Shock is a life-threatening condition where tissues do not receive enough oxygen due to reduced blood flow. If untreated, shock progresses through stages from initial compensation to irreversible organ failure. The main types of shock are hypovolemic, cardiogenic, distributive, and obstructive. Management involves treating the underlying cause, restoring circulating volume with fluids, and providing supportive care like oxygen therapy. Nurses play an important role in monitoring for shock progression and supporting medical management.

1. Shock
Mr.Aby Thankachan,
M.Sc(N),PGDSH
Senior Nursing Tutor

2. DEFINITION
2
1. Shock can be best be defined as a condition
in which tissue perfusion is inadequate to
deliver oxygen and nutrients to support vital
organs and cellular function.
2. Shock is a syndrome characterized by
decreased tissue perfusion and impaired
cellular metabolism. This results in an
imbalance between the supply of and
demand for oxygen and nutrients.

3. Contd….
3
3.Shock is a condition where the
tissues in the body do not receive
enough oxygen and to allow cells to
function.
4.Shock is defined as failure of the
circulatory system to maintain
adequate perfusion to vital organs.

4. It’s critical and life threatening
medical emergency / complex syndrome
results from acute, generalized, inadequate
perfusion involving reduction in blood flow to
the tissues below that needed level to deliver
the oxygen and nutrition for normal tissue
function leading to dysfunction of organs and
cells.

5. PATHOPHYSIOLOGY
If untreated shock progress
through three stages.
Inadequate management
allows shock to progressively
worsen passing through
these stages until death
occurs.

6. STAGES OF SHOCK
 Initial Stage
 Compensatory Stage
 Progressive Stage
 Irreversible Stage

7. INITIAL STAGE
Initially, the body compensates
with the onset of shock.
No changes are noted clinically.
Changes are beginning to occur
on the cellular level.

8. COMPENSATORY STAGE
Activation of SNS - activation of epinephrine
and nor epinephrine.
Vasoconstriction, increased heart rate, and
increased contractility of the heart contribute
to maintaining adequate cardiac output.
Kidneys release renin into blood
formation of angiotensin & release of
aldosterone, ADH

9. Decreased CO
SNS stimulation
Epinephrine &
nor epinephrine
released
Vasoconstriction
Increased SVR
Renin secreted by
kidney
Angiotension
Aldosterone
ADH
Increase blood volume
hydrostatic pressure
fluid pulled into
capillary
Blood Pressure Maintained

10. CLINICAL
MANIFESTATIONS
10
Normal B.P
Increased respiratory rate
Skin- cold & clammy
Hypoactive bowel sounds
Decreased urine output
Mental status changes- confusion

11. MANAGEMENT
11
•
•
•
•
•
MEDICAL MANGEMENT
Fluid replacement
Medication therapy
NURSING MANAGEMENT
Monitoring tissue perfusion
Reducing anxiety
Promoting safety

12. PROGRESSIVE STAGE
Vicious circle of compensation
eventually leads to decompensation.
Mean arterial pressure starts to fall -
SBP below 90.

13. CLINICAL FEATURES
RESPIRATORY:
o rapid & shallow
o Crackles
o Decreased arterial oxygen
o Increased CO2
o Pulmonary edema
o Interstitial inflammation & fibrosis
o ARDS 47

14. CARDIOVASCULAR:
Dysrhythmias
Ischemia
14
o
o
o
o
o
o
o
o
Rapid HR- > 150 bpm
Chest pain
Rised cardiac enzyme levels
NEUROLOGIC
Mental status changes-Confusion
Lethargy
Dilated pupils, sluggish reaction to light

15. RENAL EFFECTS
o Acute renal failure
HEPATIC EFFECTS
o susceptible to Infection
o Elevated liver enzymes& bilirubin
levels
15

16. GI EFFECTS
o Stress ulcer
o Bloody diarrhea
o Bacterial toxin translocation
HEMATOLOGIC EFFECTS
o DIC
16

17. MEDICAL MANAGEMENT
17
IV FLUIDS& MEDICATIONS
Early enteral support
Antacids, histamine-2 blockers, or
anti-peptic agents.

18. NURSING MANAGEMENT
Preventing complications
Promoting rest and comfort
Supporting family members
18

19. IRREVERSIBLE STAGE
19
Severe organ damage
Low B.P
Complete renal and liver failure
Multiple organ dysfunction
progressing to complete organ
failure has occurred, and death is
imminent.

20. MANAGEMENT
20
MEDICAL
 Same as progressive stage
 Antibiotic agents & immunomodulation
therapy
NURSING
 Offering brief explanations to the patient
 Provide opportunities for the family to
see, touch, and talk to the patient.

21. OVERALL MANAGEMENT
IN SHOCK
21
Fluid replacement
Vasoactive medications
Nutritional support

22. TYPES OF SHOCK
Hypovolemic Shock
Cardiogenic Shock
Distributive Shock
–Neurogenic shock
–Septic shock
–Anaphylactic shock
Obstructive shock

23. Most common type of shock
–Decreased intravascular volume
• Primary cause = loss of blood or
body fluids from an internal or
external source
23
HYPOVOLEMIC SHOCK
Scalp laceration 3rd degree/full thickness burn

24. CONTD…
• INTERNAL: Hemorrhage, severe
burns, severe dehydration
• EXTERNAL: Trauma, Surgery,
Vomiting, Diarrhoea, Diuresis,
Diabetes insipidus
24

25. CLINICAL FEATURES
25
A rapid, weak, thready pulse
Cool, clammy skin
Rapid and shallow breathing
Hypothermia
Thirst and dry mouth
Cold and mottled skin (Livedo
reticularis)

26. MANAGEMENT
26
MEDICAL
 Treatment of the underlying cause
-
- Fluid & blood replacement
Redistribution of fluid by positioning
 Pharmacologic therapy
NURSING
o Administering blood & fluids safely
o oxygen

27. CARDIOGENIC SHOCK
PATHOPHYSIOLOGY
Decreased cardiac contractility
Decreased stroke volume and
cardiac output
Pulmonary congestion, Decreased
systemic tissue perfusion,
Decreased coronary artery perfusion
61

28. MANAGEMENT
MEDICAL
 Correction of underlying causes
 Initiation of first-line treatment
•
•
• Supplying supplemental oxygen
Controlling chest pain
Providing selected fluid support
62

29. CONTD…
•
•
•
Administering vasoactive
medications
Controlling heart rate with
medication or by implementation of
a transthoracic or intravenous
pacemaker
Implementing mechanical cardiac
support 63

30. NURSING
 Preventing cardiogenic shock.
 Monitoring hemodynamic status.
 Administering medications and
intravenous fluids.
 Maintaining intra-aortic balloon
counter pulsation.
64

31. Circulatory or distributive shock –
abnormal displacement of blood
volume in the vasculature.
65
DISTRIBUTIVE SHOCK
Urticaria/anaphylaxis Meningococcic sepsis

32. TYPES
1.Septic shock
2. Neurogenic shock
3. Anaphylactic shock
66

33. RISK FACTORS
Septic shock- immuno suppression,
extremes of age, malnourishment,
chronic illness, invasive procedures.
Neurogenic shock – spinal cord
injury, spinal anesthesia, depressant
action of medications, glucose
deficiency.
Anaphylactic shock- penicillin
sensitivity, transfusion reaction.bee
sting allergy, latex sensitivity. 67

34. SEPTIC SHOCK
Caused by widespread infection.
Vasodilation
Maldistribution of blood volume
Decreased venous return
Decreased stroke volume
Decreased cardiac output
Decreased tissue perfusion
34

35. MANAGEMENT
35
•
•
•
•
MEDICAL
identifying and eliminating the
cause of infection.
Fluid replacement.
PHARMACOLOGIC THERAPY
Antibiotic sensitivity.
3rdgeneration cephalosporin +
amino glycoside

36. NUTRITIONAL THERAPY
70
serum albumin.
•
•
•
•
•
•
Nutritional supplementation - within
the first 24 hours .
Enteral feedings
NURSING MANAGEMENT
Follow aseptic technique.
Monitor for signs of infection.
Monitor hemodynamic status, fluid
intake& output& nutritional status.
Daily weight & close monitoring of

37. NEUROGENIC SHOCK
71
vasodilation occurs as a result of a
loss of sympathetic tone.
may have a prolonged course
(spinal cord injury) or a short one
(syncope or fainting)
Dry, warm skin & bradycardia.

38. MANAGEMENT
MEDICAL
1. Restoring sympathetic tone through
stabilization of a spinal cord injury
or, in the instance of spinal
anaesthesia, by positioning the
patient properly.
2. Specific treatment depends on its
cause. If hypoglycemia (insulin
shock) is the cause, glucose is
rapidly administered. 72

39. NURSING
•
•
•
Elevate and maintain the head of
the bed at least 30 degrees.
. In suspected spinal cord injury,
neurogenic shock may be
prevented by carefully immobilizing
the patient.
Applying elastic compression
stockings and elevating the foot of
the bed
73

40. • Check the patient daily for any
redness, tenderness, warmth of the
calves, and positive Homans sign
(calf pain on dorsiflexion of the
foot).
• Administering heparin or low-
molecular-weight heparin
(Lovenox) as prescribed, applying
elastic compression stockings, or
initiating pneumatic compression of
the legs may prevent thrombus
formation. 74

41. •
41
Performing passive range of motion
of the immobile extremities.
• In the immediate post injury period,
the nurse must monitor the patient
closely for signs of internal bleeding
that could lead to hypovolemic
shock.

42. ANAPHYLACTIC SHOCK
42
Caused by severe allergic reaction
when a patient who has already
produced antibodies to a foreign
substance (antigen) develops a
systemic antigen–antibody
reaction.

43. Due to antibody responses
Release of histamine Vasodilatation
Increased capillary Permeability
Severe bronchoconstriction
Decreased oxygen supply and
utilization
Inadequate tissue Perfusion
43

44. MANAGEMENT
44
MEDICAL
 Removing the causative antigen
(e.g., discontinuing an antibiotic
agent), administering medications
that restore vascular tone, and
providing emergency support of
basic life functions.

45.  Epinephrine
 Diphenhydramine
 Nebulized medications ( albuterol)
 cardiopulmonary resuscitation
 ET Intubation or tracheotomy
NURSING
 Assessing all patients for allergies
or previous reactions to antigens
and communicating the existence
of these allergies or reactions to
others. 79

46.  Assess the patient’s understanding
of previous reactions and steps
taken by the patient and family to
prevent further exposure to
antigens.
 Advise the patient to wear or carry
identification that names the
Specific allergen or antigen.
 When administering any new
medication, the nurse observes the
patient for an allergic reaction. 80

47.  Identify patients at risk for
anaphylactic reactions to contrast
agents (radiopaque, dye-like
substances that may contain
iodine) used for diagnostic tests.
 Take immediate action if signs and
symptoms occur, and must be
prepared to begin cardiopulmonary
resuscitation if cardio respiratory
arrest occurs.
47

48.  In addition to monitoring the
patient’s response to treatment, the
nurse assists with intubation if
needed, monitors the
hemodynamic status, ensures
intravenous access for
administration of medications, and
administers prescribed medications
and fluids, and documents
treatments and their effects.
48

49. Obstructive shock may be
due to cardiac tamponade or a tension
pneumothorax.
Obstructive shock is a form of shock associated
with physical obstruction of the great vessels or
the heart itself. Pulmonary embolism and cardiac
tamponade are considered forms of obstructive
shock.
Obstructive shock has much in common with
cardiogenic shock, and the two are frequently
grouped together.

50. DIAGNOSIS
No laboratory Test-but high
index suspicion and physical
signs of inadequate tissue
perfusion and oxygen are
base to initiate treatment.

51. INITIAL MANAGEMENT
Successful management
of shock patient requires
team work. Senior team of
anesthetist, Specialist -
Physician, hematologist,
and nurse other support
staff like neonatologist,
radiologist, theatre team
and dedicated porter. To
be in contact.

52. Management should start once
diagnosis made aiming for
prompt restoration of tissue
perfusion and oxygenation.
Management of underlying
etiology is next step until
resuscitation is initiated.
Cont’d

53. ABC
AIRWAY
Airway-high flow oxygen (15lts/min by
mask with reservoir bag)
Protected by tracheal intubation if
there is potential compromise
BREATHING
ventiation should be checked and
supported if inadequate
CIRCULATION
insert two widebore peripheral
intravenous canulas
Initial circulatory management aims to
restore circulating volume and reverse
hypotension with crystaliod.
keep ready blood for transfusion (6
units)
Samples can be drawn for full blood
count, coagulation screen, urea,
electrolytes and cross matching.
Continues monitoring the response.
Cont’d

54. SPECIFIC MANAGEMENT
Hemorrhagic shock: Infusion and
transfusion
Blood transfusion is must
Crystalloids- Normal saline has to
be infused initially for immediate
volume replacement.
colloids- polygelatin solutions
(Heamaccel) are iso-osmotic with
plasma maintenance of cardiac
efficiency.
6liters of crystalloids may be
needed for loss of 1liter of plasma
volume.
Hemodynamic monitoring should
be aimed to maintain systolic
BP>90mmhg, mean arterial
pressure>60mmNg, CVP 12-15mm
H2O and pulmonary capillary wedge
pressure 14-18 mmHg.

55. Administration of oxygen to
avoid metabolic acidosis
In the later phases,
ventilation by endo- tracheal
intubation may be necessary.
Oxygen delivery should be
continued to maintain O2
saturation>92%, PaCO2 30-
35mmHg and PH<7.35
Cont’d

56. MECHANICAL SUPPORT
Intra-aortic balloon pump (IABP)
Ventricular assist device (VAD)
Artificial heart (TAH)
Extracorporeal membrane
oxygenation (ECMO)

58. PREVENTION OF SHOCK
Preoperatively:
 His blood should be adequate in
quantity and volume.
 His tissues should be adequately
hydrated.
 He should be mobile.
 Patient should be kept warm on his
journey from ward to theatre. 84

59. Post operatively:
 Fluid and electrolyte replacement
normal saline, dextrose 5%, plasma
and rest and relief from the pain
continues.
 Gentle handling by nursing staff
will help in prevention of shock.
 Diuretics like mannitol .
 If oliguria persists furosemide can
be given.
 Dopamine

60. COMPLICATIONS
60
1. ARDS
2. Multiple Organ Failure