Anda di halaman 1dari 35

ACS

Shock
ACS

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

Key Issues : Shock Management


Recognize inadequate organ perfusion
Identify the cause
Hemorrhagic vs nonhemorrhagic
Treatment
Stop the bleeding!
Restore volume
ACS

Cardiac Physiology

CO = SV X HR

Preload Contractility Afterload

Venous Vascular
dp / dt
Capacitance Tone
ACS

Pathophysiology
ACS

Cellular Alteration in shock


ACS

Recognition of Shock State


1. Tachycardia
2. Vasoconstriction
2. Cardiac output
Narrow pulse pressure
3. Map
3. Blood Flow

Caoution : Compensatory mechanisms


ACS

Pitfalls in shock Recognition


Extremes of age
Athletes
Pregnancy
Medications
Hematocrit/hemoglobin concentration
ACS

Etiology of Shock
Hemorrhagic Nonhermorrhagic
Most common Tension

Clinical clues pneumothorax


H&P Cardiogenic

Selected Neurogenic

diagnostic tests Septic


ACS

Hemorrhagic Shock
Loss of circulating blood volume
Normal blood volume
Adult 7% of ideal weight
Child: 9 % of ideal weight
ACS

Classification of Hemorrhage
Class I-IV
Not absolute
Only A clinical guide
Subsequent treatment determined by
patient response
ACS

Class I Hemorrhage
750 mL BVL
ACS

Class II Hemorrhage
750 1500 ml BVL
ACS

Class III Hemorrhage


1500 2000 ml BVL
ACS

Class IV Hemorrhage : 2000 ml


2000 ML BVL
ACS

Fluid Shifts : Soft tissue Injury

Blood loss into Tissue


injury site edema

Compounds
intravascular loss.
ACS

Assessment and Management


Recognize shock
Stop the bleeding !
Replenish intravascular volume
Restore organ perfusion
ACS

Assessment and Management


Airway and Breathing
Oxygenate and ventilate
Pao > 80 mm hg (10,6 kpa)
Circulation
Assess
Control
Treat
ACS

Assessment and Management


Disability cerebral perfusion
Exposure/Environment
Associated injuries
Prevent hypothermia
Gastric and bladder decompression
Urinary output
ACS

Management : Vascular Access


2 large caliber, peripheral IV s
Central access
Femoral
Jugular
Subclavian
Intraosseous
Obtain blood for croossmatch
ACS

Management : Fluid Therapy


Warmed crystalloid solution
Rapid fluid bolus ringer,s lactate
Adult: 2 Liters, Rigers Lactate
Child :20 ml /kg ringer,s lactate
Monitor response to initial therapy
ACS

Reevaluate Organ perfusion


Monitor
Vital signs

CNS status

Skin perfusion

Urinary output

Pulse oximetry
ACS

Resuscitation Evaluation
Hourly Urinary Output
Inadequate output suggests
inadequate resuscitation
ACS

Acid Base Abnormalities


Monitor with ABGs
Usual etiology
Adult : Acidosis due to inadequate
perfusion
Child : Acidosis due to inadequate
ventilation
ACS

Acid Base Abnormalities


Treatment
Oxygenate and ventilate
Stop the bleeding !
Consider inadequate volume restoration
Bicarbonate rarely indicated
ACS

Therapeutic Decisions
Patient response determines
subsequent therapy
Hemodynamically normal vs

hemodynamically stable
Recognize need to resuscitate in

operating room
ACS

Therapeutic Decisions
Rapid Response
<20 % blood loss

Responds to fluid replacement

Surgical consultation evaluation

Continue to monitor
ACS

Therapeutic Decisions
Transient Response
20% -40% blood loss

Deteriorates after initial fluids

Surgical consultation evaluation

Continued fluid plus blood

Continued hemorrhage : Operation


ACS

Therapeutic Decisions
Minimal to No Response
> 40% Blood loss

No Response to fluid resuscitation

Immediate surgical consultation

Exclude nonhemorrhagic Shock

Immediate operation
ACS
Volume Replacement

Warmed fluids
Crossmatched PRBCs

Type specific

Type O, Rh negative

Autotransfusion

Coagulopathy
ACS

Pitfalls

Equating Bp with Athletes


cardiac output Pregnancy

Extremes of age Medications

Hypothermia Pacemaker
ACS

Avoiding Complications
Continued hemorrhage
Fluid overload

Invasive monitoring (ICU)

CVP
Pulmonary artery catheter
Other problems
ACS

Keys to Successful Treatment


Early control of hemorrhage
Euvolemia
Continuous reevaluation
ACS

Questions
ACS

Summary
Restore organ perfusion
Early recognition of the shock state
Oxygenate and ventilate
Stop the bleeding
Restore volume
Continuous monitoring of response
Anticipate pitfalls