Dept. of Anesthesiology & Reanimation Faculty of Medicine, Gadjah Mada University Yogyakarta, 2009 I. INTRODUCTION DEFINITION : SHOCK : STATE OF SYSTEMIC METABOLIC DEMAND WHICH DOES NOT MEET WITH BLOOD SUPPLY DIAGNOSIS : - ANAMNESIS : HISTORICAL FINDINGS WHICH POSIBLE TO CAUSE SHOCK - PHYSICAL EXAMINATION : DISCOVERED SIGNS OF SHOCK - LABORATORY FINDINGS : DEPEND ON THE TYPE OF SHOCK Intro. Continues ... ANAMNESTIC FINDINGS FOR SHOCK : - LAKE OF FLUIDS INTAKE AND/OR PROFUSE FLUIDS LOSS - ANY KINDS OF CARDIAC DISEASES - ANY KINDS OF SEVERE ILLNESS (SEPSIS, ANAPHYLACTIC REACTION, INJURY OF BACK BONE ETC. - ANY KINDS OF TRAUMA OR PATALO- GIC PROCESS ON CHEST/LUNG Intro. continues SIGNS ON THE PHYSICAL EXAMINTANION : - DECREASE OF MENTAL STATUS, & OTHER SIGNS OF ORGAN HYPOPERFUSION - HYPOTENSION - TACHYCARDIA, OR ARRYTHMIA, OR BRADY- CARDIA (DEPEND ON THE CAUSA & STADI- UM OF SHOCK) - OLIGURIA - COLD ACRAL Introduction .... LAB. FINDINGS : e.g. : - METABOLIC ASIDOSIS FOR ALL KINDS OF SHOCK - HEMOCONCENTRATION FOR HYPOVOLEMIC SHOCK - BACTERIEMIA FOR SEPTIC SHOCK - TENSION (PNEUMOTHORAX WITH LUNG COLLAPS AND MEDIASTINUM SHIFT ON CHEST X-RAY) FOR OBSTRUCTIVE SHOCK - CARDIOMEGALI OR ABNORMALITY OF CARDIAC APPEARANCE IN CHEST X-RAY AND ECG FOR CARDIAC SHOCK II. BASIC PRINCIPLES OF SHOCK MANAGEMENT AIRWAY FREE ADEQUATE BREATHING ( VENTILATE THE ALVEOLI, OPTIMIZED BLOOD OXYGENATION, INCREASE O2 DELIVERY & TISSUE OXYGENATION ) ADEQUATE CIRCULATION (INCREASE CARDIAC OUTPUT & BLOOD PRESSURE WITH FLUID, POSITIVE INOTROPES AND VASOPRESSORS DEPEND ON THE CAUSA & PATHOPHYSIOLOGY) SEARCH CAUSA AND TREAT PROMPLY GUIDE OF TREATMENT WITH CLOSED MONITORING GENERAL EARLY TARGET IN SHOCK RESUSCITATION COMPOS MENTIS A & B NORMAL C : BP SYSTOLE > 90 mmHg, HR < 100 x/mnt Cap. Refill < 2 sec. warm extremities FLUID : URINE PROD. > 0,5 cc/kg/hr Face mask-valve-bag III. MAJOR CATAGORIES OF SHOCK 1. HYPOVOLEMIC SHOCK
2. CARDIOGENIC SHOCK
3. DISTRIBUTIVE SHOCK
4. OBSTRUCTIVE SHOCK HYPOVOLEMIC SHOCK DEPLETION OF INTRAVASCULAR VOLUME CAUSA : LAKE OF FLUID INTAKE AND OR PROFUSE FLUID LOSSES ( eg. ANOREXIA, CANNOT DRINK & MEAL, PATOLOGIC T G I, HEMORRHAGE, VOMITUS, DIARRHEA, EVAPORATION OR THIRD-SPACE LOSSES ) HEMODYNAMIC PROFILE : DECREASED CO, DECREASED LEFT VENTRICULAR FILLING PRESSURE, INCREASED SVR MANAGEMENT OF HYPOVOLEMIC SHOCK STEPS A, B, C RESTORATION OF INTRAVASCULAR VOLUME WITH KOLLOID OR KRISTALLOID TARGET : NORMAL BP, PULSE & ORGAN PERFUSION (e g. adequate urine output) PRINCIPLES IN FLUID RESUSCITATION : - RAPID (to normovolumia) - CLOSED TO THE KIND OF DEFICITE FLUID - USE THE AVAILABLE FLUID CARDIOGENIC SHOCK INADEQUATE FORWORD BLOOD FLOW CAUSA: ANY PATHOLOGIES OF HEARTH HEMODYNAMIC PROFILE : DECREASED CO, HIGH VENTRICULAR FILLING PRESSURE, VARIABLE SVR MANAGEMENT OF CARDIOGENIC SHOCK STEPS A, B, C IMPROVE MYOCARDIAL FUNCTION ARRHYTMIA SHOULD BE TREATED PROMPTLY INOTROPES iv. (Dobutamine, to increase myocard contractility) VASOACTIVE DRUGS iv. (In Case of low SVR, vasoconstrictor to increase aortic diastolic pressure, in case of high SVR : vasodilator) INOTROPIC & VASOACTIVE DRUGS ADRENALIN NOREPINEPHRINE DOBUTAMINE & DOPAMINE LANOXIN ISOSORBID DINITRAT (ISDN) NTG (NITROGLYCERIN) CAPTOPRIL NOREPINEPHRINE EPHEDRINE PHENYLEPHRINE
DISTRIBUTIVE SHOCK ABNORMAL DISTRIBUTION AND PROFILE OF INTRAVASCULAR FLUID CAUSA : SEPSIS, ANAPHYLAXY, BLOCK OF SYMPATHETIC PATHWAY OR PARASYMPATIC HYPERACTIVE (NEUROGENIC), ACUTE ADRENAL IN- SUFFICIENCY HEMODYNAMIC PROFILE : NORMAL OR HIGH CO, LOW TO NORMAL LEFT VEN- TRICULAR FILLING PRESSURE, LOW SVR MANAGEMENT OF DISTRIBUTIVE SHOCK STEPS A, B, C RESTORATION & MAINTENANCE OF NORMAL INTRAVASCULAR VOLUME INCREASE BP WITH INOTROPES (IS/ARE ADMINISTERED IF PRELOAD IS ADEQUATE OR NORMOVOLUMIA) COMBINATION WITH VASOPRESSOR ANAPHYLACTIC SHOCK IS TREATED WITH EPINEPHRINE ( & SECURE A B C ) ACUTE ADRENAL INSUFF : VOLUME Tx, CORTICOSTEROIDS iv. AND VASOPRESSOR NEUROGENIC SHOCK : VOL. Tx,VASOPRESS., ATROPINE (for Bradycardia) OBSTRUCTIVE SHOCK OBSTRUCTION TO CARDIAC FILLING CAUSA : CARDIAC TAMPONADE, TENSION PNEUMOTHORAX, MASSIVE PULMONARY EMBOLI HEMODYNAMIC PROFILE : DECREASED CO, VARIABLE LEFT VENTRICULAR FILLING PRESSURE, INCREASED SVR MANAGEMENT OF OBSTRUCTIVE SHOCK STEPS A, B, C RELIEF OF OBSTRUCTON (PERICARDIOCENTESIS, PLEURAL /THORACAL PUNCTION & WSD ) MAINTENANCE OF NORMOVOLEMIA INOTROPES & VASOPRESSOR HAVE A MINIMAL ROLE DIURETICS SHOULD BE AVOIDED Spesial notice : SHOCK IS ONE OF CRITICALLY ILL, LIFE THREATENING SHOULD BE TREATED PROMPTLY, WITH RESUSCITATION THE PROGNOSIS IS CORRELATED WITH TIME CAUSA & PATOPHYSIOLOGY MAY BE COMPLICATED, THEREFORE THE MANAGEMENTS SHOULD BE ADJUSTED CLOSELY Alhamdulillahirobbilalamin