SHOCK HIPOVOLEMICO EN MEDICINA INTERNA Dr.Luis Troncoso Castro

Dr.LUIS TRONCOSO C SHOCK HIPOVOLEMICO HEMORRAGICO NUEVOS PARADIGMAS

INTRODUCCION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

SHOCK HIPOVOLEMICO ,[object Object]

CLASIFICACION SHOCK HIPOVOLEMICO ,[object Object],[object Object]

HEMORRAGICO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

NO HEMORRAGICAS ,[object Object],[object Object],[object Object],[object Object]

SHOCK HIPOVOLEMICO HEMORRAGICO

CRITERIOS ATLS PARA GRADOS DE HEMORRÁGIA Criast + HD Crist + HD cristaloides cristaloides Restitución Letargia confusión mayor ansiedad Estado mental Ind 5 - 15 20 - 30 > 30 Diuresis(ml/h) > 35 30 - 40 20 - 30 14 - 20 F resp Baja baja baja Normal o alta Presión de pulso baja baja normal normal PA > 140 > 120 > 100 < 100 FC > 40% 30 – 40% 15 – 30% Hasta 15% Pérdida (%) > 2000 1500 - 2000 750 - 1500 Hasta 750 Pérdida (ml) GRADO IV GRADO III GRADO II GRADO I

SINDROME EXANGUINACION ,[object Object],[object Object],[object Object],[object Object]

SINDROME EXANGUINACION ,[object Object]

Iniciativa Europea para el Tratamiento Avanzado de la Hemorragia The European Medical Education Initiative on Advanced Bleeding Care “ABC Initiative” Version 1 Mayo 2004

ABC : European Education Faculty France Germany UK Spain Switzerland Portugal Italy Sweden Czech Republic Poland Austria

Task Force for Advanced Bleeding Care (ABC) ,[object Object],[object Object],[object Object],[object Object]

EUROPEAN GUIDELINE ,[object Object],[object Object],[object Object],[object Object],[object Object]

MANEJO ,[object Object],[object Object]

PORQUE DETERMINAR EN QUE ETAPA NOS ENCONTRAMOS ??? ,[object Object]

OBJETIVOS FASE PRECOZ ,[object Object],[object Object],[object Object],[object Object]

OBJETIVOS FASE TARDIA ,[object Object],[object Object],[object Object]

CONTROL DE LA HEMORRAGIA ,[object Object]

CONTROL HEMORRAGIA ,[object Object],[object Object]

CONTROL HEMORRAGIA ,[object Object],[object Object],[object Object]

CONTROL HEMORRAGIA ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],CONTROL HEMORRAGIA

PREVENCION HIPOTERMIA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Hipotermia ,[object Object],[object Object],Wang HE et al: Crit Care Med 2005;33:1293-1301

EFECTOS FISIOLOGICOS DE LA HIPOTERMIA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Manejo preventivo de la Hipotermia ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object]

REANIMACION ESTANDAR ,[object Object]

REANIMACION ESTANDAR ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

REANIMACION PERMISIVA ,[object Object],Bickell WH et al: NEJM 1994 Mattox K: www.trauma.org, 2003

PORQUE? ,[object Object],[object Object],[object Object],[object Object],[object Object]

REANIMACION PERMISIVA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Nuevos paradigmas Evidencia experimental y clínica : Elevar la PA aumenta tasa de sangrado Mantener PAM 40 mmHg (PAS 70 mmHg) hasta por 60 min

EXCLUSIONES ,[object Object],[object Object],[object Object]

Manejo del shock con Hipotensión permisiva • Consciente? No IV • Inconsciente con pulso? No IV • Inconsciente sin pulso? 25 ml/kg hasta que retorne pulso palpable Mattox K 2003

FUIDOTERAPIA ,[object Object],[object Object],[object Object],[object Object],[object Object]

CRISTALOIDES ,[object Object],[object Object]

RINGER LACTATO ,[object Object],[object Object],[object Object],[object Object]

SOLUCIONES FISIOLOGICAS ,[object Object],[object Object],[object Object],[object Object],[object Object]

SOLUCIONES HIPERTONICAS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Permanencia en el espacio intravascular a los 30 min ,[object Object],[object Object],[object Object],[object Object],[object Object]

COLOIDES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

FLUIDOTERAPIA ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G: Colloids versus crystalloids for fluid resuscitation in critically ill patients . Cochrane Database Syst Rev 2004, CD000567.

CONSECUENCIAS DE LA REPOSICION DE VOLUMEN ,[object Object],[object Object],[object Object]

Triángulo de la muerte ,[object Object],[object Object],COAGULOPATIA

Acidosis ,[object Object],[object Object],[object Object]

Respuesta al Shock y Anemia ,[object Object],[object Object],[object Object],[object Object]

Transfusiones de GR ,[object Object],Messmer K: Res Exp Med 1973 Messmer K: comunicacion personal 2005

CUANDO TRANSFUNDIR G.Rojos? ,[object Object],[object Object]

RESUCITACION ,[object Object],[object Object],[object Object]

Diagnostico y monitorización del sangrado ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hb: 7-9 mg/dl

Plaquetas ,[object Object],[object Object],[object Object]

CRIOPRECIPITADO ,[object Object],[object Object],[object Object]

PLASMA FRESCO ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

COAGULOPATIA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Coagulopatía ,[object Object],[object Object],[object Object],[object Object],[object Object]

EXAMENES BASICO ,[object Object],[object Object],[object Object],[object Object]

Modelo celular de coagulación INICIACIÓN Fibroblasto Plaqueta PROPAGACIÓN Protrombina IIa Plaqueta activada AMPLIFICACIÓN Trombina Va Xa IXa FT VIIa IX X Va V XIa vWF/VIII VIIIa XI Protrombina Xa Va IXa VIIIa XIa IX X

MODELO CELULAR ,[object Object],[object Object],[object Object]

rFVIIa ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

rFVIIa ,[object Object],[object Object],[object Object],[object Object],[object Object]

Diagnostico y monitorización del sangrado RECOMENDACIÓN 10 ,[object Object],[object Object],[object Object],Valores normales ≤ 2 mmol/l - 18 mg/dl

II. Diagnostico y monitorización del sangrado RECOMENDACIÓN 10 ,[object Object],[object Object],[object Object],[object Object],[object Object],Abrason D, Scalea TM, Hitchcock R, Trooskin SZ, Hery SM, Greenspan J: Lactate clearance and survival following injury. J Trauma 1993, 35:584-588.

II. Diagnostico y monitorización del sangrado RECOMENDACIÓN 11 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Davis JW, Parks SN, Kaups KL, Glanden HE, O´Donnell-Nicol S: Admission base deficit predicts transfusíon requeriments and risk of complications. J Trauma 1996, 41: 769-774

II. Diagnostico y monitorización del sangrado RECOMENDACIÓN 11 ,[object Object],[object Object],[object Object],Mikuslaschek A, Henry SM, Donovan R, Scalea TM: Serum lactate is not preicted by anion gap or base excess after trauma resuscitation. J Trauma 1996, 40: 218-222

CONSIDERACIONES GENERALES EN HDA NO VARICOSA

HDA NO VARICOSA SHOCK 2-3 Lt S.Cristaloides + Hemoderivados MORTALIDAD 2-10% MORTALIDAD 25-35% __________________________

HDA NO VARICOSA SHOCK 2-3 Lt S.Cristaloides + Hemoderivados MORTALIDAD 2-10% MORTALIDAD 25-35% __________________________ SHOCK

HDA NO VARICOSA SHOCK 2-3 Lt S.Cristaloides + Hemoderivados MORTALIDAD 2-10% MORTALIDAD 25-35% __________________________ SHOCK CIRUGIA

HDA NO VARICOSA SHOCK 2-3 Lt S.Cristaloides + Hemoderivados MORTALIDAD 2-10% MORTALIDAD 25-35% __________________________ SHOCK ESTABLE CIRUGIA ALTO RIESGO EDA

HDA NO VARICOSA SHOCK 2-3 Lt S.Cristaloides + Hemoderivados MORTALIDAD 2-10% MORTALIDAD 25-35% __________________________ SHOCK ESTABLE CIRUGIA ALTO RIESGO BAJO RIESGO EDA

ALTO RIESGO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

ALTO RIESGO ,[object Object],[object Object],[object Object],[object Object]

INFUSION DE INHIBIDOR BOMBA PROTONES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

BAJO RIESGO ,[object Object],[object Object],[object Object],MENOR DEL 2% RIESGO DE RESANGRAMIENTO

RECORDAR ,[object Object],[object Object],[object Object],[object Object]

TRATAR LA ENFERMEDAD ULCEROSA

SHOCK HIPOVOLEMICO EN MEDICINA INTERNA Dr.Luis Troncoso Castro

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