This document discusses different types of shock, including their causes, signs and symptoms, and treatment approaches. It defines shock as a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism due to an imbalance between the supply and demand of oxygen and nutrients. The main types of shock covered are cardiogenic, hypovolemic, neurogenic, anaphylactic, and septic shock. For each type, the document details precipitating causes, physical exam findings, and collaborative care involving fluid resuscitation, vasopressor drugs, antibiotics, and other interventions to restore perfusion and prevent multiple organ dysfunction.

1. ShockArun M. Boban
Dharanidharan Jeyaseelan
W.P. Rivindu H. Wickramanayake
Tbilisi State Medical University, Georgia
3rd Year 2nd Semester – Group no. 04a
2017 November

2. Shock
 Syndrome characterized by decreased tissue perfusion and
impaired cellular metabolism.
 Imbalance between the supply and demand for O2 and
nutrients

3.  Low blood flow
- Cardiogenic
- Hypovolemic
 Mal-distribution of blood flow
- Septic
- Anaphylactic
- Neurogenic
Classification of shock

4. Low Blood Flow
Cardiogenic Shock
Definition
Systolic or diastolic dysfunction
Compromised cardiac output (CO)
Next ;

5. Continued ;
Precipitating causes
 Myocardial infarction
 Cardiomyopathy
 Blunt cardiac injury
 Severe systemic or pulmonary hypertension
 Cardiac tamponade
 Myocardial depression from metabolic problems
Next ;

6. Early manifestations
Tachycardia
Hypotension
Narrowed pulse pressure
↑ Myocardial O2 consumption
Next ;
Continued ;

7. Physical examination
 Tachypnea, pulmonary congestion
 Pallor; cool, clammy skin
 Decreased capillary refill time
 Anxiety, confusion, agitation
 ↑ in pulmonary artery wedge pressure
 Decreased renal perfusion and UO
Continued ;

8. Hypovolemic Shock
Absolute hypovolemia:
- Loss of intravascular fluid volume
 Hemorrhage
 GI loss (e.g., vomiting, diarrhea)
 Fistula drainage
 Diabetes insipidus
 Hyperglycemia
 Diuresis
Next ;

9. - Results when fluid volume moves out of
the vascular space into extravascular space
(e.g., interstitial or intra-cavitary space)
Termed third spacing
Relative hypovolemia
Next ;
Continued ;

10. Response to acute volume loss depends on
- Extent of injury or insult
- Age
- General state of health
- Anxiety
- Tachypnea
- Increase in CO, heart rate
- Decrease in stroke volume, PAWP, UO
If loss is >30%, blood volume is replaced
Clinical manifestations
Continued ;

11. Mal-distribution of Blood Flow
Neurogenic Shock
 Hemodynamic phenomenon that can occur
within 30 minutes of a spinal cord injury at
the fifth thoracic (T5) vertebra or above and
can last up to 6 weeks
 Can be in response to spinal anesthesia
 Results in massive vasodilation leading to
pooling of blood in vessels Next ;

12.  Hypotension
 Bradycardia
 Temperature dysregulation
(resulting in heat loss)
 Dry skin
 Poikilothermia (taking on the
temperature of the environment
Clinical manifestations
Continued ;

13. Anaphylactic Shock
 Massive vasodilation
 Release of mediators
 ↑ Capillary permeability
Acute, life-threatening hypersensitivity reaction
Next ;

14.  Anxiety, confusion, dizziness
 Sense of impeding doom
 Chest pain
 Incontinence
 Swelling of the lips and tongue, angioedema
 Wheezing, stridor
 Flushing, pruritus, urticarial
 Respiratory distress and circulatory failure
Clinical manifestations
Continued ;

15. Septic Shock
 Sepsis: Systemic inflammatory response to documented or
suspected infection
 Severe sepsis = Sepsis + Organ dysfunction
 Septic shock = Presence of sepsis with hypotension despite
fluid resuscitation + Presence of tissue perfusion abnormalities
 Mortality rates as high as 50%
 Primary causative organisms
- Gram-negative and gram-positive bacteria
- Endotoxin stimulates inflammatory response
Next ;

16. ↑ Coagulation and inflammation
↓ Fibrinolysis
Formation of microthrombi
Obstruction of microvasculature
Hyperdynamic state: Increased CO and
decreased SVR
Clinical manifestations
Next ;
Continued ;

17. Tachypnea/hyperventilation
Temperature dysregulation
↓ Urine output
Altered neurologic status
GI dysfunction
Respiratory failure is common
Continued ;

18. Stages of Shock
Initial Stage
 Usually not clinically apparent
 Metabolism changes from aerobic to anaerobic
- Lactic acid accumulates and must be
removed by blood and broken down by liver
- Process requires unavailable O2

19. Compensatory Stage
 Clinically apparent
- Neural
- Hormonal
- Biochemical compensatory mechanisms
 Attempts are aimed at overcoming consequences of
anaerobic metabolism and maintaining homeostasis
 Impaired GI motility
- Risk for paralytic ileus
 Cool, clammy skin from blood
- Except septic patient who is warm and flushed

20. Progressive Stage
 Begins when compensatory mechanisms fail
 Aggressive interventions to prevent multiple organ
dysfunction syndrome (MODS)
 Movement of fluid from pulmonary vasculature to
interstitium
 Pulmonary edema
 Bronchoconstriction
 ↓ Residual capacity
Next ;

21. Fluid moves into alveoli
 Edema
 Decreased surfactant
 Worsening V/Q mismatch
 Tachypnea
 Crackles
 Increased work of breathing
Next ;
Continued ;

22. Myocardial dysfunction results in
 Dysrhythmias
 Ischemia
 Myocardial infarction
End result: Complete deterioration of
cardiovascular system
Next ;
Continued ;

23.  Ulcers
 Bleeding
 Risk of translocation of bacteria
 Decreased ability to absorb nutrients
Mucosal barrier of GI system becomes ischemic
Next ;
Continued ;

24. Liver fails to metabolize drugs and wastes
 Jaundice
 Elevated enzymes
 Loss of immune function
 Risk for DIC and significant bleeding
Acute tubular necrosis/acute renal failure
Continued ;

25. Refractory Stage
 Exacerbation of anaerobic metabolism
 Accumulation of lactic acid
 ↑ Capillary permeability
 Profound hypotension and hypoxemia
 Tachycardia worsens
 Decreased coronary blood flow
 Cerebral ischemia
 Failure of one organ system affects others
 Recovery unlikely

26. Diagnostic Studies
 Thorough history and physical examination
 No single study to determine shock
 Blood studies
- Elevation of lactate
- Base deficit
 12-lead ECG
 Chest x-ray
 Hemodynamic monitoring

27. Collaborative Care
Cardiogenic Shock
Restore blood flow to the myocardium by restoring the balance
between O2 supply and demand
Thrombolytic therapy
Angioplasty with stenting
Emergency revascularization
Valve replacement
Hemodynamic monitoring
Drug therapy (e.g., diuretics to reduce preload)
Circulatory assist devices (e.g., intra-aortic balloon pump,
ventricular assist device)

28. Hypovolemic Shock
 Management focuses on stopping the loss of fluid and
restoring the circulating volume
 Fluid replacement is calculated using a 3:1 rule (3 ml of
isotonic crystalloid for every 1 ml of estimated blood loss)

29. Septic Shock
 Fluid replacement (e.g., 6 to 10 L of isotonic crystalloids
and 2 to 4 L of colloids) to restore perfusion
 Hemodynamic monitoring
 Vasopressor drug therapy; vasopressin for patients
refractory to vasopressor therapy
 Intravenous corticosteroids for patients who require
vasopressor therapy, despite fluid resuscitation, to maintain
adequate BP
Next ;

30.  Antibiotics after obtaining cultures
(e.g., blood, wound exudate, urine, stool, sputum)
 Drotrecogin alfa (Xigris)
- Major side effect: Bleeding
 Glucose levels <150 mg/dl
 Stress ulcer prophylaxis with histamine (H2)-receptor
blockers
 Deep vein thrombosis prophylaxis with low-dose
unfractionated heparin or low-molecular-weight heparin
Continued ;

31. Neurogenic Shock
In spinal cord injury: Spinal stability
 Treatment of the hypotension and bradycardia
with vasopressors and atropine
 Fluids used cautiously as hypotension is
generally not related to fluid loss
 Monitor for hypothermia

32. Anaphylactic Shock
 Epinephrine, diphenhydramine
 Maintaining a patent airway
 Nebulized bronchodilators
 Endotracheal intubation or cricothyroidotomy
may be necessary
 Aggressive fluid replacement
 Intravenous corticosteroids if significant
hypotension persists after 1 to 2 hours of
aggressive therapy

33. FIRST AID
 If you suspect a person is in shock, call 911.
Then immediately take the following steps:
 Lay the person down and elevate the legs and
feet slightly, unless you think this may cause
pain or further injury.
 Keep the person still and don't move him or her
unless necessary.
 Begin CPR if the person shows no signs of life,
such as breathing, coughing or movement. Next ;

34.  Loosen tight clothing and, if needed, cover
the person with a blanket to prevent chilling.
 Don't let the person eat or drink anything.
 If the person vomits or begins bleeding from
the mouth, turn him or her onto a side to
prevent choking, unless you suspect a spinal
injury
Continued ;