1

Shock
In ER

Objectives

Define Shock.
Recognize the shock state.
Determine the cause.
Apply treatment principles.
Apply principles of fluid management.
Monitor patients response.
Employ options for vascular access.
Recognize complications of vascular access.

Key Questions

Is the patient in shock?

What is the cause of the shock state?
What can I do about it?
What is the patients response?
What are the pitfalls?

Key Questions

Is the patient in shock?

What is shock?

What is shock?

Shock hypotension
Shock = Inadequate organ perfusion
Inadequate substrate delivery
Anaerobic metabolism
Celular dysfunction
Cell death

Key Questions

Is the patient in shock?

What is shock?
How do you recognize it?

How do you recognize it?

Scene information/mechanism of injury

Physical examination
Inadequate
Tachycardia
perfusion
Alteration in LOC, anxiety
Cold, diaphoretic skin
Urinary output
Organ
Hypotension
dysfunction
Tachypnea, shallow repirations
(AMPLE History Sec.Survey)

Recognition of Shock State

1. Tachycardia
2. Vasoconstriction
2. Cardiac output
Narrow pulse pressure
3. Map
3. Blood Flow
Caution : Compensatory mechanisms

1
0

Class I Hemorrhage
750 mL BVL (<15%)

1
1

Class II Hemorrhage
750 1500 mL BVL (15-30%)

1
2

Class III Hemorrhage

1500 2000 mL BVL (30-40%)

1
3

Class IV Hemorrhage
2000 mL BVL (>40%)

1
4

Recognition of Shock State

Some condition such as
medications, age,
pregnancy can hide signs
and symptoms

1
5

Key Quetions

Is the patient in shock?

What is shock?
How do you recognize it?
What preparations are necessary?

1
6

Preparations?

Trauma team activation?

Summon the trauma personel
Organize the equipment
Standard precautions
Warm room and fluids

1
7

Key Questions

Is the patient in shock?

What is the cause of the shock state?

1
8

What is the cause?

Hemorrhagic

Blood loos

vs

Nonhemorrhagic
Cardiogenic
Blood pump and/or rate
problem

Distributive
Blood vessel problem

Obstructive
Blood flow problem

1
9

Key Questions

Is the Patient in shock?

What is the cause of the shock state?
How do you locate the bleeding?

2
0

How to locate the bleeding?

Physical examination
Diagnostic adjuncts to primary survey
Chest x-ray
DPL / Ultrasound
AP pelvis x-ray

2
1

Key Questions

Is the patient in shock?

What is the cause of the shok state?
What can I do about it?

2
2

What can I do about it?

Restore the organ perfusion and tissue
oxygenation

Oxygen and ventilatory support (AB maneuver)

Fluid therapy
Inotrope or vasoactive drugs (if needed)
Treat the cause

2
3

What can I do about it?

Stop the bleeding!

Restore volume! : too little vs too much

Direct pressure
Operation
Reduce pelvic volume
Splint fractures

y
p
a
r
e
h
t
d
i
u
l
F

Vascular access
Warmed fluids

Prevent hypothermia!

2
4

Stop bleeding !!

2
5

Stop bleeding !!
Perdarahan luar : tekanan langsung
/perban tekan
Turniket : hanya bila hancur/
akan amputasi
Klem : merusak struktur lain
Jahit
: hanya bila perlu

2
6

y
p
a
r
e
h
t
d
i
u
l
F

What can I do about it?

Volume expansion

Heart
full

Inotrope
Vasoactive drugs

2
7

Inotrope & Vasoactive Drugs

Use after fluid resuscitation failed
(normovolemia)
More efficacious if normovolemia
May obscure hypovolemia
systolic

70

100

mmHg

nitroglycerin (ischemia)
norepinephrine
nitropruside
dopamin
dopamin (shock)
norepinephrine (+dopamin)
dobutamin (shock -)

2
8

Key Questions

Is the patient in shock?

What is the cause of the shock state?
What can I do about it?
How do I evaluate the response to
treatment?

2
9

Response evaluation?
Identify Improved Organ Perfusion

CNS: Improved LOC

Renal: Urinary output

Skin: Warm, capillary refill

Repirations: Improved rate and depth

Vital signs: Return to normal

3
0

Response evaluation?

Normal urine output :

- Neonate
= 2 ml/kg/hour
- Infant
= 1,5 ml/kg/hour
- Pre school age = 1 ml/kg/hour
-Adult
= 0,5 ml/kg/hour = 30-50ml/hour

3
1

Key Questions

Is the patient in shock?

What is the cause of the shock state?
What can I do about it?
What is the patients response?

3
2

What is the patients response?

Rapid Responder
Transient Responder
Nonresponder

3
3

Fluid management in traumatic shock

Shock

2 iv line, large caliber

Fluid Loading 1000-2000 ml

Warm fluid!!

Good response

Transient response

Mild
Blood loss

Moderate loss
On going losses

Severe
Blood loss

Shock
Non-hypovolemic

Maintenance

Fluid/blood

Fluid/blood

Re-evaluate

Surgical
resuscitation

Get more
information

Surgical
consultation

Surgical
consultation

No response

3
4

Key Questions

Is the patient in shock?

What is the cause of the shock state?
What can I do about it?
What is the patients response?
What are the pitfalls?

3
5

What are the pitfalls?

BP = Cardiac output
Age extremes
Hypothermia
Athletes
Pregnancy
Medications
Pacemaker

3
6

Questions

3
7

Summary

Is the patient in shock?

What is the cause of the shock state?
What can I do about it?
What is the patients response?
What are the pitfalls?