DEFINITION
SHOCK
Failure to
deliver and/or
utilise adequate
amounts of
oxygen
AETIOLOGY
Cardiogenic
Distributive
Obstructive
Hypovolemic
Combination
Cardinal Signs
Change in mental status
Heart rate > 90 beats per minute
Hypotension
Respiratory rate > 20
Hypothermia - Core body temperate less than 36C (96.8F)
Pulse oximetry - Relative hypoxemia
Decreased urine output
DISTRIBUTIVE SHOCK
Etiology
SIRS -SEPSIS
Anaphylaxis
Adrenal Insufficiency
Reactions to drugs or toxins
Heavy metal poisoning
Hepatic insufficiency
Neurogenic shock
SIRS - SEPSIS
Laboratory Evaluation
Complete blood count (CBC) with differential
Urinalysis
Electrolytes
Blood urea nitrogen (BUN) - Creatinine
Glucose
Cultures
Arterial blood gas
Serum lactate
MANAGEMENT
Oxygen
Vascular Access
Fluid Resuscitation
Vasoactive agents
VASOPRESSORS
Dopamine ,
Precautions :
Target MAP
65 mm Hg
Norepinephrine
(preferred)
Dobutamine or
epinephrine
Increase HR and
myocardial oxygen
demand
HI-DOSE
arrhythmia
Refractory
shock
Vasopressin
infusion
VASOPRESSIN
Normally produced by posterior
pituitary gland.
Vasopressinergic receptors (V1, V2) sympathetic
terminals
CORTICOSTEROID
Fluid resuscitation and vasopressor
hemodynamic
instability
Intravenous hydrocortisone 50 mg per 6 Hours
AETIOLOGY ANAPHYLAXIS
In hospital :
Outside hospital:
injection of drugs
blood products
plasma substitutes
contrast media
latex products or chlorhexidine.
ingestion of foods
Food additives
Insect stings
Drugs (less common)
Degranulasi
- Histamin
- PAF
-Vasodilatasi
- Permeabilitas
- Bronchokontriksi
- Prostaglandin
- Leukotrien
- Adenosin
- Serotonin
Reaksi
anafilaktoid
B. GAMBARAN KLINIS
- Permeabilitas vaskuler
- Hipereaktiv bronchus
Sendiri-sendiri / gabungan
CLINICAL SIGN
Angioedema
Urticarial
rash
Wheezing
Respiratory
distress
Paling sering
pada kulit dan sistem kardiovaskuler
Gambaran klinis
Berhubungan dengan tempat masuk Ag
Jumlah Ag yang masuk
Kecepatan absorbsi
Derajad hipersensitivitas penderita
Pathogenesis
Vasodilatation
Capillary leak of plasma
endogenous hypovolaemia
reduced venous return
lowered cardiac output
Treatment
Oxygenation :
Intubation & Mechanical
ventilation
Facemask
angioedema or laryngeal
oedema
severe bronchospasm
apnoea
cardiac arrest.
Treatment
Epinephrine
Drug of choice
Community acquired
anaphylaxis
I.M 0.31.0 mg
IM produces higher
levels > SC
Severe shock IV
injection of 35 ml
of 1:10.000
A second dose and
infusion if necessary
OTHER SYMPATHOMIMETIC-AMINES
COLLOIDS
Plasma expanders Correct acute vasodilatation and
leakage of fluid from the intravascular space
Colloid remain in the vascular compartment earlier and for longer
than Crystalloid
Less Volume than Crystalloids
CVP monitoring and haematocrit if neccesary
BRONCHOSPASM
First line : Epinephrine , if neccesary :
Nebulised salbutamol
Aminophylline 56 mg/kg IV over 30 minutes
Other agents :
Volatile anaesthesia
Ketamine
magnesium sulphate
ANTIHISTAMINES
Steroids have no
proven benefit but
also no evidence
of harm
Refractory
bronchospasm ??
MATURNUWUN