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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 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

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