Emergency shock suju 2025 untuk tugas pat

tentang materi PAT

1. SHOCK Pathophysiology, Symphtoms , Therapy Sri Martuti UKK ERIA

2. Outline Shock : Pathophysiology, Symphtoms Type of Shock dan Therapy How to choose the type of fluid How much fluid to give

3. Definition S tate of tissue hypoperfusion D ue to inadequate oxygen delivery, increased oxygen consumption, inadequate oxygen utilization (combination of these factors) Gupta 2023

4. DO2 (Delivery Oxygen) VO2 (Oxygen Compsumtion ) Shock : Patophysiology Cardiac output (CO) Arterial Oxygen Content Stroke volume Preload Contractility Afterload Heart rate Hb x 1.34 x SaO2 + 0.003 x PaO2 Low Preload : Hipovolemi c Obstruktif Septi c Low Afterload : D i str ibu t i ve Septi c Low Contactility Kardiogenic Septic

5. Tipe Shock & Patofisiologi Tank Pump Pipe

6. Symphtoms

7. Tool untuk penilaian kegawatan anak ABCDE (Airway, Breathing, Circulation, Disability, Exposure) PAT (Pediatric Assessment Triangle)

8. SAGA TAMPILAN A ppearance USAHA NAPAS Work of B reathing SIRKULASI C irculation to skin Pediatric Assesment Trangle (PAT) Segitiga Asesmen Gawat Anak (SAGA) Abnormal position Nasal flare Chest retraction Abnormal sound Tonus Interactiveness Consolabillity Look/gaze Speech/cry Cyanosis Pallor Mottled

9. Sign and Symphtome of Shock H yperventilation Tachycardia P oorly palpable pulse Cyanosis H ypotension S hows cool- map-like skin C apillary refill time > 3 seconds. Ol igo-anuria

10. Sign Hipovolemic Cardiogenic Obstructive Distributif A Patency Depend on Consiousness Respiratory rate Increased B Work of Breathing N or Increased Very Increased or Increased Breathing Sound Normal Rales or Grunting Decreased (pneumothorax) Normal (Rales in pneumonia) Sistolic BP N or hypotension Hypotension Pulse Pressure Narrow (pulsus paradoxus in tamponade) Widen (or Narrow C Pulse Rate Increased Peripheral pulse Weak Bounding Skin Pale, cold Warm Capillary Refill Time Prolonged Rapid Primary Survey Finding A B E D C

11. General Management of Shock Oxygen : Mask Oxygen, NIV, Invasif MV Vasculair Acces Fluid Rescucitaion Correct metabolic abnormalities S upportive therapy for organ dysfunction Temperature control, Sedation Definitive Therapy : depend on causes/type of shock R egular hemodynamic monitoring Goal: increase oxygen delivery and decrease oxygen demand

12. Device pd tatalaksana jalan napas Pipa nasofarings Penyangga orofarings (Guedel) Pipa Supraglotis (LMA) Pipa Ekstraglotis (combitube) Pipa ET BV Mask

13. UKURAN dan POSISI Oropharyngeal Airway

14. Memilih Face Mask

15. CE Position

16. Laringoskop Daun Lurus (Miller) Daun Lengkung (Macintosh)

17. Posisi optimal untuk laringoskopi (anak > 2 tahun)

18. Miller vs Macintosh

19. Laryngoscopy Gunakan laryngsocope yang paling familiar Gunakan 5 jari untuk memberikan tekanan eksternal

20. Endotracheal Tubes Age Diameter (mm) Lenght (cm) premature 3.0 6 + wgt in kg newborn 3.0 10 6 mo 3.5 11 1 yr 4.0 12 2 yr 4.5 13 4 yr 5.0 14-15 6 yr 5.5 15-16 ENDOTRACHEAL TUBE

21. Oral tube size (mm) Umur (thn) / 4 + 4.5 (Cote’s formula) Umur (thn) / 3 + 3 Length of ETT Oral (cm): Age (yr)/2) + 12 cm Nasal (cm): (Age (yr)/2) + 15 cm

22. Obat-obatan

23. Type Of Shock Management Hypovolemic NonHemorragic 10-20 ml/kg RL/NS, repeat as needed Consider Colloid Hemorragic Bleeding Control 10-20 ml/kg bolus, repeat as needed PRC if indication Distributif Septic Algoritm Septic shock Anaphylactic IM epinephrine 0.01 mg/kg 1:1000 10-20 ml/kg bolus, repeat as needed Inhalation albuterol Antihistamin , Steroid Infuse epinephrine 0.05-0.5 mcg/kg/ mnt Neurogenic 10-20 ml/kg bolus, repeat as needed Vasopressor Therapy Causes of Shock

24. Type Of Shock Management Cardiogenic Bradi / Tachiaritmia Algoritm Aritmia Non- aritmia Bleeding Control 5-10 ml/kg bolus, repeat as needed Vasoactive (inotropic) Consult to Cardiologist Obstructive Obstructive LV Prostaglandin E1 Consult to Cardiologist Pneumotorax Needle decompression Water Sealed Drainage Tamponade Pericardiosintesis 20 ml/kg bolus, repeat as nedeed Lung Emboli 20 ml/kg bolus, repeat as needed Trombolitic ( rTPA ), antikoagulan (heparin, enoksiparin ) Expert consul TherapyCauses of Shock

25. Vascular Acces Intraoseous Acces Peripheral Intravenous Central Catheter

26. Fluid Management in shock How to choose the type of fluid How much fluid to give

27. What Type of Fluid Crystalloids are the recommended fluids for initial resuscitation in septic shock B alanced crystalloids (Ringer lactate or PlasmaLyte ) VS crystalloids with higher chloride concentrations (0.9% normal saline) a lower risk of hyperchloremic acidosis a lower risk acute kidney injury (AKI) a lower risk overall mortality Current SSC 2020 guidelines  recommended the use of balanced salt solution over NS as bolus fluid therapy

28. Synthetic colloids (hydroxyethyl starch)  associated with increased risk of acute kidney injury, coagulopathy, and death in patients with septic shock. Use of albumin is associated with better outcomes  recommended in conditions with large fluid losses in third spaces (DSS) The latest guidelines recommend against the use of colloids in the management of sepsis and septic shock

29. What is the type of fluid : crystalloid vs colloid Kemp MEA. Southern African Journal of Anaesthesia and Analgesia . 2020;26(6 Suppl 3):S80-85

30. How Much Fluid??? Aggressive fluid resuscitation using fluid boluses of 40–60 mL/kg  consistently shown to be associated with reduced mortality.

31. Sign of fluid overload : JVP Hepatomegaly Rales Rontgen : pulmonary edema SSC 2020 Hypotension criteria : SBP < 50 mmHg  < 1 yo SBP < 60 mmHg  1-5 yo SBP < 70 mmHg  > 5 yo

32. Method of fluid administration The rapidity with which a fluid bolus can be administered is still unknown  the recommendations for pushing fluids as fast as possible in the presence of hypotension. In two pediatric RCTs : administered over 5–10 min VS over 15–20 min G reater rates of intubation G reater mechanical ventilation H epatomegaly No difference in mortality The current recommendations : a slower rate of fluid bolus administration  particularly in resource-limited settings

33. Assessing fluid overload:   C umulative fluid overload > 10% is associated with increased mortality Monitoring : fluid status, cardiac function, and fluid overload : C linical signs P oint-of-care ultrasound E chocardiography De-resuscitation  associated with better outcomes : fluid restriction use of diuretics or renal replacement therapy (RRT)

34. Therapeutic Endpoints (goals) of rescucitation Quality of central and peripheral pulses (strong, distal pulses equal to central pulses) Skin perfusion (warm, with capillary refill <2 seconds) Mental status (normal mental status) Urine output (≥1 mL/kg/hour, up to 40 mL/hour, once effective circulating volume is restored) Blood pressure (systolic pressure at least fifth percentile for age): <1 month of age: 60 mmHg 1 month to 10 years of age: 70 mmHg + [2 x age in years]  10 years of age and older: 90 mmHg Normal serum lactate ( eg , <2 mmol /L) Central venous oxygen saturation (ScvO 2 ) ≥70 percent

35. Bolus 10-20 ml/kg but patients still shock Fluid?? Drug?? Reffer ?

36. Predict of Fluid Responsiveness Passive Leg Raising (PLR) Noninvasive cardiac output monitoring : Stroke Volume Variation (SVV), Stroke Volume Index (SVI) Respiratory variations of inferior vena cava diameter IVC Collapsibilty Index (CI)

37. Conclusion : This meta-analysis suggests that RUSH protocol has generally good role to distinguish the states of shock in patients with undifferentiated shock reffered to the emergency departement

38. Drug Name Effect Inotropik Dopamin 5 – 10 mcg /kg/ mnt Dobutamin 5 – 20 mcg /kg/ mnt Epinefrin 0,05 – 0,3 mcg /kg/ mnt Contractility ↑ Heart Rate ↑ SVR : Variation effect depend on doses Fosfodiesterase inhibitor ( inodilator ) Milrinon 0,25 – 0,75 mcg /kg/ mnt Contractility ↑ Improve in coronary flow ↓ SVR Vasodilator Nitrogliserin 0,25 – 1 mcg /kg/ mnt Nitroprusid 0,5 – 4 mcg /kg/ mnt ↓ SVR Vasopresor Epinefrin > 0,3 mcg /kg/ mnt Norepinefrin 0,05 – 0,5 mcg /kg/ mnt Dopamin > 10 mcg /kg/ mnt Vasopresin 0,01 – 0,5 U /kg/jam SVR ↑ Contractility ↑ ( execp . Vasopresin )

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