Shock

Tatat A. Agustian
dr.SpAn.MKes

Objectives

Define shock
Recognize the shock state
Determine the cause
Apply treatment principles
Apply principles of fluid management
Monitor patients response
Employ options for vasculer access
Recognize complications of vascular access

Key Issues : Shock

Management
Recognize inadequate organ

perfusion
Identify the cause
Hemorrhagic vs nonhemorrhagic
Treatment
Stop the bleeding!
Restore volume

Cardiac Physiology
CO = SV X HR

Preload

Contractility

Venous
Capacitance

Afterload

Vascular
dp / dt

Tone

Cardiac Physiology
CO = stroke volume x heart rate
Stroke volume is determined by:
Preload
Volume of venous return to the heart
Venous capacitance, volume status,
difference between mean venous systemic
pressure and right atrial pressure.
Myocardial contractility
Starlings Law
Afterload
Systemic vascular resistance

Pathophysiology

Cellular Alteration in
shock

Recognition of Shock State

1. Tachycardia
2. Vasoconstriction
2. Cardiac output
Narrow pulse pressure
3. Map
3. Blood Flow
Caution : Compensatory
mechanisms

Pitfalls in shock
Recognition
Extremes of age

Athletes
Pregnancy
Medications
Hematocrit/hemoglobin
concentration

Etiology of Shock
Hemorrhagic
Nonhermorrha
Most common
gic
Clinical clues

Tension
History & Physical pneumothorax
examination

Cardiogenic
Selected

Neurogenic
diagnostic tests

Septic

Hemorrhagic Shock

Loss of circulating blood volume

Normal blood volume
Adult 7% of ideal weight
Child: 9 % of ideal weight

Classification of
Hemorrhage

Class I-IV
Not absolute
Only A clinical guide
Subsequent treatment determined
by patient response

Class I Hemorrhage
750 mL BVL

Class II Hemorrhage
750 1500 ml BVL

Class III Hemorrhage

1500 2000 ml BVL

Class IV Hemorrhage :
2000
mlML BVL
2000

Fluid Shifts : Soft tissue

Injury
Blood loss into
injury site

Compounds
intravascular loss.

Tissu
e
edem
a

Assessment and
Management

Recognize shock
Stop the bleeding !
Replenish intravascular volume
Restore organ perfusion

Assessment and
Management
Airway and Breathing

Oxygenate and ventilate

Pao > 80 mm hg (10,6 kpa)

Circulation
Assess
Control
Treat

Assessment and
Management

Disability cerebral perfusion

Exposure/Environment
Associated injuries
Prevent hypothermia
Gastric and bladder decompression
Urinary output

Management : Vascular
Access

2 large caliber, peripheral IV s

Central access
Femoral
Jugular
Subclavian
Intraosseous
Obtain blood for croossmatch

Management : Fluid
Therapy
Warmed crystalloid solution

Rapid fluid bolus ringer,s lactate

Adult: 2 Liters, Ringers Lactate
Child :20 ml /kg Ringers lactate
Monitor response to initial
therapy

Reevaluate Organ
perfusion
Monitor

Vital signs
CNS status
Skin perfusion
Urinary output
Pulse oximetry

Resuscitation
Evaluation

Hourly Urinary Output

Inadequate output suggests
inadequate resuscitation

Acid Base
Abnormalities

Monitor with ABGs

Usual etiology
Adult : Acidosis due to inadequate
perfusion
Child : Acidosis due to inadequate
ventilation

Acid Base
Abnormalities
Treatment
Oxygenate and ventilate
Stop the bleeding !
Consider inadequate volume
restoration
Bicarbonate rarely indicated

Therapeutic Decisions
Patient response determines
subsequent therapy
Hemodynamically normal vs
hemodynamically stable
Recognize need to resuscitate in
operating room

Therapeutic Decisions
Rapid Response
<20 % blood loss
Responds to fluid replacement
Surgical consultation
evaluation
Continue to monitor

Therapeutic Decisions
Transient Response
20% -40% blood loss
Deteriorates after initial fluids
Surgical consultation evaluation
Continued fluid plus blood
Continued hemorrhage :
Operation

Therapeutic Decisions
Minimal to No Response

> 40% Blood loss

No Response to fluid resuscitation

Immediate surgical consultation

Exclude nonhemorrhagic Shock

Immediate operation

Volume Replacement
Warmed fluids
Crossmatched PRBCs
Type specific
Type O, Rh negative
Autotransfusion
Coagulopathy

Pitfalls
Equating Bp
with cardiac
output
Extremes of
age

Hypothermia

Athletes
Pregnancy
Medicatio
ns
Pacemake
r

Avoiding Complications
Continued hemorrhage
Fluid overload
Invasive monitoring (ICU)
CVP
Pulmonary artery catheter
Other problems

Keys to Successful
Treatment
Early control of hemorrhage

Euvolemia
Continuous reevaluation

Summary

Restore organ perfusion

Early recognition of the shock state
Oxygenate and ventilate
Stop the bleeding
Restore volume
Continuous monitoring of response
Anticipate pitfalls