FARMAKOLOGI : DARAH & PERDARAHAN ( 3 )  HEMODYNAMIC & SHOCK SULANTO SALEH-DANU R.,dr.,SpFK. DEPT. FARMAKOLOGI & TERAPI FAKULTAS KEDOKTERAN UGM FARMAKOLOGI : DARAH & PERDARAHAN ( 3 )  HEMODYNAMIC & SHOCK

HAEMODYNAMIC and SHOCK

HEMODYNAMICS. Hemodynamic, pertaining to the movements Is the study of the relationship between PRESSURE, RESISTANCE and the FLOW of BLOOD in the cardiovasluar system. ( Aaronson, PI. & Ward J P T., 2000) Is the study of the movement of the blood and the forces concerned there in. ( Doorland’s Illustrated Medical Dictionary, 27th ed., 1988). Hemodynamic, pertaining to the movements involved in the circulation of the blood. ( Doorland’s Illustrated Medical Dictionary, 27th ed.,1988)

CO = (MABP-CVP)/ TPR CO = cardiac output, MABP = mean arterial blood pressure, TPR = total peripheral resistance, CVP = central venous pressure (copy from : Aaronson,PI., Ward,J.P.T., 1999)

AO = aorta Lg. arteries = large arteries Sm.arteries = small arteries ART = arterioles CAP = capillaries VEN = venule SV = venous Sm veins = small veins Lg veins = large veins

HEMODYNAMIC EMERGENCY PRESSURE : - hypertension - hypotension RESISTANCY : - obtruction of vessel - peripheral vasoconstriction - massive bleeding FLOW OF THE BLOOD : - blood viscocity - angina/O2 supply

BLOOD PRESSURE HAEMODYNAMICS PRESSURE RESISTANCE FLOW OF BLOOD - Stroke / CVA - Vital organ damages. PRESSURE Hypertension Hypotension - Shock RESISTANCE Vasoconstriction. Obstruction Thrombus Emboli FLOW OF BLOOD Scleroting of areteries Increase of velocity Hematokrit BLOOD PRESSURE

HYPOTENSION SHOCK

EMERGENCY ACTION BLOOD PRESSURE HYPOTENSION SHOCK organs perfusion ORGANS / TISSUES DAMAGES

DEATH BLOOD FLOW ORGANS PERFUSION CRITICAL PERIODE REVERSEIBLE IRREVERSIBLE CELLULAR / TISSUE / ORGAN INJURY DEATH

Classification of shock by mechanism and common causes. Hypovolemic shock Cardiogenic shock Obstructive shock Distributive shock ( Messina, L.M., et al., 2003 )

Tissue & organ blood flow Distributive shock Hypovolemic shock Cardiogenic shock Obstructive shock Severe Decrease in Systemic Vascular resistance Reduced Ability to Fill ventricle In diastole Severe Myocardial depression Reduced Systolic performance Reduced preload Decrease in Stroke volume Maldistribution Of blood flow In microcircul. Decrease in CO Hypotension Severe decrease in Tissue & organ blood flow Multiple organ system failure ( Parrillo, JE., 1991 )

Hypovolemic shock Loss of blood (hemorrhagic shock) - External hemorrhagic : trauma, gastrointestinal bleeding, etc. - Internal hemorrhagic : hematoma, hemothorax, hemoperitoneum. Loss of plasma : burns, exfoliative dermatitis. 3. Loss of fluid and electrolytes - External : vomiting, diarrhea, excessive sweating, hyperosmolar states (diabetic ketoacidosis, nonketotic coma) - Internal ( “third spacing”) : Pancreatitis, Ascites, Bowel obstruction.

Cardiogenic shock - Dysrhythmia : - Tachyarrhythmia - Bradyarrhythmia - “Pump failure” : secondary to myocardial infarction or other cardiomyopathy. - Acute valvular dysfunction (especially regurgitant lesions ) - Rupture of ventricular septum or free ventricular wall

Obstructive shock Tension pneumothorax Pericardial diseases ( tamponade, constriction) Diseases of pulmonary vasculature (massive pulmonary emboli, pulmonary hypertension) Cardiac tumor ( atrial myxoma ) Left atrial mural thrombus - Obstructive valvular diseases (aortic or mitral stenosis)

- Acute adrenal insufficiency Distributive shock - Septic shock - Anaphylactic shock - Neurogenic shock - Vasodilator drugs - Acute adrenal insufficiency

TREATMENT and MANAGEMENT SHOCK GENERAL MEASURE : “ ABC “  VENTILATION  Oxygen supply Advanced Cardiogenic Life Support (ACLS) Folley Catheter  urinary output Laboratory : blood count electrolyt glucose blood gas analyse coagulation parameter blood group bacterial cultur CENTRAL VENOUS PRESSURE ( CVP ) or PULMONARY CAPILLARY WEDGE PRESSURE (PCWP)

 I.V. LINE ( better use TRANFUSION SET ) 3. VOLUME REPLACEMENT.  I.V. LINE ( better use TRANFUSION SET ) HEMORRHAGIC SHOCK :  BLOOD SUBSTITUTES / WHOLE BLOOD / PBRC (Packed Blood Red Cells) + isotonic solution preventing increase of Hmt. HYPOVOLEMIC SHOCK :  Rapid bolus ISOTONIC CRISTALLOID  1 L CARDIOGENIC SHOCK :  ISOTONIC CRISTALLOID ( smaller volume ) SEPTIC SHOCK :  Large volume ISOTONIC CRISTALLOID. SHOCK in TRAUMA CAPITIS  HYPERTONIC SALINE (7.5%) plus DEXTRAN.

MEDICATIONS 4.1. VASOACTIVE THERAPY :  INOTROPIC agents  VASOPRESSOR agents - AFTER ADEQUATE FLUID RESUSCITATION - DEPENDS ON CARDIAC OUTPUT Agents : - Dobutamine - Nor-adrenaline/Nor-epinephrine - Adrenaline/Epinephrine - Dopamine - Vasopressin ( antidiuretic hormon /ADH )  DISTRIBUTIVE/VASODILATOR SHOCK 4.2. CORTICOSTEROID  SEPTIC SHOCK 4.3. Activated Protein C  as antithrombotic, profibrinolytic and Anti-inflamatory ( SEPTIC SHOCK) 4.4. ANTIBIOTIC  DEFINITIVE THERAPY in SEPTIC SHOCK 4.5. SODIUM BICARBONATE  SEPTIC SHOCK with LACTIC ACIDOSIS

PRINCIPLES SHOCK MANAGEMENT : ALLEVIATING THE PRECIPITATING CAUSE OF SHOCK; TREATING THE HAEMODYNAMIC AND METABOLIC CONSEQUENCES; 3. MANAGING THE SECONDARY MEDICAL COMPLICATIONS ( renal failure; pulmonary oedema etc.) (Benowitz, N.L., et al., 1997)

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