SHOCK - WordPress.com€¦ · 17.11.2016 · •Hypovolemic shock –variable/mechanism ....
Transcript of SHOCK - WordPress.com€¦ · 17.11.2016 · •Hypovolemic shock –variable/mechanism ....
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SHOCK
Susanna Hilda Hutajulu, MD, PhD
Div Hematology and Medical Oncology
Department of Internal Medicine
Universitas Gadjah Mada Yogyakarta
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Outline
• Definition
• Epidemiology
• Physiology
• Classes of Shock
• Clinical Presentation
• Management
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Definition
• A physiologic state characterized by
• Inadequate tissue perfusion
• Clinically manifested by
• Hemodynamic disturbances
• Organ dysfunction
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Epidemiology
• Mortality
• Septic shock – 35-40% (1 month mortality)
• Cardiogenic shock – 60-90%
• Hypovolemic shock – variable/mechanism
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Pathophysiology
• Imbalance in oxygen supply and demand
• Conversion from aerobic to anaerobic metabolism
• Appropriate and inappropriate metabolic and physiologic responses
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Pathophysiology
• Cellular physiology
• Cell membrane ion pump dysfunction
• Leakage of intracellular contents into the extracellular space
• Intracellular pH dysregulation
• Resultant systemic physiology
• Cell death and end organ dysfunction
• MSOF and death
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Pathophysiology
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Physiology
• Characterized by three stages
• Preshock (warm shock, compensated shock)
• Shock
• End organ dysfunction
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Physiology
• Compensated shock
• Low preload shock – tachycardia, vasoconstriction, mildly
decreased BP
• Low afterload (distributive) shock – peripheral
vasodilation, hyperdynamic state
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Pathophysiology
• Shock
• Initial signs of end organ dysfunction
• Tachycardia
• Tachypnea
• Metabolic acidosis
• Oliguria
• Cool and clammy skin
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Pathophysiology
• End Organ Dysfunction
• Progressive irreversible dysfunction
• Oliguria or anuria
• Progressive acidosis and decreased cardiac output
• Agitation, obtundation, and coma
• Patient death
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Classification
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Hypovolemic Shock
• Results from decreased preload
• Etiologic classes
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Hypovolemic Shock
• Hemorrhagic Shock
Parameter I II III IV
Blood loss (ml) <750 750–1500 1500–2000 >2000
Blood loss (%) <15% 15–30% 30–40% >40%
Pulse rate (beats/min) <100 >100 >120 >140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate (bpm) 14–20 20–30 30–40 >35
Urine output (ml/hour) >30 20–30 5–15 Negligible
CNS symptoms Normal Anxious Confused Lethargic
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Cardiogenic Shock
• Results from pump failure
• Decreased systolic function
• Resultant decreased cardiac output
• Etiologic categories
• Acute myocard infarct
• Arrhythmic
• Congestive heart failure
• Extracardiac (obstructive)
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Distributive Shock
• Results from a severe decrease in SVR
• Vasodilation reduces afterload
• May be associated with increased CO
• Etiologic categories
• Sepsis (vasogenic)
• Neurogenic / spinal � loss of sympathetic tone
• Other
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Distributive Shock
• Other causes
• Systemic inflammation – pancreatitis, burns
• Toxic shock syndrome
• Anaphylaxis and anaphylactoid reactions
• Toxin reactions – drugs, transfusions
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Distributive Shock
• Septic Shock
SIRS 2 or more of the following: Temp >38 or <36 HR > 90 RR > 20 WBC > 20K >10% bands
Sepsis SIRS in the presence of suspected or documented infection
Severe Sepsis Sepsis with hypotension, hypoperfusion, or organ dysfunction
Septic Shock Sepsis with hyotension unresponsive to volume resuscitation, and evidence of hypoperfusion or organ dysfunction
MODS Dysfunction of more than one organ
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Clinical Presentation
• Clinical presentation varies with type and cause, but there
are features in common
• Hypotension (SBP<90 or Delta>40)
• Cool, clammy skin (exceptions – early distributive, terminal
shock)
• Oliguria
• Change in mental status
• Metabolic acidosis
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Evaluation
• Done in parallel with treatment
• Full laboratory evaluation (cardiac enzymes, blood gas
analysis)
• Basic studies – Rontgen, ECG
• Basic monitoring – VS, urine output, CVP
• Imaging if appropriate (CT-scan)
• Echocardiography
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Treatment
• Manage the emergency
• Determine the underlying cause
• Definitive management or support
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Manage the Emergency
• Control airway and breathing
• Maximize oxygen delivery
• Place lines, tubes, and monitors
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Determine the Cause
• Often obvious based on history
• Trauma most often hypovolemic (hemorrhagic)
• Postoperative most often hypovolemic (hemorrhagic or third
spacing)
• Debilitated hospitalized patients most often septic
• Must evaluate all patients for risk factors for MI and consider
cardiogenic
• Consider distributive (spinal) shock in trauma
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Definitive Management
• Hypovolemic
• Fluid resuscitate (blood or crystalloid)
• Control ongoing loss
• Cardiogenic
• Restore blood pressure (chemical and mechanical)
• Prevent ongoing cardiac death
• Distributive
• Fluid resuscitate
• Pressors for maintenance
• immediate antibiotics control for infection
• Steroids for adrenocortical insufficiency
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Resuscitation Fluids
• Blood
• Lactated Ringers
• Normal Saline
• Colloids
• Blood Substitutes