Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock

in the in the in the in the InjuriedInjuriedInjuriedInjuried PatientPatientPatientPatient

Hasanul Arifin

Departemen Anestesiologi dan Reanimasi

Fakultas Kedokteran USU

CaO2

• Oxygen Bound (HbO2)

• Oxygen dissolved (plasma)

CaO2 = Hb x SaO2 x 1.34 + PaO2 x 0.0031

Oxygen Bound (HbO2)Oxygen Bound (HbO2)

Oxygen dissolved (plasma)Oxygen dissolved (plasma)

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Initial Management of Initial Management of Initial Management of Initial Management of

Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock Hemorrhagic Shock

Pasien Trauma

(dianggap menderita shock hypovolemia)

Hentikan Perdarahan, Ganti

Kehilangan Volume

Physical Examination

( ABCDE)

• Airway & Breathing• Keep the airway clear

• Ventilasi & Oksigenasi• Ventilasi & Oksigenasi

• Beri O2 ���� SpO2 96-98%

• Circulation ( kontrol perdarahan)• Penekanan

• PASG (Pneumatic Anti shock Garment)

• Operatip

Physical Examination

( ABCDE)

• Disability (neurologi)

• Brain perfusion

• GCS

• Respon pupil• Respon pupil

• Exposure

• Head to Too

• Cegah hypothermia ( penghangatan internal,

eksternal)

Tindakan lain

• Dekompressi ( Maag dilatation)

• Maag dilatasi ���� vagal stimulation ���� bradikardia,

hypotensi

• Risiko aspirasi

• Insersi NGT no besar untuk dekompressi, suction aktif

• Urinary Catheter

• Hematuria?

• Jumlah urine ���� renal perfusion

iv. line

• 2 (dua) iv catheter no. besar (16G, 18G)

• Vena lengan bawah

• Kalau kesulitan, akses vena besar :

�Dilakukan oleh tenaga yang

� v. subclavia

� v. jugularis interna

� v. femoralis

� Sekalian ambil contoh darah (laboratorium)

Dilakukan oleh tenaga yang

terlatih, jangan sampai

menimbulkan komplikasi

( peneumothorax,

hematothorax, arterial

puncture )

Vein Selection

• Both upper limbs should be inspected to

identify possible veins for cannulation.

• Potential veins can then be palpated to assess

their condition.their condition.

• An ideal vein is ‘soft and bouncy’ when

palpated.

• Veins that are tender, thrombosed or hard

should be avoided

Device selection

• It is important to select the correct vascular

access device for the patient’s specific clinical

situation

• PUR (polyurethane), modern, softer, cause

less intimal damage and are kink resistant less intimal damage and are kink resistant

which reduces the incidence of cannula failure

• PVC, Teflon, older materials are more rigid,

higher incidence of thrombophlebitis.

equipment

• Infusion standart

• Fluid (RL, NaCl, etc)

• Infusion tubing

• The following equipment for cannulation should be

assembled and placed on a clean tray:assembled and placed on a clean tray:

• cannula, antiseptic, sterile gauze, sterile saline flush,

single or multiway adapter (primed with sterile saline)

with integral ‘needle-less’ device, sterile moisture-

permeable transparent dressing, tape, and a small

sharps’ container.

Theoretical Maximum Flow Rates

Colour Gauge Flow

Yellow 24G 13 ml/min

Blue 22G 30 ml/min

Pink 20G 55 ml/min

Green 18G 80-100 ml/min

White 17G 135 ml/min

Grey 16G 180 ml/min

Orange or Brown 14G 270 ml/min

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Class IClass I Class IIClass II Class IIIClass III Class IVClass IV

BloodBlood--Loss[ml]Loss[ml] -->750>750 750750--15001500 15001500--20002000 >2000>2000

BloodBlood--loss [%BV]loss [%BV] -->15%>15% 1515--30%30% 3030--40%40% >40%>40%

PulsePulse--Rate [x/min.]Rate [x/min.] <100<100 >100>100 >120>120 >140>140

BloodBlood--PressurePressure NormalNormal NormalNormal DecreasedDecreased DecreasedDecreased

Estimated Fluid and Blood Losses Based on Estimated Fluid and Blood Losses Based on

Patient’s Initial PresentationPatient’s Initial Presentation

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PulsePulse--PressurePressure N or N or increasedincreased

DecreasedDecreased DecreasedDecreased DecreasedDecreased

Respiratory RateRespiratory Rate 1414--2020 2020--3030 3030--3535 >35>35

Urine outUrine out--put put [ml/hour][ml/hour]

>30>30 2020--3030 55--1515 NegligibleNegligible

Mental status/CNSMental status/CNS Slightly Slightly anxiousanxious

Midly Midly anxiousanxious

Anxious Anxious and and confusedconfused

Confused Confused and and lethargiclethargic

EEBV BV = 70 ml/kg= 70 ml/kg

Kegunaan Klinis

Tabel Prakiraan Kehilangan Darah• Dengan menyesuaikan tanda dan gejala dari penderita pada

tabel, dapat diperkirakan berapa kehilangan darah yang sdhterjadi.

• Kemudian kita dapat memperhitungkan berapa jumlah cairanyang harus diberikan untuk resusitasi

• Bila post resisitasi belum ada tanda perbaikan, maka• Bila post resisitasi belum ada tanda perbaikan, makakemungkinan :

– Ongoing loss

– Prakiraan ada kesalahan (BB tidak sesuai, kurang jeli menilai tanda dangejala

– Ada tambahan kehilangan cairan lain selain perdarahan

– Shock bukan ok. perdarahan

Initial Fluid Therapy

• Tujuan :

• mengisi intravaskular dalam waktu singkat � preload � mekanisme

hemodinamik

• Cairan :

• Kristalloid• Kristalloid• Ringer Lactat

• Ringer Asetat

• NaCl 0.9%

• Rule : 3 for 1 (1000 mL perdarahan ganti 3000 mL)

• Kolloid ���� rule 1 : 1 ( 500 mL perdarahan ganti 500 mL)

TOTAL BODY WATER : 60% TOTAL BODY WEIGHTTOTAL BODY WATER : 60% TOTAL BODY WEIGHT

36 L36 L60 kg60 kg

Physiologic principles of Physiologic principles of

fluid managementfluid management

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ISF

9L9L

ISFISF IVFIVF ICFICF

3L3L 24 L24 L

Hasanul, 2002Hasanul, 2002

PhysiologyPhysiologydefinitiondefinition

•• CrystalloidCrystalloid is the term commonly is the term commonly

applied to solutions that do not applied to solutions that do not

contain any highcontain any high--molecularmolecular--weight weight

compounds and thus have an compounds and thus have an oncoticoncoticcompounds and thus have an compounds and thus have an oncoticoncotic

pressure of zeropressure of zero

•• ColloidColloid is the term used to denote is the term used to denote

solutions that have an solutions that have an oncoticoncotic

pressure similar to that of plasma.pressure similar to that of plasma.

Jenis cairan yang beredar :Jenis cairan yang beredar :

•• KristalloidKristalloid ( D5W, RL, RA, NaCl )( D5W, RL, RA, NaCl )

•• Kolloid Kolloid ( Albumin, HES, Expafusin, ( Albumin, HES, Expafusin,

Gelatine)Gelatine)

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Gelatine)Gelatine)

•• Cairan NutrisiCairan Nutrisi ( Intrafusin, Ivelip, ( Intrafusin, Ivelip,

Triofusin)Triofusin)

D5WD5W

3L3L

Physiologic principles of Physiologic principles of

fluid managementfluid management

26/08/2010 28

ISF

9L9L

ISFISF IVFIVF ICFICF

3L3L 24 L24 L750 ml750 ml 250 ml250 ml 2 L2 L

Hasanul, 2002Hasanul, 2002

RL,NaClRL,NaCl

3L3L

Physiologic principles of Physiologic principles of

fluid managementfluid management

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ISF

9L9L

ISFISF IVFIVF ICFICF

3L3L 24 L24 L2250ml2250ml 750 ml750 ml

Hasanul, 2002Hasanul, 2002

AlbuminAlbumin--

5%5%

1 L1 L

Physiologic principles of Physiologic principles of

fluid managementfluid management

26/08/2010 30

ISF

9L9L

ISFISF IVFIVF ICFICF

3L3L 24 L24 L1L1L

Hasanul, 2002Hasanul, 2002

HESHES--6%6%

1L1L

Physiologic principles of Physiologic principles of

fluid managementfluid management

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ISFISFISF IVFIVF ICFICF

3L3L 24 L24 L1000ml1000ml

Hasanul, 2002Hasanul, 2002

9L9L

AlbuminAlbumin--

25%25%

100 cc100 cc

Physiologic principles of Physiologic principles of

fluid managementfluid management

Volume expanderVolume expander

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ISF

9L9L

ISFISF IVFIVF ICFICF

3L3L 24 L24 L500500

Hasanul, 2002Hasanul, 2002

400400

HaemacelHaemacel

1L1L

Physiologic principles of Physiologic principles of

fluid managementfluid management

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ISFISFISF IVFIVF ICFICF

3L3L 24 L24 L700ml700ml

Hasanul, 2002Hasanul, 2002

9L9L300ml300ml

FLUID REPLACEMENTFLUID REPLACEMENTFLUID REPLACEMENTFLUID REPLACEMENT

3 : 1 Rule3 : 1 Rule3 : 1 Rule3 : 1 Rule3 : 1 Rule3 : 1 Rule3 : 1 Rule3 : 1 RuleClass I Crystalloid

Class II Crystalloid

+ Colloid ?

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34

+ Colloid ?

Class III Crystalloid

+Colloid, Blood

Class IV Crystalloid

+Colloid, BloodHasanulHasanul, , 20092009

Pola kerja penanganan shock

perdarahan

Penderita datang dengan Penderita datang dengan

perdarahanperdarahan

Pasang infus jarum kaliber Pasang infus jarum kaliber

besar (16G, 18G), ambil besar (16G, 18G), ambil

Ukur tekanan darah, hitung Ukur tekanan darah, hitung

nadi, nilai perfusi, produksi nadi, nilai perfusi, produksi

HasanulHasanul, , 20092009

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besar (16G, 18G), ambil besar (16G, 18G), ambil

sample darahsample darah

nadi, nilai perfusi, produksi nadi, nilai perfusi, produksi

urineurine

Tentukan estimasi jumlah Tentukan estimasi jumlah

perdarahan, minta darahperdarahan, minta darah

Guyur cepat Ringer Laktat atau NaCl Guyur cepat Ringer Laktat atau NaCl

0.9%0.9% [[hangat, 39hangat, 3900CC] ] 3x prakiraan lost3x prakiraan lost--

volume [1volume [1--2 liter]2 liter] evaluasievaluasi

•• PulsePulse--Rate [x/min.]Rate [x/min.]

•• BloodBlood--PressurePressure

•• PulsePulse--PressurePressure

•• Respiratory RateRespiratory Rate

•• Urine outUrine out--put [ml/hour]put [ml/hour]

•• Mental status/CNSMental status/CNS

ev

alu

asi

ev

alu

asi

•• Mental status/CNSMental status/CNS

normalnormal

ev

alu

asi

ev

alu

asi

Thank you for listeningThank you for listeningThank you for listeningThank you for listeningThank you for listeningThank you for listeningThank you for listeningThank you for listening

and to be continuedand to be continuedand to be continuedand to be continuedand to be continuedand to be continuedand to be continuedand to be continued

8/26/2010 37

and to be continuedand to be continuedand to be continuedand to be continuedand to be continuedand to be continuedand to be continuedand to be continued

ManagementManagementManagementManagement selanjutnyaselanjutnyaselanjutnyaselanjutnya• Rapid response,

perdarahan <20%

• Transient response,

perdarahan 20-40% BV

ongoing loss

resusitasi tdk adekwat

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resusitasi tdk adekwat

RL, NaCl 0.9%, Kolloid, Darah ?

• Minimal, no response

Perdarahan >40%

Tindakan bedah segera

Transfusi darah

Hasanul, 2003Hasanul, 2003

Efek volume infus 1 L cairan Kolloid pada

kompartement tubuh [BB,70kg]

L a r u t a nL a r u t a n Vol. plasmaVol. plasma Vol. interstetialVol. interstetial Vol.intraselVol.intrasel

Albumin-5% 1000 - -

PPF [Plasma Protein

Fraction-5%] 1000 - -

Gelafundin 1000 - -

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Haemacel 700 +300 -

Dextran-40 1600 -260 -340

Dextran-70 1300 -130 -170

Expafusin 1000 - -

Haes-steril-6% 1000 - -

Haes-steril-10% 1450 -450 -

Hasanul, 2003

TRANSIENT RESPONSE,TRANSIENT RESPONSE,

DARAH BELUM DATANG,DARAH BELUM DATANG,

KOLLOIDKOLLOID

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KOLLOIDKOLLOID

1:11:1

Transfusion, indications

• Indications for transfusion in normovolemic

anemia,

– VO2 < normal range (indicating an oxygen debt)

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– VO2 < normal range (indicating an oxygen debt)

– Blood lactate > 4 mmol/L

– O2ER > 0.5

TransfusiTransfusiTransfusiTransfusiTransfusiTransfusiTransfusiTransfusi,,,,,,,,

Target 7 Target 7 -- 9g%9g%

Rule of Rule of -- 55

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ml Wholeml Whole--Blood = 5 x delta Blood = 5 x delta HbHb x BB x BB

contoh:

BB 60 kg, Hb 6g%, WB yang dibutuhkan = 5 x 3 x 60

= 900 ml

= 4 bag [unit]

HasanulHasanul, , 20092009

Why does hypothermia happen?

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Hypothermia

� Casualties who are hypovolemic quickly

become hypothermic.

� Body temperatures below 91° F causes the

vicious triad.

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vicious triad.

– Hypothermia

– Acidosis

– Coagulopathy