Initial Treatment of

Shock in ER

Erwin Siregar
RS Jantung dan Pembuluh Darah
Harapan Kita
Type of Shock
• Hypovolemic shock :
– Haemorrhage
– Dehydration
• Septic shock
• Cardiogenic shock
• Neurogenic shock

The 2nd National Symposium on Emergencies, August 28th, 2005

Hypovolemic shock
• Initial resuscitation important

– FLUID
– Drugs
– Monitoring

The 2nd National Symposium on Emergencies, August 28th, 2005

Body Fluids
• Water comprises about 60 % total body
weight

• Extracellular fluid (20 % tbwt)

– Interstitial (15 % tbwt)
– Intravascular (5 % tbwt)
– Transcellular (CSF, aqueous humour etc)
– Intracellular fluid (40 % tbwt)

The 2nd National Symposium on Emergencies, August 28th, 2005

Distribution of Fluid
• 70 kg man (57 % water)
• Total 42 liters
– Extracellular 14 liters (20 % of mass)
• Interstitial fluid ~ 11.2 liters
• Intravenous (plasma) ~ 2.8 liters
– Intracellular 28 liters (40 % of mass)
• Red blood cells ~ 2 liters

The 2nd National Symposium on Emergencies, August 28th, 2005

Type of Fluids
• Crystalloid
• Colloid :
– Isotonic colloid
– Hypertonic colloid
• Hypertonic saline

The 2nd National Symposium on Emergencies, August 28th, 2005

Crystalloids
• True solutions
• Freely distributed across semi
permeable membranes
• Plasma expansion < infused volume
• Rapidly excreted
• Expansion ECF : PV ~ 4 : 1
• Limited duration of effect (+ 90 min)

The 2nd National Symposium on Emergencies, August 28th, 2005

• Crystalloids
– Extracellular space expanders
– Limited plasma volume expansion
– Maintain urine output
– Reduce plasma oncotic pressure
– Range of electrolyte content
– CHEAP

The 2nd National Symposium on Emergencies, August 28th, 2005

Isotonic Colloids
• Suspension of large particles
• Generally limited to vascular compartment
• Volume for volume plasma expansion
• Excretion determined by molecular size
• Osmotic effect dependent on number of
particles
• Duration of effect 2-12 hours

The 2nd National Symposium on Emergencies, August 28th, 2005

Hypertonic colloid/ solutions
• Expansion of intravascular space
• Contraction of ECF

The 2nd National Symposium on Emergencies, August 28th, 2005

Crystalloid vs Colloid ?
Colloid advantages Colloid disadvantages
• Intravascular space • Coagulation problem
expanders • Variable electrolyte
• Volume for volume content
expansion • Variable half life
• Rapid resuscitations • Adverse reactions
• Maintain oncotic • EXPENSIVE !!!
pressure
• Less tissue edema
• Less pulmonary
edema

The 2nd National Symposium on Emergencies, August 28th, 2005

Crystalloid vs Colloid ?
Early 1990
• Place of colloids firmly established
• Role of crystalloids being challenged:
increased tissue oedema equated to
increased lung oedema
increased brain oedema
• “The end of crystalloid era”
Twigley & Hilma, Anaesthesia, 1985

The 2nd National Symposium on Emergencies, August 28th, 2005

So what went wrong ???
As colloids are not associated with an
improvement in survival, and as they
are more expensive than crystalloids,
it is hard to see how their continued
use in these patient types can be
justified outside the context of
randomized controlled trials

Cochrane Database Review, 2000

The 2nd National Symposium on Emergencies, August 28th, 2005

How good are the crystalloids ?

The 2nd National Symposium on Emergencies, August 28th, 2005

Is normal saline NORMAL ??
• Is 0.9 % saline isotonic ?
– Normal plasma osmolality 280-290
mOsm/l
– 0.9 % saline = 154 x 2 = 308 mOsm/l
• Is it physiological ?
– pH = 6.35
– Chloride load can cause acidosis

• ABNORMAL SALINE ???

The 2nd National Symposium on Emergencies, August 28th, 2005

Ringer’s vs Saline
• No real difference in most situations
• Sodium and acid load from saline
• Lactate’s in Ringer only important in
the presence of liver failure
• Ringer’s low in sodium and
osmolality (275 mOsm/L)

The 2nd National Symposium on Emergencies, August 28th, 2005

Key Point on Crystalloids
• Large volume are frequently required
• Large volume of abnormal solutions
may produce abnormality
• Some evidence of brain edema
• Saline :
– Hypernatremia and acidosis
• Ringer’s
– Hyponatremia and alkalosis

The 2nd National Symposium on Emergencies, August 28th, 2005

Hypertonic Salines (7.5 %)
• High osmolality (2400 mOsm/l)
• Small volume resuscitation
• Reduces cerebral no-reflow in CPR
– Fischer M, Resusctitaion, 1996
• Decreases brain water in head injury
– Sheik AA, Crit Care Med, 1996
• Effective for a limited period only
– Favre Schweiz, Med Wochenschnr, 1996
• Reversed trauma-induced
immunosuppresion
– Coimbra R, J Surg Res, 1996

The 2nd National Symposium on Emergencies, August 28th, 2005

Colloids
• Plasma protein fractions
• Gelatins
• Dextrans
• Starches

The 2nd National Symposium on Emergencies, August 28th, 2005

Plasma Derived Colloids
• Plasma (FFP, cryoprecipitate)
– Coagulations problem only
• Albumin
• Plasma protein fractions /SHS

The 2nd National Symposium on Emergencies, August 28th, 2005

Albumin
• Expensive
• No evidence of benefit
• Some evidence of harm
• ANZICS SAFE study :
– 7000 patients randomized to Alb or NS
– Increased mortality with albumin ( p< 0.05) in
trauma (more intracerebral bleeding)

The 2nd National Symposium on Emergencies, August 28th, 2005

Gelatins
• Moderate molecular weight
28-35 kDa
• Short duration of actions
2 – 4 hrs
• Minimal coagulation disturbances
• Significant allergic risk
Haemacel > Gelofusin

The 2nd National Symposium on Emergencies, August 28th, 2005

Dextran
• MW 40 – 70 kDa
• Prolonged duration of effect
• Improved microcirculation
• Significant impairment of
coagulation
• Small anaphylactoid risk
• Some risk of renal dysfunction

The 2nd National Symposium on Emergencies, August 28th, 2005

Starches
• Range of molecular weight
70-450 kDa
determines properties
• Long to very long duration
• May improve microcirculation and
endothelial function
• Moderate to small coagulation effect
• Minimal anaphylactoid risk

The 2nd National Symposium on Emergencies, August 28th, 2005

Colloid, summary
• Gelatins,
– Short term volume effect
– Minimal effect on coagulation
– No dose limitation
• Dextrans,
– Medium term volume effect
– Significant coagulant inhibition
– Renal effect with Dex40
– Limit 15 ml/kg/24 hr
• HES
– Medium to long term volume effect
– Minimal to moderate coagulation effect
– Limit 33 ml/kg/24hr (6%) or 20 ml (10 %)

The 2nd National Symposium on Emergencies, August 28th, 2005

Fluid Balance Consequences in
Early Shock
• Mobilization of ECF
• Hemodilution of plasma
– ? Coagulation effect
– Gradual fall in Hb
• Maintenance of vascular space at the
expense of the ECF

The 2nd National Symposium on Emergencies, August 28th, 2005

Late shock
• Capillary leak
• Loss of plasma volume
• Tissue edema
• Organ edema (lung, kidney)
• Multiple Organ Failure

The 2nd National Symposium on Emergencies, August 28th, 2005

OBJECTIVES
• Early, complete restoration of tissue
oxygenation
• Minimal biochemical disturbances
• Preservation of renal function
• Avoidance of transfusion
complications

The 2nd National Symposium on Emergencies, August 28th, 2005

Fluid Choices
• Well-balanced resuscitation fluid
resembling extracellular fluid
• Rapid volume expansion of
intravascular space
• Sustained expansion
• No sugar

The 2nd National Symposium on Emergencies, August 28th, 2005

Problems with BLOOD
• Disease
• Biochemical abnormalities :
– Hypernatremia
– Acidosis
– Hyperkalaemia
– Hypocalcaemia
• Delayed effects :
– Metabolic alkalosis
– Hypokalaemia
– Immunomodulation

The 2nd National Symposium on Emergencies, August 28th, 2005

Blood
• Limit transfusions
• Transfusion threshold < 7 g/dL
• Maintenance leve 7-9 g/dL
• Older patients and those with
ischemic heart disease may need
higher Hb

The 2nd National Symposium on Emergencies, August 28th, 2005

 Timing of Resuscitation
• Do not delay transfer for resuscitation
• Priority is arrest of hemorrhage
• Commence aggressive resuscitation
once control of bleeding is imminent

Pepe et al, Emerg Med Clin North Am, 1998

The 2nd National Symposium on Emergencies, August 28th, 2005

 Timing of Resuscitation
• Controlled fluid resuscitation
• Balance hypoperfusion vs bleeding risk
• Anemia than hypovolemia
• Not yet proven that colloids reduce
mortality in trauma patients
• In SIRS, HES may reduce capillary leak
• HS solutions may benefit head injuries
• Hemoglobin-based oxygen carriers may be
useful in future

Nolan, Resuscitation, 2001

The 2nd National Symposium on Emergencies, August 28th, 2005

Selection of Fluids
• Early aggressive crystalloid therapy
(2-3 liters RL, 0.9 % saline)
• Colloids if needed :
– Short duration colloid if volume
requirement is temporary
– Long acting colloid otherwise
• Red blood cells if Hct < 25
• FFP, cryoprecipitate only for
coagulation problems

The 2nd National Symposium on Emergencies, August 28th, 2005

DRUGS
• Inotropes :
– Dobutamine
– Dopamine
– Adrenaline
• Vasopressors
– Noradrenaline
– Adrenaline
– Vasopressin
– Phenylephrine

The 2nd National Symposium on Emergencies, August 28th, 2005

MONITORING
• Non invasive
– NIBP
– Urine output
– HR
– Capillary filling
– Pulse oxymetry
• Invasive
– Arterial line
– CVP
– PA pressure (Swan
Ganz catheter)

The 2nd National Symposium on Emergencies, August 28th, 2005

DOBUTAMIN

• Agonis β-1 yang poten

• Kontraktilitas miokard ↑
• Heart Rate sedikit ↑
• Efek vasodilatasi ringan :
inodilator
• Memperbaiki perfusi
splanknikus
The 2nd National Symposium on Emergencies, August 28th, 2005
Dopamin
• Dosis kecil – sedang ( sampai 7 µg/kgBB/mnt ) β-
adrenergik
• Dosis besar α- adrenoreseptor ↑
vasokonstriksi

Dopamin : inotropik + vasokonstriktor

• Kerugian :
– Takikardia : iskemia miokard ; hati-hati
– Dapat menyebabkan “steal effect” pada GI tract
– Dapat mengganggu fungsi “pituitary gland” & tiroid
– Dapat mempunyai efek immunosupresif

The 2nd National Symposium on Emergencies, August 28th, 2005

 NORADRENALIN
(VASCON®)

• Neurotransmitter postsynaps
adrenergic
• Stimulasi α-1 dan β-1
adrenoreseptor
• Dosis rendah : efek β
• Vasokonstriksi dan MAP ↑
The 2nd National Symposium on Emergencies, August 28th, 2005
ADRENALIN
• Mempunyai aktivitas β-1, β-2,
dan α-1 yang poten
• Pada sepsis MAP ↑ oleh karena
CO ↑ (stroke volume ↑)

• Kerugian :
– Kebutuhan O2 miokard ↑
– Laktat serum ↑

The 2nd National Symposium on Emergencies, August 28th, 2005

 VASOPRESIN (ADH)

• Dapat dipakai sebagai

vasokonstriktor bila vaso
konstriktor katekolamin tidak
berhasil

• Mengurangi perfusi
splanknikus
The 2nd National Symposium on Emergencies, August 28th, 2005
 FENILEFRIN

• α-1 agonis murni

• Sebagai vasokonstriktor tidak
menyebabkan takikardia
• Sering dipakai di anestesi dan
ICU untuk mengatasi dilatasi

The 2nd National Symposium on Emergencies, August 28th, 2005

 SEKALI LAGI !!

Persisten hipotensi,
tambahkan vasopresin

Pasien
Hipotensif Target
Resusitasi Persisten Hipotensi
Tentukan PCWP
Cairan Tambah Noradrenalin
Target ≥15mmHg
MAP

MAP N, oliguria, CO↓,

Tambah dobutamin,
dopamin

The 2nd National Symposium on Emergencies, August 28th, 2005

Conclusion
• Initial treatment in ER ,is Critical and very
important to avoid further complications
(organs, etc)
• Knowledge of presenting shock is of
paramount importance
• Familiar with characteristics of various
resuscitation fluids
– Blood is used if absolutely necessary
• Knowledge of inotropes and vasopressors
• Ability to use invasive monitors an
advantage

The 2nd National Symposium on Emergencies, August 28th, 2005

The 2nd National Symposium on Emergencies, August 28th, 2005