Sinkop dan Syok

dr. Rosalin Maruf

Moderator
dr. Ceva Pitoyo, Sp.PD, K-P, KIC
SINKOP
Sinkop
Definitions

• Syncope is define as TLOC (Transient Loss of

Consciousness) due to cerebral hypoperfusion,
characterized by a rapid onset, short duration, and
spontaneous complete recovery.

• TLOC is define as a state of real or apparent LOC with loss

of awareness, characterized by amnesia for the period of
unconsciousness, abnormal motor control, loss of
responsiveness, and a short duration.
Classification
of syncope
Pathophysiology
Conditions that may be incorrectly
diagnose as syncope
Diagnostic Evaluation and Risk Stratification
Clinical Features
Diagnostic Test

1) Carotid Sinus Massage

2) Orthostatic Challenge
3) Basic Autonomic Function Tests
4) ECG
5) Video Recording in Suspected Syncope
6) Electrophysiological Study
7) Endogenous Adenosine and Other Biomarkers
8) Echocardiography
9) Exercise Stress Testing
Treatment of Syncope
SYOK
Cardiogenic shock - a major component of the the mortality
associated with cardiovascular disease (the #1 cause of
U.S. deaths)
Hypovolemic shock - the major contributor to early mortality
from trauma (the #1 cause of death in those < 45 years of
age)
Septic shock - the most common cause of death in
American ICUs (the 13th leading cause of death overall in
US)
Definisi

• Sindroma Klinis yang terjadi akibat perfusi jaringan yang

tidak adekuat.10
• Suatu sindrom klinis yang terjadi akibat gangguan
hemodinamik dan metabolik ditandai dengan kegagalan
system sirkulasi untuk mempertahankan perfusi yang
adekuat ke orga n-organ vital tubuh.1

10Antono, Dono. Dalam: Irawan C. Pitoyo C, Rinaldi I. Imels Basic II. Jakarta: Departemen Ilmu Penyakit Dalam Fakultas
Kedokteran Universitas Indonesia – Rumah Sakit Cipto Mangunkusumo; 2018; h 183 – 187
1 Setiyohadi B, Subekti I. Pemeriksaan Fisis Umum dan Kulit. Dalam: Setiati S, Alwi I, Sudoyo AW, Simadibrata M, Setiyohadi B,

Syam AF, editor. Buku Ajar Ilmu Penyakit Dalam Jilid I, Edisi ke-6. Jakarta: Interna Publishing; 2014: h. 130.
Patofisiologi dan Klasifikasi
HYPOVOLEMIC
Hemorrhagic
• Trauma
• Gastrointestinal
• Retroperitoneal
Fluid depletion (nonhemorrhagic)
• External fluid loss
- Dehydration
- Vomiting
- Diarrhea
- Polyuria
• Interstitial fluid redistribution
- Thermal injury
- Trauma
- Anaphylaxis

Increased vascular capacitance (venodilatation)

• Sepsis
• Anaphylaxis
• Toxins/drugs
CARDIOGENIC
Myopathic
• Myocardial infarction (hibernating myocardium)
• Left ventricle
Right ventricle
Myocardial contusion (trauma)
Myocarditis
Cardiomyopathy
Post-ischemic myocardial stunning
Septic myocardial depression
Pharmacologic
• Anthracycline cardiotoxicity
• Calcium channel blockers
Mechanical
• Valvular failure (stenotic or regurgitant)
• Hypertropic cardiomyopathy
• Ventricular septal defect
Arrhythmic
• Bradycardia
• Tachycardia
EXTRACARDIAC OBSTRUCTIVE

Impaired diastolic filling (decreased ventricular preload)

• Direct venous obstruction (vena cava)
- ntrathoracic obstructive tumors
• Increased intrathoracic pressure
- Tension pneumothorax
- Mechanical ventilation (with excessive pressure or volume depletion)
- Asthma
• Decreased cardiac compliance
- Constrictive pericarditis
- Cardiac tamponade

Impaired systolic contraction (increased ventricular afterload)

• Right ventricle
- Pulmonary embolus (massive)
- Acute pulmonary hypertension
• Left ventricle
- Saddle embolus
- Aortic dissection
DISTRIBUTIVE

Septic (bacterial, fungal, viral, rickettsial)

Toxic shock syndrome
Anaphylactic, anaphylactoid
Neurogenic (spinal shock)
Endocrinologic
• Adrenal crisis
• Thyroid storm
Toxic (e.g., nitroprusside, bretylium)
Prinsip Umum Tatalaksana

Syok Cairan Vasopresor Inotropik

Hipovolemik + - -

Distributif + + +/-

Kardiogenik - - +
Obstruktif +/- +/- +/-
Syok Hipovolemik
Management of
Hypovolaemic Shock
Skor Daldiyono

• Cairan diberikan dalam 2 jam

RESUSITASI CAIRAN:
Jenis Cairan
Uraian Kristaloid Koloid
Lama bertahan di Singkat Bertahan lebih
intravaskular lama
Kondisi stabilisasi Sementara Bertahan lebih
hemodinamik lama
Kebutuhan cairan Lebih banyak Lebih sedikit
Risiko edema jaringan Ada Kecil
Perfusi sistem kapiler Tidak sempurna Lebih baik
Risiko anafilaksis Tidak ada Ada
Tekanan onkotik plasma Menurun Dapat
dipertahankan
Harga Murah Lebih mahal
Targets11
• Traditional Physiological targets
– Return of systolic BP >90 mmHg or to normal for that person
– MAP >65 mmHg
– Pulse rate <100 x/i
– CVP >10 mmHg
– A sustained rise of CVP >7 mmHg in response to fluid

• Perfusion Targets
– Urine Output >0.5 ml/kg/h
– Lactate of less than 2 mmol/L
– Resolving base deficit
– Central Venous Oxymetry level 70-80%
– CRT <4s
– Cilinical impression of improved skin perfusion and peripheral
pulses
 • Invasive Measurment Targets
– Cardiac Index of >2,5 L/min/m3
– Pulmonary artery occlusion pressure of >15 mmHg
– Echocardiogram assesment of LV end diastolic volume and CO
– Mixed venous oximetry of 70-75%

11 Garret. Shock Overview : Textbook of Adult Emergency Medicine. ameron, et all. 2009. Churchill Livingstone.
Syok Kardiogenik
Syok Kardiogenik

• Syok kardiogenik terjadi ketika ventrikel kiri gagal memompa

darah yang membawa oksigen ke jaringan perifer akibat
perubahan kontraktilitas.
• Penyebab: infark miokard, gagal jantung, gangguan irama
jantung (disritmia), kelainan katup jantung
Penatalaksanaan
Syok Septik