Shock

Noormanto
Departemen Ilmu Kesehatan Anak
FK-UGM/RS Dr Srdjito
Yogyakarta
Difinisi

 Gangguan sirkulasi  oksigenasi

jaringan
 Coma = gangguan kesadaran
 Shock  penurunan kesadaran 
coma
Pengertian

Tekanan darah
 Normal 120/80 mmHg
– 120 = tekanan sistolik
– 80 = tekanan diastolik (tahanan sistemik)
– 120 - 80 = tekanan nadi
 Pre-shock: 100/80 mmHg
 Shock: 80/0 mmHg atau tidak terukur
 Pengertian

120 120
pressure (mmHg)

pressure (mmHg)
100
80 80

0 2 4 8 0 2 4 8
Time (second) Time (second)
Normal Pre-shock
Pengertian

Determining a child’s circulatory status:

 blood pressure is a poor indicator of
cardiovascular homeostasis
  more valuable: the evaluation of
 heart rate
 end-organ perfusion (including capillary refill,
the quality of the peripheral pulses)
 urine output
 and acid-base status
Pengertian

 COP = S V x HR
 COP harus konstan  supaya hemodinamik
stabil
 COP  kompesasi HR bila tidak Shock
 SV menurun akibat dari:
– Volume darah menurun
– Kelainan jantung
– Kelainan pembuluh darah
 Patofisiologi
Shock

COP •Ventilasi
•HR
•TD
Perfusi jaringan Sekresi katekolamin

hipoksia

Metabolisme
anoksia Sekresi histamin, bradikinin
Anaerob

Relaksasi spingter vasodilatasi

Asidosis metabolik
prekapiler
Bendungan vena
DIC Trombus Darah ke jaringan
Edema
interstitiel
 Pathophysiology, Signs and Symptoms, and
Treatment of the Various Forms of Shock
Type of Shock Pathophysiology Signs and Symptoms Treatment
Hypovolemic CO, SVR intravascular± HR, pulses, delayed CR, hyperpnea, Repeat boluses of 20 mL/kg crystalloid as
interstitial volume dry skin, sunken eyes, oliguria indicated Blood products as indicated
loss BP normal until late for acute blood loss
Septic CO, SVR (classic adult, HR, BP, pulses, delayed CR, Repeat boluses of 20 mL/kg crystalloid; may
20% pediatric) hyperpnea, MS changes, third- need >60 mL/kg in first hour Consider
spacing, edema colloid if poor response to crystalloid
Pharmacologic support of BP with dopamine
or norepinephrine

CO, SVR (60% HR, normal to BP, pulses, delayed Repeat boluses of 20 mL/kg crystalloid; may
pediatric) CR, hyperpnea, MS changes, need >60 mL/kg in first hour Consider
third-spacing, edema colloid if poor response to crystalloid
Pharmacologic support of CO with dopamine
or epinephrine

CO, SVR (20% HR, BP, pulses, delayed CR, Repeat boluses of 20 mL/kg crystalloid; may
pediatric) hyperpnea, MS changes, third- need >60 mL/kg in first hour Consider
spacing, edema colloid if poor response to crystalloid
Pharmacologic support of CO and BP with
dopamine or epinephrine

CO=cardiac output, SVR=systemic vascular resistance, HR=heart rate,

BP=blood pressure, CR=capillary refill, MS=mental status,
JVD=jugular venous distension
 Pathophysiology, Signs and Symptoms, and
Treatment of the Various Forms of Shock

Type of Shock Pathophysiology Signs and Symptoms Treatment

Distributive Anaphylacxis: Angioedema, rapid third space of Repeat boluses of 20 mL/kg
CO, SVR fluids, BP, respiratory distress crystalloid as indicated
Pharmacologic support of SVR with
norepinephrine or phenylephrine
Spinal cord injury: BP with normal HR, paralysis Pharmacologic support of SVR with
normal CO, SVR with loss of vascular tone norepinephrine or phenylephrine
Fluid resuscitation as indicated by
clinical status and associated
injuries
Cardiogenic CO, normal to Normal to HR, pulses, delayed Pharmacologic support of CO with
SVR CR, oliguria, JVD, hepatomegaly dobutamine, milrinone, dopamine
BP normal until late in course Judicious fluid replacement as
indicated clinically

CO=cardiac output, SVR=systemic vascular resistance, HR=heart rate,

BP=blood pressure, CR=capillary refill, MS=mental status,
JVD=jugular venous distension
 Pembagian shock
1. Shock Kardiogenik
• Mekanik
• Gangguan ritme jantung
• Ketidak mampuan kontraksi otot
2. Shock Hipovolemik
• Perdarahan akut
• Kehilangan cairan
 Absolut : GEA dehidrasi berat, luka bakar
 Relatif : DHF, anoksia
3. Shock Distributif
• Neurogenik
• Anafilaktik
4. Shock Septik
Gejala klinis:

 Gangguan kesadaran
 Kulit pucat, teraba dingin dan lembab
 Tanda vital:
– Nadi cepat, isi kecil
– Pernafasan cepat,
– Tekanan darah menurun
 Oligouria sampai anuria (< 1 ml/kgBB/hr)
 Gangguan keseimbangan asam-basa
 Tanda-tanda dari penyakit primernya
Penatalaksanaan:
 Perawatan umum
 Bebaskan jalan nafas, oksigenasi 1-2 l/mt
 Cairan:
– Larutan kristaloid (Ringer laktat, Na Cl 0,9%)
– Plasma atau plasma ekspander (albumin,
dextran)
– Darah atau PRC
 Koreksi gangguan asam basa
 Glukosa sebagai sumber kalori
 Obat-obatan
 Vasoactive Medications
Agent (dose range) Site of Action Clinical Effect
Dopamine (3 to 20 mcg/kg Beta, increasing alpha Inotrope, vasoconstriction, chronotrope, increases
per min) with increasing dose PVR
Dobutamine (1 to 20 Beta2>beta1 Inotrope, vasodilation (beta2), decreases PVR
mcg/kg per min)
Epinephrine (0.01 to 1.0 Beta>alpha Inotrope, chronotrope, vasoconstriction
mcg/kg per min)
Norepinephrine (0.01 to 1.0 Alpha>beta Vasoconstriction, increases SVR, inotrope,
mcg/kg per min) chronotrope
Phenylephrine (0.1 to 0.5 Alpha Vasoconstriction, increases SVR
mcg/kg per min)
Amrinone (1 to 20 mcg/kg Type III Inotrope, chronotrope, vasodilator
per min) phosphodiesterase
inhibitor
Milrinone (0.25 to 1.0
mcg/kg per min)
Nitroprusside (0.5 to 10 Vasodilator, Decreases afterload
mcg/kg per min) arterial>venous
Vasopressin (0.0003 to V1 vascular receptor Vasoconstriction, vasodilation of circle of Willis,
0.008 U/kg per min) stimulation of cortisol secretion

PVR=pulmonary vascular resistance, SVR=systemic vascular resistance

Pemantauan:

 Keadaan umum, kesadaran

 Tanda-tanda vital
 EKG
 Keseimbangan cairan, elektrolit dan
asam basa
 Fungsi ginjal
 Kemungkinan DIC
Bagan penanganan shock:

Syok dengan disfungsi jantung

Oksigen Koreksi faktor non

Koreksi aritmia kardiogenik

Kongesti paru Tentukan gejala Hipoperfusi perifer

yang dominan

Perfusi perifer Perfusi perifer Obat inotropik

cukup inadekuat
Volume sirkulasi
Obat inotropik
Vasodilator Pertimbangkan
Diuretik vasodilator hipovolumik Hipervolumik Tidak tahu

Terapi cairan vasodilator

Bagan penanganan shock:
Syok Hipovolemik

•Lar. Kristaloid 20 ml/kgBB dalam 1-2 jam

Monitor:
•Tanda vital
•Balan ciran Tidak ada Perbaikan
•Asam basa perbaikan •Tensi baik
•Elektrolit •Perfusi baik
•Gula darah •Urin>0,7ml/kgBB/jam
•Hct Plasma/albumin 5%
20 ml/kgBB
•Cairan rumatan
Tidak
•Sering dipantau
•Cari sebab
Ulangi cairan 10-20 ml/kgBB

CVP >10 mmHg CVP CVP < 10 mmHg

•Cairan hati-hati perbaikan

•Cari sebab lain syok Cairan terus
•Obat kardiovaskular tidak
Bagan penanganan shock:

Syok anafilaktik
•Pasang torniquet
Proksimal tempat
Suntikan -->Inj.
Adrenalin 0,1-0,3
ml sc/im
Inj. Adrenalin/epinefrin
•Terlentang, kaki tinggi
0,1-0,3 ml sc /im
•Bebaskan jalan nafas
•Oksigen 1-2 l/menit
Ringan
•Difenhidramin 10-20 ml Berat
•Kortikosteroid dosis tinggi
•Aminofilin 3-4 mg/kgBB iv

•Cairan infus NaCl 0,9%

•Bila kejang--> diazepam
0,3-0,5 mg/kgBB
•Intubasi bila ada obstruksi