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SHOCKDR. Med. dr. Untung Widodo, SpAn.KIC.Dept. of
Anesthesiology & ReanimationFaculty of Medicine, Gadjah Mada
UniversityYogyakarta, 2009
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I. INTRODUCTIONDEFINITION : SHOCK : STATE OF SYSTEMIC METABOLIC
DEMAND WHICH DOES NOT MEET WITH BLOOD SUPPLYDIAGNOSIS : - ANAMNESIS
: HISTORICAL FINDINGS WHICH POSIBLE TO CAUSE SHOCK - PHYSICAL
EXAMINATION : DISCOVERED SIGNS OF SHOCK - LABORATORY FINDINGS :
DEPEND ON THE TYPE OF SHOCK
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Intro. Continues ...ANAMNESTIC FINDINGS FOR SHOCK : - LAKE OF
FLUIDS INTAKE AND/OR PROFUSE FLUIDS LOSS - ANY KINDS OF CARDIAC
DISEASES - ANY KINDS OF SEVERE ILLNESS (SEPSIS, ANAPHYLACTIC
REACTION, INJURY OF BACK BONE ETC. - ANY KINDS OF TRAUMA OR PATALO-
GIC PROCESS ON CHEST/LUNG
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Intro. continuesSIGNS ON THE PHYSICAL EXAMINTANION : - DECREASE
OF MENTAL STATUS, & OTHER SIGNS OF ORGAN HYPOPERFUSION -
HYPOTENSION - TACHYCARDIA, OR ARRYTHMIA, OR BRADY- CARDIA (DEPEND
ON THE CAUSA & STADI- UM OF SHOCK) - OLIGURIA - COLD ACRAL
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Introduction ....LAB. FINDINGS : e.g. : - METABOLIC ASIDOSIS FOR
ALL KINDS OF SHOCK - HEMOCONCENTRATION FOR HYPOVOLEMIC SHOCK -
BACTERIEMIA FOR SEPTIC SHOCK - TENSION (PNEUMOTHORAX WITH LUNG
COLLAPS AND MEDIASTINUM SHIFT ON CHEST X-RAY) FOR OBSTRUCTIVE SHOCK
- CARDIOMEGALI OR ABNORMALITY OF CARDIAC APPEARANCE IN CHEST X-RAY
AND ECG FOR CARDIAC SHOCK
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II. BASIC PRINCIPLES OF SHOCK MANAGEMENTAIRWAY FREE ADEQUATE
BREATHING ( VENTILATE THE ALVEOLI, OPTIMIZED BLOOD OXYGENATION,
INCREASE O2 DELIVERY & TISSUE OXYGENATION )ADEQUATE CIRCULATION
(INCREASE CARDIAC OUTPUT & BLOOD PRESSURE WITH FLUID, POSITIVE
INOTROPES AND VASOPRESSORS DEPEND ON THE CAUSA &
PATHOPHYSIOLOGY)SEARCH CAUSA AND TREAT PROMPLYGUIDE OF TREATMENT
WITH CLOSED MONITORING
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GENERAL EARLY TARGET IN SHOCK RESUSCITATION COMPOS MENTISA &
B NORMALC : BP SYSTOLE > 90 mmHg, HR < 100 x/mnt Cap. Refill
< 2 sec. warm extremitiesFLUID : URINE PROD. > 0,5
cc/kg/hr
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Face mask-valve-bag
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III. MAJOR CATAGORIES OF SHOCK 1. HYPOVOLEMIC SHOCK
2. CARDIOGENIC SHOCK
3. DISTRIBUTIVE SHOCK
4. OBSTRUCTIVE SHOCK
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HYPOVOLEMIC SHOCKDEPLETION OF INTRAVASCULAR VOLUMECAUSA : LAKE
OF FLUID INTAKE AND OR PROFUSE FLUID LOSSES ( eg. ANOREXIA, CANNOT
DRINK & MEAL, PATOLOGIC T G I, HEMORRHAGE, VOMITUS, DIARRHEA,
EVAPORATION OR THIRD-SPACE LOSSES )HEMODYNAMIC PROFILE : DECREASED
CO, DECREASED LEFT VENTRICULAR FILLING PRESSURE, INCREASED SVR
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MANAGEMENT OF HYPOVOLEMIC SHOCKSTEPS A, B, CRESTORATION OF
INTRAVASCULAR VOLUME WITH KOLLOID OR KRISTALLOIDTARGET : NORMAL BP,
PULSE & ORGAN PERFUSION (e g. adequate urine output)PRINCIPLES
IN FLUID RESUSCITATION : - RAPID (to normovolumia) - CLOSED TO THE
KIND OF DEFICITE FLUID - USE THE AVAILABLE FLUID
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CARDIOGENIC SHOCKINADEQUATE FORWORD BLOOD FLOWCAUSA: ANY
PATHOLOGIES OF HEARTHHEMODYNAMIC PROFILE : DECREASED CO, HIGH
VENTRICULAR FILLING PRESSURE, VARIABLE SVR
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MANAGEMENT OF CARDIOGENIC SHOCKSTEPS A, B, CIMPROVE MYOCARDIAL
FUNCTIONARRHYTMIA SHOULD BE TREATED PROMPTLYINOTROPES iv.
(Dobutamine, to increase myocard contractility)VASOACTIVE DRUGS iv.
(In Case of low SVR, vasoconstrictor to increase aortic diastolic
pressure, in case of high SVR : vasodilator)
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INOTROPIC & VASOACTIVE
DRUGSADRENALINNOREPINEPHRINEDOBUTAMINE &
DOPAMINELANOXINISOSORBID DINITRAT (ISDN)NTG
(NITROGLYCERIN)CAPTOPRILNOREPINEPHRINEEPHEDRINEPHENYLEPHRINE
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DISTRIBUTIVE SHOCKABNORMAL DISTRIBUTION AND PROFILE OF
INTRAVASCULAR FLUIDCAUSA : SEPSIS, ANAPHYLAXY, BLOCK OF SYMPATHETIC
PATHWAY OR PARASYMPATIC HYPERACTIVE (NEUROGENIC), ACUTE ADRENAL
IN-SUFFICIENCYHEMODYNAMIC PROFILE : NORMAL OR HIGH CO, LOW TO
NORMAL LEFT VEN-TRICULAR FILLING PRESSURE, LOW SVR
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MANAGEMENT OF DISTRIBUTIVE SHOCKSTEPS A, B, CRESTORATION &
MAINTENANCE OF NORMAL INTRAVASCULAR VOLUMEINCREASE BP WITH
INOTROPES (IS/ARE ADMINISTERED IF PRELOAD IS ADEQUATE OR
NORMOVOLUMIA)COMBINATION WITH VASOPRESSORANAPHYLACTIC SHOCK IS
TREATED WITH EPINEPHRINE ( & SECURE A B C )ACUTE ADRENAL INSUFF
: VOLUME Tx, CORTICOSTEROIDS iv. AND VASOPRESSORNEUROGENIC SHOCK :
VOL. Tx,VASOPRESS., ATROPINE (for Bradycardia)
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OBSTRUCTIVE SHOCKOBSTRUCTION TO CARDIAC FILLINGCAUSA : CARDIAC
TAMPONADE, TENSION PNEUMOTHORAX, MASSIVE PULMONARY
EMBOLIHEMODYNAMIC PROFILE : DECREASED CO, VARIABLE LEFT VENTRICULAR
FILLING PRESSURE, INCREASED SVR
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MANAGEMENT OF OBSTRUCTIVE SHOCKSTEPS A, B, CRELIEF OF OBSTRUCTON
(PERICARDIOCENTESIS, PLEURAL /THORACAL PUNCTION & WSD
)MAINTENANCE OF NORMOVOLEMIAINOTROPES & VASOPRESSOR HAVE A
MINIMAL ROLEDIURETICS SHOULD BE AVOIDED
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Spesial notice :SHOCK IS ONE OF CRITICALLY ILL, LIFE
THREATENINGSHOULD BE TREATED PROMPTLY, WITH RESUSCITATIONTHE
PROGNOSIS IS CORRELATED WITH TIMECAUSA & PATOPHYSIOLOGY MAY BE
COMPLICATED, THEREFORE THE MANAGEMENTS SHOULD BE ADJUSTED
CLOSELY
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Alhamdulillahirobbilalamin