Types of Shock and Stages of Shock

SHOCKSHOCK
PresentsPresents
byby
S. VimalaS. Vimala

SHOCKSHOCK
DefinitionDefinition::
 Acute wide spread impaired tissueAcute wide spread impaired tissue
perfusionperfusion
 Circulatory collapse which leads toCirculatory collapse which leads to
hypoperfusion & hypoxiahypoperfusion & hypoxia
 Cellular, metabolic andCellular, metabolic and
hemodynamic disarrangementshemodynamic disarrangements
occuroccur

ShockShock
 Shock is defined as inadequateShock is defined as inadequate
perfusion to the tissues of the bodyperfusion to the tissues of the body
 The body isn’t getting enoughThe body isn’t getting enough
oxygen or nutrients to feed itself.oxygen or nutrients to feed itself.
 There are different types of shockThere are different types of shock
and though they are all similar, theyand though they are all similar, they
act upon the body in different ways.act upon the body in different ways.

Clinical Manifestations:Clinical Manifestations:
of Shockof Shock
 Differ according with the stageDiffer according with the stage
 Try to improve tissue perfusion:Try to improve tissue perfusion:
Depends on how much O2 isDepends on how much O2 is
availableavailable
 If it is transported to the tissuesIf it is transported to the tissues
 If they are able to use it.If they are able to use it.

Clinical Manifestations:Clinical Manifestations:
of Shockof Shock
This is affected by: Hb level,This is affected by: Hb level,
cardiac output and pulmonary gascardiac output and pulmonary gas
exchangeexchange
Hb and cardiac output are going toHb and cardiac output are going to
depend on the HR, preload,depend on the HR, preload,
afterload and contractilityafterload and contractility

How does it happen?How does it happen?
 Shock is a process that happens on aShock is a process that happens on a
cellular level.cellular level.
 Most forms of shock are caused byMost forms of shock are caused by
inadequate delivery, which meansinadequate delivery, which means
the body doesn’t have the adequatethe body doesn’t have the adequate
amounts of oxygen or nutrients itamounts of oxygen or nutrients it
needs to surviveneeds to survive

How does it happen?How does it happen?
 Some are caused bySome are caused by
inadequate utilization,inadequate utilization,
meaning the body has what itmeaning the body has what it
needs to survive, it justneeds to survive, it just
doesn’t know how to use it.doesn’t know how to use it.
 Shock, if not quicklyShock, if not quickly
recognized and rapidlyrecognized and rapidly
reversed, will be fatal.reversed, will be fatal.

ShockShock
 CausesCauses::
 Decrease volume or loss ofDecrease volume or loss of
intravascular volume (Hypovolemic)intravascular volume (Hypovolemic)
 Decrease cardiac output or ImpairedDecrease cardiac output or Impaired
myocardial function (Cardiogenic)myocardial function (Cardiogenic)
 Maldistribution of intravascularMaldistribution of intravascular
volume (Distributive)volume (Distributive)

Maldistribution of intravascularMaldistribution of intravascular
volume (Distributive)volume (Distributive)
 Severe antibody antigen reactionSevere antibody antigen reaction
(Anaphylactic)(Anaphylactic)
 Loss of sympathetic toneLoss of sympathetic tone
(Neurogenic)(Neurogenic)
 Microorganisms invading bodyMicroorganisms invading body
systems (Septic)systems (Septic)

The Four (4) Stages of ShockThe Four (4) Stages of Shock
 Initial StageInitial Stage:: ↓↓ cardiac output,cardiac output,
impaired tissue perfusion.impaired tissue perfusion.
As blood supply to tissuesAs blood supply to tissues ↓↓ 
aerobic metabolism for a shortaerobic metabolism for a short
periodperiod  anaerobic metabolism toanaerobic metabolism to
get some energyget some energy byproducts arebyproducts are
producedproduced acid lactic formationacid lactic formation 
cellular damagecellular damage

Initial StageInitial Stage
↓ COCO ↓↓
↓ ↓↓ ↓↓ ↓↓
Impaired tissue PerfusionImpaired tissue Perfusion
↓↓ ↓↓ ↓↓ ↓↓
Anaerobic MetabolismAnaerobic Metabolism
↓↓ ↓↓ ↓↓ ↓↓
Lactic acidemiaLactic acidemia
↓↓ ↓↓ ↓↓ ↓↓
Cellular damageCellular damage

STAGES OF SHOCKSTAGES OF SHOCK
Stage of CompensationStage of Compensation
 Stage of Compensation (sympatheticStage of Compensation (sympathetic
activatesactivates  cool, pupils dilated etc)cool, pupils dilated etc)
 Pathway:Pathway:
• Decreased cardiac output leads toDecreased cardiac output leads to
reflex sympathetic stimulationreflex sympathetic stimulation
causing increase HR and peripheralcausing increase HR and peripheral
vasoconstrictionvasoconstriction

STAGES OF SHOCKSTAGES OF SHOCK
Stage of CompensationStage of Compensation
 PathwayPathway
 BP rises and skin is cold and clammyBP rises and skin is cold and clammy
due to peripheral vasoconstrictiondue to peripheral vasoconstriction
 Urine output drops (oliguria) due toUrine output drops (oliguria) due to
renal artery vasoconstrictionrenal artery vasoconstriction

Stage Of CompensationStage Of Compensation
cont.cont.
 Compensatory StageCompensatory Stage: the body is: the body is
trying to improve the tissue perfusion.trying to improve the tissue perfusion.
The sympathetic NSThe sympathetic NS  Neural,Neural,
hormonal & chemical responses.hormonal & chemical responses.
 NeuralNeural::
 ↑↑ HR,HR, ↑↑ heart contractility, arterialheart contractility, arterial
and venous vasoconstrictionand venous vasoconstriction 
blood is going to be shunted toblood is going to be shunted to
the body organsthe body organs

cont.cont.
 HormonalHormonal::
 Renin responseRenin response  angiotensin IIangiotensin II 
AldosteroneAldosterone  ADH this is going toADH this is going to
retain H2O and Naretain H2O and Na
 Anterior pituitaryAnterior pituitary ↑↑ ACTHACTH 
adrenocortex is stimulatedadrenocortex is stimulated
glucocorticoidsglucocorticoids  ↑↑ glucoseglucose
 Adrenal medulla stimulationAdrenal medulla stimulation 
epinephrine & norepinephineepinephrine & norepinephine

cont.cont.
 ChemicallyChemically::
 Epinephrine causes an increase inEpinephrine causes an increase in
HR/Cardiac contractility andHR/Cardiac contractility and
therefore tissue perfusiontherefore tissue perfusion
 Norephrine causes arterialNorephrine causes arterial
vasocontriction and shunts bloodvasocontriction and shunts blood
away from non vital organs to vitalaway from non vital organs to vital
organs.organs.
 The response of the Pt is toThe response of the Pt is to
hyperventilatehyperventilate ∴∴ it tries to do is toit tries to do is to
neutralize the lactic acidosisneutralize the lactic acidosis

cont.cont.
NeurologicNeurologic
↓ ↓↓ ↓↓ ↓↓
Sympathetic ChemoreceptorsSympathetic Chemoreceptors
↓↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓↓
VasoconstrictionVasoconstriction ↑↑ HRHR ↑↑Rate/DepthRate/Depth
Contractility RespirationContractility Respiration
↓↓ ↓↓ ↓↓
Shunting ofShunting of ↑↑ COCO
BloodBlood ↓↓PaCo2PaCo2
TissueTissue
Perfusion RespiratoryPerfusion Respiratory
AlkalosisAlkalosis

cont.cont.
EndocrineEndocrine
↓↓ ↓↓ ↓↓ ↓↓
RAS ACTHRAS ACTH
↓↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓↓
VasoconstrictionVasoconstriction GlucorticoidGlucorticoid
Na+ and H2Na+ and H2 ↓↓ ↓↓
retentionretention ↑↑ SerumSerum
GlucoseGlucose

Stage of ProgressionStage of Progression
 Progressive StageProgressive Stage: the: the
compensatory mechanisms arecompensatory mechanisms are
starting to failstarting to fail
 Na & K pump and the cellularNa & K pump and the cellular
membranes failmembranes fail  cellular deathcellular death
(rupture) and then every system in the(rupture) and then every system in the
body is affectedbody is affected
 Cardiac: PtCardiac: Pt  ventricular failureventricular failure
 NeurologicallyNeurologically  cerebralcerebral
hypoperfusionhypoperfusion
 Thermoregulation failureThermoregulation failure

Stage of Progression cont.Stage of Progression cont.
 ComaComa
 PulmonaryPulmonary  Acute respiratory failureAcute respiratory failure
 Renal: ATN, renal vasoconstriction, renalRenal: ATN, renal vasoconstriction, renal
hypoperfusionhypoperfusion
 Disseminated Intravascular CoagulationDisseminated Intravascular Coagulation
(DIC)(DIC)
 GI: gram-negative bacteria enter into theGI: gram-negative bacteria enter into the
systemsystem
 Hepatic & pancreatic failureHepatic & pancreatic failure

Stage of Impaired PerfusionStage of Impaired Perfusion
(Progressive Shock)(Progressive Shock)
 Pathway:Pathway:
 Prolonged vasoconstriction causesProlonged vasoconstriction causes
irreversible ischemic injury. Adverseirreversible ischemic injury. Adverse
effects that occur as a direct consequenceeffects that occur as a direct consequence
of decreased perfusion:of decreased perfusion:
 Anaerobic metabolism of glucoseAnaerobic metabolism of glucose  lacticlactic
acidosisacidosis
 Cell necrosis as in ATNCell necrosis as in ATN  acute renalacute renal
failurefailure

Stage of Impaired PerfusionStage of Impaired Perfusion
(Progressive Shock)(Progressive Shock)
 Acute alveolar damageAcute alveolar damage  intra-alveolarintra-alveolar
edema, hemorrhage and formation of aedema, hemorrhage and formation of a
hyaline-fibrin membrane (Shock Lung)hyaline-fibrin membrane (Shock Lung)
ARDSARDS
 Anoxic necrosis of liverAnoxic necrosis of liver  Nutmeg LiverNutmeg Liver
 Ischemic necrosis of intestinesIschemic necrosis of intestines  releaserelease
of bacterial toxinsof bacterial toxins  worsening shockworsening shock

Stage of DecompensationStage of Decompensation
 Pathway:Pathway:
 Hypoxia and acidosisHypoxia and acidosis  failure of reflexfailure of reflex
(sympathetic) peripheral vasoconstriction(sympathetic) peripheral vasoconstriction
(vasodilation)(vasodilation)  progressive hypotensionprogressive hypotension
until perfusion of heart and brain reachuntil perfusion of heart and brain reach
critical levelscritical levels
 Prognosis for Shock depends upon causePrognosis for Shock depends upon cause
and stage at which treatment is begunand stage at which treatment is begun

Initial StageInitial Stage
↓ ↓↓ ↓↓ ↓↓
Compensatory StageCompensatory Stage
↓↓ ↓↓ ↓↓ ↓↓
Compensatory mechanism begin to failCompensatory mechanism begin to fail
↓↓ ↓↓ ↓↓ ↓↓
Some irreversible cellular damageSome irreversible cellular damage

 The shock cycle begins to perpetuateThe shock cycle begins to perpetuate
itselfitself
 BP and blood flow can not be maintainedBP and blood flow can not be maintained
 Anaerobic metabolism cannot sustainAnaerobic metabolism cannot sustain
cellular activitycellular activity
 Irreversible cellular damage occursIrreversible cellular damage occurs
 Organ dysfunction appearsOrgan dysfunction appears

Refractory StageRefractory Stage
 Refractory StageRefractory Stage: Irreversible: Irreversible
 MODSMODS multiple organmultiple organ
dysfunction syndromedysfunction syndrome
 RenalRenal  hepatichepatic  pulmonarypulmonary
 cardiaccardiac

Critical Care NursingCritical Care Nursing
 You live by the motto "to be right isYou live by the motto "to be right is
only half the battle, to convince theonly half the battle, to convince the
doctor is more difficult."doctor is more difficult."

Types of shock:Types of shock:
 HypovolemicHypovolemic:: Circulating or intravascularCirculating or intravascular
volume lossvolume loss
 HemmorhagicHemmorhagic
 CardiogenicCardiogenic: inability of the heart to pump: inability of the heart to pump
 DistributiveDistributive: maldistribution of circulating: maldistribution of circulating
blood volumeblood volume
 SepticSeptic
 AnaphylacticAnaphylactic
 Neurogenic: loss of sympathetic toneNeurogenic: loss of sympathetic tone

TYPES OF SHOCKTYPES OF SHOCK
 Hypovolemic – decreased volume inHypovolemic – decreased volume in
circulation due to:circulation due to:
Severe hemorrhageSevere hemorrhage
GI lossesGI losses
Losses secondary to wound ofLosses secondary to wound of
surgerysurgery
BurnsBurns

Hypovolemic ShockHypovolemic Shock
 This is fluid loss in theThis is fluid loss in the
intravascular space.intravascular space.
 It is the most common due to GIIt is the most common due to GI
bleeding, trauma.bleeding, trauma.
 Two types:Two types:
Absolute and RelativeAbsolute and Relative

 AbsoluteAbsolute: due to trauma, surgery: due to trauma, surgery
of GI system (esophageal varices).of GI system (esophageal varices).
 Blood, plasmaBlood, plasma ↑↑ lossloss
 External loss of fluidExternal loss of fluid

 RelativeRelative: rupture of spleen, arterial: rupture of spleen, arterial
dissection, sepsis, hyponatremia,dissection, sepsis, hyponatremia,
internal injuries that cause a shiftinternal injuries that cause a shift
from the intravascularfrom the intravascular 
extravascular compartmentsextravascular compartments
 Loss on intravascular integrityLoss on intravascular integrity
 ↑↑ capillary permeabilitycapillary permeability

 PathologyPathology:: ↓↓ of venous returnof venous return ∴∴ ↓↓
preload (stroke volume & cardiacpreload (stroke volume & cardiac
output) = Inadequate tissueoutput) = Inadequate tissue
perfusionperfusion
 Initially pt losses about a 15%,Initially pt losses about a 15%,
which is about 750 mlwhich is about 750 ml
 At 40% or greater::::: BIG TROUBLEAt 40% or greater::::: BIG TROUBLE

 During theDuring the compensatory stagecompensatory stage wewe
want to maintain cardiac outputwant to maintain cardiac output
 ↓↓ Cardiac output = tachycardia,Cardiac output = tachycardia,
pulse narrows,pulse narrows, ↑↑ diastolic pressure,diastolic pressure,
tachypneatachypnea
 ABGs reveal a respiratory alkalosis &ABGs reveal a respiratory alkalosis &
hypoxemiahypoxemia

 ↓↓ Urinary outputUrinary output
 Skin is pale, cool, delayed capillarySkin is pale, cool, delayed capillary
refillrefill
 Jugulars are collapse (flat)Jugulars are collapse (flat)
 Neurological: change in LOCNeurological: change in LOC

 In theIn the progressive stageprogressive stage we arewe are
going to see a 1500 – 2000 ml lossgoing to see a 1500 – 2000 ml loss
 ↑↑ HR, myocardial ischemiaHR, myocardial ischemia ∴∴somesome
arrhythmiasarrhythmias
 ABGsABGs  metabolic acidosismetabolic acidosis ∴∴ PCO2PCO2
↑↑, Bicarbonate, Bicarbonate ↓↓ and PaO2and PaO2 ↓↓

 PtPt  acute renal failure where BUNacute renal failure where BUN
and creatinineand creatinine ↑↑
 When the organs start failing we areWhen the organs start failing we are
going to see the pt becomesgoing to see the pt becomes
hypotensive probably we have tohypotensive probably we have to
administer dopamine, vasopressinadminister dopamine, vasopressin

 In theIn the RefactoryRefactory we are going towe are going to
seesee ↑↑ 2000 ml loss2000 ml loss
 Severe tachycardia and thenSevere tachycardia and then
bradycardiabradycardia
 ↓↓ Preload (right atrial pressure) RAPPreload (right atrial pressure) RAP
= CVP= CVP ↓↓
 ↓↓ Stroke volumeStroke volume ↓↓ tissue perfusiontissue perfusion
 ↑↑ AfterloadAfterload  ↑↑ SVR (systemicSVR (systemic
vascular resistance)vascular resistance)

 ManagementManagement
 Prevent and correct the fluid lossPrevent and correct the fluid loss
 Restore tissue perfusionRestore tissue perfusion
 2 peripheral accesses Large2 peripheral accesses Large
bore IV’sbore IV’s
 Triple lumen catheterTriple lumen catheter
(femoral or(femoral or
jugular))jugular))
 Administer appropriate fluidsAdminister appropriate fluids

 Hypovolemic ShockHypovolemic Shock is similar tois similar to
hemorrhagic shock.hemorrhagic shock.
 The difference is the patient is losingThe difference is the patient is losing
body fluid rather than blood.body fluid rather than blood.
 This body fluid is water and/orThis body fluid is water and/or
plasma.plasma.

 This thickens the blood making itThis thickens the blood making it
difficult for the heart to put outdifficult for the heart to put out
enough volume to meet the demandsenough volume to meet the demands
of the body.of the body.
 The most common causes ofThe most common causes of
hypovolemic shock are severehypovolemic shock are severe
dehydration and severe burns.dehydration and severe burns.

 Signs and symptoms are the same asSigns and symptoms are the same as
hemorrhagic shock, but include:hemorrhagic shock, but include:
 Collapsed veins in the extremities andCollapsed veins in the extremities and
neck,neck,
 Poor skin turgorPoor skin turgor
 Concentrated, dark, strong smelling urine.Concentrated, dark, strong smelling urine.

Hemorrhagic ShockHemorrhagic Shock
 Hemorrhagic ShockHemorrhagic Shock is whenis when
the body is losing bloodthe body is losing blood
volume.volume.
 When it loses this volume, theWhen it loses this volume, the
red blood cells which carry thered blood cells which carry the
oxygen are depletedoxygen are depleted

Hemmorhagic ShockHemmorhagic Shock
 The blood loss may be causedThe blood loss may be caused
from a traumatic source, andfrom a traumatic source, and
may be quite obvious becausemay be quite obvious because
there is a copious amount ofthere is a copious amount of
blood around the body;blood around the body;
 i.e. GSW’s , stab wounds,i.e. GSW’s , stab wounds,
large lacerations,large lacerations,
amputations,etc.amputations,etc.

 The traumatic source may also beThe traumatic source may also be
from blunt trauma where the injuryfrom blunt trauma where the injury
is an organ that has torn oris an organ that has torn or
ruptured.ruptured.
 This can be the result of being hitThis can be the result of being hit
with a blunt object like a baseballwith a blunt object like a baseball
bat, slamming into the steeringbat, slamming into the steering
wheel in a vehicle crash or fallingwheel in a vehicle crash or falling
any distance.any distance.

 The solid organs of the body areThe solid organs of the body are
the organs that usually tear orthe organs that usually tear or
rupture from an impact.rupture from an impact.
 The solid organs in the abdomenThe solid organs in the abdomen
are the liver and kidneys, spleenare the liver and kidneys, spleen
(LUQ, under the rib cage), and(LUQ, under the rib cage), and
appendix (RLQ).appendix (RLQ).

 With a blunt trauma injury, theWith a blunt trauma injury, the
patient is losing blood inside theirpatient is losing blood inside their
body.body.
 A person can bleed into three areasA person can bleed into three areas
of their body: the chest cavity, theof their body: the chest cavity, the
abdominal cavity, and into bothabdominal cavity, and into both
thighsthighs
 e.g. bilateral femure.g. bilateral femur
fractures.fractures.

 Hemmorhagic shock can also beHemmorhagic shock can also be
caused from an atraumatic bleedcaused from an atraumatic bleed
commonly caused from bleedingcommonly caused from bleeding
ulcers.ulcers.

 Signs and symptoms withSigns and symptoms with
hemorrhagic shock are what mosthemorrhagic shock are what most
people think of as shock:people think of as shock:
 low blood pressure (systolic belowlow blood pressure (systolic below
100),100),
 high pulse rate (above 120), andhigh pulse rate (above 120), and
 rapid respiratory rate (greater thanrapid respiratory rate (greater than
32),32),
 the skin will be pale or cyanotic,the skin will be pale or cyanotic,
cold and sweaty.cold and sweaty.

Cardiogenic ShockCardiogenic Shock

TYPES OF SHOCKTYPES OF SHOCK
 CardiogenicCardiogenic : A form of shock: A form of shock
resulting from the heart’s failureresulting from the heart’s failure
to inadequately pump blood.to inadequately pump blood.
 This results in inadequateThis results in inadequate
delivery of oxygenated blood todelivery of oxygenated blood to
the periphery, there tissuethe periphery, there tissue
perfusion is also inadequate.perfusion is also inadequate.

 Cardiogenic ShockCardiogenic Shock may resultmay result
from many different etiologies:from many different etiologies:
 Ventricular Ischemia caused byVentricular Ischemia caused by
Acute MIAcute MI
Open Heart SurgeryOpen Heart Surgery
***** These are the most***** These are the most
common ******common ******

 Structural DefectsStructural Defects
Papillary muscle rupturePapillary muscle rupture
CardiomyopathyCardiomyopathy
Pulmonary EmbolusPulmonary Embolus
 DysrhymthmiasDysrhymthmias
Affect normal circulationAffect normal circulation

 Signs and symptoms includeSigns and symptoms include
chest painschest pains
shortness of breath with increasedshortness of breath with increased
raterate
cool, clammy skincool, clammy skin
pale or cyanotic colorpale or cyanotic color

Coarse rales in the lungsCoarse rales in the lungs
Cardiac dysrhythmiasCardiac dysrhythmias
HypotensionHypotension
tachycardiatachycardia

↓↓ CO/CICO/CI
↑↑ PA and PAWPPA and PAWP
↑↑ SVRSVR
↑ Cardiac EnzymesCardiac Enzymes
↓↓UOUO

Ineffective
Pumping
of Blood
Failure toFailure to
eject bloodeject blood
fromfrom
ventriclesventricles
↓↓
IncreasedIncreased
PulmonaryPulmonary
PressuresPressures
↓↓
PulmonaryPulmonary
CongestionCongestion
↓↓
HypoxemiaHypoxemiaInadequate tissue
perfusion
↓
S
V
↓
C
O
Pathophysiology

 Treat Underlying cause:Treat Underlying cause:
Thrombolytics,angioplasty,Thrombolytics,angioplasty,
surgery,antiarrhythmics,electricalsurgery,antiarrhythmics,electrical
therapytherapy
 ↑↑ Pumping effectivenessPumping effectiveness
Vasodilators, diurectics, inotropes,Vasodilators, diurectics, inotropes,
mechanical devicesmechanical devices

 Improve tissue perfusion O2, activityImprove tissue perfusion O2, activity
restriction,analgesics, sedativesrestriction,analgesics, sedatives
 Monitor hemodynamics, enzymes,Monitor hemodynamics, enzymes,
electrolytes, I&O, ABG’s, ECGelectrolytes, I&O, ABG’s, ECG

(Distributive shock)(Distributive shock)
Anaphylactic ShockAnaphylactic Shock
 Severe hypersensitive reactionSevere hypersensitive reaction
which leads to (antigen –which leads to (antigen –
antibody) response.antibody) response. ∴∴
 ↓↓ Tissue perfusion and shockTissue perfusion and shock
syndrome occurs as asyndrome occurs as a
consequenceconsequence

Distributive ShockDistributive Shock
 Risk factorsRisk factors
 Food allergiesFood allergies
 InsulinInsulin
 VaccinesVaccines
 DrugsDrugs
 Venoms (snakes, spiders etc)Venoms (snakes, spiders etc)
 Blood transfusionsBlood transfusions
 Environmental agentsEnvironmental agents
 LatexLatex

 It is an Ig E or non Ig E mediatedIt is an Ig E or non Ig E mediated
responseresponse
 ↑↑ Capillary permeabilityCapillary permeability
 BronchoconstrictionBronchoconstriction
 Excessive mucous productionExcessive mucous production
 Coronary vasoconstrictionCoronary vasoconstriction
 InflammationInflammation
 Cutaneous skin reactionsCutaneous skin reactions
 Constriction of intestinal wall, bladder &Constriction of intestinal wall, bladder &
uterusuterus

Exposure
Antigen –
Antibody
response Increased
Capillary
Permeability↓ Circulating
volume
↓
Decrease CO
↓
Inadequate
Tissue perfusion
Vasodilation
Pathophysiology

 Treatment:Treatment:
 Maintain adequate airwayMaintain adequate airway
Consider mechanical ventilationConsider mechanical ventilation
 CirculationCirculation
 insert large bore IV –give fluidsinsert large bore IV –give fluids
 Medications-Medications-
epinephrine, antihistamines,epinephrine, antihistamines,
bronchodilators, steroidsbronchodilators, steroids
 Educate patientEducate patient

 It starts 15 – 30 minutes withIt starts 15 – 30 minutes with
generalized itching, redness andgeneralized itching, redness and
angioedema.angioedema.
 Give epinephrineGive epinephrine  most prominentmost prominent
actions are on the heart, producing aactions are on the heart, producing a
rapid rise in blood pressure, increasedrapid rise in blood pressure, increased
strength of ventricular contraction,strength of ventricular contraction,
increase in the heart rate, andincrease in the heart rate, and
constriction of the arterioles in the skinconstriction of the arterioles in the skin
and mucosa.and mucosa.

 Epinephrine relaxes the smoothEpinephrine relaxes the smooth
muscles of the bronchi.muscles of the bronchi.
 It elevates the blood sugar level byIt elevates the blood sugar level by
increasing hydrolysis of glycogen toincreasing hydrolysis of glycogen to
glucose in the liver, and at the sameglucose in the liver, and at the same
time begins the breakdown of lipidstime begins the breakdown of lipids
in fat cells.in fat cells.
 Epinephrine has a suppressive effectEpinephrine has a suppressive effect
on the adaptive immune system.on the adaptive immune system.

 EpinephrineEpinephrine
 It is the drug of choice inIt is the drug of choice in
anaphylaxis.anaphylaxis.
 Dose: 0.1 mg/Kg of a 1:10000 dose,Dose: 0.1 mg/Kg of a 1:10000 dose,
usually given IV in 3 – 5 minutesusually given IV in 3 – 5 minutes
push.push.
 If pt is intubated we can put it downIf pt is intubated we can put it down
the tube.the tube.

Neurogenic ShockNeurogenic Shock
 Neurogenic – rare occurrenceNeurogenic – rare occurrence
resulting from loss sympathetic toneresulting from loss sympathetic tone
and is caused by an injury of theand is caused by an injury of the
spinal cord above T6.spinal cord above T6.
 Loss or suppression of sympatheticLoss or suppression of sympathetic
tone, the onset is between minutestone, the onset is between minutes
but can last for days, weeks orbut can last for days, weeks or
months, depending on the causemonths, depending on the cause

 S/SS/S
 ↓↓ BPBP
 BradycardiaBradycardia
 Skin warm & drySkin warm & dry
 Determine the cause to treat itDetermine the cause to treat it

 Signs and symptoms:Signs and symptoms:
 low blood pressure,low blood pressure,
 increased respiratory rate,increased respiratory rate,
 diaphragmatic breathingdiaphragmatic breathing
(quadriplegia (total loss of sensation(quadriplegia (total loss of sensation
and movement from the neckand movement from the neck
down).down).
 Rarely is neurogenic shockRarely is neurogenic shock
reversible.reversible.

 Risk FactorsRisk Factors
 Spinal cord injuries above the levelSpinal cord injuries above the level
of T6of T6
 Spinal anestheticSpinal anesthetic
 Emotional stressEmotional stress
 Pts with intractable painPts with intractable pain
 Pts with CN system dysfunctionPts with CN system dysfunction

 PathologyPathology
 When we loss sympathetic tone weWhen we loss sympathetic tone we
have:have:
 Massive peripheral dilatationMassive peripheral dilatation
 Impaired thermal regulationImpaired thermal regulation

 Arterial and venous vasodilatationArterial and venous vasodilatation
 ↓↓ Venous returnVenous return ∴∴ ↓↓ preloadpreload  ↓↓
CVPCVP
 ↓↓ Arterial returnArterial return ∴∴ ↓↓ afterloadafterload  ↓↓
BPBP ∴∴
 ↓↓ SVR systemic vascular resistanceSVR systemic vascular resistance

Loss of
sympathetic
tone
Loss of
thermoregulation
Massive
Vasodilation
↓ CO
Inadequate
Tissue
Perfusion
Bradycardia
Pathophysiology

Septic ShockSeptic Shock
 Septic Shock – Secondary toSeptic Shock – Secondary to
gram negative sepsis due togram negative sepsis due to
endotoxemia causing directendotoxemia causing direct
toxic vessel injurytoxic vessel injury
 Pathway:Vasodilatation leadsPathway:Vasodilatation leads
to peripheral pooling andto peripheral pooling and
relative hypovolemia andrelative hypovolemia and
decreased perfusiondecreased perfusion

 Septic ShockSeptic Shock is when an infectionis when an infection
has invaded the body and causes thehas invaded the body and causes the
cells to be unable to utilize oxygencells to be unable to utilize oxygen
and nutrients.and nutrients.
 Often intense intravenous antibioticOften intense intravenous antibiotic
therapy is required and even thentherapy is required and even then
may not be effective.may not be effective.

PathologyPathology
 Gram-negatives release endotoxinsGram-negatives release endotoxins
from their cell membrane as they lysefrom their cell membrane as they lyse
and die. Gram-positive bacteria releaseand die. Gram-positive bacteria release
exotoxins throughout their life span.exotoxins throughout their life span.
 These toxins trigger the release ofThese toxins trigger the release of
cytokines (proteins release by cells tocytokines (proteins release by cells to
signal other cells) such as tumorsignal other cells) such as tumor
necrosis factor and the interleukins.necrosis factor and the interleukins.
 They also activate phagocytic cells asThey also activate phagocytic cells as
the macrophages.the macrophages.

PathologyPathology
 Microorganism invades the CNS &Microorganism invades the CNS &
endocrinal systemendocrinal system
 Sympathetic nervous system is stimulatedSympathetic nervous system is stimulated
and release ACTH (epinephrine &and release ACTH (epinephrine &
norepinephine, glucocorticoids,norepinephine, glucocorticoids,
aldosterone, glucagons and renin)aldosterone, glucagons and renin)  afterafter
releaserelease  hypermetabolic statehypermetabolic state  massivemassive
peripheral dilatation, form of microemboli,peripheral dilatation, form of microemboli,
selective vasoconstriction &selective vasoconstriction & ↑↑ capillarycapillary
membranemembrane ∴∴ ↓↓ tissue perfusion,tissue perfusion, ↓↓ cellularcellular
perfusionperfusion  acid lactic as a result ofacid lactic as a result of
metabolic metabolismmetabolic metabolism

PathologyPathology
 These complex chemical reactionsThese complex chemical reactions
lead to multiple system effectslead to multiple system effects 
MODSMODS
 Microorganism invasionMicroorganism invasion 
inflammatory immune responseinflammatory immune response 
endothelium damageendothelium damage cellularcellular
hypoxiahypoxia

 Most frequentMost frequent
 Maldistribution of blood flow (someMaldistribution of blood flow (some
areasareas ↓↓ perfusion and on othersperfusion and on others ↑↑
the perfusion)the perfusion)
 Increased blood will occur to theIncreased blood will occur to the
heart, brain, liver and adrenalheart, brain, liver and adrenal
glands.glands.
 At the same time there’ll be aAt the same time there’ll be a
decrease in blood to the skin, lungs,decrease in blood to the skin, lungs,
kidneys and viscera.kidneys and viscera.

 It is a sepsis-induced shock withIt is a sepsis-induced shock with
hypotension despite adequate fluidhypotension despite adequate fluid
replacement that producereplacement that produce
• Mortality rate > 45% depending on theMortality rate > 45% depending on the
population agepopulation age
 Primary source is gram-negative &Primary source is gram-negative &
positive bacteria , aerobes andpositive bacteria , aerobes and
anaerobes, fungi or viral.anaerobes, fungi or viral.
 Gram-negatives are more frequentGram-negatives are more frequent

 Risk FactorsRisk Factors
 DiabetesDiabetes
 MalnutritionMalnutrition
 Alcohol abuseAlcohol abuse
 CirrhosisCirrhosis
 Respiratory infectionsRespiratory infections
 HemorrhageHemorrhage
 CancerCancer
 SurgerySurgery

 Risk FactorsRisk Factors
 Traumatic injuries with peritonealTraumatic injuries with peritoneal
contaminationcontamination
 BurnsBurns
 Prolonged IV cannulationProlonged IV cannulation
 AbscessesAbscesses
 Multiple blood transfusionsMultiple blood transfusions

 2 types: Exogenous and2 types: Exogenous and
EndogenousEndogenous
 ExogenousExogenous (hospitals)(hospitals)
 EndogenousEndogenous (skin, GI track,(skin, GI track,
respiratory & GU, catheters, EGT,respiratory & GU, catheters, EGT,
ETT)ETT)

 Intrinsically: age of pt andIntrinsically: age of pt and
comorbiditiescomorbidities
 Extrinsically: Drug therapy, fluidExtrinsically: Drug therapy, fluid
therapy and surgerytherapy and surgery
 Similar to toxic shock syndromeSimilar to toxic shock syndrome
(tampons(tampons  gram-positives causedgram-positives caused
by staphylococcus aureus)by staphylococcus aureus)

 Venous system dilateVenous system dilate  ↓↓ preloadpreload
both in right and left ventriclesboth in right and left ventricles ∴∴
 ↓↓ RVPRVP
 ↓↓ afterload,afterload, ↓↓ SVR,SVR, ↓↓ BPBP

 Signs and symptoms include: inSigns and symptoms include: in
early stages, high blood pressure,early stages, high blood pressure,
high pulse rate and high respiratoryhigh pulse rate and high respiratory
rate, fever, chills, and sweats.rate, fever, chills, and sweats.
 In late stages, the opposite, lowIn late stages, the opposite, low
blood pressure, low pulse rate, lowblood pressure, low pulse rate, low
respiratory rate and low bodyrespiratory rate and low body
temperature.temperature.

Three StagesThree Stages
have been identifiedhave been identified
 EarlyEarly
 HyperdynamicHyperdynamic
 Compensated stage:Compensated stage:

StagesStages
 EarlyEarly
 TachycardiaTachycardia
 ↑↑ Cardiac indexCardiac index
 Skin warm and flushedSkin warm and flushed
 Normal BPNormal BP

StagesStages
 Hyperdynamic stageHyperdynamic stage
 As shock progressesAs shock progresses
 Diastolic BPDiastolic BP ↓↓
 Pulse widensPulse widens
 Peripheral pulses are boundingPeripheral pulses are bounding
 Temperature can be normal,Temperature can be normal,
elevated or below normalelevated or below normal

StagesStages
 Late Hyperdynamic, uncompensatedLate Hyperdynamic, uncompensated
 Widespread organ dysfunction beginsWidespread organ dysfunction begins
to occurto occur
 BPBP ↓↓  hypotensionhypotension
 ↑↑ Peripheral edema is more evidentPeripheral edema is more evident
 Labored TachypneaLabored Tachypnea
 CracklesCrackles ∴∴ pulmonary interstitialpulmonary interstitial
edemaedema
 Sputum copious, pink and frothySputum copious, pink and frothy

StagesStages
 Late septic shockLate septic shock
 BPBP ↓↓ 90 mmHg90 mmHg
 Cold extremitiesCold extremities
 MODSMODS
 ↓↓ Urinary outputUrinary output
 Abdominal distentionAbdominal distention
 Absence of BSAbsence of BS
 Bleeding from invasive linesBleeding from invasive lines 
Disseminated intravascularDisseminated intravascular
coagulation (DIC)coagulation (DIC)

StagesStages
 Late septic shockLate septic shock
 MODSMODS
 PetechiaePetechiae
 Cardiac dysrhythmiasCardiac dysrhythmias
 ABGs:you will see hypoxemia,ABGs:you will see hypoxemia,
hypercapniahypercapnia
 Metabolic acidosis (Lactic acidosis)Metabolic acidosis (Lactic acidosis)
 COMACOMA

StagesStages
 Shift to left of WBC (later)Shift to left of WBC (later)
 ↑↑ of glucose and the pt develops anof glucose and the pt develops an
insulin resistanceinsulin resistance
 Obtain blood cultures right away,Obtain blood cultures right away,
then initiate broad-spectrumthen initiate broad-spectrum
antibiotics, when results of theantibiotics, when results of the
cultures return adjust the antibiotics.cultures return adjust the antibiotics.

TreatmentTreatment
 Triple antibioticsTriple antibiotics
 Without the right antibioticWithout the right antibiotic ↑↑
endotoxinsendotoxins ∴∴ aggravates the caseaggravates the case
 Drugs:Drugs:
 Vasoconstrictors (dopamine orVasoconstrictors (dopamine or
norepinephrine (Levophed))norepinephrine (Levophed))
 Platelet aggregated antagonistPlatelet aggregated antagonist
((Aspirin and NSAIDs *non-steroidal anti-Aspirin and NSAIDs *non-steroidal anti-
inflammatory drugs):inflammatory drugs):
 Steroids shownSteroids shown nono benefitbenefit

Shock SyndromesShock Syndromes
 1. True or False: Regardless of the1. True or False: Regardless of the
cause, Shock means inadequatecause, Shock means inadequate
tissue perfusion.tissue perfusion.

 List down the complication of shockList down the complication of shock

Types of Shock and Stages of Shock

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Types of Shock and Stages of Shock

Similar to Types of Shock and Stages of Shock (20)

More from chettinad college of nursing

More from chettinad college of nursing (20)

Recently uploaded

Recently uploaded (20)

Types of Shock and Stages of Shock