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Shock
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Objectives
 Define shock
 Recognize the shock state
 Determine the cause
 Apply treatment principles
 Apply principles of fluid management
 Monitor patient’s response
 Employ options for vascular access
 Recognize complications of vascular access
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Key Issues : Shock Management

 Recognize inadequate organ perfusion
 Identify the cause
• Hemorrhagic vs nonhemorrhagic
 Treatment
• Stop the bleeding!
• Restore volume
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Cardiac Physiology

CO = SV x HR

Preload Contractility Afterload

Venous Vascular
dp / dt
Capacitance Tone
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Pathophysiology
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Cellular Alteration in shock

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Recognition of Shock State

1. Tachycardia
2. Vasoconstriction
2.  Cardiac output
Narrow pulse pressure
3.  Map
3.  Blood Flow

Caution : Compensatory mechanisms

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Pitfalls in shock Recognition

 Extremes of age
 Athletes
 Pregnancy
 Medications
 Hematocrit / hemoglobin concentration
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Etiology of Shock
Hemorrhagic Nonhemorrhagic
 Most common  Tension

 Clinical clues pneumothorax

• H&P  Cardiogenic

• Selected  Neurogenic

diagnostic tests  Septic

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Hemorrhagic Shock
 Loss of circulating blood volume
 Normal blood volume
• Adult 7% of ideal weight
• Child: 9 % of ideal weight
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Classification of Hemorrhage

 Class I-IV
 Not absolute
 Only a clinical guide
 Subsequent treatment determined by
patient response
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Class I Hemorrhage
750 mL BVL
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Class II Hemorrhage
750 – 1500 mL BVL
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Class III Hemorrhage

1500 – 2000 mL BVL
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Class IV Hemorrhage
≥ 2000 mL BVL
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Fluid Shifts : Soft – tissue Injury

Blood loss into Tissue

injury site edema

Compounds
intravascular loss
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Assessment and Management

 Recognize shock
 Stop the bleeding !
 Replenish intravascular volume
 Restore organ perfusion
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Assessment and Management

 Airway and Breathing
• Oxygenate and ventilate
• PaO2 > 80 mm Hg (10.6 kPa)
 Circulation
• Assess
• Control
• Treat
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Assessment and Management

 Disability – cerebral perfusion
 Exposure / Environment
• Associated injuries
• Prevent hypothermia
 Gastric and bladder decompression
 Urinary output
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Management : Vascular Access

 2 large – caliber, peripheral IVs
 Central access
• Femoral
• Jugular
• Subclavian
 Intraosseous
 Obtain blood for crossmatch
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Management : Fluid Therapy

 Warmed crystalloid solution

 Rapid fluid bolus Ringer’s lactate
• Adult : 2 liters Ringer’s lactate
• Child : 20 ml /kg Ringer’s lactate
 Monitor response to initial therapy
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Reevaluate Organ perfusion

Monitor
 Vital signs

 CNS status

 Skin perfusion

 Urinary output

 Pulse oximetry
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Resuscitation Evaluation
Hourly Urinary Output
Inadequate output suggests
inadequate resuscitation
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Acid –Base Abnormalities

 Monitor with ABGs
 Usual etiology
• Adult : Acidosis due to inadequate
perfusion
• Child : Acidosis due to inadequate
ventilation
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Acid –Base Abnormalities

 Treatment
• Oxygenate and ventilate
• Stop the bleeding !
• Consider inadequate volume
restoration
 Bicarbonate rarely indicated
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Therapeutic Decisions
 Patient response determines
subsequent therapy
 Hemodynamically “normal” vs

hemodynamically “stable”
 Recognize need to resuscitate in

operating room
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Therapeutic Decisions

Rapid Response
 < 20% blood loss

 Responds to fluid replacement

 Surgical consultation evaluation

 Continue to monitor
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Therapeutic Decisions
Transient Response
 20% - 40% blood loss

 Deteriorates after initial fluids

 Surgical consultation evaluation

 Continued fluid plus blood

 Continued hemorrhage : Operation

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Therapeutic Decisions
Minimal to No Response
 > 40% blood loss

 No response to fluid resuscitation

 Immediate surgical consultation

 Exclude nonhemorrhagic shock

 Immediate operation
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Volume Replacement

Warmed fluids
 Crossmatched PRBCs

 Type – specific

 Type O, Rh negative

 Autotransfusion

 Coagulopathy
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Pitfalls

 Equating Bp  Athletes
with cardiac  Pregnancy

output  Medications

 Extremes of age  Pacemaker

 Hypothermia
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Avoiding Complications
 Continued hemorrhage
 Fluid overload

 Invasive monitoring (ICU)

• CVP
• Pulmonary artery catheter
 Other problems
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Keys to Successful Treatment

 Early control of hemorrhage

 Euvolemia

 Continuous reevaluation
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Questions
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Summary
 Restore organ perfusion
 Early recognition of the shock state
 Oxygenate and ventilate
 Stop the bleeding
 Restore volume
 Continuous monitoring of response
 Anticipate pitfalls