Diagnosis and Management of Shock

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Objectives

• Identify the major types of shock and principles of management

• Review fluid resuscitation and use of vasopressor and inotropic agents

• Understand concepts of O2 supply and demand

• Discuss the differential diagnosis of oliguria

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Shock

• Always a symptom of primary cause• Inadequate blood flow to meet tissue oxygen

demand• May be associated with hypotension• Associated with signs of hypoperfusion: mental

status change, oliguria, acidosis

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Shock Categories

• Cardiogenic• Hypovolemic• Distributive• Obstructive

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Cardiogenic Shock

• Decreased contractility• Increased filling pressures, decreased LV

stroke work, decreased cardiac output• Increased systemic

vascular resistance – compensatory

Hypovolemic Shock

• Decreased cardiac output

• Decreased filling pressures

• Compensatory increase in systemic vascular resistance

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Distributive Shock

• Normal or increased cardiac output• Low systemic vascular resistance• Low to normal filling pressures• Sepsis, anaphylaxis, neurogenic,

and acute adrenal insufficiency

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Obstructive Shock

• Decreased cardiac output• Increased systemic vascular

resistance• Variable filling pressures dependent

on etiology• Cardiac tamponade, tension

pneumothorax, massive pulmonary embolus

Cardiogenic Shock Management

• Treat arrhythmias • Diastolic dysfunction may require

increased filling pressures • Vasodilators if not hypotensive• Inotrope administration

Cardiogenic Shock Management

• Vasopressor agent needed if hypotension present to raise aortic diastolic pressure

• Consultation for mechanical assist device

• Preload and afterload reduction to improve hypoxemia if blood pressure adequate

Hypovolemic Shock Management

• Volume resuscitation – crystalloid, colloid• Initial crystalloid choices– Lactated Ringer’s solution– Normal saline (high chloride may produce

hyperchloremic acidosis)• Match fluid given to fluid lost– Blood, crystalloid, colloid

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Hypovolemic Shock Management

• Perhitungan Estimated Blood Vol:• Dewasa: 70 cc/kgBB• Anak: 80 cc/kgBB• Bayi: 90 cc/kgBB• Syok karena trauma: 90% disebsbkan oleh

hemoragik syok

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Hypovolemic Shock Management

• Pasang infus 2 jalur dg iv catheter yang pendek dan besar (no16/18)

• Ambli blood sample untuk px lab dan usaha darah

• Beri cairan RL 2000 cc yang dihangatkan sebagai cairan awal

• Tetap mengikuti tahapan resusitasi A-B-C-D

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Distributive Shock Therapy

• Restore intravascular volume• Hypotension despite volume therapy– Inotropes and/or vasopressors

• Vasopressors for MAP < 60 mm Hg• Adjunctive interventions dependent on

etiology

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Obstructive Shock Treatment

• Relieve obstruction– Pericardiocentesis – Tube thoracostomy – Treat pulmonary embolus

• Temporary benefit from fluid or inotrope administration

Fluid Therapy• Crystalloids– Lactated Ringer’s solution– Normal saline

• Colloids– Hetastarch– Albumin– Gelatins

• Packed red blood cells• Infuse to physiologic endpoints

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Fluid Therapy

• Correct hypotension first• Decrease heart rate• Correct hypoperfusion abnormalities• Monitor for deterioration of oxygenation

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Inotropic / Vasopressor Agents• Dopamine

– Low dose (2-3 g/kg/min) – mild inotrope plus renal effect

– Intermediate dose (4-10 g/kg/min) –inotropic effect

– High dose ( >10 g/kg/min) –vasoconstriction

– Chronotropic effect

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Inotropic Agents

• Dobutamine

–5-20 g/kg/min

– Inotropic and variable chronotropic effects

–Decrease in systemic vascular resistance

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Inotropic / Vasopressor Agents

• Norepinephrine

–0.05 g/kg/min and titrate to effect

– Inotropic and vasopressor effects

–Potent vasopressor at high doses

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Inotropic / Vasopressor Agents

• Epinephrine–Both and actions for inotropic and

vasopressor effects–0.1 g/kg/min and titrate– Increases myocardial O2 consumption

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Therapeutic Goals in Shock

• Increase O2 delivery

• Optimize O2 content of blood• Improve cardiac output and

blood pressure• Match systemic O2 needs with O2 delivery• Reverse/prevent organ hypoperfusion

Oliguria

• Marker of hypoperfusion• Urine output in adults

<0.5 mL/kg/hr for >2 hrs• Etiologies –Prerenal–Renal–Postrenal

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Evaluation of Oliguria

• History and physical examination• Laboratory evaluation– Urine sodium– Urine osmolality or specific gravity– BUN, creatinine

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Evaluation of Oliguria

Laboratory Test Prerenal ATN

Blood Urea Nitrogen/ >20 10–20 Creatinine RatioUrine Specific Gravity >1.020 <1.010Urine Osmolality (mOsm/L) >500 <350Urinary Sodium (mEq/L) <20 >40Fractional Excretion of Sodium (%) <1 >2

Therapy in Acute Renal Insufficiency• Correct underlying cause• Monitor urine output• Assure euvolemia• Diuretics not therapeutic• Low-dose dopamine may urine flow• Adjust dosages of other drugs• Monitor electrolytes, BUN, creatinine• Consider dialysis or hemofiltration

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Pediatric Considerations

• BP not good indication of hypoperfusion• Capillary refill, extremity temperature better

signs of poor systemic perfusion • Epinephrine preferable to norepinephrine due to more

chronotropic benefit• Fluid boluses of 20 mL/kg titrated to BP or total 60

mL/kg, before inotropes or vasopressors

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Pediatric Considerations

• Neonates – consider congenitalobstructive left heart syndrome as cause of obstructive shock

• Oliguria–<2 yrs old, urine volume <2 mL/kg/hr–Older children, urine volume

<1 mL/kg/hr

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Key Points