Pleno 2 Kgd Unfinished

8/18/2019 Pleno 2 Kgd Unfinished

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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'



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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



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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"



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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



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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!



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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'



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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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67/121

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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72/121

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#%(


97/121

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(%(


98/121

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


100/121

'

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


102/121

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(


104/121

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#'


105/121

P!t&op&'(%olo#'


106/121


107/121

Cl%"%)!l m!"%$e(t!t%o"(


108/121

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"(


110/121


111/121

D%!#"o(%(


112/121

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


113/121

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


114/121

@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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117/121


118/121


119/121


120/121

Pre-e"t%o"


121/121

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

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