UPDATE IN SHOCK MANAGEMENT - Syahfri

UPDATE
IN SHOCK
MANAGEMENT
SYAFRI K. ARIF

Department of Anesthesiology , Intensive care and Pain Management
Faculty of Medicine Hasanuddin university
Makassar
Introduction
Classi<ication of shock
• Hypovolemic shock
• Distributive shock
• Cardiogenic shock
• Obstructive shock
Standi T, Annecke T, Cascorbi I, Heller AR, Sabashnikov A, Teske W. The nomenclature, deGinition, and distinction of types of shock. Dtsch Arztebl Int. 2018; 115: 757–68.
Hypovolemic Shock
DeGinition
•  Condition of inadequate organ perfusion caused by loss of

intravascular volume, usually acute.
Results
•  A drop in cardiac preload to a critical level and reduced macro-

and microcirculation, with negative consequences for tissue
metabolism and the triggering of an inGlammatory reaction.
Hypovolemic Shock
Hemorrhagic shock
• Resulting from acute hemorrhage without major soft tissue injury.
Traumatic hemorrhagic shock
• Resulting from acute hemorrhage with soft tissue injury and, in addition, release of immune system
activators
Hypovolemic shock in the narrower sense
• Resulting from a critical reduction in circulating plasma volume without acute hemorrhage
Traumatic hypovolemic shock
• Resulting from a critical reduction in circulating plasma volume without acute hemorrhage, due to soft
tissue injury and the release of immune system mediators.
Hypovolemic Shock
Treatment
•  Immediate intravascular volume replacement (Gluid

resuscitation) with balanced crystalloids
•  Rapid bleeding control
•  Surgical management should be undertaken as soon as
possible using the damage control surgery (DCS)
•  Persisting hypotension à prompt administration of a
vasconstrictor
Haemorrhagic shock
Activate the trauma team
•  External haemorrhage à easily identiGied during the primary survey.

•  Occult blood loss à chest, abdomen, pelvis, retroperitoneum or long
bones.
•  Hypotension following injury must be attributed to blood loss until
proven otherwise.
•  Simple clinical observation: level of consciousness, skin colour, RR,
HR and pulse pressure à organ perfusion.
•  The elderly, children, athletes and individuals with chronic medical
conditions do not respond to blood loss in a uniform manner.
Rao S, Martin F. Guidelne for management of massive blood loss in trauma. Update in Anesthesia. 2019:124-9.
Haemorrhagic shock
Table 1. Grading shock - estimated blood loss based on patient’s clinical signs at presentation
Haemorrhagic shock
Stop the bleeding
• Intravenous replacement of intravascular

volume cannot succeed without deGinitive
control of bleeding.
• Compression bandages, use of limb tourniquets
and application of a pelvic binder for fractured
pelvis.
Haemorrhagic shock
Restore circulating volume
•  Prolonged hypovolaemic shock à high mortality

rate because of progression to organ failure andDIC.
•  The Girst priority à restoration of blood volume to
maintain tissue perfusion and oxygenation.
•  Fluid resuscitation must be started when early signs
and symptoms of blood loss are suspected, not when
blood pressure is falling or absent.
Haemorrhagic shock
Red cell transfusion
•  The loss of over 40% of blood volume is immediately life

threatening.
•  Red cell transfusion is usually required when 30-40% of the blood
volume is lost.
•  Rarely indicated when the Hb concentration >10 gr/dl, almost
always indicated when it is <6 gr/dl.
•  After equilibration and redistribution of crystalloid, the Hb
measured may actually be higher or lower than that during the
resuscitation period.
Haemorrhagic shock
Red cell transfusion
•  In a well-compensated patient without heart

disease, Hb 6 gr/dl may be an appropriate
transfusion trigger.
•  In patients with stable heart disease and with an
expected blood loss of 300ml à Hb 8gr/dl.
•  Older patients and those with co-morbidities, which
limit the ability to raise CO àHb 10gr/dl
Haemorrhagic shock
Stabilise the patient
•  The primary injury has been addressed à

transferred to the ICU for further treatment.
•  Regular clinical observations, haemoglobin levels
and blood gas analysis to ensure that resuscitation is
adequate and that bleeding is not continuing.
•  Haemostasis is secured à standard venous
thromboprophylaxis.
Haemorrhagic shock
Table 2. Interpretation of response to initial Gluid resuscitation.
Distributive Shock
DeGinition
•  A state of relative hypovolemia resulting from pathological

redistribution of the absolute intravascular volume
Causes
•  Loss of regulation of vascular tone

•  Volume being shifted within the vascular system
•  Disordered permeability of the vascular system with shifting of
intravascular volume into the interstitium.
Distributive Shock
Subtypes
• Septic shock
• Anaphylactic/anaphylactoid shock
• Neurogenic shock
Septic shock
Sepsis
•  Sepsis-3 criteria: a dysregulated response by the body to an

infection resulting in life-threatening organ dysfunctions.
Septic shock
•  A lactate value above 2 mmol/L and persistent hypotension

requiring the administration of vasopressors to keep MAP
>65 mmHg.
Septic shock
Treatment
•  Infusion of balanced crystalloid solutions

•  Administration of vasopressors, in some cases also
inotropic drugs
•  Organ replacement therapy
•  Advanced invasive monitoring
•  Broad-spectrum antibiotic therapy
•  Source control (causal treatment)
Table 3. Recommendations for Selected Interventions in Sepsis and Septic Shock.
Allen JM, Feild C, Shoulders BR, Voils SA. Recent updates in the pharmacological management of sepsis and septic shock: a systematic review focused on Gluid resuscitation,
vasopressors, and corticosteroid. Annals Pharmacother. 2019;53(4):385–95.
Anaphylactic and anaphylactoid shock
Characteristic
•  Massive histamine-mediated vasodilation and maldistribution with a shift of Gluid

from the intravascular to the extravascular space.
Treatment
•  Constant monitoring, as late reactions including arrhythmias, myocardial ischemia,

and respiratory failure may manifest as late as 12 hours after the initial event.
•  Administration of epinephrine (plus norepinephrine, if necessary)
•  Forced Gluid replacement
•  Sympathomimetics and glucocorticoids
•  Histamine antagonists
Neurogenic shock
DeGinition
•  State of imbalance between sympathetic and

parasympathetic regulation of cardiac action and vascular
smooth muscle.
Sign
•  Profound vasodilation with relative hypovolemia while blood

volume remains unchanged, at least initially.
Neurogenic shock
Management
• Hemodynamic stabilization
• Initial C-spine immobilization
• Surgical intervention
Dave S, Cho JJ. Neurogenic shock [online]. May 6th 2019 [cited on January 7th 2020]. Available from: URL: http://emedicine.medscape.com.
Neurogenic shock
Treatment
•  Treatment of the cause

•  Rapid Gluid replacement
•  Norepinephrine is given at increasing dosages
until peripheral vascular resistance rises
•  Direct- or indirect-acting sympathomimetics
•  Mineralocorticoids
Cardiogenic shock
DeGinition
•  A disorder of cardiac function in the form of a critical reduction of the

heart’s pumping capacity, caused by systolic or diastolic dysfunction leading
to a reduced ejection fraction or impaired ventricular Gilling.
Signs
•  SAP <90 mmHg or mean arterial blood pressure of 30 mmHg below the
baseline value and cardiac index (CI) <1.8 L/min/m2 without
pharmacologic or mechanical support or <2.0 L/min/m2 with support.
•  Evidence of cardiac dysfunction is required, together with the exclusion of
other types of shock (differential diagnosis).
Cardiogenic shock
Treatment
•  Removing the cardiac causes of the shock.

•  The earliest possible coronary reperfusion in ACS
•  Symptomatic treatment
•  Catecholamines (dobutamine), norepinephrine, epinephrine
•  Vasodilators
•  Calcium sensitizers
•  PDE3 inhibitors
•  Antiarrhythmic drugs
•  Mechanical circulatory support
Obstructive Shock
DeGinition
•  A condition caused by the obstruction of the great vessels or the heart itself.
Causes
•  Vena cava compression syndrome

•  Tension pneumothorax
•  Pericardial tamponade
•  High-PEEP ventilation.
•  Pulmonary artery embolism
•  Mediastinal space-occupying mass
•  Intracardial mass
Obstructive Shock
Treatment
• Immediate causal treatment

• Pulmonary embolism à thrombolysis
• Tension pneumothorax or pericardial
tamponade à thoracic or pericardial drainage
• Leriche syndrome à surgical embolectomy
Table 4. Typical drugs for treatment of the various types of shock

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UPDATE

• Condition of inadequate organ perfusion caused by loss of

• A drop in cardiac preload to a critical level and reduced macro-

• Resulting from acute hemorrhage without major soft tissue injury.

Traumatic hemorrhagic shock

Hypovolemic shock in the narrower sense

Traumatic hypovolemic shock

• Immediate intravascular volume replacement (Gluid

Activate the trauma team

• External haemorrhage à easily identiGied during the primary survey.

Stop the bleeding

• Intravenous replacement of intravascular

Restore circulating volume

• Prolonged hypovolaemic shock à high mortality

Red cell transfusion

• The loss of over 40% of blood volume is immediately life

Red cell transfusion

• In a well-compensated patient without heart

Stabilise the patient

• The primary injury has been addressed à

• A state of relative hypovolemia resulting from pathological

• Loss of regulation of vascular tone

• Sepsis-3 criteria: a dysregulated response by the body to an

• A lactate value above 2 mmol/L and persistent hypotension

• Infusion of balanced crystalloid solutions

• Massive histamine-mediated vasodilation and maldistribution with a shift of Gluid

• Constant monitoring, as late reactions including arrhythmias, myocardial ischemia,

• State of imbalance between sympathetic and

• Profound vasodilation with relative hypovolemia while blood

• Treatment of the cause

• A disorder of cardiac function in the form of a critical reduction of the

• Removing the cardiac causes of the shock.

• Vena cava compression syndrome

• Immediate causal treatment

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•  Condition of inadequate organ perfusion caused by loss of

•  A drop in cardiac preload to a critical level and reduced macro-

• Resulting from acute hemorrhage without major soft tissue injury.

•  Immediate intravascular volume replacement (Gluid

•  External haemorrhage à easily identiGied during the primary survey.

• Intravenous replacement of intravascular

•  Prolonged hypovolaemic shock à high mortality

•  The loss of over 40% of blood volume is immediately life

•  In a well-compensated patient without heart

•  The primary injury has been addressed à

•  A state of relative hypovolemia resulting from pathological

•  Loss of regulation of vascular tone

•  Sepsis-3 criteria: a dysregulated response by the body to an

•  A lactate value above 2 mmol/L and persistent hypotension

•  Infusion of balanced crystalloid solutions

•  Massive histamine-mediated vasodilation and maldistribution with a shift of Gluid

•  Constant monitoring, as late reactions including arrhythmias, myocardial ischemia,

•  State of imbalance between sympathetic and

•  Profound vasodilation with relative hypovolemia while blood

•  Treatment of the cause

•  A disorder of cardiac function in the form of a critical reduction of the

•  Removing the cardiac causes of the shock.

•  Vena cava compression syndrome

• Immediate causal treatment