Kuliah Shock

8/18/2019 Kuliah Shock

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SHOCK

MEDICINE FACULTYABDURRAB UNIVERSITY

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*A T +


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.e%inition o% Shock

/nade0uate #er%usion and o1ygenation o%cells


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.e%inition o% Shock

/nade0uate #er%usion and o1ygenation o%cells leads to)

Cellular dys%unction and damage'rgan dys%unction and damage


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2hy should you care

High mortality - ,!-4!5

Early on the e%%ects o% ', de#rivation onthe cell are E6E S/7$E

Early intervention reduces mortality


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*atho#hysiology

8 ty#es o% shockCardiogenic'bstructiveHy#ovolemic.istributive


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*atho#hysiology) 'vervie&

Tissue #er%usion is determined by Mean Arterial *ressure 9MA*:

MA* ; C' 1 S6

Heart rate Stroke 6olume


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Cardiogenic Shock)*atho#hysiology

Heart %ails to #um# blood out

MA* ; C' 1 S6

H Stroke 6olume


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Cardiogenic Shock)*atho#hysiology

Normal

MA* ; C' 1 S6

Cardiogenic

MA* ; ↓ C' 1 S6 MA* ; ↓ C' 1 ↑ S6↓ MA* ; ↓↓ C' 1 ↑ S6


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Cardiogenic Shock) Causes

↓ MA* ; ↓ CO (HR x Stroke Volume) 1 ↑ S6

.ecreased Contractility 9Myocardial /n%arction< myocarditis<cardiomy#othy< *ost resuscitation syndrome %ollo&ing cardiac arrest:

Mechanical .ys%unction = 9*a#illary muscle ru#ture #ost-M/< Severe Aortic Stenosis< ru#ture o% ventricular aneurysms etc:

Arrhythmia = 9Heart block< ventricular tachycardia< S6T< atrial

%ibrillation etc :

Cardioto1icity 97 blocker and Calcium Channel 7locker 'verdose:


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'bstructive Shock)*atho#hysiology

Heart #um#s &ell< but the out#ut is decreaseddue to an obstruction 9in or out o% the heart:

MA* ; C' 1 S6

H 1 Stroke volume


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'bstructive Shock)*atho#hysiology

Normal

MA* ; C' 1 S6

'bstructive

MA* ; ↓ C' 1 S6 MA* ; ↓ C' 1 ↑ S6↓ MA* ; ↓↓ C' 1 ↑ S6


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'bstructive Shock) Causes

↓ MA* ; ↓ CO ( HR x Stroke Volume) 1 ↑ S6

Heart is &orking but there is a block to the out%lo&Massive #ulmonary embolism

Aortic dissectionCardiac tam#onadeTension #neumothora1

'bstruction o% venous return to heart6ena cava syndrome - eg neo#lasms< granulomatous diseaseSickle cell s#lenic se0uestration


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Hy#ovolemic Shock)*atho#hysiology

Heart #um#s &ell< but not enough bloodvolume to #um#

MA* ; C' 1 S6

H 1 Stroke volume


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Hy#ovolemic Shock)*atho#hysiology

Normal

MA* ; C' 1 S6

Hy#ovolemic

MA* ;↓

C' 1 S6 MA* ; ↓ C' 1 ↑ S6↓ MA* ; ↓↓ C' 1 ↑ S6


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Hy#ovolemic Shock) Causes

↓ MA* ; ↓ CO ( HR x Stroke Volume) 1 ↑ S6

.ecreased /ntravascular volume 9*reload: leads to .ecreasedStroke 6olumeHemorrhagic - trauma< G/ bleed< AAA ru#ture< ecto#ic #regnancyHy#ovolemic - burns< G/ losses< dehydration< third s#acing 9e g#ancreatitis< bo&el obstruction:< Adesonian crisis< .iabetic>etoacidosis


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.istributive Shock)*atho#hysiology

Heart #um#s &ell< but there is #eri#heralvasodilation due to loss o% vessel tone

MA* ; C' 1 S6

H 1 Stroke volume


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.istributive Shock)*atho#hysiology

Normal

MA* ; C' 1 S6

.istributive

MA* ; co 1 ↓ S6

MA* ; ↑ co 1 ↓ S6↓ MA* ; ↑ co 1 ↓↓ S6


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.istributive Shock) Causes

↓ MA* ; ↑ C' 9H 1 S6: 1 ↓ S6

$oss o% 6essel tone/n%lammatory cascade

Se#sis and To1ic Shock Syndrome Ana#hyla1is*ost resuscitation syndrome %ollo&ing cardiac arrest

.ecreased sym#athetic nervous system %unctionNeurogenic - C s#ine or u##er thoracic cord in(uries

To1ins.ue to cellular #oisons -Carbon mono1ide< methemoglobinemia<cyanide.rug overdose 9a+ antagonists:


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To Summari?e

T !e o"S#o$k

I%&ult '# & olo $E""e$t

Com!e%&*t o%

Cardiogenic Heart %ails to #um#blood out

↓ CO BaroRc↑ SVR

'bstructive Heart #um#s &ell< butthe out%lo& is obstructed


Hemorrhagic Heart #um#s &ell< but

not enough bloodvolume to #um#

↓ CO 7aro c↑ SVR

.istributive Heart #um#s &ell< butthere is #eri#heralvasodilation

↓ SVR ↑ CO


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'k@it s really not THAT sim#le

MA* ; C' 1 S6

H 1 Stroke volume

*reload A%terload Contractility


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T !e o"S#o$k

I%&ult '# & olo $E""e$t

Com!e%&*t o%

Com!e%&*t o%He*rt R*te

Com!e%&*t o%Co%tr*$t l t

Cardiogenic Heart %ails to#um# bloodout


↑ ↑

'bstructive Heart #um#s&ell< but the

out%lo& isobstructed


↑ ↑

Hemorrhagic Heart #um#s&ell< but notenough bloodvolume to

#um#

↓ CO 7aro c↑ SVR

↑ ↑

.istributive Heart #um#s&ell< butthere is#eri#heralvasodilation

↓ SVR ↑ CO ↑

No Change -in neurogenic

shock

↑

No Change -in neurogenic

shock


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Additional Com#ensatoryMechanisms

enin-Angiotensin-Aldosterone Mechanism A// com#onents lead to vasoconstriction Aldosterone leads to &ater conservation

A.H leads to &ater retention and thirst

/n%lammatory cascade


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Case +

,8 year old male*reviously healthy$ives in a malaria endemic area 9*NG:7rought in by %riends a%ter a %ight - he &as kickedin the abdomenHe is agitated< and &on t lie %lat on the stretcher H 4,< 7* +,B D,< Sa', 4 5< ,B


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Stages o% Shock

Timeline and #rogression &illde#end on)

-Cause

-*atient Characteristics

-/ntervention

/nsult

*reshock9Com#ensation:

Shock9Com#ensation'ver&helmed:

End organ.amage

.eath


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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood

$oss Abdominal tenderness and girth


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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood $oss Abdominal tenderness and

girth

*reshock Hemo&t*t $ $om!e%&*t o%MA* ; ↓ CO (↑ HR x ↓ SV ) 1↑ SVR.ecreased C' is com#ensated byincrease in H and S6

MA* is maintainedH &ill be increasedE1tremities &ill be cool dueto vasoconstriction


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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood

$oss Abdominal tenderness andgirth

*reshock Hemo&t*t $ $om!e%&*t o%MA* ; ↓ CO (HR x ↓ SV ) 1 ↑ SVR.ecreased C' is com#ensatedby increase in H and S6

MA* is maintainedH &ill be increasedE1tremities &ill be cool due tovasoconstriction

Shock Com#ensatory mechanisms%ail

MA* is reducedTachycardia< dys#nea<restlessness


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Case +) Stages o% ShockSt* e '*t#o!# & olo Cl % $*l F %+ % &/nsult S#lenic u#ture -- 7lood $oss Abdominal tenderness and girth

*reshock Hemo&t*t $ $om!e%&*t o%MA* ; ↓ CO (HR x ↓ SV ) 1 ↑ SVR.ecreased C' is com#ensated

by increase in H and S6

MA* is maintainedH &ill be increasedE1tremities &ill be cool due to

vasoconstriction

Shock Com#ensatory mechanisms%ail

MA* is reducedTachycardia< dys#nea<restlessness

Endorgandys%unction

Cell death and organ %ailure .ecreased renal %unction$iver %ailure.isseminated /ntravascularCoagulo#athy.eath


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/s this Shock

Signs and sym#toms$aboratory %indings

Hemodynamic measures


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Sym#toms and Signs o% Shock

$evel o% consciousness

/nitially may sho& %e& sym#tomsContinuum starts &ith

An1iety AgitationCon%usion and .elirium'btundation and Coma

I% %"*%t&'oor to%eU%"o$u&e+ *,e-e*k $rLet#*r .Com*(Su%ke% or /ul % "o%t*%elle)


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*ulseTachycardia H F +!! - 2hat are a %e& e1ce#tions

a#id< &eak< thready distal #ulses

es#irationsTachy#neaShallo&< irregular< labored


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7lood *ressureMay be normal.e%inition o% hy#otension

Systolic 4! mmHg

MA* B mmHg8! mmHg dro# systolic 7* %rom %rom baseline

ChildrenSystolic 7* + month ; B! mmHg

Systolic 7* + month - +! years ; D! mmHg I 9, 1 age in years:

/n children hy#otension develo#s l*te0 l*te0 l*teA !re1term %*l e2e%t



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SkinCold< clammy 9Cardiogenic< 'bstructive<Hemorrhagic:

2arm 9.istributive shock:Mottled a##earance in children$ook %or #etechia

.ry Mucous membranes$o& urine out#ut ! ml kg hr


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H !o2olem $S#o$k

D &tr /ut 2eS#o$k

C*r+ o e% $S#o$k

O/&tru$t 2eS#o$k

HR /ncreased /ncreased9Normal inNeurogenicshock:

May beincreased ordecreased

/ncreased

3V' $o& $o& High High

B' $o& $o& $o& $o&

SKIN Cold 2arm 9Coldin severeshock:

Cold Cold

CA'REFILL

Slo& Slo& Slo& Slo&


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Em#iric Criteria %or Shock

4 out o" 5 $r ter * #*2e to /e met

/ll a##earance or altered mental status

Heart rate F+!!es#iratory rate F ,, 9or *aC', 3, mmHg:"rine out#ut ! ml kg hr

Arterial hy#otension F ,! minutes duration$actate F 8


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$actate

$actate is increased in Shock

*redictor o% Mortality

Can be used as a guide to resuscitation

Ho&ever it is not necessary< or available inmany settings


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Management o% Shock

History*hysical e1am

$abs'ther investigationsTreat the Shock - Start treatment as soon

as you sus#ect *re-shock or ShockMonitor


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Historical Jeatures

Trauma*regnant

Acute abdominal #ain6omiting or .iarrheaHematoche?ia or hematemesis

Jever Jocus o% in%ectionChest #ain


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*hysical E1am

6itals - H < 7*< Tem#erature< es#iratoryrate< '1ygen SaturationCa#illary blood sugar 2eight in children


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*hysical E1am

/n a #atient &ith normal level o%consciousness - *hysical e1am can bedirected to the history


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*hysical E1am

/n a #atient &ith abnormal level o% consciousness*rimary survey

Cardiovascular 9murmers< K6*< mu%%led heart sounds:

es#iratory e1am 9crackles< &hee?es:< Abdominal e1am

ectal and vaginal e1amSkin and mucous membranes

Neurologic e1amination


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$aboratory Tests

C7C< Electrolytes< Creatinine 7"N< glucoseI - $actateI - Ca#illary blood sugar I - Cardiac En?ymes7lood Cultures - %rom t&o di%%erent sites7eta HCG

I - Cross Match


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'ther investigations

ECG"rinalysis

CLI - EchoI - JAST


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Treatment

St*rt tre*tme%t mme+ *tel


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Stages o% Shock

Early /ntervention can arrest or

reduce the damage

/nsult


Shock9Com#ensation

'ver&helmed:

End organ.amage

.eath


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Treatment

A7C s to + Air&ay7reathingCirculation*ut the #atient on a monitor i% available

Treat underlying cause


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Treatment) Air&ay and 7reathing

Give o1ygen


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Consider /ntubation/s the cause 0uickly reversible

Generally no need %or intubation

3 reasons to intubate in the setting o% shock/nability to o1ygenate/nability to maintain air&ay2ork o% breathing

Treatment) Air&ay and 7reathing


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Treatment) Circulation

Treat the e*rl signs o% shock 9Cold<clammy .ecreased ca#illary re%illTachycardic Agitated :

.' N'T 2A/T %or hy#otension


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Start /6 I - Central line 9or /ntraosseous:.o 7lood 2ork I - 7lood Cultures


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Jluids - ,! ml kg bolus 1 3Normal saline

inger s lactate


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7ack to Case +

,8 year old male*reviously healthy$ives in a malaria endemic area 9*NG:7rought in by %riends a%ter a %ight - he &as kickedin the abdomenHe is agitated< and &on t lie %lat on the stretcher

H 4,< 7* +,B D,< Sa', 4 5< ,B


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Case +

'n e1aminationE1tremely agitatedClammy and coldHeart e1am - normalChest e1am - good air entry

Abdomen - bruised< tender< distended

No other signs o% trauma


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Case +) Management

Hemorrhagic 9Hy#ovolemic Shock: A7C s

Monitors

',/ntubate/6 lines 1 ,< Jluid boluses< Call %or 7lood - ' ty#e7lood &ork including cross match

Treat "nderlying Cause


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Case +) Management

Hemorrhagic 9Hy#ovolemic Shock: A7C s

Monitors',

/ntubate/6 lines 1 ,< Jluid boluses< Call %or 7lood - ' ty#e7lood &ork including cross match

Treat "nderlying CauseGive 7lood

Call the surgeon stat/% the #atient does not res#ond to initial boluses and blood#roducts - take to the '#erating oom


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7lood *roducts

"se blood #roducts i% no im#rovement to %luids* 7C -+! ml kg

'- in child-bearing years and 'I in everyone elseI - *latelets


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Case ,

,3 year old &oman in Addis AbabaHas been %atigued and short o% breath %or a%e& daysShe %ainted and %amily brought her inThey tell you she has a heart #roblem


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Case ,

H +3,< 7* DB 3B< Sa', OO5< 3!< Tem# 3B 3 A##earance - obtundedCardiovascular e1am - S+< S,< irregular<holosytolic murmer< K6* is cm ASA< no edemaChest - bilateral crackles< accessory muscle use

Abdomen - unremarkable

est o% e1am is normal


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Stages o% Shock

2hat stage is she at

/nsult


Shock9Com#ensation

'ver&helmed:End organ.amage

.eath


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Case ,) Management

Cardiogenic Shock A7C s

Monitors

',/6 and blood &orkECG - Atrial Jibrillation< rate +3! s



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Case ,) Management


Monitors',/6 and blood &ork/ntubateECG - Atrial Jibrillation< rate +3! s



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Case ,) 2hy &ould you intubate

/s the cause 0uickly reversible

3 reasons to intubate in the setting o% shock/nability to o1ygenate/nability to maintain air&ay2ork o% breathing

UNLIKELY

/nability to o1ygenate 9*ulmonary edema<

Sa', OO5:

AccessoryMuscle "se


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Case ,) 2hy /ntubate

Strenuous use o% accessory res#iratorymuscles 9i e &ork o% breathing: can)

/ncrease ', consum#tion by !-+!!5.ecrease cerebral blood %lo& by !5


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Case ,) Management


Monitors',/6 and blood &ork/ntubateECG - Atrial Jibrillation< rate +3! s



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Case ,) Management

Cardiogenic ShockTreat "nderlying Cause

$asi1

Atrial Jibrillation - Cardioversion ate control/notro#es - .obutamine I - Nore#ine#hrine96aso#ressor:$ook %or #reci#itating causes - in%ectious


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6aso#ressors in Cardiogenic Shock

Nore#ine#hrine.o#amine

E#ine#hrine*henyle#hrine


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Case 3

3B year old &oman*edestrian hit by a car

She is brought into the hos#ital , hrs a%teraccidentShort o% breathHas been com#laining o% chest #ain


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Case 3

H +,B< S7* O,< Sa', D!5< 3B< Tem# 3'btunded< Accessory muscle useTrachea is deviated to $e%t

Heart - distant heart soundsChest - decreased air entry on the right< brokenribs< subcutaneous em#hysema

Abdominal e1am - normal A#art %rom bruises and scra#es no other signs o%trauma


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Stages o% Shock

2hat stage is she at

/nsult


Shock9Com#ensation


.eath


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Case 3) Management

'bstructive Shock A7C s

Monitors',/6/ntubate72



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Case 3) Management



Treat "nderlying CauseNeedle thoracentesisChest tube

CL


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Case 3) Management



Treat "nderlying CauseNee+le t#or*$e%te& &Chest tube

CL


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Case 3) Management



Treat "nderlying CauseNee+le t#or*$e%te& &Chest tube

C6RI%tu/*te " %o re&!o%&e


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Case 3

Pou #er%orm a needle thoracentesis - heara hissing soundChest tube is inserted success%ullyH 4B< 7* +!! DB< Sa', 4B5 on ',< ,BPou resume your clinical duties< and callthe surgeon


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Case 3

+ hr has gone byPou are having lunch

The nurse #uts her head through the doorto tell you about another #atient at triage<and as she is leaving 7y the &ay< that&oman &ith the chest tube< is %eeling not

so good and leaves


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Case 3

Pou are back at the bedsideThe #atient is obtunded again*ale and Clammy

H +3!< 7* OB ,< Sa', 4B5 on ',Chest tube seems to be &orkingTrachea is midlineHeart - NormalChest - Good air entry

Abdomen - decreased bo&el sounds< distended


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Combined Shock

.i%%erent ty#es o% shock can coe1istCan you think o% other e1am#les


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Monitoring

6itals - 7*< H < Sa',Mental Status"rine 'ut#ut 9F +-, ml kg hr:2hen something changes or i% you do notobserve a res#onse to your treatment -re-e1amine the #atient


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Can &e measure cell hy#o1ia

$actate - &e already talked about - a surrogate

6enous '1ygen Saturation - more direct measure


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6enous '1ygen Saturation

Hg carries ',

A #ercentage o% ', is e1tracted by thetissue %or cellular res#iration

"sually the cells e1tract 3!5 o% the ',


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6enous '1ygen Saturation

Svo, ; Mi1ed venous o1ygen saturationMeasured %rom #ulmonary artery by S&an-Gan? catheter

Normal F B 5

Scvo, ; Central venous o1ygen saturationMeasured through central venous cannulation o% S6C or

Atrium - i e Central $ine

Normal F D!5


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*A T ,


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Case 8

8! year old male"Q abdominal #ain< %ever< %atigued %or -B

daysNo #ast medical history


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Case 8

H ++!< 7* +!! D,< Sa', 4B5< T 34 ,< ,B.ro&sy2arm skin

Heart - S+< S,< no MurmersChest - good A E 1 ,

Abdomen - decreased bo&el sound< tender "Q


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Stages o% Shock

2hat stage is he at

/nsult


Shock9Com#ensation


.eath


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Stages o% Se!& &

S/ S

SE*S/S

SE6E ESE*S/S

SE*T/CSH'C>

M'.S .EATH


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.e%initions o% Se#sis

S &tem $ I%"l*mm*tor Re&!o%&e S %+rome (SIRS) = ,or F o%)-Tem# F 3O or 3B

- F ,!-H F 4! min

-27C F+,


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Se!& & = S/ S &ith !ro2e% or &u&!e$te+m $ro/ *l &our$e

Se2ere Se!& & = se#sis &ith one or moresigns o% organ dys%unction or hy#o#er%usion


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Se!t $ o$k 7 Se#sis I e%ractoryhy#otension

-"nres#onsive to initial %luids ,!-8!cc kg =6aso#ressor de#endant

MODS = multi#le organ dys%unction

syndrome-, or more organs


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Stages o% Se#sis

Mortality

D5

+B5

,!5

D!5

S/ S

SE*S/S

SE6E ESE*S/S

SE*T/CSH'C>

M'.S .EATH


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*atho#hysiologyCom#le1 #atho#hysiologic mechanisms


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*atho#hysiology

/n%lammatory Cascade)Humoral< cellular and Neuroendocrine 9TNJ< /$etc:

Endothelial reactionEndothelial #ermeability ; leaking vessels

Coagulation and com#lement systemsMicrovascular %lo& im#airment


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*atho#hysiology

End result ; Global Cellular Hy#o1ia


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Jocus o% /n%ection

Any %ocus o% in%ection can cause se#sisGastrointestinalG"'ralSkin


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isk Jactors %or Se#sis

/n%ants/mmunocom#romised #atients

.iabetesSteroidsH/6Chemothera#y malignancyMalnutrition

Sickle cell disease.isru#ted barriers

Joley< burns< central lines< #rocedures


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7ack to Case 8H ++!< 7* +!! D,< Sa', 4B5< T 34 ,< ,!.ro&sy2arm skinHeart - S+< S,< no MurmersChest - good A E 1 ,

Abdomen - decreased bo&el sound< tender "Q


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Case 8) Management.istributive Shock 9SE*S/S:

A7C sMonitors',/6 %luids ,! cc kg 1 3/ntubate72



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esuscitation in Se#sis

E*rl o*l + re$te+ t#er*! 1 R 2er& et *l NE3M 899:

"sed in #t s &ho have) an in%ection< , or more S/ S< have asystolic 4! a%ter ,!-3!cc ml or have a lactate F 8

Emergency #atients by emergency doctors

esuscitation #rotocol started early - B hrs


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7AC T' '" EQ"AT/'N


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7AC> T' '" EQ"AT/'N

MA* ; C' 1 S6

9H 1 Stroke volume:

*reload A%terload

Contractility

7AC> T' '" EQ"AT/'N


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7AC> T' '" EQ"AT/'N

MA* ; C' 1 S6

9H 1 Stroke volume:

*reload A%terload

Contractility

* l d


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*reload

.e#endent on intravascular volume/% de#leted intravascular volume 9due to increased endothelial#ermeability: - * E$'A. .EC EASES

Can use the C6* as measurement o% #reloadNormal ; O-+, mm Hg

* l d


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*reload

Ho& do you correct decreased #reload 9or intravascularvolume:

Give %luidsivers sho&ed an average o% ; L in %irst B hours

2hat is the end #oint

7AC> T' '" EQ"AT/'N


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7AC> T' '" EQ"AT/'N

MA* ; C' 1 S6

9H 1 Stroke volume:

*reload A%terload

Contractility

A%t l d


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A%terload

A"terlo*+ +eterm %e& t &&ue !er"u& o%

"sing the MA* as a surrogate measure - >ee# bet&een B!-4!mm Hg

/n se#sis a%terload is decreased d t loss o% vessel tone

A%t l d


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A%terload

Ho< +o ou $orre$t +e$re*&e+ *"terlo*+=

"se vaso#ressor agentNore#ine#hrine

Alternative .o#amine or *henyl#ehrine

7AC> T' '" EQ"AT/'N


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7AC> T' '" EQ"AT/'N

MA* ; C' 1 S6

9H 1 Stroke volume:

*reload A%terload

Contractility

Contractility


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Contractility

"se the central venous o1ygen saturation9Scv',: as a surrogate measure

Sho&n to a be a surrogate %or cardiac inde1

>ee# F D!5

Contractility


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Contractility

Ho< to m!ro2e S$2O8 > ?9@=

'#timi?e arterial ', &ith non-rebreather

Ensure a hematocrit F 3! 9Trans%use to reach a hematocrit o% F 3!:

"se /notro#e - .obutamine , ug kg #er minute and titrated 9ma1,!ug kg:

Re&! r*tor Su!!ort - /ntubation 9.on t %orget to sedate and #araly?e:

Suspect infectionD i hi 2h

E DT


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Document source within 2hrs

The high risk pt: Systolic < 90 after bolus

Or Lactate !mmol"l

#b$ within % hr & source control

'() 'rystalloi*


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The high risk pt: systolic < 90 after bolus

Or Lactate !mmol"l

#b$ within % hr & source control

'() 'rystalloi*


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The high risk pt: systolic < 90 after bolus

#b$ within % hr #n* source control

MAP (UrineOutput)

,ore flui*s< ./ mm3g

,#) (asopressors


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Case 8) Management

.istributive Shock 9SE*S/S: A7C s

Monitors',/6 %luids ,! cc kg/ntubate72

Treat "nderlying CauseA$et*m %o!#e%

Antibiotics - IVE EARLYSource control - the 8 . s ; .rain< .ebride< .evice removal<.e%initive Control

A ibi i


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Antibiotics

E*rl A%t / ot $&

2ithin 3-Bhrs can reduce mortality - 3!5

2ithin + hr %or those severely sick

.on t &ait %or the cultures = treat em#irically thenchange i% need

'ther treatments %or severe se#sis)


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ther treatments %or severe se#sis)

Glucocorticoids

Glycemic Control Activated #rotein C

Cou#le o% &ords about Steroids in


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se#sis@

Ne< u +el %e& "or t#e m*%* eme%t o"&e!& & *%+ &e!t $ o$k 7 Sur2 2 %Se!& & C*m!* %

Grade ,C = consider steroids %or se#tic shockin #atients &ith 7* that res#onds #oorly to %luidresuscitation and vaso#ressors

Cr t $*l C*re Me+ 899 3*% 5 8 5


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Concluding emarks

>no& ho& to distinguish di%%erent ty#es o%shock and treat accordingly

$ook %or e*rl signs o% shock

SH'C> ; hy#otension


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Concluding emarks

Choose cost e%%ective and high im#actinterventions

Do %ot %ee+ $e%tr*l l %e& *%+ S$2O8 measurements to make an im#act


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Concluding emarks

A7C s to +Can t intubate

Give o1ygen

.evelo# algorithms %or bag valve mask ventilationTreat %ever to decrease res#iratory rate

Treat early &ith %luids - need lots o% it


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Concluding emarks

Monitor the #atient.o not need central venous #ressure andScv',

"se the H < MA*< mental status< urine out#ut$actate clearance


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Concluding emarks

Start antibiotics &ithin an hour.o not &ait %or cultures or blood &ork

Date post:	06-Jul-2018
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Kuliah Shock

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