Shock

Pryambodho, dr.SpAn Dep.Anestesiologi FKUI/RSCM

Jumat 15 April 2011

What is Shock?
= hypotension ? = low blood pressure ? = haemorrhage ? = unconscious ?

Jumat 15 April 2011

Shock =
Clinical syndrome Associated with signs of hypoperfusion: mental status change, oliguria, acidosis, etc May be associated with hypotension Inadequate organ perfusion and tissue oxygenation to meet tissue oxygen demand

Jumat 15 April 2011

Physiological response to shock

Normally the body can compensate for some decreased tissue perfusion through a variety of mechanisms When compensation fails, shock develops and if uncorrected becomes irreversible

Jumat 15 April 2011

Physiological response to shock

Sympathetic Nervous System Adrenal response (neuro-humoral) Systemic response Progressive vasoconstriction Increased blood flow to major organs Increased cardiac output Increased respiratory rate and volume Decreased urine output (water retention) Decreased gastric activity

Jumat 15 April 2011

Pathophysiology
Initially, neurohumoral compensatory mechanisms maintain perfusion to vital organs If appropriate treatment is not promptly instituted, these compensatory mechanisms are overwhelmed, producing ischemia, cellular damage, multiple organ failure and death

Jumat 15 April 2011

Shock at the cellular level

Decreased blood flow to the tissues causes
cellular hypoxia Anaerobic metabolism begins Cell swelling, mitochondrial disruption, and eventual cell death; tissues die; organs fail; organ systems fail If Low Perfusion States persists compensatory response fail Irreversible Death imminent!!

Jumat 15 April 2011

Normal Hemodynamic
Venous Return VR

Cardiac Output CO

4800 = 60 x 80 cc
Perfusion

VR equals CO CO = Heart Rate x Stroke Volume SV = f . EDV. C. TPR

Jumat 15 April 2011

Jumat 15 April 2011

Reaksi kompensasi

Jumat 15 April 2011

Pathophysiology

Imbalance between organ perfusion & oxygen demand DO2 = Oxygen content x Cardiac output Oxygen content depends on Hb & SaO2 SaO2 depends on Airway & Breathing Cardiac Output & Hb are parts of Circulation matters

Jumat 15 April 2011

Volume (preload)

SVR (afterload) Rate (f) Pump (contractility)

CO

CO = HR x SV
Preload
Jumat 15 April 2011

Contractility

Afterload

Common features of shock

Heart rate Blood pressure Pulse pressure Arterial pH Mentation change

Shock

Respiratory rate

Urine output - Neonate < 2 ml/kg/hour - Infant < 1,5 ml - Pre school age < 1 ml - Adult < 0,5 ml

Peripheral perfusion - cold, pale , clammy

Jumat 15 April 2011

Shock Categories
1. Hypovolemic : haemorrarghic, dehydration
Blood volume problem

2. Cardiogenic : AMI, severe dysrhytmia, pericardial tamponade

Blood pump and/or rate problem

Jumat 15 April 2011

Shock Categories
3. Distributive: septic shock, anaphylaxis, neurogenic shock
Blood vessel problem

4. Obstructive: aortic stenosis, massive pulmonary embolus

Blood flow problem

Jumat 15 April 2011

Rapid formulation of working Dx

Defining features of shock Heart rate Respiratory rate Mentation changes Blood pressure Urine output Arterial pH

Jumat 15 April 2011

Rapid formulation of working Dx

Defining features in compensatory shock Can be difficult to detect with subtle indicators Tachycardia Decreased skin perfusion Alterations in mental status Some condition such as medications, age, pregnancy can hide signs and symptoms

Jumat 15 April 2011

Rapid formulation of working Dx

Is cardiac output reduced?
High-output hypotension (CO ) Septic shock Is CO reduced? Pulse pressure Diastolic pressure Peripheral perfusion Capillary refill time Heart sounds Temperature White cell count Site of infection
Jumat 15 April 2011

Low-cardiac-output (CO ) Cardiogenic & Hypovolemic Yes Cool Slow Muffled -

No Warm Rapid Crisp or or ++

Rapid formulation of working Dx

Is the heart too full?
Reduced pump function Cardiogenic shock Is the heart too full? Symptoms clinical context Jugular venous pressure S3, S4, gallop rhythm Respiratory crepitations Chest radiograph Yes Angina, ECG +++ +++ Large heart Upper lobe flow Pulmonary edema Reduced venous return Hypovolemic shock No Hemorrhage, diarrhea, burns Normal (small)

Jumat 15 April 2011

Rapid formulation of working Dx

What does not fit? Overlapping etiologies (septic-cardiogenic, septichypovolemic, cardiogenic-hypovolemic) Other etiologies
High output hypotension Liver failure Severe pancreatitis Trauma + SIRS Thyroid storm Arteriovenous fistula High right atrial pressure hypotension Pulmonary hypotension Right ventricular infarction Cardiac tamponade Nonresponsive hypovolemia Adrenal insufficiency Anaphylaxis Neurogenic shock

Get more information Echocardiography, CVP, Swan-ganz catheterization, etc

Jumat 15 April 2011

Shock management
Recognize inadequate organ perfusion Identify the cause (working diagnosis)
Hypovolemic Cardiogenic Distributive Obstructive

Restore the organ perfusion and tissue oxygenation

Oxygen and ventilatory support Fluid therapy Inotrope or vasoactive drugs Treat the cause

Jumat 15 April 2011

Shock management
Recognize inadequate organ perfusion Identify the cause (working diagnosis)
Hypovolemic Cardiogenic Distributive Obstructive

Restore the organ perfusion and tissue oxygenation

Oxygen and ventilatory support Fluid therapy Inotrope or vasoactive drugs Treat the cause ABC resusitasi

Jumat 15 April 2011

Goals of Respiratory Management

To protect the airway To correct inadequate oxygenation and ventilation To rest the respiratory muscle Caution in cervical trauma!

A-B

Jumat 15 April 2011

Goals Therapy of Shock

Reverse the pathophysiologic abnormalities Avoid adverse consequences of excessive therapy Titration: too little vs too much Test Response Maintain body temperature!

C-E

Jumat 15 April 2011

Shock management

Volume expansion

Heart full

Inotrope Vasoactive drugs

Jumat 15 April 2011

Shock management

Volume expansion

Heart full

Inotrope Vasoactive drugs

Jumat 15 April 2011

Fluid challenge
Fluid deficit may exist in all kinds of shock Is the heart too full?
No : Crystalloid 1 2 L (20 ml/kg) fast Not too full (cardiogenic shock without obvious fluid overload) Crystalloid 250 ml in 20 minute Yes : No fluid challenge

Jumat 15 April 2011

Fluid challenge
Assess patient response Next therapeutic decision depend on patient response
Better : continue with fluid challenge Transient :
Continue with fluid therapy On going losses : find and fix

No response:
Severe hypovolemia

Other etiologies

Jumat 15 April 2011

Fluid management in traumatic/ haemorrargic shock

Shock Fluid Loading 1000-2000 ml
Warm fluid!!

Good response Mild Blood loss Maintenance

Surgical consultation
Jumat 15 April 2011

Transient response Moderate loss On going losses Fluid/blood

Surgical consultation

No response Severe Blood loss Fluid/blood

Surgical resuscitation

Shock Non-hypovolemic Re-evaluate

Get more information

Re-assess Organ Perfusion

Monitor Vital signs CNS state Peripheral perfusion Pulse oximetry Urine output

Jumat 15 April 2011

Vasoactive & Inotropic agents

Use after fluid resuscitation failed (normovolemia)
More efficacious if normovolemia May obscure hypovolemia

systolic

70

100

mmHg

epinephrine nitroglycerin (ischemia) norepinephrine nitropruside dopamin dopamin (shock) norepinephrine (+dopamin) dobutamin (shock -)
Jumat 15 April 2011

Vasoactive & Inotropic agents

After fluid resuscitation !! Elevate MAP to 60-65 mmHg Watch out: Excessive vasoconstriction monitor lactate!
Ischemia Contractility

Jumat 15 April 2011

Anaphylactic shock
Severe systemic hypersensitivity reaction Characterized by: hypotension & airway compromise Potentially life threatening Classic tipe I hypersensitivity reaction (mediated by IgE) Watch out: mild allergic reaction may progress to severe anaphylaxis

Jumat 15 April 2011

Anaphylactic shock
Inadequate perfusion of tissues through maldistribution of blood flow Intravascular volume is maldistributed because of alterations in blood vessels Cardiac pump & blood volume are normal but blood is not reaching the tissues

Jumat 15 April 2011

Anaphylactic shock
History & physical examination Clinical signs of systemic allergic: urticaria, angioedema, abdominal pain, nausea & vomiting, bronchospasm, rhinorrhea, cutaneus flushing, etc + Hypotension & airway compromise !! Begin: within first hour - 8 hours after exposure The faster onset, the more severe

Jumat 15 April 2011

Anaphylactic shock
Therapy: ABC resuscitation first !!! Drug: Epinephrine
adult: 0,3 - 0,5 mg SC or IM (1:1000) 0,1 mg IV (1:100.000) children: 0,01mg/kg SC or IM (1:1000)

only given after ABC resusitasion, no cardiac arrest, in severe hypotension may be repeated after 10 - 20 mnt.

Jumat 15 April 2011

Anaphylactic shock
Subsequentmanagement Givean(histamines(chlorpheniramine1020mgslowly IV) Givecor(costeroids(200mghydrocor(soneIV) Bronchodilators(salbutamol250ugIVor2.55mgby nebulizer,aminophylline250mgupto5mg/kgbyslow IV) RefertoICU

Jumat 15 April 2011

Old and New Paradigm of Shock

Jumat 15 April 2011

Old and New Paradigm of Shock Shock

Ischemic Cellular Damage

Organ Failure

Death

Jumat 15 April 2011

Old and New Paradigm of Shock Shock Shock

Hypoxic Cellular Priming Ischemic Cellular Damage Reperfusion Injury Organ Failure Cellular Damage Death Multiple Organ Failure Death
Jumat 15 April 2011

Inflammation

Trauma

Hemorrhage

Hypoxia Prime insult

Cellular ischemia Resuscitation Reperfusion injury

Vasoconstriction Microcirculatory thrombosis Leukocyte/platelet/RBC aggregation

Primary perpetuators

Microcirculatory flow maldistribution

Leukocyte-mediated cell injury Cytokine and other mediator effects, locally and systemically

Secondary perpetuators

Gut translocation Sepsis

Jumat 15 April 2011

Tertiary perpetuators

Haldane

Hypoxia not only stops the machine It wrecks the machine!

Time saving is life saving!

Jumat 15 April 2011

Haldane

Hypoxia not only stops the machine It wrecks the machine!

Time saving is life saving!

Jumat 15 April 2011

Summary
Early recognition of shock state Oxygenation and ventilation Restore organ perfusion Monitor patient response Titrate therapy Prompt and appropriate action

Jumat 15 April 2011

Thank U 4 your attention!

Jumat 15 April 2011

Thank U 4 your attention!

Jumat 15 April 2011