SHOCKDR. Med. dr. Untung Widodo, SpAn.KIC.Dept. of Anesthesiology & ReanimationFaculty of Medicine, Gadjah Mada UniversityYogyakarta, 2009

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

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

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

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

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

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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III. MAJOR CATAGORIES OF SHOCK 1. HYPOVOLEMIC SHOCK

2. CARDIOGENIC SHOCK

3. DISTRIBUTIVE SHOCK

4. OBSTRUCTIVE SHOCK

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

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

CARDIOGENIC SHOCKINADEQUATE FORWORD BLOOD FLOWCAUSA: ANY PATHOLOGIES OF HEARTHHEMODYNAMIC PROFILE : DECREASED CO, HIGH VENTRICULAR FILLING PRESSURE, VARIABLE SVR

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)

INOTROPIC & VASOACTIVE DRUGSADRENALINNOREPINEPHRINEDOBUTAMINE & DOPAMINELANOXINISOSORBID DINITRAT (ISDN)NTG (NITROGLYCERIN)CAPTOPRILNOREPINEPHRINEEPHEDRINEPHENYLEPHRINE

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

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)

OBSTRUCTIVE SHOCKOBSTRUCTION TO CARDIAC FILLINGCAUSA : CARDIAC TAMPONADE, TENSION PNEUMOTHORAX, MASSIVE PULMONARY EMBOLIHEMODYNAMIC PROFILE : DECREASED CO, VARIABLE LEFT VENTRICULAR FILLING PRESSURE, INCREASED SVR

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

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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