SHOCK Susanna Hilda Hutajulu, MD, PhD Div Hematology and Medical Oncology Department of Internal Medicine Universitas Gadjah Mada Yogyakarta
Outline Definition Epidemiology Physiology Classes of Shock Clinical Presentation Management
Definition A physiologic state characterized by Inadequate tissue perfusion Clinically manifested by Hemodynamic disturbances Organ dysfunction
Epidemiology Mortality Septic shock 35-40% (1 month mortality) Cardiogenic shock 60-90% Hypovolemic shock variable/mechanism
Pathophysiology Imbalance in oxygen supply and demand Conversion from aerobic to anaerobic metabolism Appropriate and inappropriate metabolic and physiologic responses
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
Pathophysiology
Physiology Characterized by three stages Preshock (warm shock, compensated shock) Shock End organ dysfunction
Physiology Compensated shock Low preload shock tachycardia, vasoconstriction, mildly decreased BP Low afterload (distributive) shock peripheral vasodilation, hyperdynamic state
Pathophysiology Shock Initial signs of end organ dysfunction Tachycardia Tachypnea Metabolic acidosis Oliguria Cool and clammy skin
Pathophysiology End Organ Dysfunction Progressive irreversible dysfunction Oliguria or anuria Progressive acidosis and decreased cardiac output Agitation, obtundation, and coma Patient death
Classification
Hypovolemic Shock Results from decreased preload Etiologic classes
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
Cardiogenic Shock Results from pump failure Decreased systolic function Resultant decreased cardiac output Etiologic categories Acute myocard infarct Arrhythmic Congestive heart failure Extracardiac (obstructive)
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
Distributive Shock Other causes Systemic inflammation pancreatitis, burns Toxic shock syndrome Anaphylaxis and anaphylactoid reactions Toxin reactions drugs, transfusions
Distributive Shock Septic Shock SIRS Sepsis Severe Sepsis Septic Shock MODS 2 or more of the following: Temp >38 or <36 HR > 90 RR > 20 WBC > 20K >10% bands SIRS in the presence of suspected or documented infection Sepsis with hypotension, hypoperfusion, or organ dysfunction Sepsis with hyotension unresponsive to volume resuscitation, and evidence of hypoperfusion or organ dysfunction Dysfunction of more than one organ
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
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
Treatment Manage the emergency Determine the underlying cause Definitive management or support
Manage the Emergency Control airway and breathing Maximize oxygen delivery Place lines, tubes, and monitors
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
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
Resuscitation Fluids Blood Lactated Ringers Normal Saline Colloids Blood Substitutes