You are on page 1of 17

The Golden Hour

is the time in which resuscitation of severely injured patients must begin to achieve maximal survive
R. Adams Cowley, MD

The lethal factor in shock is inadequate cellular oxygen delivery, leads to irreversible anoxic cellullar injury that kills a critical mass of cells

16/04/2013

Hasanul, 2002

THE GOLDEN HOUR


Probability of Survival
R. Adams Cowley, MD

100

80
60 40 20 0

% survival

30

60

90

minutes

Survival is related to severity and duration


16/04/2013

Hasanul, 2002

OXYGEN TRANSPORT DO2 = CaO2 x CO VO2 = [CaO2-CvO2] x CO


CaO2 = SaO2 x Hb x 1.34 CvO2 = SvO2 x Hb x 1.34 SHOCK,
16/04/2013

DO2 < VO2


Hasanul, 2003
3

PRE-LOAD

CONTRACTILITY

AFTER-LOAD

STROKE VOLUME

HEART-RATE

CARDIAC OUTPUT

TOTAL PERIPHERAL RESISTANCE

16/04/2013

BLOOD PRESSURE
Hasanul, 2003

PERDARAHAN

HILANG VOLUME HILANG ERITROSIT


16/04/2013

Hasanul, 2003

SHOCK

B1, B2,

nafas sesak, RR , cuping hidung

HR , nadi halus cepat, TD. N/ Pulse-press. , perfusi dingin, pucat, basah, capill.refill > 2 det., lactic-acid
anxious, confused, lethargy urine out-put , <0.5 ml/kg/jam, pekat

B3, B4,

16/04/2013

Hasanul, 2003

Estimated Fluid and Blood Losses Based on Patients Initial Presentation


Class I
Blood-Loss[ml] Blood-loss [%BV] Pulse-Rate [x/min.] Blood-Pressure Pulse-Pressure Respiratory Rate Urine out-put [ml/hour] Mental status/CNS ->750 ->15% <100 Normal N or increased 14-20 >30 Slightly anxious

Class II
750-1500 15-30% >100 Normal Decreased 20-30 20-30 Midly anxious

Class III Class IV


1500-2000 30-40% >120 Decreased Decreased 30-35 5-15 Anxious and confused >2000 >40% >140 Decreased Decreased >35 Negligible Confused and lethargic

BV = 70 ml/kg
16/04/2013

Hasanul, 2003
7

FLUID REPLACEMENT 3 : 1 Rule


Class I Class II Class III Crystalloid Crystalloid + Colloid ? Crystalloid +Colloid, Blood Crystalloid +Colloid, Blood
Hasanul, 2003
8

Class IV
16/04/2013

Pola kerja penanganan shock perdarahan


Hasanul, 2003

Penderita datang dengan perdarahan Pasang infus jarum kaliber besar (16G, 18G), ambil sample darah Ukur tekanan darah, hitung nadi, nilai perfusi, produksi urine

Tentukan estimasi jumlah perdarahan, minta darah Guyur cepat Ringer Laktat atau NaCl 0.9% [hangat, 390C] 3x prakiraan lost-volume [1-2 liter]

evaluasi
9

16/04/2013

Management selanjutnya

Rapid response, perdarahan <20% Transient response, perdarahan 20-40% BV ongoing loss resusitasi tdk adekwat RL, NaCl 0.9%, Kolloid, Darah ? Minimal, no response Tindakan bedah segera Transfusi darah
Hasanul, 2003
10

16/04/2013

Efek volume infus 1 L cairan Kolloid pada kompartement tubuh [BB,70kg]


Laruta n
Albumin-5%
PPF [Plasma Protein Fraction-5%] Gelafundin Haemacel Dextran-40 Dextran-70 Expafusin

Vol. plasma
1000
1000 1000 700 1600 1300 1000

Vol. interstetial
-300 -260 -130 -

Vol.intrasel
-340 -170 -

Haes-steril-6%
Haes-steril-10%
16/04/2013

1000
1450

-450

Hasanul, 2003
11

TRANSIENT RESPONSE, DARAH BELUM DATANG,

KOLLOID
1:1

16/04/2013

12

Transfusi,
Target
Rule of - 5

7 - 9g%

ml Whole-Blood = 5 x delta Hb x BB
contoh:

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


= 900 ml
16/04/2013 13

Hasanul, 2003

= 4 bag [unit]

16/04/2013

14

Transient response, darah belum datang.


Perdarahan pada

Usia tua Ibu hamil Pasca bedah major (reseksianastomose) Varices esofagus Anak-anak

Plasmanate
16/04/2013

(1:1)

15

16/04/2013

16

Plasma Protein Fraction ( PPF-5%), Plasmanate


100 ml Plasmanate
Mengandung :

4.4gr Human Albumin 0.6gr alfa dan beta globulin 0.05 gr gamma globulin Natrium 145mEq/L Kalium 0.25 mEq/l Chlorida 100 mEq/L
16/04/2013

Hasanul, 2002

17