SHOCK

DR. Med. dr. Untung Widodo,

SpAn.KIC.
Dept. of Anesthesiology &
Reanimation
Faculty of Medicine, Gadjah Mada

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 PATALOGIC 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 BRADYCARDIA (DEPEND ON THE CAUSA & STADIUM 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

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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
NOREPINEPHRIN
E
DOBUTAMINE &
DOPAMINE
LANOXIN

ISOSORBID
DINITRAT (ISDN)
NTG
(NITROGLYCERIN)
CAPTOPRIL
NOREPINEPHRIN
E
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

Alhamdulillahirobbilala
min