General Management of SHOCK

AIRWAY

Maintain airway- consider intubation if

necessary
BREATHING 100% O2 via non-rebreather mask
CIRCULATI 2 large bore (14-16G) cannulae
ON
Consider inotropes support
IV dopamine 5-10 g/kg/min
IV dobutamine 5-10 g/kg/min
(esp for cardiogenic shock)
IV norephinephrine 5-20g/kg/min
(esp for septic shock)
T
R
MONITORIN Pulse Oximetry
A
E
H NG
G
ECG
BP
LU NEY
D
I
Heart Rate
K
Urine Output catheterize patient

SEPTIC
SHOCK

SEPTIC SHOCK- Investigations

FBC (WBC)
Blood FEME
Coagulation Profile
(PT/PTT/fibrinogen/D-dimer)
Blood C&S
ABG
CXR
ECG
Urine FEME
Urine C&S

SEPTIC SHOCK- Management

TREAT INFECTION with
BROAD SPECTRUM
ANTIBIOTICS
CIRCULATORY SUPPORT
VASOACTIVE MEDICATION

1. Addressing the infection

-Antibiotic therapy
.Broad-spectrum intravenous antibiotics: should
be initiated within the first hour after obtaining
appropriate cultures
.For pneumonias, the initial broad-spectrum
antibiotic coverage should be narrowed to
focus on the causative organisms identified on
culture.
.For intra-abdominal infections, therapies
remain broadly directly at the range of intraabdominal organisms
-Source control

Antibiotic therapy
Gram + (burns, FB )

Immunocompetent
w/o obvious source

Immunocompromis
ed w/o obvious
source

Anaerobic source
(intraabdominal,
biliary, female
genital tract,

IV cefazolin 2g
IV Vancomycin 1g
3rd generation cephalosporin
(IV ceftriaxone 1g) or
Quinolones (ciprofloxacin
200mg)
Antipseudomonal abx
(IV ceftazidime 1g) or
Quinolones
+ aminoglycoside
(Gentamycin 80 mg)
IV metronidazole 500 mg
+ ceftriaxone 1g
+ IV gentamycin 80 mg

2. Circulatory support

-Early goal-directed therapy

Adjustments of cardiac preload, afterload,
and contractility to balance oxygen
delivery with oxygen demand
-In the first 6 hours, the goal of resuscitation
are as follows:
CVP : 8 - 12mmHg
MAP at least > 65mmHg
Urine output at least 0.5mg/kg/hour
Mixed SvO2 at least 70%

3. Vasoactive medications
-

Noradrenaline

is commonly used in septic shock.

Acts mainly on a1 receptors with few effects on b1 receptors.

Actions
Increases blood pressure by peripheral vasoconstriction.
Indications
Septic shock where peripheral vasodilation may be
causing hypotension.
Cautions
Acts by increasing afterload and therefore not appropriate
for use in patients in cardiogenic shock. Blood supply to
kidneys and peripheries may be reduced.
Dose
Initiated at an infusion rate of 8-12 ug/min and then
maintenance dose 2-4 ug/min

-Dopamine

Acts on D, 1 and 1 receptors, depending on the dose administered.

Higher dose stimulates both 1 and D receptors
Produces cardiac stimulation and also renal vasodilation
Half-life : 2 min
Onset : 5 min
Duration : 10 min
Indications :
Hypotension
Low cardiac output
Poor perfusion of vital organs
Septic shock patient who remain hypotensive after adequate
volume expansion
Contraindication :
Hypersensitivity to dopamine
Ventricular fibrillation/tachyarrythmia

Anaphylactic Shock

Secure the airway-give 100% O2

Intubate if respiratory obstruction

Anaphylactic
Shock
Management

Remove the cause; raise feet to restore circulation

IM Adrenaline 0.5mg
Repeat every 5min if needed based on vital signs
until better
IV Chlorphenamine 10mg
IV Hydrocortisone 200mg
IVI 0.9% saline
Titrate against BP
If wheeze, treat for asthma
May require ventilatory support
If still hypotensive, admit ICU
IVI adrenaline aminophylline and nebulized
salbutamol

Anaphylactic Shock: Further

Mx
Admit ward. Monitor ECG
Cont chlorphenamine 4mg/6H PO if itching
Suggest a MedicAlert bracelet naming the
culprit allergen
Teach about self-injected adrenaline
(Epipen) to prevent a fatal attack
Skin-prick test showing specific IgE help
identify allergens to avoid

HYPOVOLAEMIC
SHOCK

HypoV Shock- Principle of management

Irrespective of the cause, the first concern of physician is restore
delivery of oxygen to the tissue rapidly and completely to prevent
organ damage (ABC)
Airway
-Maintain patent airway
Breathing
-Ensure adequate oxygenation and ventilation
Circulation
-Restore cardiac output and blood pressure
Elevate Legs (in hypoV shock)
Monitoring investigation Hb, WBC, APTT, PT, ABG, ECG, electrolyte,
glucose, lactate, BUN, chest x ray
Treat the underlying causes depends on causes of shock
Fluid replacement, if persistent low BP, consider inotrope.
Treat complications

HypoV Shock- Principle of management

In active bleeding , control site of hemorhage before infusion
high volume fluid therapy
Reason :increase fluid lead to increase in BP, which will lead to
increase bleeding from the site. It also dilutes available
coagulation hemorrhage control so, resuscitation should be
proceed parallel with surgery
Prior definitive surgical haemorrhage control, if BP was near
normal or normal, avoid >>> fluid resuscitation.
If hypotensive with ongoing blood loss, obtain 6 units of GXM
and transfuse early with whole blood/ combined packed
RBC,FFP, platelets. No waiting! Contact surgeon urgently.
But a patient with bowel obstruction and hypovolaemic shock
must be adequately resuscitated before undergoing surgery
otherwise the additional surgical injury stimulate inflammatory
action and increase severity of end organ insult.
Hypotonic solutions (dextrose) are poor volume expanders
should not be used in shock unless the deficit is free water loss
(diabetes insipidus) or patient are sodium overloaded

Goal of resuscitation
Central venous pressure (CVP) 812 mm
Hg
Mean arterial pressure 65 mm Hg
Urine output 0.5 mL.kg-1.hr-1/ 40ml
Central venous (superior vena cava)
oxygen saturation 70%, or mixed venous
65%

Types of fluid
There is no overt differences in response or
outcome between crystalloid solution
(Normal saline or Ringers lactate) and
colloids (albumin)
But oxygen carrying capacity of both
crystalloid and colloids are zero
If blood being lost, ideal replacement of fluid
is blood, although crystalloid therapy may be
required while awaiting blood products
*20ml/kg - children
*2000ml crystalloid - adult

CRSTALLOID VS COLLOID
Funny how crystalloid is cheaper than colloid,
considering the name crystalloid is used
Cheaper and readily available, with less side effect
Cheap, but needed in large volume to achieve
equivalent colloids , lose 1 replace with 3
CRYSTALLOIDS: Ringers lactate, normal saline,
Hartmans solution
Colloid: Albumin, gelatins, hetastarch,plasma protein,
dextran

CARDIOGENIC
SHOCK

Cardiogenic Shock Management

1. Intubate
2. Give oxygen either by face mask or endotracheal

intubation ( ALL SHOCK O2 IS A MUST)

3. Correct arrhythmia

4. PAC (Swan-Ganz) monitoring if in ICU (pulmonary artery

catheter)
5. Optimize filling pressure:
1.
2.

IVF if only volume depleted. Shock with RVF may respond

better to fluid resuscitation. Give IV 500ml boluses with
frequent review.
If no volume depletion, give inotropes ie dobutamine

Monitoring for
patients in shock

Monitoring for patients in

shock
Minimum standard
- Electrocardiogram
- Pulse oximetry
- Blood pressure
- Urine output

Additional modalities
Central venous pressure
Invasive blood pressure
Cardiac output
Base deficit and serum lactate

Electrocardiogram monitoring

Detect dysrhythmias and severe

myocardial ischemia
Useful in cardiogenic shock

Pulse oximetry
Simple non-invasive monitor
Gives information on the adequacy of arterial
oxygenation and peripheral tissue perfusion (pulse
volume and oxygen saturation of haemoglobin)

Blood pressure
Depends on patient volumes status, myocardial
function and compensatory mechanism initiated
by sympathetic nervous system
Satisfactory BP does not exclude shock, its only
of use when placed in the context of a full
clinical assessment

Urine output
Indirect measurement of vital organ
perfusion(kidney)
Increase in urine output, indicator of successful
resuscitation

Central venous pressure

Assessed dynamically as the response to fluid challenge
Normal CVP rise of 2-5cmHO
Patient with no change in CVP require further fluid
resuscitation
measured by an internal jugular or subclavian central line

Base deficit and Serum lactate

Lactic acid generated by cells undergoing anaerobic respiration
Degree of lactic acidosis measured by serum lactate level/base
deficit
Sensitive tool for both diagnosis of shock and monitoring response
to therapy
Normal lactate level-2mmol/L
Reduction of 10% lactate every 2 hours- improving

TAKE HOME RAYA HOLIDAY MASSAGE

MESSAGE
SEPTIC- NORADRENALINE, HIGH DOSE DOPAMINE
ANAPHYLACTIC- ADRENALINE
CARDIOGENIC- DOBUTAMINE
HYPOVOLEMIC- DO NOT GIVE DOPAMINE, WILL BURDEN
THE HEART