TATA LAKSANA

KEGAWATDARURATAN DI
BIDANG ILMU PENYAKIT DALAM
 Pendahuluan
• Pendekatan gawat darurat berdasarkan tanda
dan gejala
• “Basic Life Support”
• 43 topik kajian dalam modul IMELS, tema
disajikan berdasarkan kekerapan ditemui dalam
keseharian pasien2 penyakit dalam
• Menjaga serta meningkatkan kompetensi dokter
SpPD
• Mampu memberikan pelayanan kegawatdarutan
yg optimal demi peningkatan pelayanan bagi
masyarakat.
Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam
• Syok hipovolemik
• Syok anafilaktik
• Henti jantung
• Intoksikasi dengan ancaman hidup
• Sindrom distres pernafasan akut
• Pneumonia berat
• Pneumotoraks
• Efusi pleura masif
• Jejas paru karena suhu (trauma inhalasi)
• Emboli paru
• Gagal hati akut
Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam
• Ensefalopati hepatikum
• Kolangitis akut
• Pankreatitis
• Kolesistitis akut
• Hematemesis melena
• Hematoskezia
• Ileus paralitik
• Krisis hipertensi
• Hipokalemia
• Hiperkalemia
• Hiponatremia
 Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam
• Hematuria masif
• Gangguan ginjal akut
• Bradikardia simtomatik
• Takikardia dengan pulse
• Sindroma koroner akut
• Edema paru akut kardiogenik
• Sindrom delirium akut
• Koagulasi intravaskular diseminata
• Sindrom vena kava superior
• Sindrom lisis tumor
• Ketoasidosis diabetikum
 Kegawatdaruratan Di Bidang
Ilmu Penyakit Dalam
• Hipoglikemia
• Krisis tiroid
• Sepsis
• Leptospirosis (sindrom Weil)
• Malaria berat
• Tifoid toksik
• Keracunan makanan
• Tertelan zat korosif
• Gigitan binatang berbisa
• Sengatan panas
 Shock
• Definition
• Epidemiology
• Physiology and Pathophysiology
• Classes of Shock
• Clinical Presentation
• Management
• Controversies
 Definition
• A physiologic state characterized
by
– Inadequate tissue perfusion

• Clinically manifested by
– Hemodynamic disturbances
– Organ dysfunction
 Epidemiology
• Mortality
– Septic shock – 35-40% (1 month
mortality)
– Cardiogenic shock – 60-90%
– Hypovolemic shock –
variable/mechanism
 Physiology
• Basic unit of life = cell
• Cells get energy needed to stay alive
by reacting oxygen with fuel (usually
glucose)
• No oxygen, no energy
• No energy, no life
 Physiology
• Cardiovascular System
– Transports oxygen, fuel to cells
– Removes carbon dioxide, waste products
for elimination from body

Cardiovascular system must

be able to maintain sufficient
flow through capillary beds to
meet cell’s oxygen and fuel
needs
 Flow =
Perfusion

Adequate Flow Inadequate Flow

= Adequate = Indequate
Perfusion Perfusion
(Hypoperfusion)

Hypoperfusio
n = Shock
 Physiology
• What is needed to maintain
perfusion?
– Pump : Heart
– Pipes : Blood vessels
– Fluid : Blood
• How can perfusion fail?
– Pump Failure
– Pipe Failure
– Loss of Volume
 Pathophysiology
• Imbalance in oxygen supply and demand
• Conversion from aerobic to anaerobic
metabolism
• Appropriate and inappropriate metabolic
and physiologic responses
• Characterized by three stages
– Preshock (warm shock, compensated shock)
– Shock
– End organ dysfunction
 Pathophysiology
• Compensated shock
– Low preload shock – tachycardia, vasoconstriction,
mildly decreased BP
– Low afterload (distributive) shock – peripheral
vasodilation, hyperdynamic state
• Shock
– Initial signs of end organ dysfunction
– Tachycardia
– Tachypnea
– Metabolic acidosis
– Oliguria
– Cool and clammy skin
 Pathophysiology
• End Organ Dysfunction
– Progressive irreversible dysfunction
– Oliguria or anuria
– Progressive acidosis and decreased CO
– Agitation, obtundation, and coma
– Patient death
 Classification
• Schemes are designed to simplify
complex physiology
• Major classes of shock
– Hypovolemic
– Cardiogenic
– Distributive
 Hypovolemic Shock
• Results from decreased preload
• Etiologic classes
– Hemorrhage - e.g. trauma, GI bleed,
ruptured aneurysm
– Fluid loss - e.g. diarrhea, vomiting,
burns, third spacing, iatrogenic
Hypovolemic Shock
• Hemorrhagic
Shock
Parameter I II III IV
Blood loss (ml) <750 750–1500 1500–2000 >2000
Blood loss (%) <15% 15–30% 30–40% >40%
Pulse rate
(beats/min) <100 >100 >120 >140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate
(bpm) 14–20 20–30 30–40 >35
Urine output
(ml/hour) >30 20–30 5–15 Negligible
CNS symptoms Normal Anxious Confused Lethargic

Crit Care. 2004; 8(5): 373–

381.
 Cardiogenic Shock
• Results from pump failure
– Decreased systolic function
– Resultant decreased cardiac output
• Etiologic categories
– Myopathic
– Arrhythmic
– Mechanical
– Extracardiac (obstructive)
 Distributive Shock
• Results from a severe decrease in
SVR
– Vasodilation reduces afterload
– May be associated with increased CO
• Etiologic categories
– Sepsis
– Neurogenic / spinal
– Other (next page)
 Distributive Shock
• Other causes
– Systemic inflammation – pancreatitis,
burns
– Toxic shock syndrome
– Anaphylaxis and anaphylactoid
reactions
– Toxin reactions – drugs, transfusions
– Addisonian crisis
– Myxedema coma
Distributive Shock
• Septic Shock
 Clinical Presentation
• Clinical presentation varies with type
and cause, but there are features in
common
• Hypotension (SBP<90 or Delta>40)
• Cool, clammy skin (exceptions – early
distributive, terminal shock)
• Oliguria
• Change in mental status
• Metabolic acidosis
 Evaluation
• Done in parallel with treatment!
• H&P – helpful to distinguish type of shock
• Full laboratory evaluation (including H&H,
cardiac enzymes, ABG)
• Basic studies – CxR, EKG, UA
• Basic monitoring – VS, UOP, CVP, A-line
• Imaging if appropriate – FAST, CT
• Echo vs. PA catheterization
– CO, PAS/PAD/PAW, SVR, SvO2
 Treatment
• Manage the emergency
• Determine the underlying cause
• Definitive management or support
 Manage the Emergency
• Your patient is in extremis –
tachycardic, hypotensive, obtunded
• How long do you have to manage
this?
• Suggests that many things must be
done at once
• Draw in ancillary staff for support!
• What must be done?
 Manage the Emergency
• One person runs the code!
• Control airway and breathing
• Maximize oxygen delivery
• Place lines, tubes, and monitors
• Get and run IVF on a pressure bag
• Get and run blood (if appropriate)
• Get and hang pressors
• Call your senior/fellow/attending
 Determine the Cause
• Often obvious based on history
• Trauma most often hypovolemic
(hemorrhagic)
• Postoperative most often hypovolemic
(hemorrhagic or third spacing)
• Debilitated hospitalized pts most often septic
• Must evaluate all pts for risk factors for MI
and consider cardiogenic
• Consider distributive (spinal) shock in trauma
 Case
• 85 y/o M 4 hours postop S/P sigmoid
resection for perforated diverticulitis
is hypotensive on a monitored bed at
70/40

• Best actions for the first 5 minutes?

 Definitive Management
• Hypovolemic – Fluid resuscitate (blood
or crystalloid) and control ongoing loss
• Cardiogenic - Restore blood pressure
(chemical and mechanical) and prevent
ongoing cardiac death
• Distributive – Fluid resuscitate,
pressors for maintenance, immediate
abx/surgical control for infection,
steroids for adrenocortical insufficiency
 Controversies
• IVF Resuscitation
– Limited resuscitation in penetrating trauma
– Use of hypertonic saline resuscitation in
trauma
– Endpoints for prolonged resuscitation
• Pressors
– Best pressors for distributive shock
• Monitoring
– Most appropriate timing and use for PA
catheterization or intermittent echocardiogram