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.. ..ANY KINDS OF TRAUMA OR PATALOGIC PROCESS ON CHEST/LUNG .LAKE OF FLUIDS INTAKE AND/OR PROFUSE FLUIDS LOSS .  ANAMNESTIC FINDINGS FOR SHOCK : . Continues . ANAPHYLACTIC REACTION.ANY KINDS OF CARDIAC DISEASES .ANY KINDS OF SEVERE ILLNESS (SEPSIS. INJURY OF BACK BONE ETC.

DECREASE OF MENTAL STATUS.COLD ACRAL .TACHYCARDIA.Intro.HYPOTENSION .OLIGURIA . & OTHER SIGNS OF ORGAN HYPOPERFUSION . OR ARRYTHMIA. continues  SIGNS ON THE PHYSICAL EXAMINTANION : . OR BRADYCARDIA (DEPEND ON THE CAUSA & STADIUM OF SHOCK) .

.. : .HEMOCONCENTRATION FOR HYPOVOLEMIC SHOCK .METABOLIC ASIDOSIS FOR ALL KINDS OF SHOCK .  LAB.TENSION (PNEUMOTHORAX WITH LUNG COLLAPS AND MEDIASTINUM SHIFT ON CHEST X-RAY) FOR OBSTRUCTIVE SHOCK .Introduction .BACTERIEMIA FOR SEPTIC SHOCK . FINDINGS : e..g.CARDIOMEGALI OR ABNORMALITY OF CARDIAC APPEARANCE IN CHEST X-RAY AND ECG FOR CARDIAC SHOCK .

INCREASE O2 DELIVERY & TISSUE OXYGENATION ) ADEQUATE CIRCULATION (INCREASE CARDIAC OUTPUT & BLOOD PRESSURE WITH FLUID.II. BASIC PRINCIPLES OF SHOCK MANAGEMENT      AIRWAY FREE ADEQUATE BREATHING ( VENTILATE THE ALVEOLI. POSITIVE INOTROPES AND VASOPRESSORS DEPEND ON THE CAUSA & PATHOPHYSIOLOGY) SEARCH CAUSA AND TREAT PROMPLY GUIDE OF TREATMENT WITH CLOSED MONITORING . OPTIMIZED BLOOD OXYGENATION.

> 0.GENERAL EARLY TARGET IN SHOCK RESUSCITATION     COMPOS MENTIS A & B NORMAL C : BP SYSTOLE > 90 mmHg. warm extremities FLUID : URINE PROD.5 cc/kg/hr . HR < 100 x/mnt Cap. Refill < 2 sec.

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Face mask-valve-bag .

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DISTRIBUTIVE SHOCK 4. CARDIOGENIC SHOCK 3. OBSTRUCTIVE SHOCK . HYPOVOLEMIC SHOCK 2.III. MAJOR CATAGORIES OF SHOCK 1.

VOMITUS. DECREASED LEFT VENTRICULAR FILLING PRESSURE. EVAPORATION OR THIRD-SPACE LOSSES )  HEMODYNAMIC PROFILE : DECREASED CO. HEMORRHAGE. INCREASED SVR  . ANOREXIA.HYPOVOLEMIC SHOCK DEPLETION OF INTRAVASCULAR VOLUME  CAUSA : LAKE OF FLUID INTAKE AND OR PROFUSE FLUID LOSSES ( eg. DIARRHEA. CANNOT DRINK & MEAL. PATOLOGIC T G I.

B.CLOSED TO THE KIND OF DEFICITE FLUID . PULSE & ORGAN PERFUSION (e g.USE THE AVAILABLE FLUID  .RAPID (to normovolumia) . adequate urine output)  PRINCIPLES IN FLUID RESUSCITATION : . C  RESTORATION OF INTRAVASCULAR VOLUME WITH KOLLOID OR KRISTALLOID  TARGET : NORMAL BP.MANAGEMENT OF HYPOVOLEMIC SHOCK STEPS A.

HIGH VENTRICULAR FILLING PRESSURE. VARIABLE SVR .CARDIOGENIC SHOCK    INADEQUATE FORWORD BLOOD FLOW CAUSA: ANY PATHOLOGIES OF HEARTH HEMODYNAMIC PROFILE : DECREASED CO.

B. C IMPROVE MYOCARDIAL FUNCTION ARRHYTMIA SHOULD BE TREATED PROMPTLY INOTROPES iv. (In Case of low SVR. vasoconstrictor to increase aortic diastolic pressure.MANAGEMENT OF CARDIOGENIC SHOCK      STEPS A. to increase myocard contractility) VASOACTIVE DRUGS iv. in case of high SVR : vasodilator) . (Dobutamine.

INOTROPIC & VASOACTIVE DRUGS     ADRENALIN NOREPINEPHRINE DOBUTAMINE & DOPAMINE LANOXIN       ISOSORBID DINITRAT (ISDN) NTG (NITROGLYCERIN) CAPTOPRIL NOREPINEPHRINE EPHEDRINE PHENYLEPHRINE .

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LOW TO NORMAL LEFT VENTRICULAR FILLING PRESSURE. LOW SVR . ACUTE ADRENAL INSUFFICIENCY HEMODYNAMIC PROFILE : NORMAL OR HIGH CO.DISTRIBUTIVE SHOCK    ABNORMAL DISTRIBUTION AND PROFILE OF INTRAVASCULAR FLUID CAUSA : SEPSIS. BLOCK OF SYMPATHETIC PATHWAY OR PARASYMPATIC HYPERACTIVE (NEUROGENIC). ANAPHYLAXY.

ATROPINE (for Bradycardia)  . AND VASOPRESSOR  NEUROGENIC SHOCK : VOL.MANAGEMENT OF DISTRIBUTIVE SHOCK STEPS A. CORTICOSTEROIDS iv. Tx. 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.VASOPRESS..

OBSTRUCTIVE SHOCK    OBSTRUCTION TO CARDIAC FILLING CAUSA : CARDIAC TAMPONADE. INCREASED SVR . TENSION PNEUMOTHORAX. MASSIVE PULMONARY EMBOLI HEMODYNAMIC PROFILE : DECREASED CO. VARIABLE LEFT VENTRICULAR FILLING PRESSURE.

PLEURAL /THORACAL PUNCTION & WSD )  MAINTENANCE OF NORMOVOLEMIA  INOTROPES & VASOPRESSOR HAVE A MINIMAL ROLE  DIURETICS SHOULD BE AVOIDED  . C  RELIEF OF OBSTRUCTON (PERICARDIOCENTESIS.MANAGEMENT OF OBSTRUCTIVE SHOCK STEPS A. B.

WITH RESUSCITATION THE PROGNOSIS IS CORRELATED WITH TIME CAUSA & PATOPHYSIOLOGY MAY BE COMPLICATED.Spesial notice :     SHOCK IS ONE OF CRITICALLY ILL. LIFE THREATENING SHOULD BE TREATED PROMPTLY. THEREFORE THE MANAGEMENTS SHOULD BE ADJUSTED CLOSELY .

Alhamdulillahirobbil’alamin .