1 SHOCK SHOCK DR. Med. dr. Untung Widodo, DR. Med. dr. Untung Widodo, SpAn.KIC. SpAn.KIC. Dept. of Anesthesiology & Dept. of Anesthesiology & Reanimation Reanimation Faculty of Medicine, Faculty of Medicine, Gadjah Gadjah Mada University Mada University Blok Kegawatdaruratan, 2 November 2011 [09]
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SHOCSHOCKK
DR. Med. dr. Untung Widodo, DR. Med. dr. Untung Widodo, SpAn.KIC.SpAn.KIC.
Dept. of Anesthesiology & Dept. of Anesthesiology & ReanimationReanimation
Faculty of Medicine, Faculty of Medicine, Gadjah Mada Gadjah Mada UniversityUniversity
Yogyakarta, 200Yogyakarta, 20099
Blok Kegawatdaruratan, 2 November 2011 [09]
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I. INTRODUCTIONI. INTRODUCTION
DEFINITION :DEFINITION : SHOCK : SHOCK : STATE OF STATE OF SYSTEMIC METABOLIC SYSTEMIC METABOLIC
DEMANDDEMAND WHICH WHICH DOES NOT MEET WITH DOES NOT MEET WITH BLOOD SUPPLYBLOOD SUPPLY
DIAGNOSIS : DIAGNOSIS : - ANAMNESIS : HISTORICAL FINDINGS- ANAMNESIS : HISTORICAL FINDINGS WHICH POSIBLE TO CAUSE SHOCKWHICH POSIBLE TO CAUSE SHOCK - PHYSICAL EXAMINATION : DISCOVERED- PHYSICAL EXAMINATION : DISCOVERED SIGNS OF SHOCKSIGNS OF SHOCK - LABORATORY FINDINGS : DEPEND ON - LABORATORY FINDINGS : DEPEND ON
THETHE TYPE OF SHOCKTYPE OF SHOCK
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Intro. Continues ...Intro. Continues ...
ANAMNESTIC FINDINGS FOR SHOCK :ANAMNESTIC FINDINGS FOR SHOCK :
- LAKE OF FLUIDS INTAKE AND/OR- LAKE OF FLUIDS INTAKE AND/OR
PROFUSE FLUIDS LOSSPROFUSE FLUIDS LOSS
- ANY KINDS OF CARDIAC DISEASES- ANY KINDS OF CARDIAC DISEASES
- ANY KINDS OF SEVERE ILLNESS- ANY KINDS OF SEVERE ILLNESS
- ANY KINDS OF TRAUMA OR PATALO-- ANY KINDS OF TRAUMA OR PATALO-
GIC PROCESS ON CHEST/LUNGGIC PROCESS ON CHEST/LUNG
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Intro. continuesIntro. continues
SIGNS SIGNS ON THE PHYSICAL EXAMINTANION ON THE PHYSICAL EXAMINTANION :: - DECREASE OF MENTAL STATUS, & OTHER- DECREASE OF MENTAL STATUS, & OTHER SIGNS OF ORGAN HYPOPERFUSIGNS OF ORGAN HYPOPERFUSSIONION - HYPOTENSION- HYPOTENSION - TACHYCARDIA, OR ARRYTHMIA, OR- TACHYCARDIA, OR ARRYTHMIA, OR BRADYBRADY-- CARDIACARDIA (DEPEND ON THE CAUSA (DEPEND ON THE CAUSA & STADI- & STADI- UM OF SHOCKUM OF SHOCK) ) -- OLIGURIAOLIGURIA - COLD ACRAL - COLD ACRAL
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Introduction ....Introduction ....
LAB. FINDINGS :LAB. FINDINGS : e.g. :e.g. : - METABOLIC ASIDOSIS FOR ALL KINDS OF - METABOLIC ASIDOSIS FOR ALL KINDS OF
SHOCKSHOCK - HEMOCONCENTRATION FOR HYPOVOLEMIC- HEMOCONCENTRATION FOR HYPOVOLEMIC SHOCKSHOCK - BACTERIEMIA FOR SEPTIC SHOCK- BACTERIEMIA FOR SEPTIC SHOCK - TENSION (PNEUMOTHORAX WITH LUNG - TENSION (PNEUMOTHORAX WITH LUNG
COLLAPSCOLLAPS AND MEDIASTINUM SHIFTAND MEDIASTINUM SHIFT ON CHEST X-RAY ON CHEST X-RAY) )
FORFOR OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK - CARDIOMEGALI OR ABNORMALITY OF - CARDIOMEGALI OR ABNORMALITY OF
CARDIACCARDIAC APPEARANCE IN CHEST X-RAY AND ECG FORAPPEARANCE IN CHEST X-RAY AND ECG FOR CARDIAC SHOCK CARDIAC SHOCK
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II. BASIC PRINCIPLESII. BASIC PRINCIPLES OF SHOCK MANAGEMENT OF SHOCK MANAGEMENT
AIRWAY FREE AIRWAY FREE ADEQUATE BREATHING ADEQUATE BREATHING (( VENTILATE THE ALVEOLI, OPTIMIZED BLOOD VENTILATE THE ALVEOLI, OPTIMIZED BLOOD
III. MAJOR CATAGORIES OF III. MAJOR CATAGORIES OF SHOCKSHOCK
1. HYPOVOLEMIC SHOCK1. HYPOVOLEMIC SHOCK
2. CARDIOGENIC SHOCK2. CARDIOGENIC SHOCK
3. DISTRIBUTIVE SHOCK3. DISTRIBUTIVE SHOCK
4. OBSTRUCTIVE SHOCK4. OBSTRUCTIVE SHOCK
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HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK
DEPLETION OF INTRAVASCULAR DEPLETION OF INTRAVASCULAR VOLUMEVOLUME
CAUSA : LAKE OF FLUID INTAKE AND CAUSA : LAKE OF FLUID INTAKE AND OR PROFUSE FLUID LOSSES OR PROFUSE FLUID LOSSES
( eg. ( eg. ANOREXIA, CANNOT DRINK & ANOREXIA, CANNOT DRINK & MEAL, PATOLOGIC T G I, MEAL, PATOLOGIC T G I, HEMORRHAGE, VOMITHEMORRHAGE, VOMITUSUS, DIARRHEA, DIARRHEA,, EVAPORATION EVAPORATION OR THIRD-SPACE OR THIRD-SPACE LOSSES )LOSSES )
MANAGEMENT OF HYPOVOLEMIC MANAGEMENT OF HYPOVOLEMIC SHOCKSHOCK
STEPS A, B, CSTEPS A, B, C RESTORATION OF INTRAVASCULAR RESTORATION OF INTRAVASCULAR
VOLUME WITH KOLLOID OR VOLUME WITH KOLLOID OR KRISTALLOIDKRISTALLOID
TARGET : NORMAL BP, PULSE & ORGAN TARGET : NORMAL BP, PULSE & ORGAN PERFUSION (e g. adequate urine output)PERFUSION (e g. adequate urine output)
PRINCIPLES IN FLUID RESUSCITATION :PRINCIPLES IN FLUID RESUSCITATION : - RAPID (to normovolumia)- RAPID (to normovolumia) - CLOSED TO THE KIND OF DEFICITE - CLOSED TO THE KIND OF DEFICITE
FLUIDFLUID - USE THE AVAILABLE FLUID- USE THE AVAILABLE FLUID
MANAGEMENT OF CARDIOGENIC MANAGEMENT OF CARDIOGENIC SHOCKSHOCK
STEPS A, B, CSTEPS A, B, C IMPROVE MYOCARDIAL FUNCTIONIMPROVE MYOCARDIAL FUNCTION ARRHYTMIAARRHYTMIA SHOULD BE TREATED SHOULD BE TREATED
PROMPTLYPROMPTLY INOTROPES iv. (Dobutamine, to INOTROPES iv. (Dobutamine, to
increase myocard contractility)increase myocard contractility) VASOACTIVE DRUGS iv. (In Case of VASOACTIVE DRUGS iv. (In Case of
low SVR, vasoconstrictor to increase low SVR, vasoconstrictor to increase aortic diastolic pressure, in case of high aortic diastolic pressure, in case of high SVR : vasodilator)SVR : vasodilator)
ABNORMAL DISTRIBUTION AND ABNORMAL DISTRIBUTION AND PROFILE OF INTRAVASCULAR FLUIDPROFILE OF INTRAVASCULAR FLUID
CAUSA : SEPSIS, ANAPHYLAXY, CAUSA : SEPSIS, ANAPHYLAXY, BLOCK OF SYMPATHETIC PATHWAY BLOCK OF SYMPATHETIC PATHWAY OR PARASYMPATIC HYPERACTIVE OR PARASYMPATIC HYPERACTIVE (NEUROGENIC), ACUTE ADRENAL (NEUROGENIC), ACUTE ADRENAL IN-SUFFICIENCYIN-SUFFICIENCY
HEMODYNAMIC PROFILE : NORMAL HEMODYNAMIC PROFILE : NORMAL OR HIGH OR HIGH COCO, LOW TO NORMAL LEFT , LOW TO NORMAL LEFT VEN-TRICULAR FILLING PRESSURE, VEN-TRICULAR FILLING PRESSURE, LOW LOW SVRSVR
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MANAGEMENT OF DISTRIBUTIVE MANAGEMENT OF DISTRIBUTIVE SHOCKSHOCK STEPS A, B, CSTEPS A, B, C RESTORATION & MAINTENANCE OF RESTORATION & MAINTENANCE OF
NORMAL INTRAVASCULAR VOLUMENORMAL INTRAVASCULAR VOLUME INCREASE BP WITH INOTROPESINCREASE BP WITH INOTROPES (IS/ARE ADMINISTERED IF PRELOAD IS (IS/ARE ADMINISTERED IF PRELOAD IS
ADEQUATE OR NORMOVOLUMIA)ADEQUATE OR NORMOVOLUMIA) COMBINATION WITH VASOPRESSORCOMBINATION WITH VASOPRESSOR ANAPHYLACTIC SHOCK IS TREATED WITH ANAPHYLACTIC SHOCK IS TREATED WITH
EPINEPHRINE EPINEPHRINE ( & SECURE A B C ) ( & SECURE A B C ) ACUTE ADRENAL INSUFF : VOLUME Tx, ACUTE ADRENAL INSUFF : VOLUME Tx,
CORTICOSTEROIDS iv. AND VASOPRESSORCORTICOSTEROIDS iv. AND VASOPRESSOR NEUROGENIC SHOCK : VOL. NEUROGENIC SHOCK : VOL.
MAINTENANCE MAINTENANCE OF OF NORMOVOLEMIANORMOVOLEMIA INOTROPES & VASOPRESSOR HAVE A INOTROPES & VASOPRESSOR HAVE A
MINIMAL ROLEMINIMAL ROLE DIURETICS SHOULD BE AVOIDEDDIURETICS SHOULD BE AVOIDED
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Spesial notice :Spesial notice :
SHOCK IS ONE OF CRITICALLY ILL, SHOCK IS ONE OF CRITICALLY ILL, LIFE THREATENINGLIFE THREATENING SHOULD BE TREATED PROMPTLY, SHOULD BE TREATED PROMPTLY,
WITH RESUSCITATIONWITH RESUSCITATION THE PROGNOSIS IS CORRELATED THE PROGNOSIS IS CORRELATED
WITH TIMEWITH TIME CAUSA & PATOPHYSIOLOGY MAY CAUSA & PATOPHYSIOLOGY MAY
BE COMPLICATED, THEREFORE BE COMPLICATED, THEREFORE THE MANAGEMENTS SHOULD BE THE MANAGEMENTS SHOULD BE ADJUSTED CLOSELYADJUSTED CLOSELY