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Shock

In ER

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Objectives

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

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Key Questions

Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls?

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Key Questions

Is the patient in shock?• What is shock?

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What is shock?

Shock ≠ hypotension Shock = Inadequate organ perfusion

Inadequate substrate delivery

Anaerobic metabolism Celular dysfunction

Cell death

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Key Questions

Is the patient in shock?• What is shock?• How do you recognize it?

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How do you recognize it?

Scene information/mechanism of injury Physical examination

• Tachycardia• Alteration in LOC, anxiety • Cold, diaphoretic skin Urinary output• Hypotension• Tachypnea, shallow repirations

(AMPLE History – Sec.Survey)

Inadequate

perfusion

Organ

dysfunction

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Recognition of Shock State

1. Tachycardia

2. Vasoconstriction

2. Cardiac output

Narrow pulse pressure

3. Map

3. Blood Flow

Caution : Compensatory mechanisms

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Class I Hemorrhage

750 mL BVL (<15%)

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Class II Hemorrhage

750 – 1500 mL BVL (15-30%)

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Class III Hemorrhage

1500 – 2000 mL BVL (30-40%)

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Class IV Hemorrhage ≥ 2000 mL BVL (>40%)

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Recognition of Shock State

Some condition such as medications, age,

pregnancy can hide signs and symptoms

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Key Quetions

Is the patient in shock?• What is shock?• How do you recognize it?• What preparations are necessary?

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Preparations?

Trauma team activation? Summon the trauma personel Organize the equipment Standard precautions Warm room and fluids

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Key Questions

Is the patient in shock? What is the cause of the shock state?

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What is the cause?

Hemorrhagic vs

Blood loos

Nonhemorrhagic

• Cardiogenic– Blood pump and/or rate

problem

• Distributive– Blood vessel problem

• Obstructive– Blood flow problem

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Key Questions

Is the Patient in shock? What is the cause of the shock state?

• How do you locate the bleeding?

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How to locate the bleeding?

Physical examination Diagnostic adjuncts to primary survey

• Chest x-ray

• DPL / Ultrasound

• AP pelvis x-ray

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Key Questions

Is the patient in shock? What is the cause of the shok state? What can I do about it?

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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

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What can I do about it? Stop the bleeding!

• Direct pressure • Operation• Reduce pelvic volume• Splint fractures

Restore volume! : “too little vs too much”• Vascular access• Warmed fluids

Prevent hypothermia!

Fluid therapy

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Stop bleeding !!

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Turniket : hanya bila hancur/ akan amputasiKlem : merusak struktur lainJahit : hanya bila perlu

Stop bleeding !!

Perdarahan luar : tekanan langsung /perban tekan

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What can I do about it?

Volume expansion InotropeVasoactive drugs

Heartfull

Fluid therapy

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Inotrope & Vasoactive Drugs• Use after fluid resuscitation failed

(normovolemia)– More efficacious if normovolemia– May obscure hypovolemia

7070 100100 mmHgmmHg

• norepinephrinenorepinephrine• dopamindopamin

• dopamin (shock)dopamin (shock)• norepinephrine (+dopamin)norepinephrine (+dopamin)• dobutamin (shock -)dobutamin (shock -)

• nitroglycerin (ischemia)nitroglycerin (ischemia)• nitroprusidenitropruside

systolicsystolic

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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?

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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

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Response evaluation?

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

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Key Questions

Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response?

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What is the patient’s response?

Rapid Responder Transient Responder Nonresponder

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Fluid management in traumatic shockFluid management in traumatic shock

ShockShock

Fluid Loading 1000-2000 mlFluid Loading 1000-2000 ml

Good responseGood response

MildMildBlood lossBlood loss

Transient responseTransient response

MaintenanceMaintenance

Moderate lossModerate lossOn going lossesOn going losses

Fluid/bloodFluid/blood

No responseNo response

SevereSevereBlood lossBlood loss

ShockShockNon-hypovolemicNon-hypovolemic

Fluid/bloodFluid/blood Re-evaluateRe-evaluate

SurgicalSurgicalconsultationconsultation

SurgicalSurgicalconsultationconsultation

SurgicalSurgicalresuscitationresuscitation

Warm fluid!!Warm fluid!!

Get moreGet moreinformationinformation

2 iv line, large caliber

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Key Questions

Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls?

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What are the pitfalls?

BP = Cardiac output Age extremes Hypothermia Athletes Pregnancy Medications Pacemaker

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Questions

?

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Summary Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls?