SHOCK AND FLUID SHOCK AND FLUID

THERAPY IN SHOCK THERAPY IN SHOCK THERAPY IN SHOCK THERAPY IN SHOCK

Bambang Suryono SBambang Suryono S

LIFE THREATLIFE THREAT

Dimana saja!!Dimana saja!!

Kapan saja!!Kapan saja!!

Pada siapa saja!!Pada siapa saja!! Pada siapa saja!!Pada siapa saja!!

Life ThreatLife Threat

OrangOrang sehatsehat

TRAUMA/PENYAKIT MENDADAKTRAUMA/PENYAKIT MENDADAK

TERANCAM JIWATERANCAM JIWA

PENYELAMATAN PENYELAMATAN

TAHAP LIFE SUPPORTTAHAP LIFE SUPPORT

BASIC LIFE SUPPORTBASIC LIFE SUPPORT

ADVANCED LIFE SUPPORTADVANCED LIFE SUPPORT

PROLONGED LIFE SUPPORTPROLONGED LIFE SUPPORT PROLONGED LIFE SUPPORTPROLONGED LIFE SUPPORT

FLUID THERAPYFLUID THERAPY

..

SHOCKSHOCK

Inadequate tissue perfusion along with Inadequate tissue perfusion along with

cellular hypoxia and oxygen debt, which cellular hypoxia and oxygen debt, which

results in cellular dysfunction and is caused results in cellular dysfunction and is caused

by inadequate systemic oxygen delivery or by inadequate systemic oxygen delivery or by inadequate systemic oxygen delivery or by inadequate systemic oxygen delivery or

impairment of cellular oxygen uptakeimpairment of cellular oxygen uptake..

Stages of ShockStages of Shock

1. A 1. A nonprogressivenonprogressive stage (compensated)stage (compensated)

in which the normal circulatory mechanisms in which the normal circulatory mechanisms

eventually cause full recovery without help from eventually cause full recovery without help from

outside therapyoutside therapyoutside therapyoutside therapy

2. A 2. A progressive stage, progressive stage, in which, without in which, without therapy, the shock become steadily worse until therapy, the shock become steadily worse until

death.death.

3. An 3. An irreversible stageirreversible stage

EVALUATION OF SYMPTOMSEVALUATION OF SYMPTOMS

HISTORYHISTORY

In In hypovolemichypovolemic shock : blood loss, trauma, shock : blood loss, trauma,

fluid losses, dehydration, third spacing or fluid losses, dehydration, third spacing or

other fluid losses. other fluid losses. other fluid losses. other fluid losses.

HistoryHistory

In adult In adult drop Systolic BP > 40 mmHg drop Systolic BP > 40 mmHg significant hypotensionsignificant hypotension

General Symptoms of ShockGeneral Symptoms of Shock

CNS changes CNS changes

*Confusion, coma, combative behavior, *Confusion, coma, combative behavior,

agitation, stuporagitation, stupor

Skin changesSkin changes

*Cool, clammy, warm, diaphoresis*Cool, clammy, warm, diaphoresis

Cardiovascular Cardiovascular

*Increase or decrease heart rate, *Increase or decrease heart rate,

arrhythmia, angina, low high or normalarrhythmia, angina, low high or normal

cardiac output, changes in pulmonary pressurecardiac output, changes in pulmonary pressure

General symptoms of shockGeneral symptoms of shock

Pulmonary Pulmonary

*Increased RR, increase or decrease in*Increased RR, increase or decrease in

endend-- tidal CO2, decrease O2 saturation,tidal CO2, decrease O2 saturation,

increased pulmonary pressures,increased pulmonary pressures, increased pulmonary pressures,increased pulmonary pressures,

respiratory failure, decreased tidal volume,respiratory failure, decreased tidal volume,

decreased FRCdecreased FRC

RENALRENAL

*Decreased urine output, elevation in BUN and *Decreased urine output, elevation in BUN and creatininecreatinine levels, change in urine electrolyte levelslevels, change in urine electrolyte levels

Common effects of shock on organsCommon effects of shock on organs

SystemicSystemic : Capillary leak, formation of micro: Capillary leak, formation of micro

vascular shunts, cytokine releasevascular shunts, cytokine release

CardiovascularCardiovascular : circulatory failure,: circulatory failure,

depression of cardiovascular function,depression of cardiovascular function, depression of cardiovascular function,depression of cardiovascular function,

arrhythmiaarrhythmia

HaematologicHaematologic : : bone marrow suppression,bone marrow suppression,

coagulopathycoagulopathy, DIC, platelet, DIC, platelet

dysfunctiondysfunction

.. Hepatic Hepatic : liver insufficiency, elevation of: liver insufficiency, elevation of

liver enzyme levels, liver enzyme levels, coagulopathycoagulopathy

NeuroendocrineNeuroendocrine : change in mental status, : change in mental status,

adrenal suppression, insulinadrenal suppression, insulin

resistance, thyroid dysfunctionresistance, thyroid dysfunction

Renal :Renal : renal insufficiency, change in urinerenal insufficiency, change in urine Renal :Renal : renal insufficiency, change in urinerenal insufficiency, change in urine

electrolyte levels, elevation of BUN electrolyte levels, elevation of BUN

and and creatininecreatinine levelslevels

Cellular :Cellular : cellcell--toto--cell dehiscence, cellularcell dehiscence, cellular

swelling, mitochondrial dysfunction,swelling, mitochondrial dysfunction,

cellular leakcellular leak

Hypovolemic shockHypovolemic shock

Cause :Cause : depletion of fluid in the intravascular depletion of fluid in the intravascular space (hemorrhage, vomiting, diarrhea, space (hemorrhage, vomiting, diarrhea, dehydration, capillary leak or a combinationdehydration, capillary leak or a combination))

SIRSSIRS capillary leakcapillary leak SIRSSIRS capillary leakcapillary leak

Findings : Findings : decreased CO, decreased PCWP, decreased CO, decreased PCWP, increase SVRincrease SVR

Echo :Echo :decreased rightdecreased right--sided filling, decreased sided filling, decreased stroke volume, increase aortic diameterstroke volume, increase aortic diameter

PerdarahanPerdarahan

Kehilangan akut darah dari sistim sirkulasiKehilangan akut darah dari sistim sirkulasi

Estimated blood volume /EBV:Estimated blood volume /EBV:

* Adult : 7% BW * Adult : 7% BW male 70 ml/kgmale 70 ml/kg

female 65 ml/kg female 65 ml/kg female 65 ml/kg female 65 ml/kg

*Children : 8*Children : 8--9% BW9% BW

The Role of FluidsThe Role of Fluids

Optimal organ function requires the twoOptimal organ function requires the two--

way movement of substrates and cell way movement of substrates and cell

products products between the circulatory system and between the circulatory system and the cells themselves.the cells themselves.the cells themselves.the cells themselves.

ClassificationClassification of of infusinfusion fluidsion fluids

11.D.Dextrose/glukose/fruktoseextrose/glukose/fruktose solutionsolution

2.2.CCrryystalstallloid : oid : RResusesusccitaitattiion fluidon fluid (Ringer (Ringer

laktat, Ringer asetat)laktat, Ringer asetat)

Maintenance fluid:Maintenance fluid:

Kaen 3A, Kaen 3B, Kaen MG3Kaen 3A, Kaen 3B, Kaen MG3

Tutofusin OPSTutofusin OPS

3.3.CColollloid : Dextran 40 ,70, Gelatin, Hydroxy oid : Dextran 40 ,70, Gelatin, Hydroxy

ethylethyl--starch, starch, artificial bloodartificial blood

InfusInfusion fluidsion fluids

4.4.ParenteralParenteral nutritionnutrition : : ccarboharbohyydratdratee,,

protein/protein/amino acidsamino acids

lipid, lipid,

combinationcombination

TriofusinTriofusin, , TriofusinTriofusin EE--1000, 1000, AminofusinAminofusin,,

AminolebanAminoleban, , LipovenousLipovenous

5.5.Blood productsBlood products : albumin, FFP, SPPS,: albumin, FFP, SPPS,

cryoprecipitatecryoprecipitate

CrystalloidCrystalloid

Expand the plasma volume by about 200 ml Expand the plasma volume by about 200 ml

perper--liter infused liter infused diluting circulating proteins, diluting circulating proteins, plasma COPplasma COP

Potentially harmful interstitial Potentially harmful interstitial overhydrationoverhydration Potentially harmful interstitial Potentially harmful interstitial overhydrationoverhydration

Crystalloid need to be administered at volumes 3 Crystalloid need to be administered at volumes 3

to 5to 5--folds greater than of (folds greater than of (isooncoticisooncotic) colloids ) colloids

to achieve comparable plasma volumes and to achieve comparable plasma volumes and resuscitation endpointsresuscitation endpoints

Infusion management: Infusion management:

A rational strategyA rational strategy Two different therapies for two different diagnosis Two different therapies for two different diagnosis

fluid substitution and fluid resuscitation.fluid substitution and fluid resuscitation.

The basis considerations:The basis considerations:

1.Save the endothelial 1.Save the endothelial glycocalyxglycocalyx from degradation due to from degradation due to 1.Save the endothelial 1.Save the endothelial glycocalyxglycocalyx from degradation due to from degradation due to

hyperinfusionhyperinfusion

2.Substitute fluid loss or dehydration using crystalloid 2.Substitute fluid loss or dehydration using crystalloid

infusionsinfusions

3.Replace volume loss or 3.Replace volume loss or hypovolemiahypovolemia with colloidal with colloidal

tetrastarchtetrastarch solutions until normalization of solutions until normalization of the circulating the circulating

blood volumeblood volume

ColloidColloid The intravascular COP after colloid infusion is influenced The intravascular COP after colloid infusion is influenced

by baseline COP, the degree of by baseline COP, the degree of hemodilutionhemodilution and the COP and the COP

of the infused volume and its plasma retention, determined of the infused volume and its plasma retention, determined

by the molecular weight distribution.by the molecular weight distribution.

Albumin solutions are Albumin solutions are monodispersemonodisperse (MW of 69 (MW of 69 kDakDa)) Albumin solutions are Albumin solutions are monodispersemonodisperse (MW of 69 (MW of 69 kDakDa))

Gelatins are Gelatins are polydispersepolydisperse and in excess of 75% of the and in excess of 75% of the

molecules are to be smaller than the renal threshold of 30 molecules are to be smaller than the renal threshold of 30

kDakDa..

ColloidColloid HydroxyHydroxy--ethylethyl--starch solutions is very starch solutions is very polydispersepolydisperse, ,

defined by degree of substitution and by MW.defined by degree of substitution and by MW.

The greater of degree of substitution The greater of degree of substitution the greater the greater

the resistance of degradation the resistance of degradation prolongs the prolongs the effectiveness of HES as a plasma expandereffectiveness of HES as a plasma expandereffectiveness of HES as a plasma expandereffectiveness of HES as a plasma expander

Colloid with a low COP50/COP10 ratio will be lost Colloid with a low COP50/COP10 ratio will be lost

more rapidly from intravascular spacemore rapidly from intravascular space

The resulting sealing effect may attenuate fluid The resulting sealing effect may attenuate fluid

extravasationextravasation independently of the COP by albumin.independently of the COP by albumin.

Replace Normal Replace Normal

Hypotonic infusionHypotonic infusion

5% dextrose 5% dextrose

increases ICF > ECFincreases ICF > ECF

ICF ISF PlasmaICF ISF Plasma

Replace Normal loss (IWL + urine)

Replace Normal loss (IWL + urine)

85 ml85 ml255 ml255 ml660 ml660 ml

Cairan

Infus IsotonicInfus Isotonic

Ringers acetate

Ringers lactate Normal saline

Ringers acetate Ringers lactate Normal saline

increases ECFincreases ECF

ICF ISF PlasmaICF ISF Plasma

Replace acute/abnormalloss

Replace acute/abnormalloss

800 ml 200 ml

RL 2liter/15 menit

PerdarahanPerdarahan

MulaiMulai segerasegera resusitasiresusitasi cairancairan agressifagressif::

Rule 3:1 Rule 3:1 untukuntuk perdarahanperdarahan akutakut

PengobatanPengobatan disesuaikandisesuaikan dengandengan responrespon

pasienpasien padapada terapiterapi awalawalpasienpasien padapada terapiterapi awalawal

Tanda perdarahanTanda perdarahan

KlasKlas II (BB 70 Kg)(BB 70 Kg) ----------------------------------------------------------------------------------------------------------------------

PerdarahanPerdarahan ml ml sampaisampai 750750

PerdarahanPerdarahan (%BV) (%BV) sampaisampai 15%15%

NadiNadi < 100< 100

TensiTensi NormalNormal

TekTek NadiNadi (mmHg) (mmHg) Normal Normal atauatau naiknaik TekTek NadiNadi (mmHg) (mmHg) Normal Normal atauatau naiknaik

NafasNafas 14 14 -- 2020

Urine ml/jam Urine ml/jam > 30> 30

SSP/status mental SSP/status mental sedikitsedikit CemasCemas

PenggantianPenggantian cairancairan KristaloidKristaloid

((hukumhukum 3:1)3:1)

Tanda perdarahanTanda perdarahan

Klas IIKlas II ----------------------------------------------------------------------------------------------------------------------

Perdarahan ml 750Perdarahan ml 750--15001500

Perdarahan (%BV) 15Perdarahan (%BV) 15--30%30%

Nadi >100Nadi >100

Tensi NormalTensi Normal Tensi NormalTensi Normal

Tek Nadi (mmHg) TurunTek Nadi (mmHg) Turun

Nafas 20Nafas 20--3030

Urine ml/jam 20Urine ml/jam 20--3030

SSP/status mental Cemas sedangSSP/status mental Cemas sedang

Penggantian cairan KristaloidPenggantian cairan Kristaloid

(hukum 3:1)(hukum 3:1)

Tanda perdarahanTanda perdarahan

KlasKlas IIIIII ----------------------------------------------------------------------------------------------------------------------

PerdarahanPerdarahan ml 1500ml 1500--20002000

PerdarahanPerdarahan (%BV) 30(%BV) 30--40%40%

NadiNadi > 120> 120

TensiTensi TurunTurun TensiTensi TurunTurun

TekTek NadiNadi (mmHg) (mmHg) TurunTurun

NafasNafas 3030--4040

Urine ml/jam 5Urine ml/jam 5--1515

SSP/status mental SSP/status mental CemasCemas gelisahgelisah

PenggantianPenggantian cairancairan KristaloidKristaloid & & darahdarah

((hukumhukum 3:1)3:1)

Tanda perdarahanTanda perdarahan

Klas IVKlas IV ----------------------------------------------------------------------------------------------------------------------

Perdarahan ml >2000Perdarahan ml >2000

Perdarahan (%BV) >40%Perdarahan (%BV) >40%

Nadi >140Nadi >140

Tensi turunTensi turun Tensi turunTensi turun

Tek Nadi (mmHg) turunTek Nadi (mmHg) turun

Nafas >35Nafas >35

Urine ml/jam tak adaUrine ml/jam tak ada

SSP/status mental gelisah/letargiSSP/status mental gelisah/letargi

Penggantian cairan kristaloid & Penggantian cairan kristaloid & darahdarah (hukum 3:1)(hukum 3:1)

Perdarahan bermaknaPerdarahan bermakna

perlu konsultasi BEDAHperlu konsultasi BEDAHperlu konsultasi BEDAHperlu konsultasi BEDAH

..

Keputusan PengobatanKeputusan Pengobatan

Respon pasien pada resusitasi cairan Respon pasien pada resusitasi cairan

merupakan penentu terapi berikutnyamerupakan penentu terapi berikutnya

INGATINGAT

Bedakan antara Bedakan antara hemodinamik stabilhemodinamik stabil dan dan Bedakan antara Bedakan antara hemodinamik stabilhemodinamik stabil dan dan

hemodinamik normalhemodinamik normal

Keputusan TerapiKeputusan Terapi

ResponRespon cepatcepat

*< 20% *< 20% perdarahanperdarahan

**StabilStabil : : responrespon padapada penggantianpenggantian cairancairan

**LanjutkanLanjutkan monitormonitor **LanjutkanLanjutkan monitormonitor

**EvaluasiEvaluasi dandan konsultasikonsultasi bedahbedah

Keputusan TerapiKeputusan Terapi

ResponRespon transienttransient

2020--40% 40% perdarahanperdarahan

TidakTidak stabilstabil : : memburukmemburuk setelahsetelah terapiterapi cairancairan

awalawal awalawal

LanjutkanLanjutkan cairancairan dandan darahdarah

EvaluasiEvaluasi dandan konsultasikonsultasi bedahbedah

PerdarahanPerdarahan berlanjutberlanjut : : operasioperasi

Keputusan terapiKeputusan terapi

TakTak adaada responrespon (minimal)(minimal)

> 40% > 40% perdarahanperdarahan

TakTak adaada responrespon padapada terapiterapi cairancairan

SingkirkanSingkirkan kemungkinankemungkinan shock shock SingkirkanSingkirkan kemungkinankemungkinan shock shock

nonnon-- hemorrhagikhemorrhagik

OperasiOperasi segerasegera

Diagnosis & pengobatanDiagnosis & pengobatan

PitfallsPitfalls

**TensiTensi tidaktidak samasama dengandengan cardiac outputcardiac output

**UmurUmur

**AtlitAtlit **AtlitAtlit

**HipotermiHipotermi

**PengobatanPengobatan

**PacuPacu--jantungjantung

Differential DiagnosisDifferential Diagnosis

Distributive shockDistributive shock

HypovolemicHypovolemic shockshock

Obstructive shockObstructive shock

CardiogenicCardiogenic shockshock CardiogenicCardiogenic shockshock

DDDD

HypovolemicHypovolemic shockshock Dehydration (low fluid intake, diarrhea, bowel Dehydration (low fluid intake, diarrhea, bowel

obstruction, sweating or diabetes obstruction, sweating or diabetes insipidusinsipidus))

DiuresisDiuresis (diuretics, hyperglycemia)(diuretics, hyperglycemia) DiuresisDiuresis (diuretics, hyperglycemia)(diuretics, hyperglycemia)

Capillary leak and third spacing (burns, sepsis, Capillary leak and third spacing (burns, sepsis,

pancreatitis, surgical stress) pancreatitis, surgical stress)

Hemorrhage (trauma , GIT bleeding, fractures, Hemorrhage (trauma , GIT bleeding, fractures,

vascular injuries, ectopic pregnancy, etc)vascular injuries, ectopic pregnancy, etc)

AnemiaAnemia

Management and TherapyManagement and Therapy

The basic goal of shock therapy is the restoration The basic goal of shock therapy is the restoration of effective perfusion to vital organs and tissue of effective perfusion to vital organs and tissue before the onset of cellular injury.before the onset of cellular injury.

Basic resuscitation Basic resuscitation ::

1.Rapid placement of a 1.Rapid placement of a largelarge-- bore bore i.vi.v line line or a or a 1.Rapid placement of a 1.Rapid placement of a largelarge-- bore bore i.vi.v line line or a or a highhigh--flow central line as a route for fluid flow central line as a route for fluid resuscitationresuscitation

2. 2. Secure the airway Secure the airway and and on on mechanical ventilation mechanical ventilation if necessary highif necessary high--flow oxygenation flow oxygenation oxygen oxygen saturation > 92% & PaO2 > 60saturation > 92% & PaO2 > 60

Put Put 3.Foley catheter 3.Foley catheter

Fluid resuscitationFluid resuscitation

2/3 crystalloid + 1/3 colloid2/3 crystalloid + 1/3 colloid

Loss of blood volume:Loss of blood volume:

> 25% > 25% erythrocyte concentrationerythrocyte concentration

> 60% > 60% 4 erythrocyte concentration4 erythrocyte concentration > 60% > 60% 4 erythrocyte concentration4 erythrocyte concentration

+ FFP+ FFP

> 80% > 80% polytransfusionpolytransfusion + AT < 50.000+ AT < 50.000

+ + thrombocytethrombocyte

Massive red blood cell transfusion Massive red blood cell transfusion microfiltermicrofilter

. . Diagnose and treat underlying cause Diagnose and treat underlying cause

concomittantly.concomittantly.

Laboratory: Laboratory:

CrossmatchingCrossmatching

Hb/Hct/ATHb/Hct/AT

Electrolyte, creatinineElectrolyte, creatinine Electrolyte, creatinineElectrolyte, creatinine

BGA & pH, lactate, coagulation parameterBGA & pH, lactate, coagulation parameter

Transaminases, albuminTransaminases, albumin

General goals for support of shock patientsGeneral goals for support of shock patients

Hemodynamic supportHemodynamic support

MAP > 60MAP > 60--65 mmHg65 mmHg

PCWP= 15PCWP= 15--18 mmHg18 mmHg

Cardiac index > 2.1 L/min per m2 of body surface Cardiac index > 2.1 L/min per m2 of body surface

area for area for cardiogeniccardiogenic and obstructive shockand obstructive shock

Cardiac index > 4.0 L/min per m2 body surface Cardiac index > 4.0 L/min per m2 body surface

area for septic, traumatic, or hemorrhagic shockarea for septic, traumatic, or hemorrhagic shock

General goalsGeneral goals

Optimization of oxygen deliveryOptimization of oxygen delivery

HbHb level > 10 g/dllevel > 10 g/dl

Arterial oxygen saturation > 92%Arterial oxygen saturation > 92%

Reversal of organ system dysfunctionReversal of organ system dysfunction

Maintain urine output > 0.5 ml/kg per hourMaintain urine output > 0.5 ml/kg per hour

A Fluid ChallengeA Fluid Challenge

A diagnostic intervention designed to give A diagnostic intervention designed to give

an indication of whether a patient with an indication of whether a patient with

hemodynamic compromise will benefit from hemodynamic compromise will benefit from

further fluid replacementfurther fluid replacementfurther fluid replacementfurther fluid replacement

To administer a preTo administer a pre--determined volume of iv determined volume of iv

fluid over a short period of time while fluid over a short period of time while

measuring a change in the patientmeasuring a change in the patients s cardiovascular parameterscardiovascular parameters

The aim:The aim:

To differentiate hypovolemia, or relative To differentiate hypovolemia, or relative

hypovolemia, which might improve with hypovolemia, which might improve with

further fluid, further fluid, fromfrom cardiac failure or a full cardiac failure or a full further fluid, further fluid, fromfrom cardiac failure or a full cardiac failure or a full

intravascular volume in which case further fluid intravascular volume in which case further fluid

will not improve things and may cause will not improve things and may cause

deteriorationdeterioration

Indication fluid challengeIndication fluid challenge

Cardiac index 120 bpmbpm

OliguriaOliguria (urine output < 25(urine output < 25--30 ml/hr)30 ml/hr)

Lactic acidosisLactic acidosis Lactic acidosisLactic acidosis

Oxygen delivery < 600 ml/min/m2Oxygen delivery < 600 ml/min/m2

Cool extremitiesCool extremities

The need for The need for vasoactivevasoactive drugdrug

Pulmonary Pulmonary arteriarteri occlusive pressure (PAOP) < 18 mmHgocclusive pressure (PAOP) < 18 mmHg

The Surviving Sepsis Resuscitation Bundle The Surviving Sepsis Resuscitation Bundle

recommends: 1000 ml crystalloid or 300recommends: 1000 ml crystalloid or 300--500 ml 500 ml

of colloid over 30 minutes.of colloid over 30 minutes.

In ICU : 250 ml colloid run 5In ICU : 250 ml colloid run 5--10 minutes10 minutes In ICU : 250 ml colloid run 5In ICU : 250 ml colloid run 5--10 minutes10 minutes

ProtocolProtocol

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

CVP PAOP ACTIONCVP PAOP ACTION

mmHg mmHgmmHg mmHg

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

During fluid challenge increase > 5 Increase > 7 Stop infusion,During fluid challenge increase > 5 Increase > 7 Stop infusion,

WAIT & reassessWAIT & reassess

Following fluid challenge increase 3Following fluid challenge increase 3--5 Increase 35 Increase 3--7 WAIT & reassess7 WAIT & reassessFollowing fluid challenge increase 3Following fluid challenge increase 3--5 Increase 35 Increase 3--7 WAIT & reassess7 WAIT & reassess

Following fluid challenge increase < 3 Increase < 3 Safe to repeat fluid Following fluid challenge increase < 3 Increase < 3 Safe to repeat fluid

bolus if indicatedbolus if indicated

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Balans CairanBalans Cairan

Tiap pemberian cairan harus dibuat balans Tiap pemberian cairan harus dibuat balans

cairan: tiap 6 atau 8 jam, dihitung total tiap 24 cairan: tiap 6 atau 8 jam, dihitung total tiap 24

jam.jam.

Semua cairan masuk dihitung: oral dan infusSemua cairan masuk dihitung: oral dan infus Semua cairan masuk dihitung: oral dan infusSemua cairan masuk dihitung: oral dan infus

Setiap cairan keluar dihitung: urine, Setiap cairan keluar dihitung: urine,

muntah/NGT, diare, drain, IWL (insensibel muntah/NGT, diare, drain, IWL (insensibel

water loss)water loss)

Fluid resuscitation in traumatic shockFluid resuscitation in traumatic shock::

1. ABC1. ABC

2. Restored tissue oxygenation2. Restored tissue oxygenation

3. Avoid / prevent tissue injury3. Avoid / prevent tissue injury 3. Avoid / prevent tissue injury3. Avoid / prevent tissue injury

4. Monitor vital sign4. Monitor vital sign

5. Collaboration to allied surgeon5. Collaboration to allied surgeon