Stop Bleeding

Bagian Anestesiologi dan Reanimasi

FK Unsyiah – RSUZA
Banda Aceh
Pasien Kritis /
Trauma
Penatalaksanaan awal
Life Support
Resusitasi
Stabilisasi

Terapi Definitif
 Sebelum Stop bleeding…..

Airway dan Breathing evaluasi dulu

Bleeding Un-stopable
Un-treatable
Under Diagnosis

SHOCK HIPOVOLEMIA
 RESPON HEMODINAMIK
REDISTRIBUSI ALIRAN DARAH

HYPOTENSION

STIMULASI NEUROENDOKRIN

BLOOD FLOW BLOOD FLOW

PROTECTED DECREASED
Heart Skin
Brain Muscle
Adrenal/pituitary gland Splanchnic circulation
 Stages of shock
Parameter Class 1 Class 2 Class 3 Class 4

%Blood Loss <15% 15-30% 30-40% >40%

Pulse <100 >100 >120 >140

BP Normal Normal Decreased Decreased

UOP (ml/h) >30 20-30 5-15 <5

Mental Anxious Agitated Confused Lethargic

Status
Therapeutic Goals in Shock

• Increase O2 delivery
• Optimize O2 content of blood
• Improve cardiac output and
blood pressure
• Match systemic O2 needs with O2 delivery
• Reverse/prevent organ hypoperfusion
 Tata-laksana
mengatasi perdarahan hebat
• Airway
• Breathing
• Circulation and hemorrhage
control

• Shock position
• Replace blood loss
• Stop / minimize the bleeding process
 Jenis perdarahan
• Dapat ditekan (Compressible)
- permukaan tubuh, ekstremitas

• Tidak dapat ditekan (Non-compressible)

- intra-abdominal
- harus diatasi dengan pembedahan
- memerlukan resusitasi cairan
Dapat ditekan (Compressible hemorrhage)
- permukaan tubuh, ekstremitas

Gunakan sarung tangan / lapis plastik

 Bebat tekan

Gunakan 2 gulung kasa

mengganti volume sirkulasi

• Pasang infus jarum besar

• Ambil sampel darah
– u/ crossmatch dan periksa Hb

• Beri infus cairan

– RL (Ringer Laktat)

– NaCl 0.9% (Garam Fisiologis)

– RA (Ringer Asetat)
 Bleeding and signs
(adult patient)

• Bleeding < 750 ml 750-1500ml > 1500ml

• Cap. refill normal prolonged prolonged
• Pulse rate < 100 > 100 > 120
• Systolic BPnormal normal decrease
• Breathing normal 20-30 > 30-40
• Consciousnes normal agitated agitated/
coma
Shock position Raise
both legs

300 - 500 ml of blood

in the legs will be shifted
toward central circulation

This is the quickest help

which can be provided
everywhere
raise
 Bleeding patient
estimate blood loss
|
shock position
insert 2 large bore iv catheter
obtain blood sample for cross matching
|
infuse RL 1000 (+ 1000 prn)

Warm, pink, dry perfusion Bad perfusion

pulse < 100 pulse >100, BP-syst <100
BP-syst > 100 |
| Add more RL
Slower infusion up to 2- 4 x est. blood loss
Location & Estimation of blood loss

Closed Femur fracture 1.5-2 litre

Closed Tibia fracture 0.5 litre
Pelvic fracture 3 litre
Hemothorax 2 litre
Rib fracture (each) 150 ml
Wound, fist size 500 ml
Blood clot, fist size 500 ml
Concealed hemorrhage
• Intra-abdominal (liver,
spleen, arteries)
• Pleural cavities
• Pelvis
• Long bones (esp. femur)
• Scalp (children)
Internal bleeding (example: liver rupture)
1. Survival depends on quick infusion and prompt surgery
2. If bleeding remains uncontrollable, do staged operation
(Damage Control Surgery)
Insert large bore needle in large
veins
1. Vena cubiti, basilica

2. Vena jugularis ext

(3. Vena subclavia)

(4. Vena saphena magna)

?
 intra-osseus infusion at tibia
(only for NaCl, Ringer’s Lactate, Ringer’s Acetate)

Don’t inject
Sodium bicarbonate
 BLOOD TRANSFUSION
considered when

Hemodynamic remains unstable

despite “adequate” fluid replacement

Hemoglobin < 7 g/dl

and patient still losing
blood
 Fluid infusion

• Colloids or crystalloids?
• Consider hypotensive resuscitation if
bleeding is not under control or surgery
needs longer time to proceed,
80-90 mmHg systolic seems reasonable *)

*) do not over resuscitate to normal values

 Fluid infusion

• Warm all infusion fluid (38C) since hypothermia < 35C results
in coagulation abnormalities

• In case infusion IS NOT available, consider oral fluid

replacement if patient is conscious or nasogastric fluid
therapy:
– Low concentration of glucose / salt

– Diluted cereal porridge

 SHOCK
(hypovolemic, cardiogenic)
|
metabolic acidosis
Old formula for Bicarb |
1/3 x BW x BE
is intended for do not give
Acute Renal Failure Na-bicarbonate
NOT for shock pts

Consider Na-bicarbonate only if

- pH < 7.10 (increase to 7.15-7.20)
- BE > -10 (reduce to -5)
Terima Kasih