Dr.devi-syok Diagnosis & Penanganannya

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    SYOK DIAGNOSIS &

    PENANGANANNYA

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    DESKRIPSI SYOKSuplai aliran darah ke jaringan inadekuatKebutuhan nutrien tidak terpenuhi

    Hasil metabolisme (toxic) tidak dapat dikeluarkan

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    PatofisiologiFase awal pemeliharaan curah jantung

    Rllasee katkolamin irama jantung naik (HR ),kontraktilitas naikStimulasi simpatis resistensi vaskuler sistemik naik(SVR), tekanan arteri naik (arterial pressure ) Venokonstriksi preload

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    Bledsoe et al., Essentials of Paramedic Care:Division 1II 2006 by Pearson Education, Inc. Upper SaddleRiver, NJ

    Vena Cavaand

    Systemic Veins

    Aortaand

    Systemic Arteries

    SystemicCapillaries

    Pulmonary Arteries

    LUNGS

    Pulmonary Veins

    Right Atrium

    Right Ventricle

    Left Atrium

    Left Ventricle

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    Patofisiologi (lanjutan)Fase lanjut mekanisme kompensasi gagal

    Penurunan curah jantung (CO), penurunan tekananarteriMikrosirkulasi sludging (tersumbat)

    Disfungsi selulerPenurunan delivery oksigen dan substrat energi

    anaerob, asidosis sistemik (depresi otot polos danmiokard), gagal organSyok irreversibel

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    PATHOPHYSIOLOGY OF SHOCKSYNDROME

    Cells switch from aerobic to anaerobic metabolismlactic acid production

    Cell function ceases & swellsmembrane becomes more permeable

    electrolytes & fluids seep in & out of cell

    Na+/K+ pump impairedmitochondria damage

    cell death

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    Kriteria diagnosisVital signsHypotensive < 90 mmHgMAP < 60 mmHgTachycardia : Weak and Thready pulseTachypneic -blow off CO2 R espiratoryalkalosis

    Mental status : (LOC) restless, irritable, apprehensive unresponsive, painful stimuli only

    Decreased Urine output

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    Shock Do you remember how to

    quickly estimate bloodpressure by pulse?

    60

    80

    70

    90

    If you palpate a pulse, you know SBP is at

    least this number

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    Etiology of circulatory shock

    1. Hypovolemic - intravascular fluid volume losshemorrhage, fluid depletion or

    sequestration

    2. Cardiogenic - impairment of heart pumpmyopathic lesions : myocardialinfarction, cardiomyopathiesdysrhythmias

    obstructive and regurgitant lesions ofintracardial blood flow mechanics

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    3. Obstructive - factors extrinsic to cardiac valves andmyocardium

    v. cava obstruction, pericardialtamponade,pulmonary embolism,coarctation of aorta

    4. Distributive - pathologic redistribution of intravascularfluid volumesepticaemia : endotoxic, secondary tospecific infectionanaphylactic

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    NORMAL

    1. HYPOVOLEMIC 2. CARDIOGENIC

    3. DISTRIBUTIVE

    High Resistance 4. OBSTRUCTIVELow Resistance

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    Goals of Treatment

    ABCDE A irway

    control work of Breathing optimize Circulation assure adequate oxygen Delivery achieve End points of resuscitation

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    What Type of Shock is This?Laki-laki, 20 th, dibawakeUGD post KLL ,tampak jejas di pelvis,hipotensi, takikardi,afebris, akral dingin

    Types of Shock Hypovolemic

    Septic Cardiogenic Anaphylactic Neurogenic ObstructiveHypovolemic Shock

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    Hypovolemic Shock

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    Hypovolemic Shock Non-hemorrhagic Vomiting Diarrhea Bowel obstruction, pancreatitis Burns Neglect, environmental (dehydration)

    Hemorrhagic GI bleed Trauma Massive hemoptysis AAA rupture Ectopic pregnancy, post-partum bleeding

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    Hypovolemic Shock ABCs Establish 2 large bore IVs or a central line

    Crystalloids Normal Saline or Lactate Ringers Up to 3 liters

    Transfuse

    O negative or cross matched Control any bleeding Arrange definitive treatment

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    Evaluation of Hypovolemic Shock CBC ABG/lactate

    Electrolytes BUN, Creatinine Coagulation studies

    Type and cross-match

    As indicated CXR

    Pelvic x-ray Abd/pelvis CT Chest CT GI endoscopy

    Bronchoscopy Vascular radiology

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    What Type of Shock is This? An 81 yo F resident of a nursing

    home presents to the ED withaltered mental status. She is febrile

    to 39.4, hypotensive with a widenedpulse pressure, tachycardic, with warm extremities

    Types of Shock Hypovolemic

    Septic Cardiogenic Anaphylactic Neurogenic ObstructiveSeptic

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    Septic Shock

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    Sepsis Two or more of SIRS criteria Temp > 38 or < 36 C HR > 90 RR > 20 WBC > 12,000 or < 4,000

    Plus the presumed existence of infection Blood pressure can be normal!

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    Sepsis

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    Septic Shock Clinical signs: Hyperthermia or hypothermia Tachycardia Wide pulse pressure Low blood pressure (SBP

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    Ancillary Studies Cardiac monitor Pulse oximetry

    CBC, Chem 7, coags, LFTs, lipase, UA ABG with lactate Blood culture x 2, urine culture CXR Foley catheter (why do you need this?)

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    Persistent Hypotension If no response after 2-3 L IVF, start a vasopressor(norepinephrine, dopamine, etc) and titrate toeffect

    Goal: MAP > 60 Consider adrenal insufficiency: hydrocortisone 100

    mg IV

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    Treatment Algorithm

    Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med. 2001:345:1368-1377.

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    Cardiogenic Shock Signs:

    Cool, mottled skin

    Tachypnea Hypotension Altered mental status Narrowed pulse pressure Rales, murmur

    Defined as: SBP < 90 mmHg

    CI < 2.2 L/m/m 2 PCWP > 18 mmHg

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    Etiologies What are some causes of cardiogenic shock?

    AMI

    Sepsis Myocarditis Myocardial contusion Aortic or mitral stenosis, HCM Acute aortic insufficiency

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    Pathophysiology of Cardiogenic Shock

    Often after ischemia, loss of LV function Lose 40% of LV clinical shock ensues

    CO reduction = lactic acidosis, hypoxia Stroke volume is reduced

    Tachycardia develops as compensation Ischemia and infarction worsens

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    Ancillary Tests EKG CXR

    CBC, Chem 10, cardiac enzymes, coagulation studies Echocardiogram

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    Treatment of Cardiogenic Shock Goals- Airway stability and improving

    myocardial pump function

    Cardiac monitor, pulse oximetry Supplemental oxygen, IV access Intubation will decrease preload and result

    in hypotension Be prepared to give fluid bolus

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    Treatment of Cardiogenic Shock AMI Aspirin, beta blocker, morphine, heparin If no pulmonary edema, IV fluid challenge If pulmonary edema

    Dopamine will HR and thus cardiac work Dobutamine May drop blood pressure Combination therapy may be more effective

    PCI or thrombolytics RV infarct

    Fluids and Dobutamine (no NTG) Acute mitral regurgitation or VSD

    Pressors (Dobutamine and Nitroprusside)

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    Anaphalactic Shock

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    Anaphylactic Shock Anaphylaxis a severe systemic

    hypersensitivity reaction characterized by

    multisystem involvement IgE mediated

    Anaphylactoid reaction clinically

    indistinguishable from anaphylaxis, do notrequire a sensitizing exposure Not IgE mediated

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    Anaphylactic Shock What are some symptoms of anaphylaxis?

    First- Pruritus, flushing, urticaria appear

    Next- Throat fullness, anxiety, chest tightness,shortness of breath and lightheadedness

    Finally- Altered mental status, respiratorydistress and circulatory collapse

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    Anaphylactic Shock Risk factors for fatal anaphylaxis Poorly controlled asthma Previous anaphylaxis

    Reoccurrence rates 40-60% for insect stings 20-40% for radiocontrast agents 10-20% for penicillin

    Most common causes Antibiotics Insects Food

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    Anaphylactic Shock Mild, localized urticaria can progress to full anaphylaxis Symptoms usually begin within 60 minutes of exposure

    Faster the onset of symptoms = more severe reaction Biphasic phenomenon occurs in up to 20% of patients

    Symptoms return 3-4 hours after initial reaction has cleared

    A lump in my throat and hoarseness heralds life -

    threatening laryngeal edema

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    Anaphylactic Shock- Diagnosis Clinical diagnosis

    Defined by airway compromise, hypotension, or

    involvement of cutaneous, respiratory, or GIsystems Look for exposure to drug, food, or insect Labs have no role

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    Anaphylactic Shock- Treatment ABCs

    Angioedema and respiratory compromise requireimmediate intubation

    IV, cardiac monitor, pulse oximetry IVFs, oxygen Epinephrine

    Second line Corticosteriods H1 and H2 blockers

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    Anaphylactic Shock- Treatment Epinephrine

    0.3 mg IM of 1:1000 (epi-pen) Repeat every 5-10 min as needed Caution with patients taking beta blockers- can cause severe

    hypertension due to unopposed alpha stimulation For CV collapse, 1 mg IV of 1:10,000 If refractory, start IV drip

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    Anaphylactic Shock - Treatment Corticosteroids Methylprednisolone 125 mg IV Prednisone 60 mg PO

    Antihistamines H1 blocker- Diphenhydramine 25-50 mg IV H2 blocker- Ranitidine 50 mg IV

    Bronchodilators Albuterol nebulizer Atrovent nebulizer Magnesium sulfate 2 g IV over 20 minutes

    Glucagon For patients taking beta blockers and with refractory hypotension 1 mg IV q5 minutes until hypotension resolves

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    Anaphylactic Shock - Disposition All patients who receive epinephrine should be

    observed for 4-6 hours If symptom free, discharge home If on beta blockers or h/o severe reaction in past,

    consider admission

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    What Type of Shock is This? Laki-laki, 41 th dibawake UGD setelah terjatuhdari lantai 4 mengeluhkeempat ektremitastidak dapat digerakkandan baal. PFhypotensive,bradycardic, ektremitashangat

    Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic ObstructiveNeurogenic

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    Neurogenic Shock

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    Neurogenic Shock Occurs after acute spinal cord injury Sympathetic outflow is disrupted leaving

    unopposed vagal tone Results in hypotension and bradycardia Spinal shock- temporary loss of spinal reflex

    activity below a total or near total spinal cordinjury (not the same as neurogenic shock, theterms are not interchangeable)

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    Neurogenic Shock- Treatment A,B,Cs Remember c-spine precautions

    Fluid resuscitation Keep MAP at 85-90 mm Hg for first 7 days Thought to minimize secondary cord injury If crystalloid is insufficient use vasopressors

    Search for other causes of hypotension

    For bradycardia Atropine Pacemaker

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    Neurogenic Shock- Treatment Methylprednisolone Used only for blunt spinal cord injury High dose therapy for 23 hours Must be started within 8 hours Controversial- Risk for infection, GI bleed

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    What Type of Shock is This? A 24 yo M presents to the

    ED after an MVC c/o chestpain and difficultybreathing. On PE, you notethe pt to be tachycardic,hypotensive, hypoxic, and with decreased breath

    sounds on left

    Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic ObstructiveObstructive

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    Obstructive Shock

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    Obstructive Shock Tension pneumothorax Air trapped in pleural space with 1 way valve,

    air/pressure builds up Mediastinum shifted impeding venous return Chest pain, SOB, decreased breath sounds No tests needed!

    Rx: Needle decompression, chest tube

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    Obstructive Shock Cardiac tamponade Blood in pericardial sac prevents venous return to and

    contraction of heart Related to trauma, pericarditis, MI Becks triad: hypotension, muffled heart sounds, JVD Diagnosis: large heart CXR, echo Rx: Pericardiocentisis

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    Obstructive Shock Pulmonary embolism Virscow triad: hypercoaguable, venous injury, venostasis Signs: Tachypnea, tachycardia, hypoxia Low risk: D-dimer Higher risk: CT chest or VQ scan Rx: Heparin, consider thrombolytics

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    Obstructive Shock Aortic stenosis Resistance to systolic ejection causes decreased cardiac

    function Chest pain with syncope Systolic ejection murmur Diagnosed with echo Vasodilators (NTG) will drop pressure! Rx: Valve surgery

    HYPOVOLEMICEXTRACARDIAC

    CARDIOGENIC DISTRIBUTIVE

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    HYPOVOLEMIC Obstruction CARDIOGENIC DISTRIBUTIVE

    Fluid loss,

    hemorrhage

    e.g., Pericardial

    tamponadeMyocardialinjury ornecrosis

    Decreasedsystemicvascularresistance

    Myocardiacdysfunction

    Reducedsystolic performance

    Reducedfilling

    Low cardiacoutput

    Reducedpreload

    Decreased arterialpressure

    Shock

    Multiple organ

    High or normalcardiac output

    Maldistributionof blood flow in