Syok

M. Hafidz Azhari
Humairah
Ayun Puji lestari
Coni Senopadang

Pembimbing: dr. Rapto Hardian, Sp.An

 SHOCK
CIRCULATORY FAILURE
Definition leads to
INADEQUATE
VITAL ORGAN PERFUSION

Clinical weak condition, cold and

appearance clammy extremities, delirium,
oliguria
Syok
• Merupakan sindrom multifaktorial 
hipoperfusi jaringan perifer dan sentral 
hipoksia seluler dan disfungsi organ multipel.
• Perfusi menurun secara sistemik dengan gejala
yg jelas  hipotensi
• Prognosis: derajat syok, durasi, organ yang
terpengaruh, disfungsi organ sebelumnya, dan
kecenderungan genetik.
 Patofisiologi
↓
perfusi
jaringan

shock

Hipoksia
seluler
Hipoksia seluler  ↑ permeabilitas
vaskuler  radikal super oksida 
respon inflamasi  kerusakan sel
lebih lanjut  kerusakan multi-
organ
Diagnosis

• Heart rate: takikardi  bradikardi

• BP: Hipotensi  severe volume loss and
shock

Vital • Temp: hypothermia  severe hypovolemic

and septic shock
• Urin output: early guide of hypovolemia and

Sign end organ response (renal) to shock.

Delayed vital sign
• Pulse oxymetry  early indicator of
hypoxemia, invalid in hypothermic patient
 Invasive • Arterial catheter
• Central venous catheter
hemodynamic • Pulmonary arterial catheter  help
monitoring guide aggressive resuscitation

• Left ventricular end-diastolic

Cardiac volume
preload • Pulmonary artery occlusion
pressure
 • Cardiac output 
Cardiac cardiac function,
measured by PAC
flow • Systemic vascular
variable resistance index
(SVRI)
Hemodynamic variables
Measured variable Unit Normal
Range
Systolic blood pressure (SBP) mmHg 90-140
Diastolic blood pressure (DBP) mmHg 60-90
Systolic pulmonary blood pressure (PAS) mmHg 15-30
Diastolic pulmonary blood pressure (PAD) mmHg 4-12
Pulmonary artery occlusion pressure (PAOP) mmHg 2-12
Central venous pressure (CVP) mmHg 0-8
Heart Rate (HR) Beats/min 50-100
Cardiac output (CO) L/min 4-6
Right ventricular ejection fraction (RVEF) Fraction 0,4-0,6
Calculated variable Unit Normal range
Mean arterial pressure (MAP) mmHg 70-105
Mean pulmonary artery pressure mmHg 9-16
(MPAP)
Cardiac index (CI) L/min/m2 2,8-4,2
Stroke volume (SV) ML/beat Varies
Stroke volume index (SVI) mL/beat/m2 30-65
Systemic vascular resistance index Dynes 1.600-2.400
(SVRI)
Pulmonary vascular resistance index Sec/cm-5 250-340
(PVRI)
Left ventricular stroke work index g m/m2 45-62
(LVSWI)
Right ventricular stroke work index g m/m2 7-12
(RVSWI)
Right ventricular end-diastolic work mL/m2 60-100
index (RVEDWI)
Body surface area (BSA) m2 varies
Resuscitation end point
• Cellular hypoxia  anaerobic metabolism  lactic
Lactic acid acid >>  severity of shock
production • Rate of clearance of lactate  better marker of
adequate resuscitation

• The amount of base required to titrate whole blood

Base deficit to a normal pH
• Elevated base deficit  severity of shock

• The mesenteric organ will have earlier and greater

Intramucosal hypoperfusion than other organ system
pH monitoring • Gastric tonometry  early indicator of
hypoperfusion
Pembagian syok
• Hipovolemi : darah, cairan, plasma

• Obstruktif : tamponade jantung, tension

pneumothorax, emboli masif

• Kardiogenik

• Distributif : neurogenik, septik, anafilaksis

 I. Syok hipovolemik
Kehilangan volume intravaskular yang bersirkulasi dan penurunan
cardiac preload

1. Loss of blood 2. Loss of Fluid and

(hemorrhagic shock) electrolyte
▫ External hemorrhage - External
 Trauma • Vomiting
 Gastrointestinal tract • Diarrhea
bleeding - Internal (“third-spacing”)
▫ Internal hemorrhage • Pacreatitis
 Hematoma • Ascites
 Hemothorax or • Bowel obstruction
hemoperitoneum

3. Loss of plasma
(luka bakar)
Grades of hemmoragic shock
Sign & Class I Class II Class III Class IV
symptom
Blood loss Up to 750 750-1500 1500-2000 >2000
(mL)
%Blood Up to 15 15-30 30-40 >40
volume
Pulse rate <100 >100 >120 >140
Blood N N ↓ ↓
pressure
Capillary refill N ↓ ↓ ↓
RR N 20-30 30-40 >35
Urinary >30 20-30 5-15 Negligible
output
(ml/hr)
Mental status Mild anxiety Anxiety Confused Lethargic
Fluid Crystalloid Crystalloid Crystalloid + Crystalloid +
replacement blood blood
Syok hipovolemik
• Rapid infusion of multiple liters of crystalloid
• Large-bore venous access and central access is
needed
• If haemorrhage shock after 2-3 liters of fluid
 blood is transfused + source of bleeding needs
to be controlled
• Vasoconstrictor  rarely needed
• An initial, warmed fluid bolus is given as
rapidly as possible. The usual dose is 1-2 liters
for an adult and 20 ml/kg for a pediatric
patient.
• 3-for-1 rule  replace each mililiter of blood
loss with 3 mL of crystalloid fluid
• Assess the patient’s response to fluid
resuscitation
Response to Initial Fluid Resuscitation
Rapid Transient No Response
Response Response
Vital Sign Return to Normal Transient Remain abnormal
improvement,
recurrent of ↓ BP
and ↑ HR
Estimated blood Minimal (10%- Moderate and Severe (>40%)
loss 20%) ongoing (20%-
40%)
Need for more Low High High
crystalloid
Need for blood Low Moderate to high Immediate
Blood preparation Type and cross Type-specific Emergency blood
match release
Need for Possibly Likely Highly likely
operative
intervention
Grades of dehydration
Mild < 5% Moderate 5- Severe >10%
10%
Pulse rate N ↑ ↑
Blood pressure N N ↓
Respiratory rate N N Rapid
Capillary return <2 seconds 3-4 seconds >5 seconds
Urine Output N ↓ Negligible/absent
Mucous membran Moist Dry Parched
CNS/mental N/restless Drowsy Lethargic/comato
status se

5% dehydration = loss of 5 ml of fluid per 100 g body weight or 50 ml per kg

Estimating Maintenance Fluid
Requirement
Weight Rate

For the first 10 kg 4 ml/kg/h

For the next 10-20 kg Add 2 ml/kg/h

For each kg above 20 kg Add 1 ml/kg/h

 Ringan Berat
Klasifikasi atau atau
Sedang Syok

Pemberian Dibagi rata Tahap I (rehidrasi cepat) :

Cairan dlm 24 jam 20-40 cc/KgBB/1-2 jam
Defisit Tahap II :
½ sisa defisit  6 jam
½ sisanya  16-17 jam

PERUBAHAN :
-Gx Klinis
-Hematokrit
-Plasma elektrolit + Maintenance
-CVP
Contoh:
• Pasien pria, BB 50 kg, mengalami dehidrasi
moderate (dehidrasi 5%)
• Jawab:
• Estimated Fluid Therapy
5% dehydration= 50 x 50 = 2500 ml/ 24 h = 105
ml/h
Maintenance = 40+20+ 30 = 90 ml/h
Rehydration + maintenance = 195 ml/h
 II. Syok Obstruktif
• Disebabkan oleh obstruksi mekanis thd cardiac output
dgn penurunan perfusi sistemik
• Penyebab:
a. Cardiac tamponade
b. Tension pneumothorax
c. Emboli paru masif
d. Emboli udara

• Tanda: distensi vena jugularis, muffled heart sound

(tamponade), ↓ suara nafas unilateral (pneumothorax)
• Tx: memaksimalkan preload dan mengatasi obstruksi
Syok obstruktif
• Penyebab harus diidentifikasi dan ditangani
secepatnya:
a. Pericardiocentesis/ pericardiotomy  cardiac
tamponade
b. Needle decompression/ tube thoracostomy 
tension pneumothorax
c. Ventilatory and cardiac support
 III. Syok kardiogenik

• Disebabkan karena kegagalan pompa

• Penyebab: extensive myocardial infarction (>>),
reduced contractility (cardiomyopathy, sepsis
induced) aortic stenosis, mitral stenosis, atrial
myxoma, acute valvular failure, and cardiac
dysrythmias.
• Tx: memaksimalkan preload dan kerja jantung,
menurunkan after load.
Syok kardiogenik
• Optimize preload with infusion of fluids
• Optimize contractility with inotropes
• Adjust afterload to maximize CO
• Diuresis  indicated in patient with heart
failure
• PAC  guide therapy
• Identifiy and treat the underlying cause
 IV. Syok distributif

• Disebabkan oleh vasodilatasi sistemik krn

penyebab yg muncul (infeksi, anafilaksis) 
hipoperfusi sistemik dan ↑ atau ↓ cardiac output.
• Syok distributif ditingkatkan oleh respon
inflamasi
• Terjadi hipoksia seluler karena gangguan fungsi
mitokondria.
• Penyebab lain: anaphylaxis, severe trauma,
severe liver dysfunction, and neurogenic shock.
• Neurogenic shock  trauma MS servikal disertai
hilangnya tonus simpatis vaskuler.
• Gejala: hipotensi, bradikardi, ekstremitas hangat
• Tx: volume dan vasokonstriktor
Syok anafilaksis
• Anafilaksis: reaksi alergi yg berat terhadap
rangsangan apapun, onset mendadak (<24 jam),
melibatkan 1 atau lebih sistem tubuh dan
memiliki gejala antara lain bengkak, flushing,
gatal, angioedema, stridor, wheezing, sesak,
mual, diare atau syok.
Sepsis
Pediatric septic shock