Shock Management

Dr Charles A Simanjuntak, dr, SpoT(K), FICS, MPd

FKIK - Universitas Jambi
Shock:
• “A momentary pause in the
act of death.”

• John Collins Warren, 1800s

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Definition(1)

– Webster: 12 different
definitions
• 4: “the state of profound
depression of the vital processes
associated with reduced blood
volume and pressure and
caused usually by severe esp.
crushing injuries, hemorrhage,
or burns.”
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Definition(2)

–Inadequate organ perfusion

to meet the tissue’s
oxygenation demand.
–“Hypoperfusion can be
present in the absence of
significant hypotension.” -
FCCS course

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Pathophysiology
• ATP production fails, the Na+/K+
pump fails resulting in the inability
to correct the cell electronic
potential.
• Cell swelling occurs leading to
rupture and death.
• Oxidative Phosphorylation stops
& anaerobic metabolism begins
leading to lactic acid production.
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ACS

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Alteration in
LOC, anxiety Tachypnea,
shallow
Hypotension respiration
Tachycardia
Cold,
diaphoretic ↓Urinary
skin output
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Pulmonary Artery Catheter

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Types of Shock

• “Classic” Blalock 1937

– Hematogenic/Hypovolemic
– Neurogenic
– Vasogenic
– Cardiogenic

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Classification of Shock
• Low Cardiac Output states
– Hypovolemic shock
• volume loss
• Internal volume loss
– Cardiac shock
• Impaired inflow
• Primary pump dysfunction
• Impaired outflow
– Low peripheral resistance states
• Neurogenic shock
– Loss of sympathetic tone
• Vasogenic Shock
– Septic
– Anaphylactic
Carrico: ACS Early Care of the Injured Patient 4th Ed.
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 2-Sided Pump
• Right Side
– Compliant, flexible
– Low pressure, variable
volume
• Left Side
– Stiff, strong
– High pressure, fixed
volume

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Hypovolemic Shock

• Causes • Signs
– hemorrhage –  cardiac
– vomiting output
– diarrhea –  PAOP
– dehydration –  SVR
– third-space loss
– burns
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Acute Volume Loss

• Shock - Classes:

I 0-15% blood loss

II 15-30% blood loss
III 30-40% blood loss
IV >40% blood loss

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Classes of Hypovolemic Shock
Class I Class II Class III Class IV
Blood Loss < 750 750-1500 1500-2000 > 2000

% Blood Vol. < 15% 15 – 30% 30 – 40% > 40%

Pulse < 100 > 100 > 120 > 140

Blood Pressure Normal Normal Decreased Decreased

Pulse Pressure Normal Decreased Decreased Decreased

Resp. Rate 14 – 20 20 – 30 30 – 40 > 40

UOP > 30 20 – 30 5 – 15 negligible

Mental Status sl. Anxious mildly anx confused lethargic

Fluid crystalloid crystalloid blood blood

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ACS

Slightly Respiration
anxious 14-20/min

Urine
Heart rate
30 mL/hr <100/min N BP

crystalloid
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ACS

Mildly Respiration
anxious 20 –30/min
Heart rate
Urine
>100/min ↓ BP
20-30 mL/hr
↓Pulse
Crystalloid pressure
? blood CharlesASjuntak-2014 16
ACS

Confused,
anxious Respirations
30-40/min
Urine 5-25
Heart rate
ml/hr ↓ ↓ BP
> 120/min
Crystalloid
↓ ↓ Pulse
Blood, operationCharlesASjuntak-2014 17
pressure
ACS

Confused,
Respirations
lethargic
>35/min
Urine Heart rate
negligible >140/min
↓ ↓ ↓ BP
Rapid fluid,
↓ ↓ ↓ Pulse
blood, operation
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pressure
  Scene information / mechanism of injury
 AMPLE history

Inadequate Organ
perfusion dysfunction

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What are the causes?

Hemorrhagic VS Nonhemorrhagic

Blood loss Tension

pneumothorax
Cardiac tamponade
Cardiogenic
Neurogenic
Septic
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Resuscitation Fluids

• Blood
• Lactated Ringers
• Normal Saline
• Colloids
• Hypertonic Saline
• Blood Substitutes

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 How do I locate the bleeding?

Physical examination
Diagnostic adjuncts to primary survey
• Chest x-ray
• FAST / DPL
• AP x-ray of pelvis

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ACS

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 What can I do about it?

Restore Volume!
•Vascular access (catheter, sites)
•Warmed fluid (type)
Monitor response
Prevent hypothermia!

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 How do I evaluate the response?

Identify Improved Organ Function

CNS: Improved level of consciousness
Renal:  urinary output
Skin: Warm, capillary refill
Respiration: Improved rate and depth
Vital signs: Return to normal
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 What is the patient’s response?

Related to volume or persistence of

hemorrhage
Rapid responder
Transient responder
Nonresponder

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 What are the pitfalls?

Equating BP Hypothermia
with cardiac Athletes
output Pregnancy
Hemoglobin, Medications
hematocrit levels
Pacemaker
Age extremes

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 Cardiogenic Shock
• Cause
– defect in cardiac function

• Signs
–  cardiac output
–  PAOP
–  SVR
–  left ventricular stroke work (LVSW)
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 Distributive Shock
• Types
– Sepsis
– Anaphylactic
– Acute adrenal insufficiency
– Neurogenic

• Signs
– ± cardiac output
–  PAOP
– SVR
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 Obstructive Shock
• Causes
– Cardiac Tamponade
– Tension Pneumothorax
– Massive Pulmonary Embolus

• Signs
–  cardiac output
–  PAOP
–  SVR
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