Shock: Emergency approach and management

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Shock Emergency approach andEarly management The 1st priority in any pt. with shock is stabilization of their A-B-CKumpol ,MDEmergency medicineThammasat UniversityDiagnostic evaluation should occur at the same time as RESUSCITATIONEarly managementAIRWAY and BREATHINGStabilize respiration; Oxygen , intubationAssess perfusion Delayed fluid resuscitation • Different types of shock can coexist.• Follow pathophysiology of shock• Decrease Total effective plasma volume• Relative intravascular hypovolemia• Elderly, DM, take B-blocker, hypertension Restore perfusion • Choice of replacement fluid • Rate and assessment of fluid repletion• Central monitoring or assessment • Vasopressors and inotropsColloid 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.Choice of replacement fluid Colloid versus crystalloidshock 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