SHOCK

Mattox, sixth edition, page 213

Schwartz,Chapter 5, page 89
Basic Sciences Review. L.I.G Worthley. Departement of Critical Care Medicine, Flinders Medical Centre,
Adelaide, South Australia
 Shock

 a state of inadequate tissue perfusion in which the delivery of oxygen to

tissues and cells is sufficient to maintain normal aerobic metabolism.

 Is a life threatening condition of circulatory failure.

 The effect of shock are initially reversible, but rapidly become irreversible,
resulting in multiorgan failure (MOF) and death.
 Multiple organs are affected ; skin, muscle, vicera, kidney, CNS, heart.
 Mortality: Septic shock 62%, cardiogenic shock 16%, hypovolemic shock
16%, distributive shock 4%(neurogenic shock), obstructive shock 2%
 Hemorrahagic Neurogenic Cardiogenic Septic Shock Obstructive Traumatic
&
Hypovolemic

Definisi ↓tissue failure Is a by Hypoperfusi Combination

perfusion as circulatory product of on can be of several
result of pump the body’s due to insult after
loss response to mechanical injury
vasomotor invasive/ obs of the
to peripheral severe circulation
arterial localized
infection

Patof Acute blood Loss of ↓ flow + Mediator venous

loss↓ vasocontrict tissue enhance return↓
baroreseptor or impulses hypoxia effector CO↓perip
↓ ↑vascular mech for heral
vasocontrictor capacitance macrophage perfusion
↑ ↓venous &neutrophil
kemoreseptor return↓ killing↑
↓output CO procoagulan
from atrial + fibroblast,
reseptor ↑
microvasc
blood flow
 Hemorrahagic Neurogenic Cardiogenic Septic Shock Obstructive Traumatic
&
Hypovolemic

Penyebab Shock in the Spinal cord Cardiac Typically Tension Traumatic

trauma function from pneumothor patient( fem
patient after blunt bacterial/ ax/Cardiac ur #,crush
thoracic fungal tamponade injury)
trauma pathogens Comination
hypovolemic
,neurogenic,
cardiogenic,
obstructive

Diagnosis has been - - ↑ CO, -Clinical

classified ↓BP+bradyc identification peripheral -X-ray
according to ardia of cardiac vasodilation, -percardial
the -warm ext dysfunction fever,leukocy ultrasound
magnitude of - -↓CO by tosis and -
volume loss motor+sens catheterizati tachycardia, pericardioce
ory deficits on by Echo tachypnea, ntesis
- hypotension.
radiographic
 Hemorrahagic Neurogenic Cardiogenic Septic Shock Obstructive Traumatic
&
Hypovolemic

Treatment Fluid -fluid -inotropic - -correcting

resuscitation, - -dobutamin Pericardioce individual
vasopressor vasocontrict -dopamin ntesis element
or -Epinephrine -control
hemorrhage
-adequate
volume
resuscitation
-
debridement
-stabilization
of bony
 Class I Class II Class III Class IV

Blood loss (mL) Up to 15% 750-1500 1500-2000 >2000

Pulsa rate <100 >100 >120 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure N/ Decreased Decreased Decreased

RR 14-20 20-30 30-40 >35

Urine output >30 20-30 5-15 Negligible

(mL/hour)
CNS/Mental status Slightly anxious Mildly anxious Anxious,confused Confused,lethargic
 Supplemtal O2
endotracheal intubation&
mechanical ventilation

central venous and artherial catheterization

sedation, paralysis
(if intubated )or both
crystalloid
CVP <8mmHg colloid
8-12mmHg

MAP <65mmHg vasoactive agents

≥65mmHg and ≤ 90 mmHg >90mmHg

ScvO2 <70% transfusion of red cells ≥70%

≥70% until HT>30% <70%

Inotropic agents
no Goals achieved
yes

Hospital admission
 FORM OF SHOCK

Hypovolemic Distributive Cardiogenic Obstructive

Whole plasma - Septic(bacterial, dyrect myocard inhibition contraction -intrathoracic obs

Blood loss fungal,viral) -myocard infarc -Drug toxicity tumors
-abdominal/ -Pancreatitis -Toxic shock syndrome -cardiomyopathy -Anaphylactic -↑intrathoracic pressure
Thorax space -peritonitis -Anaphylactic -Cardiac by pass -Septicaemia - Tension PMX
-retroperitoneal -burns -Neurogenic(spinal shock) -myocarditis -Cardiac tamponade
-bony fracture -fistula
Clinical feature
has been classified according to myocardial depressi -Poor peripheral tissue perfusion -Clinical
the magnitude of volume loss ↓systolic & dyastolic (oligouri,drowsiness/agitation, -X-ray
Investigation function peripheral cyanosis),tachycardia, -Pericardial ultrasound
-arterial pressure,urinary output,HT hypotension,dyspnoea,infantile heart sound -Pericardiosintesis
Treatment
-fluid resuscitation(saline solution, -source identification -EKG,Chest X-ray,Echo
colloid,blood) -drainage/removal fb -blood gases,arterial lactat Pericardiosintesis
-Op control of blood loss-fluid resuscitation
-AB tx,vasopressor,inotropes 1.improve myocard O2 ventilator support 2.improve tissue perfusion
 Tissue
Hypoperfusion

yes No

Volume infusion Diagnostic Studies as Indicated

Non
responder Responder
Transient responder

OR Rapid Diagnostic Evaluation

Obstructive
OR Chest tube
Hemorrhagic Cardiogenic,Traumatic Neurogenic Septic Decompress pericard
Consider Op Tx Supportive care Supportive care Supp care Treat cardiac injury
Tx spinal injury Tx Pimer Inf

Tissue Hypoperfusion Algorithm. The most common etiology for shock in the trauma patient is hypovolemia from loss of circulating volume
 Tissue Hypoperfusion

yes no
Presentation Diagnostic Studies as Indicated
delayed acute

Consider Septic Volume Status

Shock hypervolume hypovolemic
normal

Asses Cardiac Hemorrhagic Shock

Function
hyperdynamic hypodynamic
normal
SCI Cardiogenic Shock
no yes
Tension PTX/Cardiac tamponade Neurogenic Shock
no yes

Traumatic Shock Obstructive Shock

• The ultimate goal in the treatment of shock from any etiologyis to restore
tissue perfusion, re-establish normal cellular function and prevent damage
to end-organs.
• Clinical parameters used to assess the adequacy of resuscitation in the
patient with shock include herat rate, blood pressure, and urine output.