"t GI ('mptom( 4)r!mp' !6dom%"!l p!%"3
-om%t%"#5
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@4 Red.ced B" a/ter e?+os.re to k"o," !ller#e" $ort&!t p!t%e"t 4m%"ute( to (e-er!l &our(5:
!5 I"$!"t( ; )&%ldre" : lo, ('(tol%) BP 4!#e (pe)%$%)5 or
%" ('(tol%) BP >J
65 Adult( : ('(tol%) BP H mm/# or >J $rom t&!tper(o"( 6!(el%"e
DD
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DD
• C!r)%"o%d ('"drome• 0!(o-!#!l re!)t%o"
• Ep%#lot%t%(
• upr!#lot%t%(• &o)k 4)!rd%o#e"%)3 &emorr&!#%)7&'po-olem%)3
(ept%)3 o6(tru)t%o"5
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-
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-
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Pre-e"t%o"
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Pre-e"t%o"=9 Get t&orou#& dru# !ller#' !"d !top%) &%(tor'
29 C&e)k !ll dru#( $or proper l!6ell%"#
>9 G%-e dru# or!ll' r!t&er t&!" p!re"ter!ll' ,&e" po((%6le
?9 G%-e dru# %" d%(t!l e+trem%t' %$ po((%6le ,&e" p!re"ter!l route
"e)e((!r'
9 Al,!'( &!-e re(u()%t!t%o" e*u%pme"t !-!%l!6le ,&e"!dm%"%(ter%"# !"t%#e"%) )ompou"d(
9 E"(ure t&!t p!t%e"t( ,!%t %" ED > m%"ute( !$ter dru#
!dm%"%(tr!t%o"
9 U(e u"rel!ted dru#( ,&e" $e!(%6le %" (u()ept%6le popul!t%o"
9 Pred%(po(ed p!t%e"t( (&ould )!rr' ,!r"%"# %de"t%$%)!t%o"
H9 Pred%(po(ed p!t%e"t( !re t!u#&t (el$8%"e)t%o" o$ ep%"ep&r%"e3 !"d