1 Shock In ER
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Shock
In ER
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Objectives
Define Shock. Recognize the shock state. Determine the cause. Apply treatment principles. Apply principles of fluid management. Monitor patient’s response. Employ options for vascular access. Recognize complications of vascular access.
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Key Questions
Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls?
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Key Questions
Is the patient in shock?• What is shock?
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What is shock?
Shock ≠ hypotension Shock = Inadequate organ perfusion
Inadequate substrate delivery
Anaerobic metabolism Celular dysfunction
Cell death
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Key Questions
Is the patient in shock?• What is shock?• How do you recognize it?
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How do you recognize it?
Scene information/mechanism of injury Physical examination
• Tachycardia• Alteration in LOC, anxiety • Cold, diaphoretic skin Urinary output• Hypotension• Tachypnea, shallow repirations
(AMPLE History – Sec.Survey)
Inadequate
perfusion
Organ
dysfunction
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Recognition of Shock State
1. Tachycardia
2. Vasoconstriction
2. Cardiac output
Narrow pulse pressure
3. Map
3. Blood Flow
Caution : Compensatory mechanisms
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Class I Hemorrhage
750 mL BVL (<15%)
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Class II Hemorrhage
750 – 1500 mL BVL (15-30%)
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Class III Hemorrhage
1500 – 2000 mL BVL (30-40%)
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Class IV Hemorrhage ≥ 2000 mL BVL (>40%)
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Recognition of Shock State
Some condition such as medications, age,
pregnancy can hide signs and symptoms
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Key Quetions
Is the patient in shock?• What is shock?• How do you recognize it?• What preparations are necessary?
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Preparations?
Trauma team activation? Summon the trauma personel Organize the equipment Standard precautions Warm room and fluids
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Key Questions
Is the patient in shock? What is the cause of the shock state?
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What is the cause?
Hemorrhagic vs
Blood loos
Nonhemorrhagic
• Cardiogenic– Blood pump and/or rate
problem
• Distributive– Blood vessel problem
• Obstructive– Blood flow problem
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Key Questions
Is the Patient in shock? What is the cause of the shock state?
• How do you locate the bleeding?
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How to locate the bleeding?
Physical examination Diagnostic adjuncts to primary survey
• Chest x-ray
• DPL / Ultrasound
• AP pelvis x-ray
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Key Questions
Is the patient in shock? What is the cause of the shok state? What can I do about it?
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What can I do about it?
• Restore the organ perfusion and tissue oxygenation – Oxygen and ventilatory support (AB maneuver)– Fluid therapy– Inotrope or vasoactive drugs (if needed)– Treat the cause
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What can I do about it? Stop the bleeding!
• Direct pressure • Operation• Reduce pelvic volume• Splint fractures
Restore volume! : “too little vs too much”• Vascular access• Warmed fluids
Prevent hypothermia!
Fluid therapy
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Stop bleeding !!
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Turniket : hanya bila hancur/ akan amputasiKlem : merusak struktur lainJahit : hanya bila perlu
Stop bleeding !!
Perdarahan luar : tekanan langsung /perban tekan
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What can I do about it?
Volume expansion InotropeVasoactive drugs
Heartfull
Fluid therapy
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Inotrope & Vasoactive Drugs• Use after fluid resuscitation failed
(normovolemia)– More efficacious if normovolemia– May obscure hypovolemia
7070 100100 mmHgmmHg
• norepinephrinenorepinephrine• dopamindopamin
• dopamin (shock)dopamin (shock)• norepinephrine (+dopamin)norepinephrine (+dopamin)• dobutamin (shock -)dobutamin (shock -)
• nitroglycerin (ischemia)nitroglycerin (ischemia)• nitroprusidenitropruside
systolicsystolic
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Key Questions
Is the patient in shock? What is the cause of the shock state? What can I do about it?
• How do I evaluate the response to
treatment?
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Response evaluation?
Identify Improved Organ Perfusion CNS: Improved LOC Renal: Urinary output Skin: Warm, capillary refill Repirations: Improved rate and depth Vital signs: Return to normal
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Response evaluation?
Normal urine output :Normal urine output :- Neonate = 2 ml/kg/hour- Neonate = 2 ml/kg/hour- Infant = 1,5 ml/kg/hour- Infant = 1,5 ml/kg/hour- Pre school age = 1 ml/kg/hour- Pre school age = 1 ml/kg/hour-Adult Adult = 0,5 ml/kg/hour = 30-50ml/hour = 0,5 ml/kg/hour = 30-50ml/hour
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Key Questions
Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response?
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What is the patient’s response?
Rapid Responder Transient Responder Nonresponder
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Fluid management in traumatic shockFluid management in traumatic shock
ShockShock
Fluid Loading 1000-2000 mlFluid Loading 1000-2000 ml
Good responseGood response
MildMildBlood lossBlood loss
Transient responseTransient response
MaintenanceMaintenance
Moderate lossModerate lossOn going lossesOn going losses
Fluid/bloodFluid/blood
No responseNo response
SevereSevereBlood lossBlood loss
ShockShockNon-hypovolemicNon-hypovolemic
Fluid/bloodFluid/blood Re-evaluateRe-evaluate
SurgicalSurgicalconsultationconsultation
SurgicalSurgicalconsultationconsultation
SurgicalSurgicalresuscitationresuscitation
Warm fluid!!Warm fluid!!
Get moreGet moreinformationinformation
2 iv line, large caliber
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Key Questions
Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls?
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What are the pitfalls?
BP = Cardiac output Age extremes Hypothermia Athletes Pregnancy Medications Pacemaker
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Questions
?
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Summary Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls?