SHOCK

DR. Med. dr. Untung Widodo, SpAn.KIC.

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 ISOSORBID
NOREPINEPHRINE DINITRAT (ISDN)
DOBUTAMINE & NTG
DOPAMINE (NITROGLYCERIN)
LANOXIN 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