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Diagnosis and Management of Shock
SHK 1®
Objectives
• Identify the major types of shock and principles of management
• Review fluid resuscitation and use of vasopressor and inotropic agents
• Understand concepts of O2 supply and demand
• Discuss the differential diagnosis of oliguria
SHK 2®
Shock
• Always a symptom of primary cause• Inadequate blood flow to meet tissue oxygen
demand• May be associated with hypotension• Associated with signs of hypoperfusion: mental
status change, oliguria, acidosis
SHK 3®
Shock Categories
• Cardiogenic• Hypovolemic• Distributive• Obstructive
SHK 4®
Cardiogenic Shock
• Decreased contractility• Increased filling pressures, decreased LV
stroke work, decreased cardiac output• Increased systemic
vascular resistance – compensatory
Hypovolemic Shock
• Decreased cardiac output
• Decreased filling pressures
• Compensatory increase in systemic vascular resistance
SHK 6®
Distributive Shock
• Normal or increased cardiac output• Low systemic vascular resistance• Low to normal filling pressures• Sepsis, anaphylaxis, neurogenic,
and acute adrenal insufficiency
SHK 7®
Obstructive Shock
• Decreased cardiac output• Increased systemic vascular
resistance• Variable filling pressures dependent
on etiology• Cardiac tamponade, tension
pneumothorax, massive pulmonary embolus
Cardiogenic Shock Management
• Treat arrhythmias • Diastolic dysfunction may require
increased filling pressures • Vasodilators if not hypotensive• Inotrope administration
Cardiogenic Shock Management
• Vasopressor agent needed if hypotension present to raise aortic diastolic pressure
• Consultation for mechanical assist device
• Preload and afterload reduction to improve hypoxemia if blood pressure adequate
Hypovolemic Shock Management
• Volume resuscitation – crystalloid, colloid• Initial crystalloid choices– Lactated Ringer’s solution– Normal saline (high chloride may produce
hyperchloremic acidosis)• Match fluid given to fluid lost– Blood, crystalloid, colloid
SHK 11®
Hypovolemic Shock Management
• Perhitungan Estimated Blood Vol:• Dewasa: 70 cc/kgBB• Anak: 80 cc/kgBB• Bayi: 90 cc/kgBB• Syok karena trauma: 90% disebsbkan oleh
hemoragik syok
SHK 12®
Hypovolemic Shock Management
• Pasang infus 2 jalur dg iv catheter yang pendek dan besar (no16/18)
• Ambli blood sample untuk px lab dan usaha darah
• Beri cairan RL 2000 cc yang dihangatkan sebagai cairan awal
• Tetap mengikuti tahapan resusitasi A-B-C-D
SHK 14®
Distributive Shock Therapy
• Restore intravascular volume• Hypotension despite volume therapy– Inotropes and/or vasopressors
• Vasopressors for MAP < 60 mm Hg• Adjunctive interventions dependent on
etiology
SHK 16®
Obstructive Shock Treatment
• Relieve obstruction– Pericardiocentesis – Tube thoracostomy – Treat pulmonary embolus
• Temporary benefit from fluid or inotrope administration
Fluid Therapy• Crystalloids– Lactated Ringer’s solution– Normal saline
• Colloids– Hetastarch– Albumin– Gelatins
• Packed red blood cells• Infuse to physiologic endpoints
SHK 18®
Fluid Therapy
• Correct hypotension first• Decrease heart rate• Correct hypoperfusion abnormalities• Monitor for deterioration of oxygenation
SHK 19®
Inotropic / Vasopressor Agents• Dopamine
– Low dose (2-3 g/kg/min) – mild inotrope plus renal effect
– Intermediate dose (4-10 g/kg/min) –inotropic effect
– High dose ( >10 g/kg/min) –vasoconstriction
– Chronotropic effect
SHK 20®
Inotropic Agents
• Dobutamine
–5-20 g/kg/min
– Inotropic and variable chronotropic effects
–Decrease in systemic vascular resistance
SHK 21®
Inotropic / Vasopressor Agents
• Norepinephrine
–0.05 g/kg/min and titrate to effect
– Inotropic and vasopressor effects
–Potent vasopressor at high doses
SHK 22®
Inotropic / Vasopressor Agents
• Epinephrine–Both and actions for inotropic and
vasopressor effects–0.1 g/kg/min and titrate– Increases myocardial O2 consumption
SHK 23®
Therapeutic Goals in Shock
• Increase O2 delivery
• Optimize O2 content of blood• Improve cardiac output and
blood pressure• Match systemic O2 needs with O2 delivery• Reverse/prevent organ hypoperfusion
Oliguria
• Marker of hypoperfusion• Urine output in adults
<0.5 mL/kg/hr for >2 hrs• Etiologies –Prerenal–Renal–Postrenal
SHK 25®
Evaluation of Oliguria
• History and physical examination• Laboratory evaluation– Urine sodium– Urine osmolality or specific gravity– BUN, creatinine
SHK 26®
Evaluation of Oliguria
Laboratory Test Prerenal ATN
Blood Urea Nitrogen/ >20 10–20 Creatinine RatioUrine Specific Gravity >1.020 <1.010Urine Osmolality (mOsm/L) >500 <350Urinary Sodium (mEq/L) <20 >40Fractional Excretion of Sodium (%) <1 >2
Therapy in Acute Renal Insufficiency• Correct underlying cause• Monitor urine output• Assure euvolemia• Diuretics not therapeutic• Low-dose dopamine may urine flow• Adjust dosages of other drugs• Monitor electrolytes, BUN, creatinine• Consider dialysis or hemofiltration
SHK 28®
Pediatric Considerations
• BP not good indication of hypoperfusion• Capillary refill, extremity temperature better
signs of poor systemic perfusion • Epinephrine preferable to norepinephrine due to more
chronotropic benefit• Fluid boluses of 20 mL/kg titrated to BP or total 60
mL/kg, before inotropes or vasopressors
SHK 29®
Pediatric Considerations
• Neonates – consider congenitalobstructive left heart syndrome as cause of obstructive shock
• Oliguria–<2 yrs old, urine volume <2 mL/kg/hr–Older children, urine volume
<1 mL/kg/hr
SHK 30®
Key Points