DM Alif - DM Safira – DM Yudith

Clerkship 2018
• Clinical syndrome that results from inadequate
tissue perfusion
• Imbalance between the delivery of and requirements
for oxygen and substrate
• cellular dysfunction or cellular injury induces the
production and release of damage-associated
molecular patterns (DAMPs or "danger signals") and
inflammatory mediators
• further compromise perfusion MOF death €
The hemodynamic, oxygen transport, and oxygen utilization components of shock management
Shock-induced vicious cycle
Classification of Shock
• Hypovolemic
• Traumatic
• Cardiogenic (Intrinsic, Compressive)
• Septic (Hyper-hypodinamic)
• Neurogenic
• Hypoadrenal
Definitions, etiologies, and therapies
of various shock states (Cecil)
A schematic of the
host
immunoinflammatory
Physiologic Characteristics of the
Various Forms of Shock (Harrisson’s)
Most common form of shock
Causes:
loss of red blood cell mass and
plasma from hemorrhage
loss of plasma volume alone due to extravascular fluid
sequestration or GI, urinary, and insensible losses
Diagnosis:
• signs of hemodynamic instability and the suspected source
of volume loss
• initial normal hematocrit does not disprove the presence
of significant blood loss
• Plasma losses cause hemoconcentration
free water loss leads to hypernatremia
Hypovolemic Shock
Initial resuscitation:
rapid reexpansion of the circulating intravascular
blood volume
• isotonic saline
• Ringer's lactate
interventions to control ongoing losses
Needs support of respiratory function
Starling’s Law: stroke volume and cardiac
output rise with the increase in preload
The hallmark:
decrease in peripheral vascular resistance that occurs
despite increased levels of vasopressor catecholamines
Hyperventilation is often an early sign of the
septic response
Disorientation, confusion, and other manifestations of
encephalopathy may also develop early on, particularly in
the elderly and in individuals with preexisting neurologic
impairment
Stress ulceration can lead to upper
gastrointestinal bleeding
Prolonged or severe hypotension may induce acute hepatic
injury or ischemic bowel necrosis
Definitions Used to Describe the Condition of Septic Patients
Antimicrobial Agents
should be started as soon as samples of blood and
other relevant sites have been obtained for culture
Removal of the Source of Infection
Hemodynamic, Respiratory, and Metabolic Support
The primary goals are to restore adequate oxygen and
substrate delivery to the tissues as quickly as possible
and to improve tissue oxygen utilization and cellular
metabolism
General Support
nutritional supplementation
Prophylactic
heparinization ?
prevention of skin breakdown, nosocomial infections, and
stress ulcers
tight control of the blood glucose concentration
The normal host response to the stress of
illness, operation, or trauma requires that the
adrenal glands hypersecrete cortisol in excess
of that normally required
characterized by loss of homeostasis with
reductions in systemic vascular
resistance, hypovolemia, and reduced
cardiac output
Critical illness, including trauma and sepsis,
may also induce a relative hypoadrenal state
Diagnosis: ACTH stimulation € inconsistent
Tx for hemodynamically unstable patient:
dexamethasone sodium phosphate 4 mg IV
Simultaneous volume resuscitation
and pressor support are required
The need for simultaneous mineralocoid
is unclear
• Dobutamine:
• inotropic with simultaneous afterload reduction € minimizing
cardiac-oxygen consumption increases as cardiac output increases.
• Dopamine:
• inotropic and chronotropic agent
• supports vascular resistance in those whose blood pressure will not
tolerate peripheral vascular dilation
• Norepinephrine:
• primarily supports blood pressure through vasoconstriction and
increases myocardial oxygen consumption while placing marginally
perfused tissues such as extremities and splanchnic organs
• at risk for ischemia or necrosis
inotropic without chronotropy.

• Arginine-vasopressin
(antidiuretic hormone)
• increase afterload
• may better protect vital organ blood flow and prevent pathologic
Vasopressor
Agents
• Patients in shock require care in an ICU
Careful and continuous assessment of the
physiologic status is necessary
• Arterial pressure through an indwelling line,
pulse, and respiratory rate should be
monitored continuously
• Foley catheter should be inserted to follow
urine flow
• mental status should be assessed frequently