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Syok Pada Anak
Haryson Tondy Winoto,dr.,Msi.Med.,Sp.A
Bag. Anak UWKS
Definition
• Failure of delivery oxygen and substrates to
meet the metabolic demands of the tissue beds
SUPPLY < DEMAND
Oxygen delivery < Oxygen Consumption
DO2 < VO2
• Failure to remove metabolic end-products
• Result of inadequate blood flow and/or oxygen
delivery
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Definition • Common pathway
– Failure to deliver substrates conversion to anaerobic metabolism
• Reversible if recognized early
• Irreversible organ damage at the late stage
– Progressive acidosis and eventually cell death
• Early recognition is key
3
Types of Shock
Type Pathophysiology Signs & Symptoms
Hypovolemic ↓ PRELOAD: ↓CO, ↑ SVR,
intravascular volume loss
↑HR, ↓ pulses, delayed cap
refill, dry skin, sunken eyes,
oliguria
Distributive ↓ AFTERLOAD (SVR)
Anaphylactic ↑ CO, ↓ SVR Angioedema, low BP,
wheezing, resp. distress
Spinal Normal CO, ↓ SVR Low BP without tachycardia;
paralysis, h/o trauma
Cardiogenic ↓ CO, variable SVR Normal to ↑ HR, ↓ pulses,
delayed CR, JVD, murmur or
gallop, hepatomegaly
Septic Variable More to come
Pathophysiology
• Children
– Higher % body water
– Higher resting metabolic rate
– Higher insensible losses
– Lower renal concentrating ability
– Subtle signs/symptoms
• Higher risk for organ hypo-perfusion
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Pathophysiology
O2 supply < O2 demand
O2 delivery < O2 consumption
DO2 < VO2
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Hemodynamic response to hemorrhage model for cardiovascular response to hypovolemia from hemorrhage (based on normal data). Adapted from Schwaitzberg SD, Bergman KS, Harris BH. A pediatric trauma model of continuous hemorrhage. J Pediatr Surg. Jul 1988;23(7):605-9.
Blood Pressure and Volume
% blood loss % BP
25% Normal
50% 60% o
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•BP drops quickly after
reaching 50% blood loss
•CO follows BP closely
Oxygen delivery (DO2)
• DO2 = CO x CaO2
– DO2 : oxygen delivery
– CO : Cardiac output
– CaO2: arterial oxygen content
• CO = HR x SV
– HR: heart rate
– SV: stroke volume
• CaO2 = HgB x SaO2 x 1.34 + (0.003 x PaO2)
– Oxygen content = oxygen carried by HgB + dissolved
oxygen
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Oxygen delivery (DO2)
DO2 = CO x CaO2
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Critical DO2: consumption
depends on delivery
Oxygen delivery
DO2 = CO x CaO2
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Cardiac Output
Heart Rate Stroke volume
Preload Afterload Contractility
Oxygen delivery
DO2 = CO x CaO2
• CO = HR x SV
• HR is independent
– Neonates depend on HR (can’t increase SV)
• SV depends on
– Pre-load: volume of blood
– After-load: resistance to contraction
– Contractility: force
Oxygen delivery
DO2 = CO x CaO2
• CaO2 = HgB x SaO2 x 1.34 + (0.003 x PaO2)
• Normal circumstance: CaO2 is closely associated
with SaO2
• Severe anemia or in the presence of abnormal HgB
(i.e. CO poisoning) - CaO2 is strongly affected by
PaO2
Hypo-perfusion
• Poor perfusion of a vital organs leads to organ dysfunction
– Decreased urine output
– Altered mental status
– Elevated LFTs, bilirubin
• Switches to anaerobic metabolism Lactate
• Activates inflammatory cascade
– Activates neutrophils, releases cytokines
• Increases adrenergic stress response
– Increases lipolysis/glycogenolysis (also increases lactate)
– Releases catecholamine and corticosteroid
Evaluation & Treatment
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Initial Assessment
• Goals
–Immediate identification of life-
threatening conditions
–Rapid recognition of circulatory
compromise
–Early classification of the type and
cause of shock 18
Initial Assessment
• Airway
– Mental status: can the patient maintain the
airway
• Breathing
– ?impending respiratory failure
• Circulation
– Heart rate, pulses, blood pressure
– Capillary refills - perfusion
• Dextrose 19
Treatment
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Increase O2 delivery
Decrease O2 demands
Increase O2 contents
Increase cardiac output
Increase blood pressure
Early intubation
Sedation
Analgesia
Treatment: Inotropes
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Agent Site of Action Dose
Mcg/kg/min
Effects
Dopamine Dopaminergic
Beta
Alpha > Beta
1-3
5-10
11-20
Renal vasodilation
Inotrope/vasoconstriction
Increase perip. Vasc. resistance
Dobutamine Beta 1 & 2 1-20 Inotrope
Vasodilation
Epineprhine Beta > alpha 0.05 – 1.0 Inotrope, vasoconstriction
Tachycardia
Norepinephrine Alpha > beta 0.05 – 1.0 Profound vasoconstriction
inotrope
Milranone Phosphodiesterase
inhibitor
0.5 – 0.75 Inotrope
vasodilation
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