CHOQUE DE INSUFICIÊNCIA

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3 Emergência • Prof Gustavo Dias 
Definição 
4 Emergência • Prof Gustavo Dias 
Fisiopatologia 
5 Emergência • Prof Gustavo Dias 
Fisiopatologia 
PA = DC x RVP 
6 Emergência • Prof Gustavo Dias 
7 Emergência • Prof Gustavo Dias 
Estadiamento 
ℓ
8 Clínica Médica • Prof Gustavo Dias 
Classificação Quanto à Etiologia 
- Cardiogênico 
- Hipovolêmico 
- Circulatório (Séptico, Anafilático, Neurogênico) 
- Obstrutivo 
 
9 Clínica Médica • Prof Gustavo Dias 
Choque Hipovolêmico 
10 Clínica Médica • Prof Gustavo Dias 
Choque Hipovolêmico 
11 Clínica Médica • Prof Gustavo Dias 
Choque Hipovolêmico 
12 Clínica Médica • Prof Gustavo Dias 
Choque Hipovolêmico 
ℓ
13 Clínica Médica • Prof Gustavo Dias 
Choque Hipovolêmico 
ℓ
14 Clínica Médica • Prof Gustavo Dias 
Choque Cardiogênico 
15 Clínica Médica • Prof Gustavo Dias 
Choque Cardiogênico 
16 Clínica Médica • Prof Gustavo Dias 
Choque Cardiogênico Extrínseco ou Obstrutivo 
É definido como choque que ocorre em consequência a uma 
obstrução mecânica ao débito cardíaco. As causas mais 
comuns de choque obstrutivo incluem o Tamponamento 
Cardíaco, tromboembolismo Pulmonar e Pneumotórax 
hipertensivo. 
 
Atentar para Tríade de Beck nos casos de tamponamento 
cardíaco: hipotensão, aumento da PVC ou turgência jugular e 
bulhas cardíacas abafadas. 
17 Clínica Médica • Prof Gustavo Dias 
18 Clínica Médica • Prof Gustavo Dias 
Choque Cardiogênico 
19 Clínica Médica • Prof Gustavo Dias 
Choque Séptico (Brunner, 2015) 
Fase 1 = HIPERDINÂMICA 
-Aumento do DC 
-Vasodilatação 
-Pele quente e avermelhada 
-Taquicardia e taquipnéia 
 
Fase 2 = HIPODINÂMICA 
-Redução do DC 
-Vasoconstrição 
-Pele pálida, fria e úmida 
-Anúria e insuficiência múltipla de órgãos 
 
20 Clínica Médica • Prof Gustavo Dias 
Choque Séptico (ILAS, 2018) 
Sepse: Presença de disfunção ameaçadora à vida em decorrência da presença de 
resposta desregulada à infecção. 
 
As principais disfunções orgânicas são: 
• hipotensão(PAS<90mmHgouPAM<65mmHg ou queda de PA > 40 mmHg) 
• oligúria (≤0,5mL/Kg/h) ou elevação da creatinina (>2mg/dL); 
• relação PaO2/FiO2 < 300 ou necessidade de O2 para manter SpO2 > 90%; 
• contagem de plaquetas < 100.000/mm3 ou redução de 50% no número de 
• plaquetas em relação ao maior valor registrado nos últimos 3 dias; 
• lactato acima do valor de referência (hiperlactatemia); 
• rebaixamento do nível de consciência, agitação, delirium; 
• aumento significativo de bilirrubinas (>2X o valor de referência). 
21 Clínica Médica • Prof Gustavo Dias 
22 Clínica Médica • Prof Gustavo Dias 
Choque Séptico (2016) 
”Choque séptico passou a ser definido como 
presença de hipotensão com necessidade de 
vasopressores para manter pressão arterial média 
≥ 65mmHg associada a lactato ≥ 2mmol/L, após 
adequada ressuscitação volêmica (hiperlactatemia 
é um componente necessário, se disponível, para 
a definição de choque septico) 
23 Clínica Médica • Prof Gustavo Dias 
Choque Séptico (ILAS, 2018) 
INSTITUTO LATINO AMERICANO DE SEPSE 
Revisado em: agosto de 2018 
 
 
Tabela 1 – Conceitos utilizados pelo Instituto Latino Americano de Sepse 
na implementação de protocolos gerenciados de sepse. 
Classificação 
antiga 
Classificação atual 
(a ser usada) Característica 
Sepse Infecção sem disfunção 
Infecção suspeita ou 
confirmada, sem disfunção 
orgânica, de forma 
independente da presença de 
sinais de SRIS. 
Sepse grave Sepse 
Infecção suspeita ou 
confirmada associada a 
disfunção orgânica, de forma 
independente da presença de 
sinais de SRIS. 
Choque séptico Choque séptico 
Sepse que evoluiu com 
hipotensão não corrigida com 
reposição volêmica (PAM ≤65 
mmHg), de forma 
independente de alterações de 
lactato. 
 
 
 
3. Triagem e rotina para atendimento 
 
 O protocolo de sepse deve ser aberto para pacientes com SUSPEITA de 
sepse e choque séptico. Cada instituição irá decidir, de acordo com sua 
disponibilidade de recursos humanos e capacidade de triagem, se o protocolo 
de sepse será aberto na presença de SRIS e suspeita de infecção (elevada 
sensibilidade, permitindo tratamento precoce e prevenindo disfunção orgânica) 
ou a partir de presença de disfunção orgânica em pacientes com suspeita de 
infecção grave, priorizando nesse caso, o atendimento dos casos mais graves. 
 Recentemente, foi descrito o escore qSOFA4, com 3 componentes: 
rebaixamento de nível de consciência, frequência respiratoria ≥ 22 ipm e pressão 
arterial sistólica abaixo de 100 mmHg. Esse escore, ainda não prospectivamente 
24 Clínica Médica • Prof Gustavo Dias 
Sequential Organ Failure Assessment (SOFA) 
A variação aguda de 2 pontos ou mais no SOFA associada à infecção define o estado séptico. 
25 Clínica Médica • Prof Gustavo Dias 
Quick SOFA (ILAS, 2018) 
• Rebaixamento de nível de consciência 
• Frequência respiratoria ≥ 22 ipm 
• Pressão arterial sistólica abaixo de 100 mmHg. 
 
Trata-se de uma ferramenta apenas para triagem, que procura 
identificar pacientes graves, e que não deve ser utilizada para 
definição de sepse. 
O qSOFA fornece um alarme que significa “não perca tempo, 
se você ainda não fez nada, por favor aja agora com rapidez”. 
26 Clínica Médica • Prof Gustavo Dias 
27 Clínica Médica • Prof Gustavo Dias 
Choque Neurogênico 
28 Clínica Médica • Prof Gustavo Dias 
Choque Neurogênico 
Etiologia: 
 
__Lesões medulares 
__Trauma Raquimedular 
__Traumatismo Craniano 
__Anestesia regional 
__Lesão do sistema nervoso 
__Uso de drogas e ainda, estados de hipoglicemia 
__Efeito depressor de medicamento 
29 Clínica Médica • Prof Gustavo Dias 
Choque Neurogênico 
No choque neurogênico, o sistema simpático não é capaz de 
responder aos estressores corporais. Portanto, as características clínicas 
do choque neurogênico são os sinais de estimulação parassimpática: 
 
__Alerta, orientado e lúcido, porém sem reflexos 
__Arreflexia (paralisia) 
__Enchimento capilar - Normal 
__Coloração da pele - Rosada 
__Pele seca e quente em lugar de pele úmida e fria 
__Hipotensão 
__Bradicardia 
30 Clínica Médica • Prof Gustavo Dias 
Choque Anafilático 
Causa: Liberação de histamina pelos mastócitos 
Sinais característicos: 
-Queda abrupta da PA 
-Aumento da permeabilidade capilar => Edema 
-Rash cutâneo 
-Broncoespasmo, edema de glote => IRA 
-Prurido 
Tratamento: 
-Epinefrina (SC, IM ou IV) 
-Anti-histamínicos 
-Corticóide 
 
 
 
 
31 Clínica Médica • Prof Gustavo Dias 
 
(VÁRZEA GRANDE -2018) EM RELAÇÃO AO CHOQUE 
HIPOVOLÊMICO, ASSINALE A AFIRMATIVA CORRETA. 
(A) Ocorre diminuição da contratilidade cardíaca. 
(B) Ocorre redução da pós-carga e diminuição da Resistência 
Vascular Sistêmica (RVS). 
(C) Ocorre a redução da pré-carga e, consequentemente, da 
Pressão Venosa Central (PVC) e da Pressão Capilar Pulmonar em 
Cunha (PCPC). 
(D) Ocorre aumento do débito cardíaco. 
32 Clínica Médica • Prof Gustavo Dias 
O PRINCIPAL OBJETIVO DA FLUIDOTERAPIA É RESTAURAR A 
PERFUSÃO TECIDUAL. AS SOLUÇÕES DE PRIMEIRA ESCOLHA 
PARA REPOSIÇÃO VOLÊMICA SÃO 
(A) soluções cristaloides isotônicas. 
(B) coloides e Ringer Lactato. 
(C) soluções hipertônicas e hiperosmolares. 
(D) soluções hiperosmolares. 
(E) soluções glicosadas e coloides. 
33 Clínica Médica • Prof Gustavo Dias 
(CEPUERJ-UERJ-2013) OS PACIENTES CRÍTICOS PODEM 
APRESENTAR ALTERAÇÕES CLÍNICAS QUE RESULTAM NOS 
DENOMINADOS ESTADOS DE CHOQUE. INDEPENDENTE DA 
ETIOLOGIA DO ESTADO DE CHOQUE, ELES POSSUEM 
CARACTERÍSTICAS EM COMUM. SÃO ELAS: 
(A) hipoperfusão celular e hipocoagulabilidade 
(B) hiperperfusão celular e hipercoagulabilidade 
(C) hipocoagulabilidade, hiperperfusão celular e ativação da 
resposta inflamatória 
(D) hipercoagulabilidade, hipoperfusão celular e ativação da 
resposta inflamatória 
 
34 
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