SHOCK & RESUSITASI CAIRAN

DEFINITION
Shock is a multifactorial syndrome leading to systemic and localized tissue hypoperfusion and resulting in cellular hypoxia and multiple organ dysfunction

DESCRIPTION
Perfusion may be decreased systemacally with obvious signs such as hypotension
Perfusion may be decreased because of maldistribution as in septic shock where systemic perfusion may appear elevated

DESCRIPTION
Prognosis is determined by
degree of shock, duration of shock, number of organ affected, previous organ dysfunction and possibly some genetic predispositition

CLASSIFICATION OF SHOCK
1. 2. 3. 4. Hypovolemic shock Obstructive shock Cardiogenic shock Distributive shock

HYPOVOLEMIC SHOCK

HYPOVOLEMIC SHOCK
Loss of circulating intravascular volume and decrease in cardiac preload
May be from hemorrhage : trauma, gastrointestinal bleeding, nontraumatic internal bleeding (aneurysm, ectopic rupture), vaginal bleeding

HYPOVOLEMIC SHOCK
May be from nonhemorrhagic fluid loss from;
gastrointestinal tract (vomiting, diarrhea, fistula), urinary loss (hyperglycemia with glucosuria), evaporative loss (fever, hyperthermia) intestinal fluid shifts (third spacing as with a bowel obstruction)

Clinical sign
Depend on volume lost
Symptoms include: tachycardia, hypotension, decreased urine output, mental status changes, tachypnea

Classification hypovolemic shock

Based on 70 Class.1 kg Blood loss (ml) Blood vol (%) Pulse rate Blood pressure Capillary refill > 750 > 15 < 100 normal normal

Class.2
750 1.500 15 - 30 > 100 normal decreased

Class.3
1.500-2.000 30 - 40 > 120 decreased decreased

Class.4
>2.000 > 40 >140 decreased decreased

Classification hypovolemic shock

Based on 70 Class.1 kg Respiratory rate Urinary output (ml/hr) Mental status Fluid replacemen t normal > 30

Class.2
20 - 30 20 - 30

Class.3
30 - 40 5 -15

Class.4
distress < 10

Mild anxiety Crysalloid

Anxiety Crystalloid

Confused Crystalloid + blood

lethargic Crystalloid + blood

DIAGNOSIS
VITAL SIGN.
Heart rate Blood pressure TemSperature Urine output Pulse oxymetri

Patient with normal or near normal signs, 50-85% are still in shock

HEART RATE (HR)

TACHYCARDIA is an early sign of significantvolume loss in shock.
The heart rate of young patient or those on blockers may be not increase Bradycardia after prolonged hypotension precludes cardiovascular collapse

BLOOD PRESSURE (BP)

HYPOTENSION and narrowing pulse pressure are a sign of severe volume loss and shock.
Mean arterial pressure (MAP) is a better guide to therapy than systolic BP

TEMPERATURE
Hyperthermia, normothermia, hypothermia may be present in shock.
Hypothermia is a sign of severe hypovolemic and septic shock

URINE OUTPUT
Early guide of hypovolemia and end organ response (renal) to shock.
This is a delayed vital sign because 1 to 2 hours are needed to obtain an acurate measure

PULSE OXIMETRY
Continuously measured and early indicator of hypoxemia but may be invalid in hypothermic patients

INVASIVE HEMODYNAMIC MONITORING

1. Arterial catheters 2. Central venous catheters (CVc) 3. Pulmonary arterial catheters (PAc)

INVASIVE HEMODYNAMIC MONITORING

Arterial catheters; give continuous blood pressure measurement.
Central venous catheters (CVc); gives continuous central venous pressure (CVP) measurement.

Arterial catheter insertion

INVASIVE HEMODYNAMIC MONITORING

Pulmonary arterial catheters (PAc) can measure CVP, right arterial (RA) pressure, pulmonary artery pressure (PAp), pulmonary arterial occlusion pressure (PAOp / wedge pressure), cardiac output (CO). PAc will help guide aggresive resuscitation in patient with severe shock

Pulmonary artery catheter

Typical pressure waveform PA catheter

CARDIAC OUTPUT CARDIAC INDEX

Cardiac output (CO) or Cardiac index (CI) reflect cardiac function and can be directly measured by a PAC.
Optimizing CI can be increased by increasing preload , increasing contractility or decreasing afterload

HEMODYNAMIC VARIABLES
MEASURED VARIABLE
VARIABLE
Systolic BP (SBP) Diastolic BP (DBP) Systolic pulmonary blood pressure (PAS) Diastolic pulmonary blood pressure (PAD) Pulmonary artery occlusion pressure (PAOP)

UNIT
mmHg mmHg

NORMAL RANGE
90 -140 60 - 90

mmHg
mmHg mmHg

15 - 30
4 - 12 2 - 12

HEMODYNAMIC VARIABLES
MEASURED VARIABLE

VARIABLE Central venous pressure (CVP)

Heart rate (HR)

UNIT
mmHg Beats/min L/min

NORMAL RANGE
0-8 50 - 100 4-6

Cardiac output (CO)

Right ventricular ejection fraction (RVEF)

fraction

0,4 0,6

HEMODYNAMIC VARIABLES
CALCULATED VARIABLE
VARIABLE
Mean arterial pressure (MAP) Mean pulmonary artery pressure (MPAP)

UNIT
mmHg

NORMAL RANGE
70 - 105

mmHg

9 - 16

Cardiac Index (CI) Stroke volume (SV) Stroke volume index (SVI)

L/min/m2 ML/ beat

mL/ beat/ m2

2,8 - 4,2 varies

30 - 65

TREATMENT
Rapid recognition and restoration of perfusion is the key to preventing multiple organ dysfunction and death.
In all forms of shock, rapid restoration of preload with infusion of fluids is the first treatment

TREATMENT
Crystalloid is first infused and then blood is infused if shock is secondary to hemorrhage.
Early diagnosis of the etiology is essential and further treatment of the shock depends on its etiology.

TREATMENT Hypovolemic shock

Rapid infusion of crystalloid, largebore venous acces is needed and central access may be necessary .
Blood tranfused after 2-3 liter crystalloid, if the cause is hemorrhage. The source of bleeding needs to be controlled

Basic management
The initial therapy of choice: replacement of intravascular volume. Physical examination may provide valuable information about the intravascular volume status (clear lung field and flat neck vein suggest a need for additional fluid resuscitation in the hypotensive patient).