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1. SHOCK

2. Introduction to shock
• Shock
• is a life-threatening medical condition or a medical emergency as
• happen as a result of inadequate blood flow throughout the body.
• can lead to other conditions such as hypoxemia, hypoxia, heart attack (cardiac arrest)
or organ damage.
• often accompanies severe injury or illness.
• Adequate blood flow to the tissues and cells requires
• adequate cardiac pump,
• effective vasculature or circulatory system, and
• sufficient blood volume.
• When one component is impaired, blood flow to the tissues is compromised.

3. Shock…..
• requires instant rapid Tx.
• Without Tx, inadequate blood flow to the tissues results in:
• poor delivery of oxygen & nutrients to the cells,
• cellular starvation,
• cell death,
• organ dysfunction progressing to organ failure, and
• eventual death.

4. Shock…..
•Stages of shock
• A convenient way to understand the physiologic responses &
subsequent clinical S & Sx is to divide the continuum into
separate stages:
• compensatory, progressive, and irreversible.

5. Shock…..
• Compensatory stage of shock:
• In this stage,
• BP remains within normal limits.
• Adequate CO is maintained by
the contribution of:
• Vasoconstriction,
• ↑ HR, and
• ↑ contractility of the heart.
• This results from:
• stimulation of the sympathetic
nervous system and
• subsequent release of
catecholamine (epi & norepi).
• The pt displays the often-described “fight or flight” response.
• The body shunts blood from organs such as the skin, kidneys, & GIT to
the brain & heart to ensure adequate blood supply to these vital organs.
• As a result, the pt’s skin is cold & clammy.
• Bowel sounds are hypoactive and urine output ↓ in response to the
release of aldosterone and ADH.

6. Shock…..
• Progressive stage of shock:
• In this stage,
• the mechanisms that regulate BP can no longer compensate and
• the MAP falls below normal limits, with an average sBP of <90 mmHg.
• Although all organ systems suffer from hypoperfusion at this stage, two events
propagate the shock syndrome.
• First, the overworked heart becomes dysfunctional and the body’s inability to
meet increased O2 demand that produces ischemia.
• The biochemical mediators results in myocardial depression.
• This leads to failure of the cardiac pump, even if the shock is not of cardiac
origin.
• Second, the auto regulatory function of the microcirculation fails in response
to numerous biochemical mediators released by the cells, resulting in
increased capillary permeability and thus return of less fluid to the heart.

7. Shock…..
• The irreversible (refractory) stage:
• represents the point along the shock continuum at which organ damage
is so severe that the pt does not respond to Tx and cannot survive.
• Despite Tx, BP remains low.
• Complete renal & liver failure
• release necrotic tissue toxins,
• creates an overwhelming metabolic acidosis.
• Anaerobic metabolism contributes to a worsening lactic acidosis.
• Reserves of ATP are almost totally depleted.
• Multiple organ dysfunction which may progress to complete organ
failure has occurred, and death is imminent.

8. Shock…..
Clinical findings in different stages of shock
Findings Compensator Progressive Irreversible
Blood pressure Normal Systolic<80–90 mmHg Requires mechanical or
pharmacologic support
Heart rate >100 beats/min >150 bpm Erratic or asystole
Respiratory status >20 breaths/min Rapid, shallow
respirations; crackles
Requires intubation
Skin Cold, clammy Mottled, petechiae Jaundice
Urinary output Decreased 0.5 mL/kg/hr Anuric, requires dialysis
Mentation Confusion Lethargy Unconscious
Acid–base balance Respiratory alkalosis Metabolic acidosis Profound acidosis

9. Shock…..
• Causes
• Heart conditions (heart attack, heart failure).
• Heavy internal/external bleeding, a serious injury or rupture of a blood
vessel.
• Fluid loss – DHN/hypovolemic shock
• Burns, Persistent vomiting or diarrhea.
• Infection – septic shock
• Severe allergic reactions – anaphylactic shock
• Brain and Spinal cord injuries – neurogenic shock

10. Shock…..
• Classification of Shock
• Based on etiology Shock can be classified into 4 classes:
A. Hypovolemic shock
• loss of blood volume (bleeding) or
• profound DHN (severe vomiting, diarrhea)
B. Cardiogenic shock
• impaired pumping ability of the heart
• Commonly occurs after a massive heart attack
C. Distributive shock
• a result of the lack of distribution/misdistribution of blood to the organs
• Septic shock
• Neurogenic shock results from the misdistribution of blood flow to the tissue that lead to great
inadequacies in tissue oxygenation, despite normal CO.
D. Obstructive shock
• results from an obstruction to blood flow at a site other than the heart
• Anaphlactic shock
• Tension pneumothorax
10

11. Shock…..
Anaphylactic shock
• It is a type of severe hypersensitivity or allergic Rxns.
• Triggers include allergy to insect stings, medicines, or foods (nuts, berries, sea
food) etc.
• Signs and Symptoms
• Skin rxns together with hives, itching, tingling mouth and flushed or pale skin.
• Swelling of the face, eyes, lips or tongue or throat,
• Swelling/tightness in throat
• Difficult/noisy breathing, difficulty talking/hoarse voice,
• Constriction of the airways, leading to wheezing and trouble breathing.
• wheeze or persistent cough,
• A weak and rapid pulse.
• Stomach pain, diarrhea, vomiting (in insect allergy).
• Persistent dizziness or collapse, Fainting/unconsciousness

12. Shock…..
Anaphylactic shock
• First Aid Measures & Emergency Care
• For insect allergy, flick out the sting if it can be seen.
• If breathing is difficult, allow to sit
• Stay with person and call for help
• Call Ambulance. If the victim is having DOB; or very unwell.
• Give the adrenaline auto injector if available.
• In the ambulance, oxygen should be administered.
• Contact parent/guardian or other emergency contact.
• Commence CPR at any time if person is unresponsive & not breathing
normally.
• If the rxns follows exposure to a chemical, wash the contact area
thoroughly with copious amounts of water.

13. Shock…..
Hypovolemic Shock
• severe blood or fluid loss
• Low cardiac output
• the heart pumps not enough blood to the body.
• This type of shock can cause many organs to stop working.
• Losing about 1/5th or more of the normal amount of blood from the body
• Blood loss can be due to bleeding from cuts, other injuries, internal bleeding,
such as in the GIT and Significant vaginal bleeding.
• The amount of circulating blood in the body may drop when we lose too many
other body fluids.
• burns, diarrhea, vomiting and excessive perspiration.

14. Shock…..
Hypovolemic Shock
• Signs & Symptoms
• Anxiety or agitation
• Cool, clammy skin
• Confusion
• Decreased or no urine output
• General weakness
• Low BP
• Low body temperature
• Pale skin color (pallor)
• Rapid breathing
• Sweating, moist skin
• Unconsciousness
• Rapid pulse, often weak and Thready

15. Shock…..
Hypovolemic Shock
• First Aid and Emergency Cares
• Get medical help right away. In the meantime, follow these steps:
• Keep the person comfortable and warm (to avoid hypothermia).
• Have the person lie flat with the feet lifted about 12 inches to increase circulation.
• However, if the person has a head, neck, back, or leg injury, do not change the person's
position unless they are in immediate danger.
• Do not give fluids by mouth.
• If the person must be carried, try to keep them flat, with the head down and feet lifted.
• Stabilize the head and neck before moving a person with a suspected spinal injury.
• Possible Complications
• Kidney damage, Heart attack, Brain damage
• Other organ damage
• Death

16. Shock…..
Cardiogenic Shock
• occurs when the heart has an impaired pumping ability.
• This may be of coronary or non-coronary event origin (severe hypoxemia, acidosis,
hypoglycemia, hypocalcaemia and tension pneumothorax).
• Causes
• The most common cause is heart attack (MI).
• This complication includes:
• A large section of heart muscle that no longer moves well or does not move at all.
• Breaking open (rupture) of the heart muscle due to damage from the heart attack.
• Dysrhythmias, such as Vtach, Vfib, or SVT; Bradycardia or heart block(AV block)
• Pericardial tamponade – Pressure on the heart due to a buildup of fluid around it.
• Tear or rupture of the muscles or tendons that support the mitral valve.
• Tear or rupture of the lower heart wall (septum) between ventricles.

17. Shock…..
Cardiogenic Shock
• Signs and Symptoms
• Chest pain or pressure
• Decreased urination
• Fast breathing and fast pulse
• Weak (Thready) pulse
• Heavy sweating, moist skin
• Lightheadedness
• Shortness of breath
• Low BP
• Coma
• Loss of alertness and ability to concentrate.
• Restlessness, agitation, confusion
• Skin that feels cool to the touch
• Pale skin color or blotchy skin

18. Shock…..
Cardiogenic Shock
• First aid measures and emergency cares
• Call for immediate medical help.
• Check ABC. If necessary, begin rescue breathing and CPR.
• Even if the victim is able to breathe on his or her own, continue to check rate of
breathing at least every 5 minutes until help arrives.
• If the victim is conscious and does not have an injury to the head, leg, neck, or
spine, place the person in the shock position.
• Lay the victim on the back and elevate the legs about 12 inches.
• If raising the legs will cause pain or potential harm, leave the person lying flat.
• Give appropriate first aid for any wounds, injuries, or illnesses.
• Keep the causality warm & comfortable.
• Loosen tight clothing.

19. Shock…..
Neurogenic shock
• occurs after damage to the CNS (brain & spinal cord)
• It is a type of distributive shock,
• results from the misdistribution of blood flow to the tissue that lead to great
inadequacies in tissue oxygenation, despite normal CO.
• is d/t from spinal shock, which pertains to loss of function due to spinal injury.
• typically affects the important nerves that compose of the autonomic nervous
system, which affects HR and other involuntary functions of the body.
• When there is injury to the nerves, the blood vessels walls begin to relax,
resulting to low BP and decreased HR.
• This may decrease the heart’s ability to adequately pump blood.
• Moreover, due to the decreased SVR, less oxygen-rich blood is delivered to the
organs.

20. Shock…..
Neurogenic shock
• Causes
• Damage or trauma to the brain or spinal cord
• Blunt injuries, such as car accidents, etc.
• Penetrating injuries, such as gunshot wounds, etc.
• Certain drugs that may affect the autonomic nervous system
• Improperly administered regional anesthesia

21. Shock…..
Neurogenic shock
• Signs and Symptoms
• Neurogenic shock and other types of distributive shock have a unique ch’c that
is only found in their type.
• This sign is the warm, dry skin, whereas in other types of shock, skin is usually
pale, cool and clammy.
• Additional S & Sx of neurogenic shock include:
• Low BP
• Bradycardia
• Weak pulse
• Victim may feel cold
• Little or no urine output
• Dizziness
• Confusion and anxiety

22. Shock…..
Neurogenic shock
• First Aid Measures and emergency care
• If an individual begins to show S/Sx of neurogenic shock, call for ambulance to take
to the nearest hospital.
• While waiting for ambulance, administer first aid cares to minimize any
complications.
• Immobilize the spine to avoid any further damage.
• Avoid moving the victim unless there is danger in the immediate environment.
• Check the victim’s ABC.
• If necessary, begin rescue breathing and CPR.
• Constantly check the RR Q5min even if the victim is capable of breathing on his or
her own.
• If there is vomiting or salivating, hold the person’s head, neck and back in a line and
roll the victim to the side as a unit and loosen any tight clothing.

23. Shock…..
Septic shock
• is a life-threatening condition that happens when BP drops to a
dangerously low level after an infection.
• At first the infection can lead to a reaction called sepsis.
• This begins with weakness, chills, and a rapid heart and breathing rate.
• Left untreated, toxins produced by bacteria can damage the small blood
vessels, causing them to leak fluid into the surrounding tissues.
• This can affect the heart's ability to pump blood to your organs, which
lowers the BP and means blood doesn't reach vital organs, such as the
brain and liver.

24. Shock…..
Septic shock
• Signs and Symptoms
• Low BP
• Change in mental state
• Diarrhea
• Nausea and vomiting
• Racing heart beat
• Lightheadedness and
• Difficulty catching breathes
• Chills and develop high fever
• Agitation and restlessness
• First Aid Measure and Emergency cares
• Call for an ambulance.
• Initial Tx includes
• support of respiratory & circulatory function,
• supplemental O2,
• mechanical ventilation, &
• volume infusion.
• If hypotension, start fluid therapy with
crystalloids, preferably N/S or LR’s solution.
• Complications of septic shock
• respiratory failure.
• heart failure.
• Kidney failure or injury.
• Abnormal blood clotting

25. SHOCK
• Even though the victim’s injuries would not otherwise be fatal, shock can
threaten the life of the victim.
• Causes
• Hemorrhage
• Severe vomiting and diarrhea.
• Burn
• Infection
• Heart attack or stroke
• Poisoning by chemicals gases, alcohol or drugs
• Other causes like stress, pain, temperature instability, and delay of Tx.
• And many other underlining causes

26. SHOCK
• Signs and Symptoms
• Pale or bluish skin and mucus membrane, cold extremities to touch.
• Moist and clammy skin.
• Weakness.
• Rapid and weak pulse but perceptible in the carotid artery
• Rapid and shallow breathing especially in case of abdominal and chest injury.
• Low BP.
• Restlessness, anxiety and severe thirst,
• Unconsciousness and hypothermia, finally death.
• Treatment Objectives
• To identify and treat the cause.
• To improve circulation.
• To ensure an adequate supply of oxygen
• To maintain normal body temperature.
• To transfer the patient to health facility immediately.

27. First Aid Measures
A. Body Position
• It must be based on type of injuries.
• The most satisfactory position for the injured person will be lying down to
improve the circulation of the body.
• If injury is on the neck or spine, don’t move the victim until he is prepared for
transportation.
• A victim with severe wounds of the lower part of the face and jaw or who is
unconscious should be placed on his side to facilitate drainage of fluids and to
avoid air way blockage.
• A person with a head injury may be kept flat or propped up but his head must not
be lower than the rest of his body.
• Raise foot of the stretcher or bed from 20-30 inches for other types of injuries.

28. 28

29. B. Regulating Body Temperature
• Keep the victim warm enough to avoid or overcome chilling.
• If the victim is exposed to cold, blankets or additional clothing should be
placed over and under him to prevent chilling.

30. C. Administering Fluids
• Give fluids by mouth if there is no medical help nearby; discontinue fluids if the victim
becomes nauseated or vomits.
• Don't give fluid by mouth if:-
• Victim is unconscious
• Victim is vomiting or about to vomit and having a convulsion.
• When a victim likely to have surgery or anesthetic or have brain or abdominal injury.
• When the victim is conscious give plenty of fluids prepared from
• half teaspoon of salt,
• two to three table spoon of sugar or honey and
• some orange or lemon juice in a litter of water.
• Encourage the victim to drink as often as possible especially until adequate urine
output.