GENERAL MANAGEMENT OF

SHOCK
MANAGEMENT
If GSC < 8 ETT intubation
oyxgen to maintain PaO2 >
60mmHg or SaO2 > 90%

• Size: 16G
• Route: peripheral 
central line 
Intraosseos line
• Wide bore
• Purpose:
• Give bolus or
infuse fluids
• Drugs administration
• blood Investigation
 • Supine or • Mean arterial pressure >60- 65
Trendelenburg mm Hg (higher in the presence
position of coronary artery disease)
• Raise the leg up • Pulmonary wedge pressure 15-18
mm Hg (may be higher for
cardiogenic shock)
Non-
Cardiogenic
• Cardiac index >2.1 L/min/m2 for
cardiogenic cardiogenic and obstructive
Shock
Shock shock
• Cardiac index >4-4.5 L/min/m2 for
septic and resuscitated
Fluids therapy +/- Fluids traumatic/hemorrhagic shock
(at least therapy (500-
1000ml) 1000ml max)

Investigation Sympathomimeti
CVP or PAC
cs
Fail to respond to Fluid therapy
CHOICE OF FLUID RESUSCITATION
• Principle:
• First: Restore intravascular volume
• Second: replete interstitial and intracellular volume
Compartment Normal COP
Glucose 5% NaCl 0.9% Colloids

Intravascular ↑ ↑ ↑↑

Interstitial ↑↑ ↑↑ —

Intracellular ↑↑↑ — —
WHY CRYSTALLOID?
• Crystalloid is preferred over than colloid because colloid :
1. inhibition of the coagulation system
2. the risk for anaphylactoid reactions
3. inhibition of renal salt and water excretion
4. Over-administration  risk of ARF
5. expensive
CHOICE OF FLUID RESUSCITATION
• Choice of Crystalloid
• Theoretically: Ringer Lactate or Hartman solution is preferred over
Normal saline
• Resemble the plasma electrolytes level
• However, Normal saline is used because
• it is cheaper.
• Isotonic Normal saline 0.9% is used in all shock condition excepts:
• Burn shock (use Parkland formula)
• Dextrose 5% ½ NS  Maintenance therapy
FLUID RESUSCITATION
FLUID LOSS
• Fluids replacement : (NS) to restore the circulatory volume
• Adult: at least1000ml over 30minutes bolus
• Pediatrics – 20ml/kg
• Calculating the % loss
• According to the sign and symptom
• Dehydration – mild moderate severe
• Blood loss – class I,II, III, IV
• According to weight loss
• (Previous healthy weight – current body weight) x 100%
FLUID MAINTENANCE
• Fluids maintenance: daily fluid loss (about 2L) + additional
fluid deficit + ongoing loss
• (fever –increase in 1degree celcius =10ml/hr loss)
• Paediatrics age group – Must use Holliday- Segard
Formula
• Adult – can use wt + 40 formula
• Maximum fluid maintenance for normal daily loss
: 120ml/ hr
EMERGENCY BLOOD TRANSFUSION
• Indications
• Severe hemorrhage > 30%
• Hb < 8%,
• Whole Blood is used.
• GXM
• 1 unit of blood = 450ml of blood
• During initial resuscitation of acute blood loss and shock, crystalloid or
colloid infused to restore circulatory volume
• Emergency blood group “O” blood should not be used
OTHERS
• Prevention of stress ulcer
• Ranitidine or PPI
• Prevention of deep vein thrombosis
• UF heparin or LMW heparin if no C/I
• Prevention of ARF
• Induce diuresis by furosemide (make sure adequate fluid
therapy)  look for hyperkalemia
• IV 2-5micro g/kg/minute of dopamine (low dose)
• Glucose control
• Insulin to prevent DKA in DM patient
• Metabolic Acidosis
• treat in severe cases only.