SHOCK &

RESUSITASI CAIRAN

Ns. Setianingsih, M. Kep

 DEFINITION
• Shock is a multifactorial
syndrome leading to systemic
and localized tissue
hypoperfusion and resulting in
cellular hypoxia and multiple
organ dysfunction
DESCRIPTION
• Perfusion may be decreased
systemacally with obvious signs
such as hypotension

• Perfusion may be decreased

because of maldistribution as in
septic shock where systemic
perfusion may appear elevated
DESCRIPTION
Prognosis is determined by
• degree of shock,
• duration of shock,
• number of organ affected,
• previous organ dysfunction and
• possibly some genetic
predispositition
CLASSIFICATION OF SHOCK

1. Hypovolemic shock
2. Obstructive shock
3. Cardiogenic shock
4. Distributive shock
HYPOVOLEMIC SHOCK
HYPOVOLEMIC SHOCK

• Loss of circulating intravascular

volume and decrease in cardiac
preload

• May be from hemorrhage : trauma,

gastrointestinal bleeding,
nontraumatic internal bleeding
(aneurysm, ectopic rupture), vaginal
bleeding
HYPOVOLEMIC SHOCK

• May be from nonhemorrhagic fluid

loss from;
• gastrointestinal tract (vomiting,
diarrhea, fistula),
• urinary loss (hyperglycemia with
glucosuria),
• evaporative loss (fever, burn,
hyperthermia)
• intestinal fluid shifts (third spacing as
with a bowel obstruction)
Clinical sign
• Depend on volume lost

• Symptoms include: tachycardia,

hypotension, decreased urine
output, mental status changes,
tachypnea
Classification hypovolemic
shock
Based on 70 Class.1 Class.2 Class.3 Class.4
kg

Blood loss > 750 750 – 1.500 1.500-2.000 >2.000

(ml)
Blood vol > 15 15 - 30 30 - 40 > 40
(%)
Pulse rate < 100 > 100 > 120 >140

Blood normal normal decreased decreased

pressure
Capillary normal decreased decreased decreased
refill
Classification hypovolemic
shock
Based on 70 Class.1 Class.2 Class.3 Class.4
kg

Respiratory normal 20 - 30 30 - 40 distress

rate
Urinary > 30 20 - 30 5 -15 < 10
output
(ml/hr)
Mental Mild anxiety Anxiety Confused lethargic
status
Fluid Crysalloid Crystalloid Crystalloid Crystalloid
replacemen + blood + blood
t
DIAGNOSIS
• VITAL SIGN.
• Heart rate
• Blood pressure
• TemSperature
• Urine output
• Pulse oxymetri

• Patient with normal or near normal

signs, 50-85% are still in shock
HEART RATE (HR)
• TACHYCARDIA is an early sign of
significantvolume loss in shock.

• The heart rate of young patient or

those on β blockers may be not
increase

• Bradycardia after prolonged

hypotension precludes
cardiovascular collapse
BLOOD PRESSURE (BP)

• HYPOTENSION and narrowing

pulse pressure are a sign of
severe volume loss and shock.

• Mean arterial pressure (MAP) is

a better guide to therapy than
systolic BP
TEMPERATURE

• Hyperthermia, normothermia,
hypothermia may be present in
shock.

• Hypothermia is a sign of severe

hypovolemic and septic shock
URINE OUTPUT

• Early guide of hypovolemia and

end organ response (renal) to
shock.

• This is a delayed vital sign

because 1 to 2 hours are
needed to obtain an acurate
measure
PULSE OXIMETRY

• Continuously measured and

early indicator of hypoxemia but
may be invalid in hypothermic
patients
INVASIVE HEMODYNAMIC
MONITORING
1. Arterial catheters
2. Central venous catheters
(CVc)
3. Pulmonary arterial
catheters (PAc)
INVASIVE HEMODYNAMIC
MONITORING
• Arterial catheters; give
continuous blood pressure
measurement.

• Central venous catheters

(CVc); gives continuous
central venous pressure (CVP)
measurement.
Arterial catheter insertion
INVASIVE HEMODYNAMIC
MONITORING
• Pulmonary arterial catheters (PAc)
can measure CVP, right arterial
(RA) pressure, pulmonary artery
pressure (PAp), pulmonary arterial
occlusion pressure (PAOp / wedge
pressure), cardiac output (CO).

• PAc will help guide aggresive

resuscitation in patient with
severe shock
Pulmonary artery catheter
Typical pressure waveform
PA catheter
CARDIAC OUTPUT – CARDIAC INDEX

• Cardiac output (CO) or Cardiac

index (CI) reflect cardiac
function and can be directly
measured by a PAC.

• Optimizing CI can be increased

by increasing preload ,
increasing contractility or
decreasing afterload
HEMODYNAMIC VARIABLES

MEASURED VARIABLE

VARIABLE UNIT NORMAL RANGE

Systolic BP (SBP) mmHg 90 -140
Diastolic BP (DBP) mmHg 60 - 90
Systolic pulmonary
blood pressure (PAS) mmHg 15 - 30
Diastolic pulmonary
blood pressure (PAD) mmHg 4 - 12
Pulmonary artery
occlusion pressure mmHg 2 - 12
(PAOP)
HEMODYNAMIC VARIABLES
MEASURED VARIABLE

VARIABLE UNIT NORMAL RANGE

Central venous
pressure (CVP) mmHg 0-8
Heart rate (HR) Beats/min 50 - 100
Cardiac output
(CO) L/min 4-6
Right ventricular
ejection fraction
(RVEF) fraction 0,4 – 0,6
HEMODYNAMIC VARIABLES

CALCULATED VARIABLE

VARIABLE UNIT NORMAL RANGE

Mean arterial mmHg 70 - 105
pressure (MAP)
Mean pulmonary
artery pressure mmHg 9 - 16
(MPAP)
Cardiac Index (CI) L/min/m2 2,8 - 4,2
Stroke volume (SV) ML/ beat varies
Stroke volume index
(SVI) mL/ beat/ m2 30 - 65
TREATMENT
• Rapid recognition and restoration of
perfusion is the key to preventing
multiple organ dysfunction and
death.

• In all forms of shock, rapid

restoration of preload with infusion
of fluids is the first treatment
TREATMENT
• Crystalloid is first infused and
then blood is infused if shock is
secondary to hemorrhage.

• Early diagnosis of the etiology

is essential and further
treatment of the shock depends
on its etiology.
TREATMENT
Hypovolemic shock
• Rapid infusion of crystalloid, large-
bore venous acces is needed and
central access may be necessary .

• Blood tranfused after 2-3 liter

crystalloid, if the cause is
hemorrhage. The source of bleeding
needs to be controlled
Basic management

• The initial therapy of choice:

replacement of intravascular volume.

• Physical examination may provide

valuable information about the
intravascular volume status (clear
lung field and flat neck vein suggest a
need for additional fluid resuscitation
in the hypotensive patient).