Professional Documents
Culture Documents
2b 10 Circ APRIL 2013-Diproteksi Unlocked
2b 10 Circ APRIL 2013-Diproteksi Unlocked
Dr Sutomo Hospital
Dept Anesthesiology & Reanimation,
Airlangga University, School of Medicine Surabaya
Emergency Medicine & Disaster Management
Working Group
Module
Day 2b
2b_Circulation 1
Day 2
1.30 Skills
Diagnosis and Understanding of Circulation emergencies
Hypovolemic shock, hemorrhagic shock
1.30 Shock position
Intravenous lines, intra osseus
Control of external hemorrhage
1.30 Skills
2b_Circulation 3
Circulation
• Jantung = pompa
• Pembuluh darah = pipa
jantung
• Darah = isi pipa
pembuluh
darah darah
2b_Circulation 4
LEFT
RIGHT
CO = HR x SV
2b_Circulation 5
Sirkulasi darah
• Cardiac Output = CO = volume darah yang
dipompa jantung satu menit
• Stroke Volume = SV = volume darah yang
dipompa jantung satu kali
• Heart rate = HR = denyut jantung per menit
• CO = HR x SV
2b_Circulation 6
Cardiac output
Jantung
=
Pembuluh pompa
darah =
pipa
Darah
=
isi pipa
Venous return
2b_Circulation 7
Krisis sirkulasi
• Hipovolemia : • Shock hipovolemik
– perdarahan
– muntaber
• Gagal jantung • Shock kardiogenik
– decomp. cordis
– infark miokard luas
• Anafilaksis, Cedera spinal, • Shock distributif
Sepsis
• Pericardial tamponade, • Shock obstruktif
tension pneumothorax
2b_Circulation 8
Cardiac output
perdarahan
multi-trauma
muntaber
peritonitis Jantung
=
Pembuluh pompa
darah =
pipa
Darah
=
isi pipa
Venous return
HIPOTENSI
50% SHOCK
Hipoksia, acidosis
2b_Circulation 13
Shock = gangguan oksigenasi jaringan / sel
2b_Circulation 14
2b_Circulation 15
Transport oksigen
Lactic acidosis
penurunan
perfusi perifer tachycardia hipotensi
dan shock
splanchnic
2b_Circulation 19
Otak dan Jantung
NORMAL
Hangat
Kering
2b_Circulation 21
Merah
Shock : Gangguan Perfusi Perifer
2b_Circulation 23
Shock: Nadi Meningkat
2b_Circulation 24
Shock : Tekanan Darah Menurun
2b_Circulation 25
Jenis shock
1. Hypovolemic:
kehilangan volume darah
2. Cardiogenic:
gangguan kerja jantung
3. Obstructive:
gangguan aliran darah masuk
dan keluar jantung
4. Distributive:
gangguan distribusi darah
di perifer
2b_Circulation Shoemaker,1992
26
Pastikan, korban sadar atau tidak waktu disapa
carotis
brachialis
radialis
femoralis
2b_Circulation 28
Cara mencari nadi carotis
|
raba trachea
|
tarik jari ke lateral
(2 cm)
2b_Circulation 29
Shock, Last Updated: October 19, 2004
Author: Adam Schwarz, MD, Clinical Associate Professor, Department
of Pediatrics, University of Arizona School of Medicine; Director of
Education Program, Division of Pediatric Critical Care, Phoenix
Children's Hospital
Initial treatment
(1) Regardless of the cause of shock, the ABCs must be evaluated and
stabilized immediately. (2) The patient's airway must be patent, and the
patient must be adequately oxygenated and ventilated. Initially, administer
100% supplemental oxygen at a high flow rate. (3) If the patient is in
respiratory distress, consider intubating and providing mechanical
ventilation. Stabilizing the airway and providing mechanical ventilation may
relieve the patient's metabolic work of breathing and facilitate elimination of
carbon dioxide, improving the coexistent metabolic acidosis. Once the
airway has been stabilized, and adequate ventilation and administration of
oxygen have been ensured, (4) immediately place attention on improving
circulation and systemic oxygen delivery (DO2). (5) Circulatory
improvement is achieved via volume expansion and, if necessary,
pharmacologic therapy with vasopressors and cardiac inotropic agents.
2b_Circulation 30
John P Pryor, MD, Instructor, Department of Surgery, Division of
Trauma and Surgical Critical Care, Hospital of the University of
Pennsylvania
2b_Circulation 32
Shock, First Aid, Update Date: 4/30/2004
Call 911 for immediate medical help.
Check the person's airway, breathing, and circulation. If necessary, begin
rescue breathing and CPR.
Even if the person is able to breathe on his or her own, continue to check
rate of breathing at least every 5 minutes until help arrives.
If the person is conscious and DOES NOT have an injury to the head, leg,
neck, or spine, place the person in the shock position.
Lay the person on the back and elevate the legs about 12 inches.
DO NOT elevate the head. If raising the legs will cause pain or potential
harm, leave the person lying flat.
Give appropriate first aid for any wounds, injuries, or illnesses.
Keep the person warm and comfortable. Loosen tight clothing.
2b_Circulation 33
The Merck Manual of Diagnosis and Therapy
Section 16. Cardiovascular Disorders Chapter 204.
Shock (1995-2005)
First aid involves keeping the patient warm, with the legs raised
slightly to improve venous return.
Hemorrhage should be stopped, airway and ventilation checked,
and respiratory assistance given if necessary.
Nothing should be given by mouth, and the patient's head should be
turned to avoid aspiration if emesis occurs.
Because tissue hypoperfusion makes absorption unreliable, all
drugs should be given IV if possible.
Although cerebral hypoperfusion may cause anxiety, sedatives or
tranquilizers should not be given.
2b_Circulation 34
Shock, Hypovolemic, Last Updated:July 12, 2006
Author: Paul Kolecki, MD, Director of Emergency Medicine Student
Education, Assistant Professor, Department of Emergency Medicine,
Thomas Jefferson University
Emergency Department Care: Three goals exist in the treatment of the patient
with hypovolemic shock as follows: (1) maximize oxygen delivery - completed by
ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and
restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.
2b_Circulation 36
Hypovolemic shock, hemorrhagic shock
2b_Circulation 37
Circulation
mengatasi perdarahan
• Hentikan perdarahan
• Posisi shock
• Pasang infus besar x 2
• Ambil sampel darah
– u/ darah donor dan periksa Hb
• Beri infus cairan, 1000 ml cepat
2b_Circulation 38
menghentikan perdarahan
dengan tekan langsung
pada luka
alasi tangan
dengan plastik
2b_Circulation 39
Bebat tekan
kasa tergulung
2b_Circulation 40
• Darah terus mengalir karena bebat tidak efektif
2b_Circulation 41
Bebat tekan / compression bandage
dengan verband elastik banyak
mengurangi perdarahan
2b_Circulation 42
Menghentikan perdarahan
prioritas utama
2b_Circulation 43
Pasang infusi pada vena besar
1. Vena cubiti, basilica
? 2b_Circulation 44
Tempat punksi
vena
jugularis
subclavia
basilica
vena lengan
lainnya
2b_Circulation 45
Pasien berdarah
perkirakan volume yang hilang
|
posisi shock
pasang infus jarum besar
ambil sample darah u/ cari donor
|
infusi RL 1000 (+ 1000 lagi)
• Cairan Kristaloid
– RL, NaCl 0.9%, RA → 2-4x EBL
– NaCl 5% atau 7.5% → 1/3 - 1/5x EBL
• Cairan Koloid
– gelatin → 2x EBL
– dextran, HES → 1x EBL
2b_Circulation 47
infus intra-osseus di tibia
2b_Circulation 48
Infus intra-osseus
• Jalur sementara sampai infus intravena
dapat dipasang.
• Infusi cairan dan obat-obat boleh masuk
intra-osseus
• Yang tidak boleh masuk lewat intra-osseus
– Natrium bicarbonat
– Transfusi ?
2b_Circulation 49
Perdarahan & tanda-tandanya
(korban dewasa)
infusi RL
sampai
normovolemia
Hb
turun
transfusi
perdarahan diberikan
hentikan jika Hb < 7
2b_Circulation 51
Hasil terapi infusi
• Sirkulasi membaik lalu stabil
– good response, normovolemia
• Sirkulasi membaik lalu merosot lagi
– transient response, masih hipovolemia,
ada perdarahan berlanjut
• Sirkulasi tidak membaik
– no response, masih tetap hipovolemia
2b_Circulation 52
waspada & cari lokasi perdarahan
• Cedera intra-abdominal
• Cedera dada
• Patah tulang panjang
• Patah tulang pinggul /
retroperitoneal
• Luka tusuk / tembus
• Luka kulit kepala
2b_Circulation 53
?
2b_Circulation 54
Case scenario on hemorrhagic case
(plenary)
2b_Circulation 55
Case scenario on hemorrhagic case
(plenary)
2b_Circulation 56
Circulation skill 1
• Identification of radial – brachial – femoral
and carotid pulse
• Evaluation and measurement of perfusion,
pulse rate, blood pressure
• Evaluation of jugular vein filling
• IV access
• Intra-osseus
• Compression bandage
• Shock position
2b_Circulation
(peer, on the floor) 59
Cardiogenic shock
2b_Circulation 60
Gangguan kerja jantung
• Contractility turun
– Cardio-myopathy, cardiac failure, infark luas
– Beta-blocker, High dose Ca-blocker
– High Spinal anesth, Deep general anesth
• Gangguan irama (arrhythmia)
– Severe bradycardia
• AV block, sinus brady
– Severe tachycardia
• SVT, AF rapid, VT
• Gangguan katub
– severe stenosis
– severe regurgitation
2b_Circulation 61
Gangguan Contractility
– Beta-blocker,
High dose Ca-blocker
– Dopamin, ephedrin,
– High Spinal anesth, adrenalin, nor-adrenalin
Deep general anesth
2b_Circulation 62
Tanda-tanda klinis
2b_Circulation 63
Terapi dengan obat-obat inotropik (+)
2b_Circulation 64
Gangguan irama jantung
2b_Circulation 65
Gangguan irama jantung
• Severe tachycardia • Amiodarone
• Beta-blocker : Propanolol
– SVT, AF rapid
• Ca-blocker : verapamil, diltiazem
• Adenosine (efek singkat)
• Digitalis (onset lambat)
• Synchronized DC 50-150 Joules