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HIPOTENSI SYOK
a. Syok hipovolemik
b. Syok septik
c. Syok kardiogenik
Apa terapinya?
a. Fluid administration
b. Inotropik
c. Vasopressor
Kasus 2
a. Syok sepsis
b. Syok kardiogenik
c. Syok hipovolemik
Clinical Signs: shock, hypoperfusion, congestive heart
failure, acute pulmonary edema
Most likely problem?
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Systolic BP Systolic BP Systolic BP Systolic BP Systolic BP
BP defines 2nd <70 mmHg 70-100 mmHg 70-100 mmHg >100 mmHg
line of action Signs/symptoms Signs/symptoms No Signs/symptoms
(see below) of shock of shock of shock
I. Acute decompensated HF or
Decompensation of chronic HF :
Symptoms and sign of AHF +, mild, not fulfil for
cardiogenic shock, pulmonary oedema or HT crisis.
II. Hypertensive AHF: symptoms and sign of HF
+ BP ↑ and preserved LV function with chest X-ray
pulmonary congestion.
III. Pulmonary oedem : Severe respiratory
distress, orthopnea and rales over the lungs, O2
saturation < 90% and verified by chest X-ray
IV. Cardiogenic shock : Tissue hypoperfusion
induced by HF after corection filling pressure. ↓ BP ( SBP <
90 mmHg or ↓ mean arterial BP > 30 mmHg), low urine
output ( < 0,5 ml/kg hr ), pulse rate > 90bpm, organ
congestion +/-, low CO → severe cardiogenic shock.
V. High output failure : ↑ CO, ↑ HR ( arrhytmia,
thyrotoxicosis, anemia, iatrogenic ), warm peripheries,
pu;monary congestion, ↓ BP as in septic shock.
VI. Right heart failure : low output syndrome with
↑ JVP, hepatomegaly and hypotension
THE KILLIP CLASSIFICATION ( Clinical
estimate )
Class III : Severe HF. Pulmonary oedema with rales in all lung
fields
P
A B
e
r Dry and warm Wet and warm
f
u L C
s Dry and cold Wet and cold
i
o
n Congestion : lungs
The forrester classification ( haemodynamic
characteristic )
T
i
s
C s Diuretics
normal
u Vasodilators
I
e
2 Pulmonary oedema
, P
2 e Fluid administration N BP : Vasodilators
r ↓ BP : Inotropics or vasopressor
f Hypovolemic
u Cardiogenic shock
s
i
Pulmonary congestion
o
n PCWP18 mmHg
Diagnostic algorithm ( clinical assesment, pts hx,
ECG, X-ray, O2 saturation,CRP, electrolytes, Cr, BNP )
Always Consider
● Clinical ● Outcome
↓ Symptoms ↓ Length of stay in the ICU
↓ Clinical sign ↓ Duration of hospitalisation
↓ BW ↑ Time to hosp. rea-dmission
↑ Diuresis ↓ Mortality
↑ Oxygenation ● Tolerability
Low rate of withdrawal from Tx
Low incidence of adverse eff.
● Laboratory ● Haemodynamic
↓ BUN and/or creatinine ↓ PCWP < 18 mmHg
↓ S-bilirubin ↑ CO or SV
↓ Plasma BNP
Electrolyte and glucose N
Initial management : Instrumentation and choice of
Tx ≈ clinical priorities
Acute H F
Y Analgesia or sedasi
Diagnosis algorithm Pts distress or in pain
N
N
N ↑ FiO2,CPAP, NIPPV
Dobutamine no 2 – 20 µ/kg/min ( β )
Dopamine no < 3 µg/kg/min, renal effect ( β )
3 – 5 µg/kg/min, inotropic ( β )
> 5 µg/kg/min(β), vasopressor (α
Norepinephrine no 0,2 – 1,0 µg/kg/min
Epinephrine 1 mg i.v at
resuscitati
on repeat 0,05 – 0,5 µg/kg/min
ed 3-5 min
MATUR SUWUN