SHOCK

DEFINITION

Patient ask to Mbah Dukun : "Mbah! what is the meaning of Shock?

Mbah Dukun Bagong answers :

Shock is a clinical syndrome resulting from hemodynamic and metabolic disorder characterized by circulatory failure to maintain adequate perfusion to the organs - the vital organs of the body. Adequate tissue perfusion depends on three main factors, namely cardiac output, blood volume, and peripheral vasomotor tone. If one of these three determinants is chaotic and other factors can not compensate, there will be a shock. Originally arterial blood pressure may be normal to compensate for increased cardiac output .


If shock persists, decreased cardiac output and peripheral vasoconstriction increases. If hypotension and vasoconstriction settling continues, hypoperfusion cause lactic acidosis, and ileus Oliguria. If arterial pressure is low enough, there is brain dysfunction and cardiac muscle. Shock is resulting from the incident on serious hemostasis disorders.

TYPES of SHOCK

Patient ask to Mbah Dukun : "How many types of Shock?

Mbah Dukun Bagong answers :

1.  Hypovolemic shock
2. Cardiogenic shock
3. Septic Shock
4. Anafilatic shock

Patient ask to Mbah Dukun : "Would you explain about them?

Mbah Dukun Bagong answers :

A. Hypovolemic Shock

Hypovolemic shock is caused by disturbance of the circulation system of blood volume in blood vessels is reduced.

 B. Cardiogenic shock

Cardiogenic shock is the inability of sufficient blood flow to the heart of the network to meet the basal metabolic disturbances due to cardiac pump function. The definition here includes a poor cardiac output and evidence of tissue hypoxia with the existence of adequate intravascular volume

C. Septic shock

Septic shock is a situation where there is a decrease in blood pressure (systolic blood pressure less than 90 mmHg or systolic blood pressure decreased more than 40 mmHg) accompanied by signs of circulatory failure, although it has been adequately fluid resuscitation or requiring vasopressor to maintain blood pressure and organ perfusion as a result of septicemia. Septic shock is caused by various types of microorganisms and a large number of mediators play a role in pathogenesis. Generally caused by gram-negative bacteria.

D. Anaphylactic Shock

A Widespread and very serious allergic reaction. Symptoms include dizziness, loss of consciousness, labored breathing, swelling of the tounge and breathing tubes, blueness of the skin, low blood pressure, heart failure, and death.

ETIOLOGY

Patient ask to Mbah Dukun : "What are etiology which cause them?

Mbah Dukun Bagong answers :

 Etiology hypovolemic shock:

1. Bleeding

• Trauma
• Subcapsular liver hematoma
• Aortic aneurysm rupture
• Gastrointestinal Bleeding

2. Loss of plasma

• Extensive burns
• Pancreatitis
• Desquamation skin
• Dumping syndrome

3. Loss of extracellular fluid

• Vomiting (vomitus)
• Diarrhea
• Very aggressive diuretic therapy
• Diabetes insipidus
• Adrenal insufficiency

Etiology Cardiogenic shock

1. Problem  ventricular ejection

- Acute Myocard Infarc

- Acute Myocarditis

- Mechanical complications

• Acute mitral regurgitation due to dysfunction of muscle or ruptur papilaris 
•  Interventriculorum septum ruptured
• free wall ruptured
• Left ventricle aneurysm
• Severe aortic stenosis
• Cardiomyopathy 
•  Myocard Contusio

2. Filling Ventricular disruption

• Heart Tamponade
• Mitral stenosis
• Miksoma the left atrium
• Ball-valve thrombus in the atrium
• Right Ventricle Infarct

Trigger factor

1. Ischemic or myocard infarct
2. Anemia:tachycardia or bradicardi
3. Infection: endocarditis, myocarditis, or infection outside the heart
4. Pulmonary embolism
5. Advantages of liquids or salt
6. Drugs myocard pressure such as  β blocker
7. Other: Pregnancy, tirotoksikosis, anemia, stress (physical or emotional), acute hypertension. 

Etiology Septic Shock

infected by organisms

Etiology Anaphylactic Shock

 Allergen

SYMPTOMS

Patient ask to Mbah Dukun : "How can i know about them?"

Mbah Dukun Bagong answers :

You have to know what their symptoms!

Symptoms of hypovolemic Shock

1. Mild ( lost < 20% blood): Cold extremities, Increased capillary filling time, Diaporesis, Veins collapse, Anxious

2: Moderate ( lost 20-40% blood): Symptoms of Mild grade plus Tachycardia, tachypneu, Oligouria, ortotastic Hypotensive

3. Severe (lost > 40% blood): Mild and moderate plus decreased consciousness, Unstable hemodynamic

Symtoms of Cardiogenic Shock

1. Systolic arterial pressure <80 mmHg (determined by measurement of intra-arterial)
2. Production of urine <20 ml / day or disturbance of mental status. Left ventricular filling pressure> 12 mmHg
3. Central venous pressure of more than 10 mmH2O considered removing the possibility of hypovolaemia
4. These situation is accompanied by: anxiety, cold sweat, cold extremity, tachycardia, and others.

Symptoms of Septic Shock

Clinical symptoms of septic shock can be divided into three groups:
1. Blood pressure. Clinically to produce adequate blood flow in coronary and cerebral circulation, blood pressure must be above a certain value,  mean arterial pressure (mean arterial pressure, MAP) 60 mmHg or systolic arterial pressure of 90 mmHg.
2. Signs of perfusion organ / tissue affected, :

• Skin: Cold and cyanosis
• Renal: decreased urine production and may lead to kidney failure.
• Hearts: possible causes hyperbilirubinemia
• Brain: chaos / confusion and when settling can cause coma.
• Lungs: respiratory failure syndrome symptoms adults.

When related to multi organ can cause metabolic acidosis by lactic acid in the blood stacked. Elevated levels of blood lactate is a bad sign.
3. Signs / symptoms of a serious systemic infection that underlies the occurrence of septic shock, the clinical signs of severe sepsis (fever, chills, weakness, nausea, vomiting) and laboratory examination showed leukocytosis with a shift to the left, sometimes thrombocytopenia or neutropenia.

Symptoms of Anaphyllactic Shock

Clinical manifestations
1. Local reactions: urticaria and local edema

Mild: swollen eyes, nasal congestion, itching of the skin and mucosa, sneezing, usually appear two hours after exposure to allergens.
Moderate: symptoms are more severe than the above symptoms was found bronchospasm, laryngeal edema, nausea, vomiting, usually occurs within two hours after exposure to antigen.
Weight: occurs immediately after exposure to the allergen, the symptoms as a reaction to the above is just more severe bronchospasm, laryngeal edema, stridor, shortness of breath, cyanosis, cardiac arrest, dysphagia, abdominal pain, diarrhea, vomiting, seizures, hypotension, arrhythmias heart, shock and coma.  Deaths by laryngeal edema and cardiac arrhythmias.

TREATMENT

Patient ask to Mbah Dukun : "So what I have to do if i find that cases?"

Mbah Dukun Bagong answers :

Treatment Hypovolemic Shock

a. Bleeding

• Placing patients at higher leg position
• Keeping the respiratory track, meet the need of oxygen.
• Put two lines intravenous infusion using a large infusion needle or other means that allow such installation CVP intraarterial route .. Give crystalloid fluids such as RL or 0.9% NaCl or colloids such as dextran with a fast drip. Giving 2-4 liters in 20-30 minutes is expected to restore hemodynamic state.
• Ongoing blood loss with a hemoglobin level ≤ 10 g / dL with a transfusion need of blood replacement. Give the PRC (packed red cells) with 1-2 units of FFP (fresh frozen plasma) for each four units of blood.
• Failure of fluid resuscitation with crystalloid is almost always caused by massive bleeding, because it should be considered to take immediate action with surgical hemostasis.
• In a state of prolonged hypovolemia, inotropes support with dopamine, vasopressin or dobutamin can be considered to have sufficient strength after ventricular blood volume be satisfied first. Giving naloxone bolus 30 Mg / kg in 3-5 min followed by 60 mcg / kg in 1 h in 5% dekstrose can help to increase MAP.

b. Loss of gastrointestinal fluid

• Give 1-2 liters of NaCl 0.9% in 30-60 minutes, then continue with additional liquid while monitoring vital signs, CVP, and PCWP.
• Check and correction of electrolyte abnormalities.

Treatment Cardiogenic Shock

• Make sure the airway remains inadequate, if not conscious intubation should be performed.
• Give oxygen 8-15 L / min by using a mask to maintain PO2 70-120 mmHg.
• The pain caused by acute myocardial infarction which can aggravate existing shock must be overcome by administration of morphine.
• Correction of hypoxia, electrolyte disturbances, and acid-base balance that occur.
• If there is tachyaritmia must be overcome: Tachyaritmia supraventikular and atrial fibrillation can be treated with digitalis, Sinus bradikardi with heart frequency <50x/minute sulfas must be overcome by giving atropine.

• Ensure adequate left ventricular filling pressure. The first priority in treating cardiogenic shock is the provision of adequate parenteral fluid using the basic guidelines or PAED PCWP or CVP. Type of liquid used depends on clinical circumstances, but it is recommended to use isotonic fluids. Intravenous fluid tolerance test is a simple way to determine whether giving intravenous fluids useful in the management of cardiogenic shock. How:

1. If PCWP or PAED <15 mmHg, it is difficult to say the pump failure, so that intravascular fluid administration should be improved with the initial test vol; ume of 100 ml through within 5 minutes. If no response is given an additional 200 ml of fluid within 10 minutes.
2. When next PCWP remained stable, followed by giving intravenous fluids 500-1000ml/jam.
3. If at the initial examination of PCWP 15-18 mmHg then given 100 ml of intravenous fluids within 10 minutes.
4. If PCWP> 20 mmHg may not dilakikan tolerance test and intravenous fluids started treatment with vasodilators.
5. If PCWP <5 mmHg infus fluids can be given even if there is pulmonary edema. But if there was an increase of lung congestion and the clinical deterioration of fluid infusion was stopped.

• Patients with inadequate tissue perfusion and adequate intravascular volume have sought possible cardiac tamponade.
• Handling of pump failure were divided based on hemodynamic subset

1. TDS> 100 mmHg: nitroglycerin 10-20 mcg / min iv
2. TDS 70-100 mm Hg and signs / symptoms of shock (-): dobutamin 20-20 mcg / kg / min
3. TDS 70-100 mm Hg and signs / symptoms of shock (): dopamine 5-15 mcg / kg / min iv
4. TDS <70 mm Hg and signs symptoms of shock (-); norepinephrine from 0.5 to 30 mcg / min iv

• The use of thrombolytic 
• PTCA, cabs, a heart transplant.

Treatment of Septic Shock

• Broad-spectrum antibiotic. Recent research states that the treatment of early stages of septic shock is to use a third-generation cephalosporins.
• Fluid therapy to improve oxygen consumption using crystalloid fluids (NaCl, RL) or koloid. Plasma ekspander and albumin is required when Ht is less than 30 vol% and serum albumin less than
• Dopamine is given when it reached the target fluid therapy, namely MAP 60 mmHg or systolic pressure is 90-110 mmHg.Dosis 2-5μg/kgBB/menit early. If this dose failed to increase MAP according to the target, then the dose can be increased until 20μ/kgBB/menit. If still fail to be restored on 2-5μg/kgBB/minute dose dopamine, but combined with levarterenol (norepinephrine). When a combination of both vasoconstrictor still fails, it means very bad prognosis.
• Corticosteroids. This treatment is still controversial. Based on several studies, dexamethasone is a corticosteroid which has the highest therapeutic index.
• Immunoglobulin
• Correcting metabolic acidosis with sodium bicarbonate until pH normal and improve the provision of electrolyte disturbances electrolyte
• Correcting hypoxia by giving oxygen equipment
• Correcting hypoglycemia or hyperglycemia
• Fix azotemia and Oliguria
• If there is widespread intravascular coagulation, treatment is basically enough to treat the disease course.
• During treatment, hemodynamic monitoring,:

1. Installation of the ECG monitor
2. Installation of arterial catheter / vein to measure the fluid balance.
3. Urinary catheterization to measure the amount of urine.
4. Fitting cuff to measure blood pressure.
5. Examination of blood gas analysis, electrolytes, lactic acid, blood coagulation tests to assess the metabolic function.
6. Serial examination of kidney and liver function
7. Installation of intravenous fluids, O2, and if necessary aggressive oxygen can be mounted Peep .

Treatment of Anaphylactic Shock

• Epinephrine 1:1000 0.01 ml / kg until reaching a maximum of 0.3 ml subcutaneously and can be given every 15-20 minutes 3-4 x samp0ai if symptoms get worse or from the initial conditions of severe illness, can be given by IM injection and even the occasional dose of epinephrine may be increased up to 0.5 ml throughout the patient did not suffer from heart problems.
• When originators allergens such as infiltration injections imunotherapy, penicillin, or insect sting, immediately given an injection of epinephrine infiltration 1: 1000 0.1 to 0.3 ml in the former site of injection to reduce the absorption of allergens earlier. If possible install tourniquet proximal from the injection site and loosen every 10 minutes and then off when the situation was under control.
• Next, two important things that must be considered in providing therapy in patients with anaphylactic shock is

1. The respiratory system is smooth, so good walking oxygenation
   - Maintaining an adequate airway. When laryngs or spasm of the bronchi, do tracheostomy or puncture the membrane of cricothyroid.
   - Giving oxygen 4-6 l / min is very important both in the respiratory and cardiovascular disorders.
   - Bronchodilators if there is airway obstruction bottom. Solution can be given beta-2 agonist salbutamol or other-0 .25 cc, 5 cc in 2-4 ml of 0.9% Nacl provided through nebulisation or aminophylline 5-6 mg / kg diluted in 20 cc of dextrose 5% or NaCl 0, 9% and given slowly about 15 minutes.
2. Cardiovascular system must function well so that adequate tissue perfusion
   - Symptoms of hypotension or shock is not succeed by giving epinephrine indicate a hipovolemi. These patients require intravenous fluids rapidly with crystalloid or colloid fluids. It is advisable to give colloidal fluids from 0.5 to 1 liter, the rest of crystalloid.
   - Oxygen is absolutely necessary and the provision of sodium bicarbonate in case of metabolic acidosis.
   - Sometimes it is necessary CVP
   - When blood pressure is still not resolved with fluid administration, the experts agree to give vasopressor via intravenous infusion. By way of dissolving 1 ml epinephrine 1: 1000 in 250 dextrose (concentration of 4 mg / ml) is given by infusion 1-4 mg / min or 15-60 microdrip / min, if necessary, the dose may be increased to a maximum of 10 mg / ml.
   - When the means of the blood vessels are not available, the state of severe anaphylaxis, American Heart Assosiacion recommends granting an endotracheal epinephrine dose given 10 ml of epinephrine 1:10.000 through long needle or a catheter through the endotracheal tube. The above measures are followed by respiratory hyperventilation to ensure rapid drug absorption.