1. Shock is defined as
o Any condition wheren there's decreased tissue perfusion
• That lower tissue perfusion
 Tonicity of blood vessel wall (decreased tonicity) esp of
the artery
• Types of shock with dec tonicity
• Neurogenic shock
• Septic shock
• Early - dec tonicity of the blood
vessel wall due to toxin being
secreted by bacteria (endotoxin)
• al
• late
• Anaphylactic shock - allergic reaction
• Hypovolemic - Most important factor in
surgery; decrease in blood volume leads
to hypotension; blood vol -- lose fluid
content --dec BP
• Hemorrhagic shock
 Function of the Heart
• If malfunctioning of myocardium esp ischemia,
atherosclerosis of coronary artery ---low CO
• Cardiac compressive shock - pericardial
tamponade
• Heart is normal
• Pericardial cavity is filled up with blood --
effusion --limiting distension of ventricle
during diastole --so CO is also low
---blood clogged in venous side of
circulation
• Patient of a surgeon now
Different Types of Shock
o Hypovolemic shock --lose volume of blood
• Hemorrhagic shock
 Low preload - than you'll have low CO; low systemic
arteriole pressure; sensed by the carotid sinus, by atrial
receptors, and receptors in kidney
• Now stimulates hypothalamus
• Could also directly stimulate the adrenal medulla
by passing the pituitary causing release of
epineph and noreph --stimulation of heart to
compensate --tachycardia
• Epi and nor also cause vasoconstriction --
inc. vascular resistance
• If you touch extremity of injury,
it's cold ---artery is constricted
• Traumatic shock
 Almost same as hypovolemic shock

2.  In addition, there's an injured tissue/organ; there are
immediate release of mediators (cytokines) ---increases
intravascular coagulation --clogging of blood in that area
• Most mediators causes vasodilatation
• Inc seepage of plasma outside of blood vessel
• Remove dead tissue in brain to remove
cytokines; dead cells secrete these mediators
• With help of monocytes, t cells
• Cardiogenic Shock
 Pertaining to the function of heart that's no longer
domain of surgeons
 Pumping action of heart fails; blood clogged behind the
heart
• Preload aread elevated
 Surgery onlyl participates if need for us to improve
perfusion of heart muscle ---cardiac bypass ---use
saphenous vein to bypass obstruction of coronary artery
• Cardiac Compressive Shock
 Heart is normal
 But low cardiac return due to extrinsic compression of
heart
• Pericardial cavity filled up with fluid in case of
infecti --pericarditis
• Filled with blood in case of blunt or penetrating
trauma (stab/gunshot) aka pericardial
tamponade
• Septic Shock
 Due to effect of toxin being released by the bacteri
 If gram + , then exotoxin release
 If gram -, then endotoxin released
• Neurogenic Shock
 Loss of arterial and venous tones
 Tonicity of veins also decreased
• Pooling of blood in the peripheral venous system
esp in splanchnic vessel ---veins of the GIT tract
• Pooled there
Cellular Changes in patients body if perfusion of blood not optimum
o If you have hypotension, it causes death to the cell because
• Due to heme part of hemoglobin carrying O2 (in cytoplasm of
RBC) not being carried to tissues
• 2 organs to maintain good oxygen level
 Brain
 Heart
 Why there's redirection of blood from other tissues to
these 2

3. • The oxygen is the end electron receptor of ETC (electron
transport chain)
 If you don't have O2 there, than entire ETC chain
stopped (to produce ATP)
• Aerobic metabolism - using glucose
• 36 - 2 = 34
• Anaerobic metabolism
• 8-10 only
 Most metabolism in cell are active processes; so you
need ATP for it to work
o Na K membrane pump
• Active process seen in cell membrane
• Continues to pump Na out and pump K in
 If doesn't work, Na continues to enter and small K out
• If Na in, drags in water (too much Na out; if
pump not work, Na keeps going in dragging in
water) ---resulting to cellular swelling ---cell dies
----brain dies
Renal response
o If you lose blood, one of the organs
• Perfusion of glomerulus goes down
o Kidney can survive 15-90 minutes if you put kidney in cold temp
• Immersed in ice bag area
• Prolonged hypoperfusion of kidney
 Functional/anatomical changes ---azotemia (elevated
creatinine)
• Important for surgeon to know whether azotemia
• Preload - treat by giving blood and fluid
• Kidney parenchymal damage - don't give
fluid; kidney already working ---kidney
edema
• Poor perfusion of glomerulus
• Use Renal Failure Index to see if preload
• Na of urine
• And plasma creatinine
If < 1, prerenal oliguria
• Kidney still functioning, poor
perfusion of glomerulus;
give fluid
If > 1 acute renal failure (24 hrs)
• Have to give fluid
simultaneously with
antidiuretics; if keep giving
fluid, pt might die of
pulmonary edema
Pulmonary response
o Damage alveolar-capillary interface
• Acute diffuse lung injury

4. o Seepage of fluid entering the interface
• Alveoli
• Due to mediators, plasma will now fill up the interface, making
it wider; so the O2 transport from alveoli goes to capillary that
will link to hemoglobin not optimum ---hypoxia ---big gap btw
alveolar line ep and epithelium of capillary
• Leekage of proteous fluid into interstium and alveolar space
o Acute respi distress syndroome
• Oxygen won't go to alveoli
• Pt goes to hypoxia
• Dec pulmonary compliance
• High airway pressure to attain adequate tidal volume
o Multiple organ failure
• Kidney and lungs
Pathophysiology of Shock
o Hypovolemic -- most common
• Hemorrhagic most common
 Lose blood from the venous side (50%); veins more
superficially located
 If artery involved, pt will most likely die
 Decrease cardiac return
 Low CO
 Low blood pressure
 Important of doctor to tell what stage hemorrhagic
shock
• Mild - lose < 20 % of blood loss
• 5 liters time .20 ---if lose < 1 liter of
blood, there will be compensation
--release of E NE, adrenergic constriction
of blood vessel; cold skin
• Thirsty - good clue that pt in shocking
condition
• Remember bp, pulse rate normal; urine
normal
• Constriction of blood vessel --cold
extremity
• Moderate
• 20-40% blood vol lost
• Eiters
• Cold extremity
• Bp still normal, but pt will start to have
low urine output due to aldosterone and
antidiuretic hormone
• Severe
• >40% of blood vol lost
• Only time that bp of patient goes down
• Signs of MI

5. • Q waves and depressed St
segments
• Why surgeon always ask pt if cold arm, and asks
for urine measurement
Compensatory Mech
o Adrenergic discharge - to compensate to have higher bp
o Hyperventilation
• What happens - you inhale and exhale rapidly
 Longer inhalation and faster exhales
 When inhale, thoracic pressure goes down so that lungs
will expand; higher respi rate, longer time of having dec
thoracic pressure - helps venous blood to go from
periphery to go to right side of heart -- better cardiac
return ---better cardiac output
o Pt will collapse
• Oxygen level of brain not optimal -- unconscious
• If lie down, better return of blood to heart not against gravity
• Have to elevate the lower extremity
o Release of fluid from interstitium into intervascular space
• In case of shock, inc epinephrine --causes constriction (pre
capillary sphincter);
 True capillaries - carrying fluid oxygen to cell; brings
waste product of cell back to blood
• Vascular shunt -- bypasses the tissue/cell
• Between shunt and true cap, you have
precapillary sphincter; in shock, epinep causes
constriction of sphincter; so instead of going to
tissue, goes to vein and back to heart
immediately
• If that happens, hydrostatic pressure decreases
so hydrostatic pressure in intercellular space
(15%) could go from half side of capillary to
replenish fluid --so better cardiac return
o Vasoactive hormones and catabolic hormones (catabolize carb, pro,
lipid resulting glycogen to glucose, amino acid,; small solutes; now go
to intercellular space by exocytosis; goes out and oncotic pressure will
increase
• Inc oncotic pressure, by osmosis (40% of our fluids inside cell);
now getting fluid coming from intracell compt to supply
decrease of fluid in vessel
• So neuroendocrine system is reason why you have normal bp
for mild and moderate shock
 But in severe, it can no longer compensate
o Inc hydrostatic pressure forcing water and protein to go to lymphatics
and replenishing the plasma of the patient
o Function of kidney

6. • Important
o Decompensation of hypovolemic shock
• Relaxation of arteriole, pre capillary spasm
 Instead of constricting pre cap, it now relaxes --bad
• Deterioration of cell membrane function
 Na K pump no longer working; cell dies
o 2 most sensitive signs of hypovolemia
• Cutaneous vasoconstriction
• Oliguria
• Most pts usually are alcoholics -- alcohol causes vasodilatation
and inhibits secretion of ADH
 Instead of oliguria, pt will have polyuria
 Smell alchol in breat, put central venous pressure to
check if pt has been corrected or still needs fluid
resucitation
Monitoring Pt In case of shock
o Admit pt
o Have to put 2 or 3 lines and have to use a wider gauge needle (gauge
16,18,19)
o Don't give D5LR, D5NMS
• Better use lactate without dextrose
• Plain NSS witout dextrose -
 Dextrose causes osmotic diurses
o Put a folicatheter -- monitor urine output hourly
• Normal urine output -- 30 ml/minute (low limit); if lower than
that, then oliguria
 In book 1 ml / minute = 60 ml
 For neonates,
• 2.5 ml / minute
o If elderlly, check heart status
• Kidney function --serum, creatine and bum
o Treat injured tissue or organ
• If need for patient to receive whole blood or packed RBC,
carries O2
Management
o Correct dehydration --give crystalloid
o Disadvantage of giving colloid
• Post resuscitation of HPN
• Inc intravascular volume at the exp
• Depression of albumin synthesis
• Dep of circulation immunoglobulin
 More expensive and less easier to titrate
Position of Patient
o Fowler position - put the foot down; fowler foot - foot down

7. o Trendulemburg -- put the head down
• Supine and elevate the leg
• Not good they said now; increasing venous return, but
abdominal organ is also pressing the diaphragm so inhalation of
pt compromised; so best position is
o Supine Position
• Elevate lower extremity
If old
o Check heart
o Arrythmia -- put in ICU --
Steroids not indicated in case of shock
O2 inhalation but correct vascular volume
o If low RBC, won't work
Causes of Refractory Shock
o Continuing blood loss
o Inadequate replacement of fluid
o Massive trauma or derangement -- just correct fluid but didn't do
debrigma of organ; if still injured, organs will form cytokines; so you
remove dead tissue
o In elderly, heart didn't compensate much --heart failure
o Infection -- community acquired (outside bacteria); sensitive to
antibiotic
• If pt stayed in hospital for week, bacteria is now hospital
bourne; resistant to drugs
Traumatic Shock
o Lose blood (plasma)
o In addition, presence of injured tissue (traumatized) -- secretes
mediators which inc pulmonary vascular resistance due to tumor
necroting factor and interleukin 1 - vasoconstriction of pulmonary
vessle
• Inc seepage of fluid; pt perfusion down due to third space loss
(fluid enters into nonfunctional compartment)
• Have microthrombi esp cytokines
o Treatment
• Have to correct fluid, hypovolemia and debridement - remove
cytokine source
Cardiogenic Shock
o All signs and symptoms of MI
o Increased central venous pressure; blood clogged on right side of
heart
• Put catheter at superior vena cava; make incision in basilic
vein; put catheter and it will end in superior vena cava
 Normal 8-10 cm water

8. • If < 8, preload down
• Cardiac return not good
• If > 10, preload elevated
• Clogging on the right side of hear
 So incase of hypovolemic, hemorrhagic shock it will be
decreased - lose blood --preload not good ---so < 8
 In cardiogenic shock, elevated due to clogging
• Picture of heart and superior vena cava description
 Put catheter and it ends in sup vena cava; 8-10 < where
water should be
o Catheter placed even in pulmonary artery but it's expensive
o Put in ICU, give analgesics to relieve pain (major stimuli)
o Monitor cardiac function of pt
• Arrythmia - give digitalis, dopamine, etc
o If CO not optimum, refer to cardiologist to place pacemaker
o Cardiologis will refer pt for invasive cardio to chec, status of coronary
artery if there's need to do bypass operation
Cardiac Tamponade
• Decreased cardiac compliance on right atrium
• Dec
• Heart not receiving optim blood during diastole - cannot dilate optimally
• Cardiac Signs and symptoms
o Neck vein engorgement
o Distant heart sound (caused by valve closure); if blood not optimum
closure of valves are low
o If cardiac return low, low CO --- hypotension
• Other signs
o Tachycardia, oliguria, cold
o Pulsus paraoxicus - when you inhale, your pulse pressure will be
higher becaue inhalation --- thoracic pressure lower --venous return --
so better CO - normal
• But pulsus, when you inhale, filling pericardial cavity - low
ventricular expansion --- so it becomes low pressure
• Diagnosis
o Clinical presentation
o History of injury
o Cardinal signs
o Water bottle shape -- req for chest xray
• Management
o Bring pt to OR
o Do an anterolateral trachotomy -- depress pericardial cavity --remove
blood there and fix whatever trauma done --cardiac return better --
better CO
• Emergency
o Use pericardiocentesis

9. • Use spinal needle; connect it to wide barrel syringe; palpate for
sternum (costal angle) left side; put needle 45 degrees directed
to left shoulder; hook the needle to ECG machine; if you insert
you won't hit the lung due to lingula of the left lung; resistance
of skin, muscle -- no more resistance --now in pericardia;
cavity --pull the plunger == if blood there, aspirate the blood --
to make sure in cavity -- push farther after the five; look at
ECG -- if pure RS pronounced -- you're hitting the ventricle --
so you pull the needle back out a bit == now you're back in the
right space
• Improves neck vein engorgement
• CO better -- hypotension lessens
• therapeutic
o If no recurrence, just observe the patient; sometimes injured vessel
damaged already
• Septic Shock
o Caused by bacterial infection
• Gram positive --exotoxin
• Gram negative - endotoxin
o Gram negative sepsis more common in surgical pts
o Usual source
• Genitourinary tract --put folicatheter
• Respiratory - pts who've had abdominal surgery; contraction of
diaphragm limited by pain; expansion of basal lobe not
optimum -- atylectesis - pneumonitis ---pneumonia
 Why in ab surgery, tell pt to have pulmonary therapy
--deep breathing, nebulization -- to prevent problem in
respi
• Alimentary
• Integumentary
o Early Septic Shock
• Have a warm extremity
• Normovolemic
• Only symptoms
 Hypotenision - due to vasodilatation from endotoxin
---have dec CO with minimal resitance, inc heart rate,
inc contractility
 Bp of patient -- due to vasodilatation
 Decreased tonicity
o Late Septic Shock
• If doctor failed to catch the sepsis, cold extremity
• Pt start to have hypovolemia --inc seepage of fluid outside
blood vessel - -third space loss
• Cause of hypertension
 Inc vascular permeability
 Decrease cardiac output due to in pulmonary vascular
resistance
 Inc peripheral resistance -- cold cyonotic extremity
 Inc peripheral pressure
o Treatment

10. • Identify organ/tissue where infection coming from
• Replace fluid - in late septic - lose fliud from dec CO and third
space loss
• Requesting for culture and sensitivity
 Culture - id bacteria
 Sensitivity -- antibiotic where bacteria is susceptible
• Early sign of gram - infection
 Hyperventilation
 Respiratory alkalosis
 Altered sensorium of patient
Neurogenic Shock
o Seen in spinal cord injuries
o Pt normovolemic and sometimes hypovolemic
o Pooling of blood in systemic venules --CO not good -- pulled in
splanchnic area due to spinal cord injury
o Only type of shock wherein you're justified to give vasoconstrictor
immediately
• Decreased tonicity of artery -- so just improtve tonicity by
giving vasoconstriction
o Treatment
• Give fluid
• Give vasoconstrictor --have to give it
• To improve Cardiac return, elevate the lower extremity