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PENANGANANNYA
DESKRIPSI SYOK
Suplai aliran(perfusi) darah ke jaringan inadekuat
Kebutuhan nutrien tidak terpenuhi
Hasil metabolisme (toxic) tidak dapat dikeluarkan
Patofisiologi
Fase awalpemeliharaan curah jantung
Rllasee katkolamin irama jantung naik (HR ),
kontraktilitas naik
Stimulasi simpatis resistensi vaskuler sistemik naik
(SVR ), tekanan arteri naik (arterial pressure )
Venokonstriksi preload
Pulmonary LUNGS
Arteries
Vena Cava
and
Systemic Right Right
Veins Atrium Ventricle
90
Etiology of circulatory shock
1. HYPOVOLEMIC 2. CARDIOGENIC
3. DISTRIBUTIVE
I 0-15% nl nl maybe nl
II 15-30% + maybe yes nl
III 30-40% +++ decr moot incr
IV >40% ++++ <60Sys incr
Hypovolemic Shock
ABCs
Establish 2 large bore IVs or a central line
Crystalloids
Normal Saline or Lactate Ringers
Up to 3 liters
Transfuse
O negative or cross matched
Control any bleeding
Arrange definitive treatment
Evaluation of Hypovolemic Shock
CBC As indicated
ABG/lactate CXR
Electrolytes Pelvic x-ray
BUN, Creatinine Abd/pelvis CT
Chest CT
Coagulation studies
GI endoscopy
Type and cross-match
Bronchoscopy
Vascular radiology
Infusion Rates
Access Gravity Pressure
Nguyen H et al. Severe Sepsis and Septic-Shock: Review of the Literature and Emergency Department Management Guidelines. Ann Emerg Med. 2006;42:28-54.
Septic Shock
Clinical signs:
Hyperthermia or hypothermia
Tachycardia
Wide pulse pressure
Low blood pressure (SBP<90)
Mental status changes
Beware of compensated shock!
Blood pressure may be normal
Ancillary Studies
Cardiac monitor
Pulse oximetry
CBC, Chem 7, coags, LFTs, lipase, UA
ABG with lactate
Blood culture x 2, urine culture
CXR
Foley catheter (why do you need this?)
Treatment of Septic Shock
2 large bore IVs
NS IVF bolus- 1-2 L wide open (if no contraindications)
Supplemental oxygen
Empiric antibiotics, based on suspected source, as
soon as possible
Persistent Hypotension
If no response after 2-3 L IVF, start a vasopressor
(norepinephrine, dopamine, etc) and titrate to
effect
Goal: MAP > 60
Consider adrenal insufficiency: hydrocortisone 100
mg IV
Treatment Algorithm
Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med. 2001:345:1368-1377.
What Type of Shock is This?
Laki-laki, 55 th, Types of Shock
dibawa ke UGD Hypovolemic
karena sesak, dan Septic
nyeri dada,r/ht. PF
hipotensi,tachycardi Cardiogenic
a dan cool and Anaphylactic
clammy extremities Neurogenic
Cardiogenic Obstructive
Cardiogenic Shock
Cardiogenic Shock
Defined as: Signs:
SBP < 90 mmHg Cool, mottled skin
CI < 2.2 L/m/m2 Tachypnea
PCWP > 18 mmHg Hypotension
Altered mental status
Narrowed pulse pressure
Rales, murmur
Etiologies
What are some causes of cardiogenic shock?
AMI
Sepsis
Myocarditis
Myocardial contusion
Aortic or mitral stenosis, HCM
Acute aortic insufficiency
Pathophysiology of Cardiogenic Shock
Often after ischemia, loss of LV function
Lose 40% of LV clinical shock ensues
CO reduction = lactic acidosis, hypoxia
Stroke volume is reduced
Tachycardia develops as compensation
Ischemia and infarction worsens
Ancillary Tests
EKG
CXR
CBC, Chem 10, cardiac enzymes, coagulation studies
Echocardiogram
Treatment of Cardiogenic Shock
Goals- Airway stability and improving
myocardial pump function
Cardiac monitor, pulse oximetry
Supplemental oxygen, IV access
Intubation will decrease preload and result
in hypotension
Be prepared to give fluid bolus
Treatment of Cardiogenic Shock
AMI
Aspirin, beta blocker, morphine, heparin
If no pulmonary edema, IV fluid challenge
If pulmonary edema
Dopamine will HR and thus cardiac work
Dobutamine May drop blood pressure
Combination therapy may be more effective
PCI or thrombolytics
RV infarct
Fluids and Dobutamine (no NTG)
Acute mitral regurgitation or VSD
Pressors (Dobutamine and Nitroprusside)
What Type
A 34 yo F presents to theof
ER Shock is This?
after dining at a restaurant
where shortly after eating the Types of Shock
first few bites of her meal,
became anxious, diaphoretic, Hypovolemic
began wheezing, noted diffuse Septic
pruritic rash, nausea, and a
sensation of her throat closing Cardiogenic
off. She is currently
hypotensive, tachycardic and
Anaphylactic
ill appearing. Neurogenic
Obstructive
Anaphalactic
Anaphalactic Shock
Anaphylactic Shock
Anaphylaxis a severe systemic
hypersensitivity reaction characterized by
multisystem involvement
IgE mediated
Anaphylactoid reaction clinically
indistinguishable from anaphylaxis, do not
require a sensitizing exposure
Not IgE mediated
Anaphylactic Shock
What are some symptoms of anaphylaxis?
First- Pruritus, flushing, urticaria appear
Decreased
Fluid loss, e.g., Pericardial systemic
Myocardial
hemorrhage tamponade vascular
injury or
necrosis resistance
Reduced
filling Reduced
systolic performance
Reduced
preload Low cardiac Myocardiac
output dysfunction
Decreased arterial
pressure High or normal
cardiac output
Shock
Maldistribution
Multiple organ of blood flow in
system failure microcirculation