1. Shock Emergency approach and
Early management
The 1st priority in any pt. with shock
is stabilization of their A-B-C
Kumpol ,MD
Emergency medicine
Thammasat University

2. Diagnostic evaluation should occur
at the same time as RESUSCITATION

3. Early management
AIRWAY and BREATHING
Stabilize respiration; Oxygen , intubation

4. Assess perfusion

5. Delayed fluid resuscitation

6. • Different types of shock can coexist.
• Follow pathophysiology of shock
• Decrease Total effective plasma volume
• Relative intravascular hypovolemia
• Elderly, DM, take B-blocker, hypertension

7. Restore perfusion
• Choice of replacement fluid
• Rate and assessment of fluid repletion
• Central monitoring or assessment
• Vasopressors and inotrops

8. Colloid versus crystalloid
• Saline versus Albumin Fluid Evaluation(SAFE) trial, 6997
severe sepsis critically. No diff between groups for any end
point (mortality)
Finfer, S, Bellomo, et al. A comparison of albumin and saline for fluid resuscitation : a systematic review. Crit care med 1999; 358-2247.
• Randomized trial compared penstarch to modified RLS in
severe sepsis; no difference in 28 day mortality.
Brunkhorst, FM et al. intensive therapy in sepsis, N Engl J Med 2008;385:125.
• Crystalloid versus colloid – clinic trials have failed to
consistently demonstrate a difference between colloid and
crystalloid in treatment of septic shock.
choi, PT, Yip, G. crystalloid vs. colloids in fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247.

9. Choice of replacement fluid
Colloid versus crystalloid

10. shock MAP< 60 ,
After initial 20-40cc/k starch, 40-60cc/k NSS
• Not possible to precisely predict the total fluid
deficit
• Rapid and large volume infusion

11. Table Isotonic Crystalloid Intravenous Infusion Rates
IV Access Gravity (80-cm Height) Pressure (300 mm Hg)
18 g peripheral IV 50–60 mL/min 120–180 mL/min
16 g peripheral IV 90–125 mL/min 200–250 mL/min
14 g peripheral IV 125–160 mL/min 250–300 mL/min
8.5 Fr 200 mL/min 400–500 mL
central venous introducer

12. Fluid challenge test
Evaluate evidenced HF
500 10 cc/kg in 5-10 min

13. Fluid challenge test
1000
Evaluate evidenced HF
20 cc/kg

14. Fluid challenge test
Consider
2000 Central monitoring
Evaluate evidenced HF
40 cc/kg

15. Fluid challenge test
3000 Need
Central monitoring
Evaluate evidenced HF
60 cc/kg

16. Fail to respond to initial fluid resuscitation.
• CVP
• Pulmonary capillary wedge pressure

17. Inotropes and vasopressors

18. • CVP 8 to 12 mmHg
• MAP > 65 , SBP > 90
mmHg
• Central venous oxygen
saturation >70%
• Hematocrit > 30%
• Proper antibiotic

19. Shock
Significant reduction of systemic
tissue perfusion

20. Emergency approach
Hypovolemic
Cardiogenic Distributive

21. Septic shock

22. Physiology

23. Compensation

24. Stages of shock

25. Stages of shock

26. Recommended approach
Diagnostic evaluation should occur at the same
time as RESUSCITATION
• Medical history
• Physical examination
• Laboratory evaluation(esp. undifferentiated shock)

27. Definition
• Systemic inflammatory response syndrome
(SIRs)
• Sepsis
• Severe sepsis
• Septic shock
• Refractory septic shock

29. SIRs +Infection Sepsis
+ Organ Severe
hypoperfusion
sepsis
-mottled skin
-cap. Refill > 3s Septic
-U/O < 0.5 cc/k/h +
-lactate > 2
shock
-Plt < 100,000 +MAP < 60 ====
-cardiac dysf. +after 20-40 cc/k starch
+ 40-60 cc/k NSS
+PCWP 12-20
+DA>5u/k/min
NE/E<0.25u/k/min
--- MAP> 60
Septic shock + DA > 15 u/k/min, NE/E >0.25---
MAP>60 Refractory septic shock

30. After
Septic shock MAP< 60 20-40cc/k starch
40-60cc/k NSS