management of shock in medical field

1. • References:
1. Sarawak Handbook Of
Medical Emergencies 3rd
Edition
2. Guide to The Essential in
Emergency Medicine by
Shirley Ooi.
3. Parrillo & Dellinger: Critical
Care Medicine, 3rd ed.
4. Civetta, Taylor, & Kirby's:
Critical Care, 4th Edition
5. http://www.cc.nih.gov/ccc/ped
web/pedsstaff/ivf.html
(Intravenous Fluid
Management)
Lim Jun Sian Batch
12

2. • Clinical syndrome that is results from
• Circulatory failure
• Reduction in oxygen deliver
• inadequate peripheral tissue and organ perfusion leading to a
• eventual cellular hypoxia with all its attendance sequalae.
• Clinically characterized by
• hypotension (Hemodynamic instability)
• SBP < 90mmHg or < 30mmHg from baseline
• Mean arterial pressure < 65mmHg
• Oliguria
• Altered mentation
• Organ failure

3. Classificationofshock Hypovolemic
Cardiogenic
Obstructive
Distributive
Septic
Anaphylactic
Neurogenic

4. Pathophysiology
• resulting from a decreased circulating blood
volume
Types of Hypovolemia
• Blood Loss
• Fluids/Plasma Loss
Most common type of shock
Diagnosis
• Readily diagnosed based on the etiology
• Pitfall
• Difficult to differentiate from cardiogenic
• A normotensive patient maybe in shock ( hypertensive patient)

5. • Medicine
• Diarrhea, Vomiting
• DKA, HHS
• Dengue shock syndrome
• Surgery
• Acute perforated
appendicitis
• GIT Bleeding(peptic ulcer,
esophageal varices)
• Burn
• Peritonitis
• Abdominal aortic
aneurysm
• Major operation
• OBG
• Hyperemesis gravidarum
• Rupture ectopic
pregnancy
• APH / PPH
• Trauma
• Abdominal
• Open fracture
• Closed fracture* (Shaft of
femur)

6. Class I Class II Class III Class IV
Blood loss
mL <750 750-1500 >1500-200 >2000
% <15 15-30 >30-40 >40
Heart rate
(beat/min)
<100 >100 >120 >140
Systolic
blood
pressure
Normal Normal Decreased Decreased
Pulse
pressure
Normal Decreased Decreased Decreased
Capillary
refill normal
Delayed Delayed Delayed Delayed
Respiratory
rate (min)
14-20 20-30 30-40 >35
Urine output
(mL/h)
>30 20-30 5-15 Minimal

7. • Cardiogenic shock (CS) is characterized by
systemic hypoperfusion due to
• cardiac pump failure caused by loss of myocardial
contractility
• severe depression of the cardiac index [<2.2 (L/min)/m2]
and
• sustained systolic arterial hypotension (<90 mmHg)
despite an elevated filling pressure [pulmonary capillary
wedge pressure (PCWP) >18 mmHg].
• Most common cause: MI
• 15% of cardiogenic shock occurs during MI attack
• 50% occurs 6 hours after MI attack

8. • Coronary artery
disease
• Acute MI
• RVF
• Secondary to AMI
• Hypertension
• Congenital Heart
disease
• ASD, VSD
• Valvular heart Disease
• Mitral valve (rupture)
• Aortic valve disease
• Dilated cardiomyopathy
• Thyrotoxicosis
• Acromegaly
• Phaeochromocytoma
• Pregnancy and peripartum
• Pericardium tamponade
• AF

9. • Septic Shock:
• sepsis-induced hypotension (systolic blood pressure
<90 mm Hg [or a drop of >40 mm Hg]) with
• signs of tissue hypoperfusion
• despite adequate fluid resuscitation for at least 1 hour
• Refractory septic shock
• Septic shock that lasts for >1 h and does not respond to
fluid or pressor administration
• Principle of mechanism
1. Peripheral vasodilation and pooling of blood

10. • Symptoms:
FEVER/hypothermia,
depends on site of
infection.
• Signs:
• Warm peripheral
extremities (due to
vasodilation)
• Febrile
• hypotension
• Tachypnea, tachycardia
• Oliguria
• Rash
• History taking:
comorbidities
• DM,
• Chronic lung disease
• alcoholism,
• liver cirrhosis,
• Recent invasive
procedure (especially in
CKF)
• HIV
• Immunosuppressive agent
(Steroid)
• Malignancy

11. • An allergic, IgE mediated, hypersensitivity
response to a foreign substance to which a
patient has been previously sensitized
• Type I hypersensitivity
• Causes:
• Drugs: penicillin, aspirin, streptomycin
• Vaccines: measles
• Blood products
• Insect bites: bees
• Food: seafood

12. • Onset:
• Commonly: 5-60min of exposure
• Delayed onset: after few hours
• Biphasic response: recurrence of symptoms 1-8 hrs later
due to late phase reaction
• Protracted anaphylaxis : persistence of symptoms up to
48hrs despite therapy
• Skin :
• Urticaria (200 cases):Area of focal dermal edema
• angioedema (20cases): Localized non-pitting deeper
edematous process
• Pruritus
• Tingling of face (usually at mouth)

15. • CVS:
• Arrhythimias
• RS:
• Laryngeal edema: hoarseness of voice, stridor, “lump in
the throat”
• Wheeze
• Dyspnea due to bronchospasm
• Coughing: ominous sign  portend onset of pulmonary
edema
• GIT
• Nausea, abdominal cramp

16. • Causes:
• Post-spinal surgery
• Spinal injury
• Clinical features:
• Bradycardia,
hypotension, warm
peripheral extremities
• Causes:
• Tension pneumothorax
• Cardiac tamponade
• Pulmonary embolism

17. • Complaints:
• Trauma
• GIT:
• Bleeding
• Diarrhea
• Vomiting
• Hematemesis
• Melena and
hematochezia
• Abdominal pain
• CVS
• Chest pain
• Dyspnea
• Palpitation
• OBG
• PVB
• Fever
• Past medical History
• Comorbidity
• Drug and allergic history
• Menstrual history
• Last menstrual

19. Hypovolem
nia
Cardiogeni
c
Neurogeni
c
Septic
Shock
(hyperdyna
mic)
Anaphylact
ic
BP Hypotensio
n
Hypotensio
n
Hypotensio
n
Hypotensio
n
Hypotensio
n
Skin
condition
Pallor,
clammy,
cold
Clammy,
cold
Warm Rigors,
fever/warm
warm
Heart Rate Tachycardia Dysrhythmi
as bradycardia
Tachycardia arrhythmias
Others Open
fractures
Ventricular
failure
Trauma to
spine
+/- Rash urticarial
others Limbs
weakness
angioedem
a
Urinary and
bladder
wheezing
Guide to The Essential in Emergency
Medicine by Shirley Ooi.

20. • CNS
• Encephalopathy
• CVS
• Reduced myocardial
contractility
• Renal
• Acute Renal Failure
• Pulmonary
• ARDS
• Atelectasis
• GIT
• Stress Ulcer
• Mesenteric Ischemia
• “Shock” liver
• Hematology
• DIVC
• Metabolic
• Hyperglycemia
• Lactic Acidosis
• Skeletal
• gangrene

22. • BP < 90mmHg
(hemodynamic instability)
• Altered mentation
• oliguria
Suspect Shock ???
Skin Condition
Clammy
Cold
Warm
Hyoovolemic Shock
Cardiogenic Shock
Obstructive Shock
Distrubutive Shock
Neurogenic Shock

23. Hypovolemic Shock
Cardiogenic Shock
Obstructive Shock
Distributive Shock
Neurogenic Shock
Check the Pulse
Tachycardia
Dysrhythmia
s(by ECG)
Bradycardia
Neurogeni
c
AnaphylacticCardiogenicSepticHypovolemic
Other
Features:
Trauma
diarrhea
vomiting
Other
Features:
Fever
Rash
others
Other
Features:
Post – MI
Sign of CCF
Other
Features:
Allergy
Urticarial
angioedema
Other
Features:
Spinal
injury
RS
Examination
Tension
Pneumothor
ax
Cardiac
Tamponad
e
BECK’S TRIAD

25. Airway Maintenance If GSC < 8 ETT intubation
Breathing – by SP02
100% oxygen
oyxgen to maintain PaO2 >
60mmHg or SaO2 > 90%
Circulation
2 large wide bore
• Size: 16G
• Route: peripheral 
central line  Intraosseos
line
• Wide bore
• Purpose:
• Give bolus or infuse
fluids
• Drugs administration
• blood Investigation
Bladder
catheterization

26. • Supine or
Trendelenburg
position
• Raise the leg up
Non-
cardiogenic
Shock
Cardiogenic
Shock
Fluids therapy
(at least
1000ml)
+/- Fluids
therapy (500-
1000ml max)
Investigation CVP or PAC
Fail to respond to Fluid therapy
Sympathomimeti
cs
• Mean arterial pressure >60-
65 mm Hg (higher in the
presence of coronary artery
disease)
• Pulmonary wedge pressure
15-18 mm Hg (may be higher
for cardiogenic shock)
• Cardiac index >2.1 L/min/m2
for cardiogenic and
obstructive shock
• Cardiac index >4-4.5
L/min/m2 for septic and
resuscitated
traumatic/hemorrhagic shock

27. Compartmen
t Glucose 5% NaCl 0.9%
Normal COP
Colloids
Intravascular ↑ ↑ ↑↑
Interstitial ↑↑ ↑↑ —
Intracellular ↑↑↑ — —

28. • Principle:
• First: Restore intravascular volume
• Second: replete interstitial and intracellular
volume
Compartmen
t Glucose 5% NaCl 0.9%
Normal COP
Colloids
Intravascular ↑ ↑ ↑↑
Interstitial ↑↑ ↑↑ —
Intracellular ↑↑↑ — —

29. • Crystalloid is preferred over than colloid because
colloid :
1. inhibition of the coagulation system;
2. the risk for anaphylactoid reactions;
3. inhibition of renal salt and water excretion;
4. Over-administration  risk of ARF
5. expensive

30. • Choice of Crystalloid
• Theoretically: Ringer Lactate or Hartman solution is
preferred over Normal saline
• Resemble the plasma electrolytes level
• However, Normal saline is used because
• it is cheaper.
• Isotonic Normal saline 0.9% is used in all shock
condition excepts:
• Burn shock (use Parkland formula)
• Dextrose 5% ½ NS  Maintenance therapy

31. 1. The value of Glucose, Na, K must be
memorized.
• Primarily used to
maintain water
balance in patients
who are not able to
take anything by
mouth
For Fluid Resuscitation
(shock, dehydration)
Fluids
Maintenance

32. Fluid
Maintenance
Electrolyte
Fluid
Resuscitation

33. Fluids loss
• Fluids replacement : (NS) to restore the
circulatory volume
• Adult: at least1000ml over 30minutes bolus
• Pediatrics – 20ml/kg
• Calculating the % loss
• According to the sign and symptom
• Dehyration – mild moderate severe
• Blood loss – class I,II, III, IV
• According to weight loss
• (Previous healthy weight – current body weight) x
100%

34. • Fluids maintenance: daily fluid loss (about 2L) +
additional fluid deficit + ongoing loss
• (fever –increase in 1degree celcius =10ml/hr
loss)
• Paediatrics age group – Must use Holliday-
Segard Formula
• Adult – can use wt + 40 formula
• Maximum fluid maintenance for normal daily loss
: 120ml/ hr

35. Rule of 4 -2-1 (Holliday-
Segard Formula)
- 4 ml per kg for the first 10
kg of body weight;
- 2 ml per kg for the next 10
kg (11-20kg);
- 1 ml per kg for any weight
>20 kg
Weight + 40
Example: Calculating
maintenance fluid
requirements for 70 kg male.
0-10 kg: 10 * 4 ml = 40 mL
11-20 kg: 10 * 2 mL = 20 mL
21-70 kg: 50 * 1 mL = 50 mL
Total = 110 mL/hr
Example: Calculating
maintenance fluid
requirements for 70 kg male.
70+40 = 110mL/hr

36. • Indications
• Severe hemorrhage > 30%
• Hb < 8%,
• Whole Blood is used.
• GXM
• 1 unit of blood = 450ml of blood
• During initial resuscitation of acute blood loss and shock,
crystalloid or colloid infused to restore circulatory volume
• Emergency blood group “O” blood should not be used
indiscrimately
• Look for side effect of transfusion

37. • Group O “positive” is used as emergency blood for man.
• Group O “negative” is used for female in reproductive
age group.
• Category of blood according to urgency
Unmatch
Emergency
blood
Rapid
Match
blood
Full
matched
blood
Availability Instant 5-10minutes 30-
45minutes
CXM not done done Done
Antibody
screen
not done not done done
Guide to The Essential in Emergency
Medicine by Shirley Ooi.

38. • Prevention of stress ulcer
• Ranitidine or PPI
• Prevention of deep vein thrombosis
• UF heparin or LMW heparin if no C/I
• Prevention of ARF
• Induce diuresis by furosemide (make sure adequate fluid
therapy)  look for hyperkalemia
• IV 2-5micro g/kg/minute of dopamine (low dose)
• Glucose control
• Insulin to prevent DKA in DM patient
• Metabolic Acidosis
• treat in severe cases only.

40. • Blood investigations
• FBC, RBS
• HCT is extremely unreliable test
• GXM
• BUSE and creatinine, lactate
• Cardiac enzyme and TnT
• Exclude acute MI
• ABG
• Metabolic acidosis, elevated lactate(>5mmol/L) and significant
base deficit are marker of poor prognosis
• Correction of these abnormalities will improve outcome (by ABC)
• However, sodium bicarnoate is not used routinely because it does little
to positively affect morbidity and survival.
• Coagulation profile , albumin
• ECG and CXR
• FAST scan (Focused assessment with sonography for trauma)

41. • Fluids
Resuscitation -
mainstay
• All fluids need to be
warmed to prevent
iatro-genically
induced
hypothermia.
ABC + Bladder
catheterization
Active
bleeding
Fluid
Resuscitatio
n
Dopamine
+/-
Dobutamine
Compressi
on
E / NE
HypotensionCVL / PAC
Hypotension
OT if
required
If MAP < 60mmHg
 CVL / PAC
sympathomime
tic drugs
external
Internal

43. • Blood Investigation
• Cardiac enzyme
• ABG
• BUSE and creatinine
• FBC , RBS
• ECG
• CXR
• Echocardiography if cause is uncertain

44. • Assessment of Venous Pressure:
reflect Right ventricular filling pressure
• Pulmonary capillary wedge pressure
(PCWP) with Swan-Ganz catheter
• useful in suspected ARDS, exclusion of
VSD, associated hypotension requiring
inotrope to guide therapy

46. Supine or Trendelenburg position
ABC + bladder catheterization
Oyxgen 35-100% via facemask
to maintain PaO2 > 60mmHg or
SaO2 > 90%
Continuous cardiac, BP,
HR, Pulse oxymetry
monitoring
• Increase inspired
oxygen to keep
SaO2 > 90%
• Mechanical
ventilation is
indicated if
• hypercapnia
• hypoxia
• Patient who are alert
and cooperative may
cope with (NIPPV)
• Correct severe
metabolic acidosis
(pH < 7.2)
• Reason: negative
inotrophic and
pro-

47. Treat underlying arrhythmias
• Insert large cannula and
give:
• Morphine IV 2.5-5mg
+ metoclopramide
10Mg IV or IM
Reduce
anxiety and
vasodilation
(use carefully)
Notice: SL GTN
and frusemide
are not used in
Cardiogenic
Shock if SBP <
NO CLINICAL OR
HEMODYNAMIC PULMONARY
CONGESTION
• Look for sign of CCF

48. NO CLINICAL OR
HEMODYNAMIC
PULMONARY
CONGESTION
(Judicious fluid challenge)
Method of giving:
Without invasive
hemodynamic monitoring
• 100ml NS or
Hartman’s Solution
over 5-10min interval
• Reassessment of BP,
HR, peripheral
perfusion, breath
sound between
successive
administration
• Max : 500-1000mL
With invasive
hemodynamic monitoring
Investigation
as above

49. Still Hypotension
Dopamine
Peripheral
hypoperfusion and
significant hypotension
 use dopamine 
increase MAP + restore
renal and coronary
perfusion
Up to 15-20 µg/kg/min
Common desired effect
dosage: 7.5-15µg/kg/min
Contraindicated
Dobutamine
Contraindicated in significant
pulmonary congestion and only
mild hypotension
Still Hypotension

50. Still Hypotension
NE/E Phosphodiesteras
e –III inhibitors
OR
NE/E
NE: beta1 and alpha
adrenergic increase
contractility +
vasoconstriction
Use if dopamine fails
Caution: both are
proarrhythmias (if AMI 
extensive myocardial
injury)
Phosphodiesterase –III
inhibitors
Eg. Amrinone and
milrinone
Indication: severe
Treat Pulmonary
Edema
With Frusemide /
GTN
SBP > 100mmHg
AMI if present
- Follow MI protocol

51. • Aminophylline (rarely use)
• Increase cardiac contractility
• Bronchodilatation
• Vasodilatation
• Mechanical circulatory support
• Intra-aortic balloon counterpulsation in tertiary
centers
• increases myocardial oxygen perfusion while
at the same time increasing cardiac output.

53. • To establish the definitive diagnosis
•Blood Culture and sensitivity (2 sets)
• For IV line sepsis:1 set from suspected
IV line, another from peripheral vein
•Urine C&S
•Stool culture
•Sputum culture
•UFEME

54. • Blood Investigation
• FBC
• ABG
• Coagulation profile with DIVC screen
• BUSE with creatinine
• LFT
• Radiological
• CXR
• USG abdomen (if indicated)
• CT(if indicated)
• LP (if indicated)

55. Management
Hemodynamic
Instability
Infection

56. ABC
Watch I/O
carefully and be
aware of other
losses
Continuous ECG, BP,
HR, Pulse oxymetry
monitoring
Bladder catheterization
Pulmonary arterial catheterization

57. Fluid Challenge
• Mainstay of
hemodynamic
supports
• Fast and rapid wide
bore fluid resuscitation
• urine output rate
should be kept at >0.5
mL/kg per hour by
continuing fluid
administration
• central venous
pressure should be
maintained at 8–12
cmH2O
Rate of administration
should be reduced if
cardiac filling
pressure increase
without concurrent
hemodynamic
improvement

58. Give low dose of
vasopressin
increase systemic
arterial pressure to
sustains the ability of
the vasculature to
autoregulate flow on a
tissue and organ level
 prevent organ
failure
Low Dose
vasopressor
• NE /
Dopamine(not in
low dose) 1st
choice
• Alternate:
Epinephrine (if BP
is poorly
responds)
• Enhance sensitivity to
vascular smooth muscle to
catacholamine  to
minimize the side effect of
using high dose vasopressor
• beneficial in catecholamine-
resistant septic shock
following adequate volume

59. • C&S before empirical antibiotic
• Intravenous broad-spectrum antimicrobials
should be initiated immediately (preferably <30
minutes) following the clinical diagnosis
• At dosing at the high end of the therapeutic
range
• Duration of therapy: 7-10 days
• Empiric antimicrobial therapy should be adjusted
to a narrower regimen within 48 to 72 hours if a
plausible pathogen is identified or patient
stabilizes clinically Where possible, early source

60. • Indications:
• Early phase of fibro-proliferative phase of ARDS
and sepsis
• History of endocrine disease and history of taking
corticosteroid therapy
• Persistent hypotension after adequate fluids
resuscitation and vasopressin
• Meta-analysis showed no convincing
evidence that early administration of high
dose corticosteroid is beneficial and they
could be harmful.

61. • Human recombinant activated protein C
(drotrecogin alfa)
• Indicated in high risk for death (APACHE II > 24 or
multi-organ failure
• Effect:
• Antithrombotic
• Anti-inflammatory
• Pro-frinolytic
• Prerequisite: Platelet count > 30,000
• Main contraindication
• Active bleeding
• CRF

63. ABC
Bladder
catheterization
ECG,RR,BP,SaO2
recumbent position
• High flow Oxygen
with facemask  fail
 ETT  difficult
intubation due to
severe laryngeal
edema 
tracheastomy /
cricothyroidotomy
Remove the inciting agent
• Prompt application of
torniquet proximally
• Insect: flick out insect
stinger with a tongue
blade
• Ingestion of allergen :
gastric lavage and
activated charcoal

64. IM aqueous
epinephrine 0.3-
0.5 ml of 1:1000
Repeat every
20minutes
• Epinephrine is the
mainstay of initial
management
• controlling symptoms
and maintaining blood
pressure.
IV Epinephrine
3 – 5ml 1:10
000
Severe
airway
compromise /
hypotension
Repeat every 5-
10min
Epinephrine
Infusion
If require
multiple doses

65. Administer
histamine
antagonists
• block vasodilation,
capillary leak, and
shock
• H1 blockade, 25–50 mg
of diphenhydramine IV
6hrly
• ; H2 blockade, 50 mg of
ranitidine IV 6hrly
aggressive fluid
resuscitation
500-1000ml of
crystalloid or colloid
in patients
who remain
hypotensive
despite
epinephrine.
Still
Hypotension

66. Still
Hypotension
Inotropes
• Maintain MAP > 60-
65mmHg
• dopamine, isoprenaline
infusion
Pulmonary artery
catheterization

67. • Nebulizer Bronchodilator
•Short acting beta2 agonist every 15-
30minutes
•Due to refractory to epinephrine
• Consider Corticosteroid
•250mg IV hydrocortisone, repeated 6
hourly
•Reduce protracted anaphylaxis
•not effective therapy for the acute
manifestations

68. • Consider glucagon administration
•Indicated for those who receive B blocker
therapy in anaphylactic shock
antagonizes the beneficial β-mediated
effects of epinephrine therapy
•1–5 mg IV over 1 minute, then 1–5
mg/hour in a continuous infusion

69. • Continuous ECG monitoring
• Close monitoring of ABG, CVP, BP
• Antihistamine 48-72hours to prevent
relapse
• Short course of steroid for 7-10 days
• Counseling

70. • Clinical features:
• Bradycardia, hypotension, warm peripheral
extremities
• Mx:
• ABC + Supine position with leg elevated
• Fluid resuscitation
• NE
• Anal wink or bulbocarvenosus reflex