SKILL LAB

SHOCK
Oleh:
Desi Suryani Dewi, S.Ked.
132011101102

Pembimbing:
dr. Dwi Ariyanti, Sp.JP

1
 Definition of Shock

Shock is an acute clinical syndrome initiated by

ineffective perfusion, resulting in severe
dysfunction of organs vital to survival.

2
 NUMBER OF PATIENTS = 43

10 14 20 13 6
100
% MORTALITY RATE

80

60

40

20

<13 13-40 41-80 81-120 >120

INITIAL ARTERIAL LACTATE mgm %

Arterial blood lactate determinations in 63 patients in shock, measured

When the patients were initially seen and before treatment was begun
This value was of prognostic, whereas a similar plot of initial blood
Preassure vs. Mortality was not
3
 THE PATIENTS IN SHOCK
+
+ DIED
160
SURVIVED
140
+
+ +
LACTATE mgm %

120 +

100

80

60 +

40

20

7.1 7.2 7.3 7,4 7,5 7,6

ARTERIAL pH
A summary of 32 in whom serial measurements of arterial blood lactate
reflect prognosis. In patents (represented by the broken lines) the lactate
rose and all patients died. In 22 patients (respresented by the solid lines)
the lactate dropped quickly to normal and all survived 4
Golden hour. Probability of survival from posttraumatic shock

100
Percent
survival
80

60

40

20

0
0 30 60 90

Minutes
From: Stene JK, Grande CM, Gieseke A, 1991
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 UNSUR2 PEMBEDA PADA SHOCK UNSUR YANG
SAMA PADA
SYOK
SYOK SYOK SYOK SYOK - COMMON
HIPOVOLEMIA KARDIOGENIK ANAFILACTIC SEPTIK TERMINAL
- PERDARAHAN PATH WAY
- KEHILANGAN
CAIRAN

GANGGUAN PENURUNAN PENURUNAN VASODILATASI GANGGUAN GANGGUAN PADA

UTAMA VOLUME` DAYA POMPA PERFUSI &
DARAH JANTUNG OKSIGENASI

MEKANISME VOLUME DAYA POMPA PEMBULUH PERFUSI &

FISIOLOGI DARAH JANTUNG DARAH OKSIGENASI
DASAR JARINGAN /
SEL

ARAH UTAMA PENGGAN- PENINGKATAN PENGEMBALIAN PERBAIKAN

PENGELO TIAN DAYA POMPA TONUS PEMBU - PERFUSI /
LAAN VOLUME JANTUNG LUH DARAH OKSIGENASI
OBAT :2
OBAT 2

- INOTROPIK VASO AKTIF

- ANTI ARITMIK

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Type of Shock

7
 RECOGNITION OF SHOCK STATE

Tachycardia
Vasoconstriction
Cardiac Out Put
Narrow Pulse Pressure
MAP
Blood Flow

Caution : Compensatory Mechanism

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CELLULAR / METABOLIC RESPONSE

Blood Loss

Inadequate
Perfusion

Cell injury
Further volume
alteration
Membrane changes

Fluid disturbance
change
Anaerobic
metabolism
Further circulation Organ Lactic
changes dysfunction acid
9
PERTOLONGAN PADA SYOK PENDEKATAN TERPADU
BERORIENTASI FUNGSI / SISTIM

1. TAHAP PERTAMA / TAHAP SEGERA

BERIKAN LIFE SUPPORT
(BANTUAN HIDUP, RESUSITASI STABILISASI)

PARU
JAN
O2 TUNG

AIRWAY CIRCULATION
(A) BREATHING (C)
(B) BRAIN
2. TAHAP KEDUA
TETAPKAN DIAGNOSA DAN TERAPI DEFENITIF
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 Treatment of Shock
Goal: Restore
perfusion
Method: Depends on
type of Shock
Basically 2 kinds:
Hypovolemic
(hemorrhagic, septic,
neurogen.)
Cardiogenic
(Impedence or primary
Cardiac Failure)
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 15 % 40 %
5%
ISF ICF
IVF

Na K
Na
D5% Koloid

IVF ISF ICF IVF ISF ICF

RL / NS

TBW=intra-cellular (ICF) + extra-

cellular fluid.

ECF = interstital (ISF) + IVF ISF ICF

intravascular (IVF).
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 Resuscitation Fluids
Blood
Lactated Ringers
Normal Saline
Colloids
Hypertonic Saline
Blood Substitutes

13
 Outcome Resusitasi Cairan
Tekanan darah mendekati 120/80 atau HR
menurun dari kondisi syok
MAP (Mean Arterial Pressure) 65 mmHg
Urine output 0,5 mL/kg/jam
Status mental normal

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 Aetiology and pathophysiology
Hypovolemic shock
absolute hypovolemia due to significant intravascular fluid depletion :
internal or external haemorage, dehydration, plasma leaks.
Relative hypovolemia due to vaodilatation without concomitant
increase in intravascular volume: anaphylactic reaction, acute
haemolysis
Septic shock
By complex mechanism, often including vasodilatation, heart failure
and absolute hypovolemia
Cardiogenic shock
Decrease of cardiac output: direct injury to the myocardium and
indirect mechanism

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 Clinical features
Sign common to most form of shock:
Pallor, mottle skin, cold extremities, sweating and thirst
Rapid and weak pulse often only detected on major arteries
(femoral or carotid)
Low BP, narrow pulse preasure, BP sometimes undetectable
CRT > 2 second
Cyanosis, dyspnoe are often present in varying degrees
depending on the mechanism
Consciousness usually maintained (more rapidly altered in
children, but anxiety, confusion, agitation or apathy are common
Oliguria or anuria

16
Sign specific to the mechanism of shock
Hypovolaemic shock
The common sign of shock listed above are typical of
hypovolaemic shock
Dont underestimated hypovolemia. Sign of shock may not
become evident untul a 50% loss of blood volume in adults.
Anaphylactic shock
Significant and sudden drop in BP
Tachycardia
Frequent cutaneus sign: rash, urticaria, angiderma
Respiratory sign: dyspnoea, bronchospasm

17
 Septic shock
High fever or hypothermia (<36 Celcius), rigors, confusion
BP may be initially maintenained, but rapidly, same pattern as
for hypovolaemic shock
Cardiogenic shock
Respiratory sign of left ventricular failure (acute pulmonary
oedema) are dominant: tachypnoe, crepitation on
auscultation
Sign of right ventricular failure: raised jugular venous
pressure, hepatojugular reflux, sometimes alone, more often
associated with signs of left ventricular failure

18
 Management
In all cases
Emergency: immediate attention to the patient
Warm the patient, lay him flat, elevate legs (except in respiratory
distress, acute pulmonary oedema)
Insert a peripheral IV line using a large calibre catheter (16G in
adults). If no IV access, use intraosseous route
Oxygen theraphy, assited ventilation in the event of repiratory
distress
Assited ventilation and external cardiac compression in the event of
cardiac arrest
Intensive monitoring: conciousness, pulse, BP, CRT, respiratory rate,
hourly urinary output (insert a urinary catheter) and skin mottling

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 Management according to the cause
Haemorrhage
Control bleeding (compression, torniquet, surgical haemostasis
Determine blood group
Priority: restore vascular volume as quickly as possible. Insert 2
peripheral IV lines (catheters 16G in adults). RL or 0.9% NaCl:
replace 3 times the estimated lossess and/or plasma subtitute:
replace 1.5 times the estimated losses
Transfuse: classically once estimated blood loss represents
approximately 30 to 40% of blood volume (25% in children).
The blood must be tested (HIV, hepatitis B and C, syphilis, etc)
refer to the MSF handbook, blood transfusion.

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21
Severe acute dehydration due to bacterial/viral gastroesnteritis
Urgently restore circulating volume using IV bolus therapy:
RL or 0.9% NaCl:
Children <2 months: 10 ml/kg over 15 minutes. Repeat (up to 3
times) if sign of shock persist.
Children 2-59 months: 20 ml/kg over 15 minutes. Repeat (up
to 3 times) if sign of shock persist
Children > 5 years and adults: 30 mg/kgBB over 30 minutes.
Repeat once if signs of shock persist.
Then replace the remaining volume deficit using continous
infusion until signs of dehydration resolve (typically 70 ml/kg
over 3 hours)
Closely monitor the patient, be careful to avoid fluid overload
in young children and elderly patient

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 Severe Anaphylactic Reaction

Determine the causal agent and remove it, e.g. stop

ongoing injections or infusions, but if in place,
maintain the IV line
Admister ephinephrine (adrenaline) IM, into the
antero-lateral tight, in the event of hypotension,
pharyngolaryngeal oedema, or breathing difficulties:
Use undilutes solution (1:1000=1 mg/ml) and a 1 ml
syringe graduated in 0,01 ml:
Children under 6 years: 0,15 ml
Children from 6-12 years: 0,3 ml
Children over 12 years and adults: 0,5 ml
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 In children, if 1 ml syringe is not available, use a
diluted solution, i.e. add 1 mg epinephrine to 9
ml of 0,9% NaCl to obtain a 0,1 mg/ml solution
(1:10000):
Children under 6 years: 1,5 ml
Children from 6 to 12 years: 3 ml
At the same time, administer rapidly RL or 0,9%
NaCl : 1 liter in adults (maximum rate); 20 ml/kg
in children, to be repeated if necessary. If there is
no clinical improvement, repeat IM epinephrine
every 5 to 15 minutes.
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 In shock persist after 3 IM injections, administration of IV
epinephrine at a constant rate by a syringe pump is necessary:
Use diluted solution, i.e. add 1 mg epinephrine (1:1000) to 9 ml
of 0,9% NaCl to obtain a 0,1 mg/ml solution (1:10000):
Children: 0,1 mg to 1 microgram/kg/minute
Adult: 0,05 to o,5 microgram/kg/minute
Corticosteroid have no effect in the acute phase. However, they
must be given once the patient is stabilized to prevent recurrence
in the short term:
Hydrocortisone hemisuccinate IV or IM
Children: 1 to 5 mg/kg/24 hours in 2 or 3 injections
Adult: 200 mg every 4 hours
In patients with bronchospasm, epinephrine is usually effective. If
the spasm persist give 10 puff of inhaled salbutamol

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 Septic Shock
Vascular fluid replacement with RL or 0,9% NaCl or
plasma subtitute.
Use of vasoconstrictors:
Dopamine IV at a constant rate by syringe pump: 10 to
20 micrograms/kg/minute or if not available epinephrin
IV at a constant rate by syringe pump: use diluted
solution, i.e. add 1 mg epinephrine (1:1000) to 9 ml of
0,9% NaCl to obtain a 0,1 mg/ml solution (1:10000).
Start with 0,1 microgram/kg/minute. Increase the dose
progressively until a clinical improvement is seen.

26
 Look for the origin of infection (abscess; ENT,
pulmonary, digestive, gynaecological orurological
infection etc) antibiotic therapy according to the
origin of infection:

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 Ampicillin IV
Children and adults: 150 to 200 mg/kg/day in 3
injections (every 8 hours)

Cloxacin IV infusion (60 minutes)

Children over 1 month: 200 mg/kg/day in
divided doses (every 6 hours); max 8 g/day
Adults: 12 g/day in 4 divided doses (every 6
hours)

28
 Amoxicillin/clavulanic acid (co-amoxiclav)
Slow IV injection (3 minutes) or IV infusion (30
minutes)
Children less than 3 months: 100 mg/kg/day in 2
divided doses (every 12 hours)
Children > 3 months and < 40 kg: 150 mg/kg/day
in divided 3 doses (every 8hours); max 6 g/day
Children 40 kg and adults: 6 g/day in 3 divided
doses (every 8 hours)

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 Ceftriaxon slow IV
Children: 100 mg/kg as a single injection
Adults: 2 g once daily

Ciprofloxacin PO (by NGT)

Children: 15 to 30 mg/kg/day in divided doses
Adults 1.5 g/day in divided doses

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 Gentamisin IM or slow IV (3 minutes) or infusion (30
minutes)
Children > 1 month and adult: 6 mg/kg once daily

Metronidazole IV infusion (30 minutes)

Children over 1 month: 30 mg/kg/day in 3 divided doses
(every 8 hours); max 1.5 g/day
Adults: 1,5 g/day in 3 divided doses (every 8 hours)

Corticosteroids not recommended, the adverse effect

outweigh the benefits

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 Cardiogenic Shock

The objective is to restore efficient cardiac

output. The treatment of cardiogenic shock
depends on its mechanism

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 Acute left heart failure with pulmonary
oedema
In the event of worsening sign with vascular
collapse, use a strong inotrope:
Dopamine IV at a contan rate by syringe
pump: 3 to 10 microgram/kg/minute
Once the haemodinamic situation allows
(normal BP, reduction in the signs of
peripheral circulatory failure), nitrates or
morphine may be cautiously introduced.

33
 Digoxin should no longer be used for cardiogenic
shock, except in the rare cases when a
supraventricular tachycardia has been diagnosed
by ECG. Correct hypoxia before using digoxin.
Digoxin slow IV
Children: one injection of 0,010 mg/kg (10
microgram/kg), to be repeated up to 4 times/24
hours if necessary
Adults: one injection of 0,25 to 0,5 mg, then
0,25 mg 3 or 4 times/hours if necessary.

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 Cardiac tamponade: restricted cardiac filling as
a result of haemopericardium or pericarditis.
Requires immediate pericardial tap after
restoration of circulating volume.
Tension pnemothorax: drainage of the
pneumothorax
Symptomatic pulmonary embolism: treat with
an anticoagulant in a hospital setting.

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36
37
38
IVF ISF ICF

Perdarahan

ICF

ISF
IVF
39
 ECF SHIFT

IVF ISF ICF

Perdarahan
Squesterasi

IVF ISF ICF

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