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 Ringers 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 Ringers 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/

Creatinine Ratio

>20

1020

Urine Specific Gravity

>1.020

<1.010

Urine Osmolality (mOsm/L)

>500

<350

Urinary Sodium (mEq/L)

<20

>40

Fractional 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 congenital
obstructive 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