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 Ringer’s 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 Ringer’s 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/ >20 10–20
Creatinine Ratio
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
