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

2. HAEMODYNAMIC
and
SHOCK

3. 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)

4. 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)

5. 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

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

7. 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

8. HYPOTENSION
SHOCK

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

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

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

12. 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 )

13. 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.

15. 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

16. 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)

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

18. 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)

19.  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.

20. 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

21. 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)

22. WASSALAMU'ALAIKUM W W