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SHOCSHOCKK

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

Dept. of Anesthesiology & Dept. of Anesthesiology & ReanimationReanimation

Faculty of Medicine, Faculty of Medicine, Gadjah Mada Gadjah Mada UniversityUniversity

Yogyakarta, 200Yogyakarta, 20099

Blok Kegawatdaruratan, 2 November 2011 [09]

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I. INTRODUCTIONI. INTRODUCTION

DEFINITION :DEFINITION : SHOCK : SHOCK : STATE OF STATE OF SYSTEMIC METABOLIC SYSTEMIC METABOLIC

DEMANDDEMAND WHICH WHICH DOES NOT MEET WITH DOES NOT MEET WITH BLOOD SUPPLYBLOOD SUPPLY

DIAGNOSIS : DIAGNOSIS : - ANAMNESIS : HISTORICAL FINDINGS- ANAMNESIS : HISTORICAL FINDINGS WHICH POSIBLE TO CAUSE SHOCKWHICH POSIBLE TO CAUSE SHOCK - PHYSICAL EXAMINATION : DISCOVERED- PHYSICAL EXAMINATION : DISCOVERED SIGNS OF SHOCKSIGNS OF SHOCK - LABORATORY FINDINGS : DEPEND ON - LABORATORY FINDINGS : DEPEND ON

THETHE TYPE OF SHOCKTYPE OF SHOCK

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Intro. Continues ...Intro. Continues ...

ANAMNESTIC FINDINGS FOR SHOCK :ANAMNESTIC FINDINGS FOR SHOCK :

- LAKE OF FLUIDS INTAKE AND/OR- LAKE OF FLUIDS INTAKE AND/OR

PROFUSE FLUIDS LOSSPROFUSE FLUIDS LOSS

- ANY KINDS OF CARDIAC DISEASES- ANY KINDS OF CARDIAC DISEASES

- ANY KINDS OF SEVERE ILLNESS- ANY KINDS OF SEVERE ILLNESS

(SEPSIS, ANAPHYLACTIC REACTION,(SEPSIS, ANAPHYLACTIC REACTION,

INJURY OF BACK BONE ETC.INJURY OF BACK BONE ETC.

- ANY KINDS OF TRAUMA OR PATALO-- ANY KINDS OF TRAUMA OR PATALO-

GIC PROCESS ON CHEST/LUNGGIC PROCESS ON CHEST/LUNG

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Intro. continuesIntro. continues

SIGNS SIGNS ON THE PHYSICAL EXAMINTANION ON THE PHYSICAL EXAMINTANION :: - DECREASE OF MENTAL STATUS, & OTHER- DECREASE OF MENTAL STATUS, & OTHER SIGNS OF ORGAN HYPOPERFUSIGNS OF ORGAN HYPOPERFUSSIONION - HYPOTENSION- HYPOTENSION - TACHYCARDIA, OR ARRYTHMIA, OR- TACHYCARDIA, OR ARRYTHMIA, OR BRADYBRADY-- CARDIACARDIA (DEPEND ON THE CAUSA (DEPEND ON THE CAUSA & STADI- & STADI- UM OF SHOCKUM OF SHOCK) ) -- OLIGURIAOLIGURIA - COLD ACRAL - COLD ACRAL

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Introduction ....Introduction ....

LAB. FINDINGS :LAB. FINDINGS : e.g. :e.g. : - METABOLIC ASIDOSIS FOR ALL KINDS OF - METABOLIC ASIDOSIS FOR ALL KINDS OF

SHOCKSHOCK - HEMOCONCENTRATION FOR HYPOVOLEMIC- HEMOCONCENTRATION FOR HYPOVOLEMIC SHOCKSHOCK - BACTERIEMIA FOR SEPTIC SHOCK- BACTERIEMIA FOR SEPTIC SHOCK - TENSION (PNEUMOTHORAX WITH LUNG - TENSION (PNEUMOTHORAX WITH LUNG

COLLAPSCOLLAPS AND MEDIASTINUM SHIFTAND MEDIASTINUM SHIFT ON CHEST X-RAY ON CHEST X-RAY) )

FORFOR OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK - CARDIOMEGALI OR ABNORMALITY OF - CARDIOMEGALI OR ABNORMALITY OF

CARDIACCARDIAC APPEARANCE IN CHEST X-RAY AND ECG FORAPPEARANCE IN CHEST X-RAY AND ECG FOR CARDIAC SHOCK CARDIAC SHOCK

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II. BASIC PRINCIPLESII. BASIC PRINCIPLES OF SHOCK MANAGEMENT OF SHOCK MANAGEMENT

AIRWAY FREE AIRWAY FREE ADEQUATE BREATHING ADEQUATE BREATHING (( VENTILATE THE ALVEOLI, OPTIMIZED BLOOD VENTILATE THE ALVEOLI, OPTIMIZED BLOOD

OOXYGENATION, XYGENATION, INCREASE O2 DELIVERYINCREASE O2 DELIVERY & TISSUE & TISSUE OXYGENATION )OXYGENATION )

ADEQUATE CIRCULATIONADEQUATE CIRCULATION ((INCREASE CINCREASE CARDIAC ARDIAC OOUTPUTUTPUT & BLOOD PRESSURE & BLOOD PRESSURE WITH FLUID, POSITIVE INOTROPES AND WITH FLUID, POSITIVE INOTROPES AND

VASOPRESSORS DEPEND ON VASOPRESSORS DEPEND ON THE CAUSA & THE CAUSA & PATHOPHYSIOLOGY)PATHOPHYSIOLOGY)

SEARCH CAUSA AND TREAT PROMPLYSEARCH CAUSA AND TREAT PROMPLY GUIDE OF TREATMENT WITH CLOSED MONITORING GUIDE OF TREATMENT WITH CLOSED MONITORING

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GENERAL EARLY TARGET GENERAL EARLY TARGET IN IN SHOCK SHOCK RESUSCITATION RESUSCITATION

COMPOS MENTISCOMPOS MENTIS A & B NORMALA & B NORMAL C : BP SYSTOLE > 90 mmHg,C : BP SYSTOLE > 90 mmHg,

HR < 100 x/mntHR < 100 x/mnt

Cap. Refill < 2 sec.Cap. Refill < 2 sec.

warm extremitieswarm extremities FFLLUID : URINE PROD. > 0,5 UID : URINE PROD. > 0,5

cc/kg/hrcc/kg/hr

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Face mask-valve-bagFace mask-valve-bag

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III. MAJOR CATAGORIES OF III. MAJOR CATAGORIES OF SHOCKSHOCK

1. HYPOVOLEMIC SHOCK1. HYPOVOLEMIC SHOCK

2. CARDIOGENIC SHOCK2. CARDIOGENIC SHOCK

3. DISTRIBUTIVE SHOCK3. DISTRIBUTIVE SHOCK

4. OBSTRUCTIVE SHOCK4. OBSTRUCTIVE SHOCK

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HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK

DEPLETION OF INTRAVASCULAR DEPLETION OF INTRAVASCULAR VOLUMEVOLUME

CAUSA : LAKE OF FLUID INTAKE AND CAUSA : LAKE OF FLUID INTAKE AND OR PROFUSE FLUID LOSSES OR PROFUSE FLUID LOSSES

( eg. ( eg. ANOREXIA, CANNOT DRINK & ANOREXIA, CANNOT DRINK & MEAL, PATOLOGIC T G I, MEAL, PATOLOGIC T G I, HEMORRHAGE, VOMITHEMORRHAGE, VOMITUSUS, DIARRHEA, DIARRHEA,, EVAPORATION EVAPORATION OR THIRD-SPACE OR THIRD-SPACE LOSSES )LOSSES )

HEMODYNAMIC PROFILE : DECREASED HEMODYNAMIC PROFILE : DECREASED COCO, DECREASED LEFT VENTRICULAR , DECREASED LEFT VENTRICULAR FILLING PRESSURE, INCREASED FILLING PRESSURE, INCREASED SVRSVR

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MANAGEMENT OF HYPOVOLEMIC MANAGEMENT OF HYPOVOLEMIC SHOCKSHOCK

STEPS A, B, CSTEPS A, B, C RESTORATION OF INTRAVASCULAR RESTORATION OF INTRAVASCULAR

VOLUME WITH KOLLOID OR VOLUME WITH KOLLOID OR KRISTALLOIDKRISTALLOID

TARGET : NORMAL BP, PULSE & ORGAN TARGET : NORMAL BP, PULSE & ORGAN PERFUSION (e g. adequate urine output)PERFUSION (e g. adequate urine output)

PRINCIPLES IN FLUID RESUSCITATION :PRINCIPLES IN FLUID RESUSCITATION : - RAPID (to normovolumia)- RAPID (to normovolumia) - CLOSED TO THE KIND OF DEFICITE - CLOSED TO THE KIND OF DEFICITE

FLUIDFLUID - USE THE AVAILABLE FLUID- USE THE AVAILABLE FLUID

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CARDIOGENIC SHOCKCARDIOGENIC SHOCK

INADEQUATE FORWORD BLOOD INADEQUATE FORWORD BLOOD FLOWFLOW

CAUSA: ANY PATHOLOGIES OF CAUSA: ANY PATHOLOGIES OF HEARTHHEARTH

HEMODYNAMIC PROFILE : HEMODYNAMIC PROFILE : DECREASED DECREASED COCO, HIGH , HIGH VENTRICULAR FILLING PRESSURE, VENTRICULAR FILLING PRESSURE, VARIABLE VARIABLE SVRSVR

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MANAGEMENT OF CARDIOGENIC MANAGEMENT OF CARDIOGENIC SHOCKSHOCK

STEPS A, B, CSTEPS A, B, C IMPROVE MYOCARDIAL FUNCTIONIMPROVE MYOCARDIAL FUNCTION ARRHYTMIAARRHYTMIA SHOULD BE TREATED SHOULD BE TREATED

PROMPTLYPROMPTLY INOTROPES iv. (Dobutamine, to INOTROPES iv. (Dobutamine, to

increase myocard contractility)increase myocard contractility) VASOACTIVE DRUGS iv. (In Case of VASOACTIVE DRUGS iv. (In Case of

low SVR, vasoconstrictor to increase low SVR, vasoconstrictor to increase aortic diastolic pressure, in case of high aortic diastolic pressure, in case of high SVR : vasodilator)SVR : vasodilator)

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INOTROPIC & VASOACTIVE INOTROPIC & VASOACTIVE DRUGSDRUGS

ADRENALINADRENALIN NOREPINEPHRINNOREPINEPHRIN

EE DOBUTAMINE & DOBUTAMINE &

DOPAMINEDOPAMINE LANOXINLANOXIN

ISOSORBID ISOSORBID DINITRAT (ISDN)DINITRAT (ISDN)

NTG NTG (NITROGLYCERIN)(NITROGLYCERIN)

CAPTOPRILCAPTOPRIL NOREPINEPHRINENOREPINEPHRINE EPHEDRINEEPHEDRINE PHENYLEPHRINEPHENYLEPHRINE

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DISTRIBUTIVE SHOCKDISTRIBUTIVE SHOCK

ABNORMAL DISTRIBUTION AND ABNORMAL DISTRIBUTION AND PROFILE OF INTRAVASCULAR FLUIDPROFILE OF INTRAVASCULAR FLUID

CAUSA : SEPSIS, ANAPHYLAXY, CAUSA : SEPSIS, ANAPHYLAXY, BLOCK OF SYMPATHETIC PATHWAY BLOCK OF SYMPATHETIC PATHWAY OR PARASYMPATIC HYPERACTIVE OR PARASYMPATIC HYPERACTIVE (NEUROGENIC), ACUTE ADRENAL (NEUROGENIC), ACUTE ADRENAL IN-SUFFICIENCYIN-SUFFICIENCY

HEMODYNAMIC PROFILE : NORMAL HEMODYNAMIC PROFILE : NORMAL OR HIGH OR HIGH COCO, LOW TO NORMAL LEFT , LOW TO NORMAL LEFT VEN-TRICULAR FILLING PRESSURE, VEN-TRICULAR FILLING PRESSURE, LOW LOW SVRSVR

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MANAGEMENT OF DISTRIBUTIVE MANAGEMENT OF DISTRIBUTIVE SHOCKSHOCK STEPS A, B, CSTEPS A, B, C RESTORATION & MAINTENANCE OF RESTORATION & MAINTENANCE OF

NORMAL INTRAVASCULAR VOLUMENORMAL INTRAVASCULAR VOLUME INCREASE BP WITH INOTROPESINCREASE BP WITH INOTROPES (IS/ARE ADMINISTERED IF PRELOAD IS (IS/ARE ADMINISTERED IF PRELOAD IS

ADEQUATE OR NORMOVOLUMIA)ADEQUATE OR NORMOVOLUMIA) COMBINATION WITH VASOPRESSORCOMBINATION WITH VASOPRESSOR ANAPHYLACTIC SHOCK IS TREATED WITH ANAPHYLACTIC SHOCK IS TREATED WITH

EPINEPHRINE EPINEPHRINE ( & SECURE A B C ) ( & SECURE A B C ) ACUTE ADRENAL INSUFF : VOLUME Tx, ACUTE ADRENAL INSUFF : VOLUME Tx,

CORTICOSTEROIDS iv. AND VASOPRESSORCORTICOSTEROIDS iv. AND VASOPRESSOR NEUROGENIC SHOCK : VOL. NEUROGENIC SHOCK : VOL.

Tx,VASOPRESS., ATROPINE (for Tx,VASOPRESS., ATROPINE (for Bradycardia)Bradycardia)

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OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK

OBSTRUCTION TO CARDIAC OBSTRUCTION TO CARDIAC FILLINGFILLING

CAUSA : CARDIAC TAMPONADE, CAUSA : CARDIAC TAMPONADE, TENSION PNEUMOTHORAX, TENSION PNEUMOTHORAX, MASSIVE PULMONARY EMBOLIMASSIVE PULMONARY EMBOLI

HEMODYNAMIC PROFILE : HEMODYNAMIC PROFILE : DECREASED DECREASED COCO, VARIABLE LEFT , VARIABLE LEFT VENTRICULAR FILLING VENTRICULAR FILLING PRESSURE, INCREASED PRESSURE, INCREASED SVRSVR

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MANAGEMENT OF OBSTRUCTIVE MANAGEMENT OF OBSTRUCTIVE SHOCKSHOCK

STEPS A, B, CSTEPS A, B, C RELIEF OF OBSTRUCTONRELIEF OF OBSTRUCTON

(PERICARDIOCENTESIS, (PERICARDIOCENTESIS, PLEURAL PLEURAL /THORACAL /THORACAL PUNCTIPUNCTIONON & WSD ) & WSD )

MAINTENANCE MAINTENANCE OF OF NORMOVOLEMIANORMOVOLEMIA INOTROPES & VASOPRESSOR HAVE A INOTROPES & VASOPRESSOR HAVE A

MINIMAL ROLEMINIMAL ROLE DIURETICS SHOULD BE AVOIDEDDIURETICS SHOULD BE AVOIDED

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Spesial notice :Spesial notice :

SHOCK IS ONE OF CRITICALLY ILL, SHOCK IS ONE OF CRITICALLY ILL, LIFE THREATENINGLIFE THREATENING SHOULD BE TREATED PROMPTLY, SHOULD BE TREATED PROMPTLY,

WITH RESUSCITATIONWITH RESUSCITATION THE PROGNOSIS IS CORRELATED THE PROGNOSIS IS CORRELATED

WITH TIMEWITH TIME CAUSA & PATOPHYSIOLOGY MAY CAUSA & PATOPHYSIOLOGY MAY

BE COMPLICATED, THEREFORE BE COMPLICATED, THEREFORE THE MANAGEMENTS SHOULD BE THE MANAGEMENTS SHOULD BE ADJUSTED CLOSELYADJUSTED CLOSELY

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Alhamdulillahirobbil’alaAlhamdulillahirobbil’alaminmin