[Controversies in the treatment of shock].

In last years there are still dilemmas about the starting of prompt resuscitation by volume restoring in haemorrhagic shock in penetrant, non-penetrant and vascular injuries. Will massive fluid administration before surgical control of bleeding, because of destroying the primary thromb, induce excessive bleeding and worse outcome, in regard to postponed resuscitation until the control of haemorrhage? What means that less fluid should be given, less than optimal, but in the quantity with which progressive circulatory shock will be avoided. According to some authors this should be followed in the treatment of non-penetrant injuries, what has been shown positive in animal models. There is also dilemma about the kind of fluid, crystalloids and what crystalloids, or colloids? Crystalloids are preferred, especially to Ringer lactat, except in the cases of traumatic brain injury when saline is better, because of mild hyperosmolarity. Hypertonic solutions 7.5% NaCl and 3% NaCl have advantages for prehospital resuscitation. As the advantages of colloids in regard to crystalloids were not proven, they should be used together with crystalloids, if the blood products are not available at the moment, and they should be given. It is considered that about 25% of overall colloid used is not justified. In the assessment of shock, i.e. tissue perfusion which is the most important parameter of shock, modern technologies measure systemic oxygenation SO2 as a balance of oxygen delivery DO2 and oxygen consumption DO2 and mixed venous blood PCO2. Noninvasive monitoring replaces invasive, and it can be even more precise and more accurate in parameter assessment. Sublingual capnography is new monitoring as indirect indicator of gut mucose perfusion and impedance monitoring which functions by means of measuring the changes of electrical impedance of thorax which are proportional to the pulse wave in aorta during systole and diastole.