Shock

Presented by Izma Daud

FKIK Universitas Muhammadiyah Banjarmasin
Ali Haedar
Lecturer & Emergency Medicine Specialist
Department of Emergency Medicine
Faculty of Medicine – University of Brawijaya
Saiful Anwar General Hospital Malang
 Pokok Bahasan
• Definisi Syok
• Klasifikasi Syok
• Tahapan Syok
• Jenis Syok
• Patofisiologi Syok
• Asuhan Keperawatan Syok
 Introduction
• Life-threatening condition
• Result from a number of primary
causes
• Be aware of physiologic effects of shock
– Be able to detect
– Report the development or worsening of
this very serious condition

Core Skills Treat for Shock

 Definisi
Syok : Adalah kondisi mengancam jiwa yang diakibatkan
ketidakmampuan sistem sirkulasi menyuplai oksigen & nutrien
ke jaringan, ditandai dengan hipoksia dan ketidakadekuatan
fungsi sel yang menyebabkan kegagalan organ dan potensial
kematian ( Kleinpell dalam Garretson, 2007 )

Keadekuatan aliran darah ke jaringan membutuhkan TIGA

komponen :
•Pompa Jantung yang adekuat
•Sistem sirkulasi yang efektif
•Volume darah adekuat
 Shock Syndrome
• Shock is defined physiologically as
inadequate delivery of substrates and
oxygen to meet the metabolic needs of the
tissues
 Hypoperfusion? So What?
Inadequate
Inadequate
Cellular
Cellular
Oxygenation
Oxygenation

Inadequate
Inadequate Anaerobic
Anaerobic Lactic
LacticAcid
Acid
Energy
Energy Metabolism
Metabolism Production
Production
Production
Production

Metabolic
Metabolic Metabolic
Metabolic
Cell
CellDeath!
Death!
Failure
Failure Acidosis
Acidosis
 Compensatory Mechanisms
Sympathetic Nervous System (SNS)-
Adrenal Response
SNS - Neurohormonal response
Stimulated by baroreceptors
•Increased heart rate
•Increased contractility
•Vasoconstriction (SVR-Afterload)
•Increased Preload
 Renin-Angiotensin-Aldosterone

Plasma
Plasma Kidney
Kidney
volume
volume
Detected by (juxtaglomerular
(juxtaglomerular
&/Or apparatus)
apparatus)
[Na+]
[Na+] Releases
Via ACE
(Angiotensin
Converting Renin
Renin
Enzyme)
Converts

Angiotensin
AngiotensinII…
II…
Angiotensin I… Angiotensinogen
AngiotensinI…
 Renin-Angiotensin-Aldosterone

vasoconstriction
vasoconstriction PVR
PVR
Angiotensin
AngiotensinII…
II…
thirst
thirst

ADH
ADH
(anti-diuretic Fluid
Fluid
(anti-diuretic BP!
BP!
hormone) volume
volume
hormone)

Adrenal
Adrenal
Releases Na+
Na+
cortex Aldosterone
Aldosterone reabsorption
cortex reabsorption
KLASIFIKASI SYOK

SYOK
HIPOVOLEMIK

SYOK SYOK
OBSTRUKTIF SYOK DISTRIBUTIF KARDIOGENIK
•Syok Neurogenik
•Syok Anafilaktik
•Syok Septik
 Classification of Shock
• COMPENSATED
– blood flow is normal or increased and may be
maldistributed; vital organ function is maintained

• UNCOMPENSATED
– microvascular perfusion is compromised; significant
reductions in effective circulating volume

• IRREVERSIBLE
– inadequate perfusion of vital organs; irreparable
damage; death cannot be prevented
 Other Classification
• Hypovolemic Shock
• Non-hemorrhagic Shock
– Cardiogenic Shock
– Septic Shock
– Neurogenic Shock
– Anaphylactic Shock/Vasogenic Shock

Core Skills Treat for Shock 12

 TAHAP SYOK ( the stages of shock)
INITIAL COMPENSATORY PROGRESSIVE REFRACTORY
• Metabolisme • Saraf simpatis • Imbalans • Kerusakan
aerob menstimulasi : elektrolit ireversibel sel
anaero 1. Pelepasan • Asidosis dan organ
• kadar asam katekolamin metabolik • kematian
laktat 2. Kontraktilitas • Asidosis
• Perubahan tanda jantung respiratory
klinis belum • Edeme perifer
tampak • Respons • Takikardi
neurohormonal : ireguler
vasokontriksi & • Hipotensi
aliran darah • Pucat
prioritas ke • Kulit dingin
organ vital • Penurunan
tingkat
• Pelepasan kesadaran
aldosteron :
output urine
( <30 menit )
• frekuensi
 Hypovolemic Shock
• Most common cause is hemorrhage
• Volume of fluid reduced
• Can not maintain adequate circulation
• Caused by:
– Protracted vomiting and diarrhea
– Hemorrhage

Core Skills Treat for Shock 14

 1. SYOK HIPOVOLEMIK
• Akibat dari penurunan preload
• Etiologi :
-Hemoragik : trauma, perdarahan GI, ruptur
aneurisma
-Non-Hemoragik / kehilangan cairan : diare,
muntah, luka bakar
Clinical Signs of Acute Hemorrhagic Shock

% Blood loss Clinical Signs

< 15 Slightly increased heart rate, local
swelling, bleeding
15-25 Increased heart rate, increased diastolic
blood pressure, prolonged capillary refill

25-50 Above findings plus: hypotension,

confusion, acidosis, decreased urine output

> 50 Refractory hypotension, refractory

acidosis, death
Core Skills Treat for Shock 16
 Common Signs of Acute Shock
• Progressive fall in systolic and diastolic BP
• Cold, clammy and pale skin
• Cyanosis
• Rapid, weak, thready pulse
• Shallow, rapid breathing
• Oliguria
• Restlessness, stupor, and loss of consciousness
as condition deteriorates

Core Skills Treat for Shock 17

 Non-Hemorrhagic Shock
• Cardiogenic Shock
• Septic Shock
• Neurogenic Shock
• Anaphylactic Shock/Vasogenic Shock

Core Skills Treat for Shock 18

 2.SYOK KARDIOGENIK
Akibat dari penurunan Pompa Jantung
Etiologi :
•Disfungsi Sistolik : infark miokard,
•kardiomiopati, hipertensi pulmonal
•Disfungsi diastolik : hipertropi ventrikel,
kardimiopati
•Disritmia : bradiaritma, takiaritma
•Gangguan Struktur : stenosis atau regurgitasi
 Cardiogenic Shock
• Decrease in contractions/contractile ability
of the myocardium
• Heart fails to circulate blood efficiently
• Reduction in cardiac output results in:
– Decreased circulating blood supply (preload)
– Decreased oxygen delivery

Core Skills Treat for Shock 20

 Cardiogenic Shock
Assess for:
 Blunt trauma to the chest
 Cardiac tamponade
 Cardiac dysrhythmias
 Myocardial infarction
 Cardiac contusion
 Tachycardia
 Muffled heart sounds
 Engorged neck veins with hypotension
 Dyspnea
 Edema in feet and ankles

Core Skills Treat for Shock 21

 3.Syok Distributif
• Akibat dari dilatasi pembuluh darah besar
Yang mengakibatkan penurunan vaskular resistance
( SVR ) yang mengakibatkan penurunan preload
• Etiologi :
1.Sepsis : Infeksi ( pneumonia, peritonitis, prosedur
invasif )
2.Neurogenik : cedera medula spinalis, anastesi
spinal, depresi pusat vasomotor
3.Reaksi Anafilaktit: Reaksi Hipersensitivitas ( Alergi)
 Septic Shock
o Bacterial infection
 Vasodilation in wound area
 General vasodilation
o Endotoxin release by microorganisms
o Gram negative organisms
o Predispose to sepsis
 Diabetes
 Cirrhosis
 Post partum infections
 Post abortion infections

Core Skills Treat for Shock 23

 Septic Shock
o Develops 2 - 5 days after injury occurs
o Carries a poor prognosis
o Direct supervision of medical officer
o Assess for:
Penetrating abdominal injuries
Signs of infection
Warm pink skin and dry elevated body
temperature
Tachycardia
Wide pulse pressures
Core Skills Treat for Shock 24
 Neurogenic Shock
o Decreased arterial resistance
o Vasodilation
o Caused by:
 Spinal cord injury
 Certain drugs
 Brain stem, spinal or torso trauma
o Signs and Symptoms:
 Hypotension without tachycardia
 Warm pink skin
 Low blood pressure

Core Skills Treat for Shock 25

 Anaphylactic Shock/Vasogenic Shock
• Onset within 30 minutes of exposure
• Primary systems:
– Cardiovascular
– Respiratory
– Cutaneous
– Gastrointestinal
– Circulatory
• Epinephrine injection

Core Skills Treat for Shock 26

 Symptoms
• Apprehension and flushing
• Tightness in chest or difficulty breathing
• Wheezing or shortness of breath
• Rapid, weak pulse
• Cyanosis
• Generalized itching or burning
• Sneezing or coughing
• Watering and itching of the eyes
• Hives
• Blood pressure drops
• Coma

Core Skills Treat for Shock 27

 Early Signs of Shock in Non Complicated
Patients
• Health provider must have high index of
suspicion
• Minimum tachycardia
• No measurable changes occur in blood
pressure, pulse pressure or respiratory rate

Core Skills Treat for Shock 28

 4.Syok Obstruktif
• Akibat dari restriksi pengisian diastolik
ventrikel kanan akibat kompresi/ penekanan
pada jantung
• Etiologi :
1.Tamponade Jantung
2.Tension Pneumothorax
3.Emboli Paru
Treatment for
Shock
Presented by Izma Daud
FKIK Universitas Muhammadiyah Banjarmasin
Ali Haedar
Lecturer & Emergency Medicine Specialist
Department of Emergency Medicine
Faculty of Medicine – University of Brawijaya
Saiful Anwar General Hospital Malang
Initial Assessment
 Cardiovascular Changes in Shock

Type Preload Afterload Contractility

Cardiogenic   
Hypovolemic   No change
Distributive   
Septic

early   
late   
 Treatment for Hypovolemic Shock

Goals - Increase tissue perfusion and

oxygenation status
• Maintain airway
• Control bleeding
• Baseline vital signs
• Level of consciousness

Core Skills Treat for Shock 35

 Treatment for Hypovolemic Shock

• Position casualty
• Keep patient at normal temperature
– Prevent hypothermia
– Minimize effect of shock
• Fluid therapy
• Drug therapy
• On-going assessment - every 10-15 minutes

36
 Treatment for Septic Shock
• Secure airway
• Administer oxygen
• Baseline vital signs
• Level of consciousness
• Position casualty
• Keep patient at normal temperature

Core Skills Treat for Shock 37

 Treatment for Septic Shock
• Fluid therapy
• Drug therapy
• On-going assessment - preformed every 10-
15 minutes

Core Skills Treat for Shock 38

 Treatment for Neurogenic Shock
• Diagnosis is one of exclusion
• Secure airway
• Administer oxygen
• Baseline vital signs
• Level of consciousness
• Position casualty

Core Skills Treat for Shock 39

 Treatment for Neurogenic Shock
• Keep patient at normal temperature
• Fluid therapy
• Drug therapy
– High dose corticosteriods given intravenously
• On-going assessment - performed every 10
-15min

Core Skills Treat for Shock 40

 Treatment for Anaphylactic Shock
• Secure airway
• Terminate exposure to causative agent
• First-line therapies, during acute stage
– Epinephrine
– IV fluids
– Oxygen
• Second-line therapies
– Antihistamines
– Corticosteroids
• Evacuate

Core Skills Treat for Shock 41

 Summary
• Shock is a very serious condition
• Early detection
• Prompt medical intervention
• Monitor casualties susceptible to shock
• Be prepared to assist
• Early identification and treatment essential

Core Skills Treat for Shock 42

 Pengkajian
• Fokus Pengkajian :
-Airway, Breathing, Circulation ( ABC )
-Tanda/ Gejala Syok :
Perifer : Penurunan perifer, kulit dingin dan
lembab/basah , CRT >2 detik, pucat, sianosis
Renal : Output Urine , 0.5 mg/kg/jam, peningkatan
ureum
Cerebral: ansietas, pusing, agitasi, penurunan kesadaran
Kardiopulmonal : penurunan TD, Takikardi, Disritmia,
Penurunan JVP dan CVP, takipneu, penurunan SPO2,
gagal nafas
Hepatik : peningkatan enzim liver ( ALT, AST ) dan
Laktat
 DIAGNOSIS KEPERAWATAN PADA PASIEN SYOK

• Perfusi jaringan perifer tidak efektif b.d:

-penurunan volume darah
-Penurunan kontraktilitas jantung
-Gangguan aliran darah sirkulasi
-vasodilatasi yang luas
Diagnosa lain yang mungkin muncul :
- Defisit volume Cairan b.d kehilangan darah aktif, perpindahan cairan
ke interstisial
- Penurunan curah jantung b.d perubahan preload : kontraktilitas ;
blokade simpatis
- Ketidakseimbangan nutrisi : kurang dari kebutuhan tubuh b.d
peningkatan metabolik
-
 Penanganan Gawat Darurat di IGD
• Airway : menjamin jalan nafas pasien paten
• Breathing : memberikan O2 untuk mempertahankan
SpO2 >97 %
• Circulation :
-hentikan perdarahan eksternal dengan penekanan
langsung
-pasang akses IV line berukuran besar (No.14 atau 16 )
-pemberian cairan hangat dengan tetesan cepat
Dosis awal 1-2 liter pada dewasa dan 20 ml/kg pada
anak
 Kehilangan Darah Internal
Berdasarkan Fraktur
TULANG KEHIANGAN DARAH ( ml )
Iga 125
Radius atau Ulna 250-500
Humerus 500-750
Tibia atau Fibula 500-1000
Femur 1000-2000
Pelvis 1000

Sumber : McSwain & Frame ( 2003 ). PHTLS, Basic and advanced prehospital
Trauma life support.5th Ed USA : Mosby
 Intervensi Keperawatan

Penanganan di IGD ( Lanjutan )

Pada pasien trauma, tidak hanya ABC tapi ABCDEFG

-Disability : Periksa tingkat kesadaran, respon pupil dan fungsi sensorik &
motorik
-Exposure : Periksa seluruh permukaan tubuh. Periksa DOTS :
•D-deformity ( deformitas )
•O-open wounds ( luka terbuka )
•T-Tenderness ( nyeri tekan )
•S-Swelling ( bengkak )
-Folley Catheter : Kateter Urine untuk penilaian produksi urine
-Gastric tube : NGT untuk dekompresi lambung untuk memiminimalkan
apirasi
 Intervensi Keperawatan ( Lanjutan..)
Penanganan Lanjut:
•Pertahankan patensi Airway
•Pertahankan oksigen sesuai kebutuhan pasien
•Persiapkan intubasi dan ventilasi mekanik jika perlu,
kebanyakan tidak perlu
•Pertahankan kateter IV. Akses vena sentral jika memungkinkan
•Beri cairan sesuai order ( kristaloid , koloid, produk darah )
•Beri posisi syok ( modified tredelenburg )