types of shock with description

1. SHOCK
Dr. Ravibhushan J. Kasale
Associate Professor, Dept. Of General Surgery
Government Medical College, Alibag Raigad

2. Definition
• Shock is defined as a state of cellular and
tissue hypoxia with either reduced oxygen
delivery or poor oxygen utilization or
increased oxygen consumption with
circulatory failure (collapse)
• A final common pathway for many
potentially lethal clinical events
(hemorrhage, trauma, burns, large MI,
massive pulmonary embolism microbial
sepsis)

3. Stages Of Shock

4. • Stage of hypoperfusion and hypoxia:
Aerobic metabolism changes to anaerobic leading to
lactic acidosis (metabolic acidosis).
• Stage of compensatory shock:
It is neuroendocrine response to maintain the
perfusion of vital organs like brain, lungs and heart.
Noradrenaline, renin-angiotensin and antidiuretic
hormone (ADH) gets activated causing
vasoconstriction of organs like gastrointestinal tract,
kidney to divert the blood to heart, lungs and brain.

5. • Stage of decompensatory
(progressive) shock:
Here compensatory mechanism fails; cell
perfusion decreases causing raised intracellular
sodium but low intracellular potassium.
Microcirculation fails leading to the failure of
kidneys, liver and lungs.
• Stage of irreversible (refractory)
shock:
Here cellular ATP metabolism is lost completely
leading into MODS and MOF (multiorgan
failure).

6. Etiology Of Shock
1. Hypovolaemic shock - due to reduction in
total blood volume. It may be due to:
A. Haemorrhage
External from wounds, open fractures
Internal from injury to spleen, liver,
mesentery or pelvis
B. Severe burns, which results in loss of plasma
C. Peritonitis, intestinal obstruction
D. Vomiting and diarrhoea of any cause

7. 2. Cardiac causes
a. Acute myocardial infarction, acute carditis
b. Acute pulmonary embolism wherein embolus
blocks the pulmonary artery at bifurcation or one of
the major branches
c. Drug induced
d. Toxaemia of any cause
e. Cardiac surgical conditions like valvular diseases,
congenital heart diseases
f. Cardiac compression causes
i. Cardiac tamponade due to collection of
blood, pus, fluid in the pericardial space which
prevents the heart to expand leading to shock.
ii. Trauma to heart

8. 3. Septic shock- is due to bacterial infections
which release toxins leading to shock
4. Neurogenic shock-due to sudden anxious
or painful stimuli causing severe splanchnic
vasodilatation. Here patient either goes for
cardiac arrest and dies or recovers fully
spontaneously.
spinal cord injury/anaesthesia can
cause neurogenic shock

9. 5. Anaphylactic shock-is due to Type 1
hypersensitivity reaction
6. Respiratory causes
a. Atelectasis (collapse) of lung
b. Thoracic injuries
c. Tension pneumothorax
d. Anaesthetic complications

10. Pathophysiology Of Shock

11. Any cause of shock
Low cardiac output
Vasoconstriction occurs as a compensation to perfuse
vital organs like brain, heart, kidneys
Because of vasoconstriction and tachycardia
Dynamic circulation increases
Tachypnoea occurs to increase the oxygen saturation
Peripheral veins (capacitance vessels) constrict
diverting blood from splanchnic system towards

12. • Decreased renal blood flow reduces the
GFR and thereby the urine output
• Renin angiotensin mechanism gets
activated causing further vasoconstriction
and aldosterone release
• Causes salt and water retention
• ADH is released
• Further concentration of urine occurs

13. • When shock persists cardiac output falls
further
• Hypotension and tachycardia occurs
leading to poor perfusion of coronaries
• Hypoxia-metabolic acidosis
• Release of cardiac depressants
• Cardiac (pump) failure

14. • Platelets are activated forming small
clots in many places
• Disseminated intravascular coagulation
(DIC) (Consumption coagulopathy)
• Further bleeding

15. Physiological Classification Of Shock
1. Distributive
• a. Septic shock
• b. Pancreatitis
• c. Severe burns
• d. Anaphylactic shock
• e. Neurogenic shock
• f. Endocrine shock
• g. Adrenal crisis
2. Cardiogenic
• a. Myocardial infarction
• b. Myocarditis
• c. Arrhythmia
• d. Valvular
• i. Severe aortic valve
insufficiency
• ii. Severe mitral valve
insufficiency

16. Physiological Classification Of Shock
3. Obstructive
• a. Tension pneumothorax
• b. Cardiac tamponade
• c. Constrictive pericarditis
• d. Pulmonary embolism
• e. Aortic dissection
4. Hypovolemic
• a. Hemorrhagic
• i. Trauma
• ii. GI bleeding
• iii. Ruptured ectopic pregnancy
• b. GI losses
• c. Burns
• d. Polyuria
• i. Diabetic ketoacidosis
• ii. Diabetes insipidus

18. Hypovolemic Shock
• Haemorrhage, may be due to injury to the
liver, spleen, bone fractures,
haemothorax, vascular injury, severe
bleeding on table during surgeries of
thyroid, liver, portal vein or major vessels.
• Vomiting, diarrhoea due to any cause.
• Burns.

19. Contd…. Clinical Features
• In early stage-tachycardia, sweating, cold
periphery,
• hypotension, restlessness, air hunger,
tachypnoea, oliguria,
• collapsed veins.
• In late stage-cyanosis, anuria, jaundice,
drowsiness

20. Anaphylactic Shock
• Injections-penicillins, anaesthetics, stings,
venom, shellfish may be having antigens
which will combine with lgE of mast cells and
basophils, releasing histamine and large
amount of SRS-A (Slow releasing substance of
anaphylaxis).
• C/F are bronchospasm, laryngeal oedema,
respiratory distress, hypotension and shock.
Rashes all over the body are commonly
observed.
• T/t - Adrenaline, Steroids, oxygenation

21. Neurogenic Shock
• It is usually due to spinal cord injury, which causes
dilatation of splanchnic vessels.
• C/F are bradycardia, hypotension, arrhythmias,
and decreased cardiac output.
• T/t - This type can safely be treated with
vasoconstrictor drugs
• Blood pressure control, oxygen delivery,
maintenance of haemodynamics, airway, fluid
therapy, intravenous methylprednisolone therapy
should be done. Dopamine and or phenylephrine
(alpha agonist) can be used.

22. Cardiogenic Shock
 Cardiogenic shock is defined as
Systolic blood pressure <90 mmHg
for 30 minutes;
Raised PCWP (pulmonary capillary
wedge pressure)> 15 mmHg.

23. Contd…
• Diagnosis is established by ECG,
echocardiography, arterial blood gas analysis,
cardiac enzymes, PCWP and electrolyte
estimation
• T/t - Proper oxygenation with intubation,
ventilator support, cardioversion, pacing,
antiarrhythmic drugs, correction of
electrolytes, avoiding fluid overload,
prevention of pulmonary oedema as
immediate measures.

24. Septic Shock
• Septic shock may be due to gram-positive
organisms, gram negative organisms, fungi,
viruses or protozoal origin.
• Gram-negative septicaemia/gram-negative
septic shock is called as endotoxic shock.
• Commonly seen in strangulated intestines,
peritonitis, gastrointestinal fistulas, biliary and
urinary infections, pancreatitis, major surgical
wounds, diabetic wounds and crush injuries.

25. Stages of septic shock
a. Hyperdynamic (warm) shock:
• This stage is reversible stage.
• Patient is still having inflammatory
response and so presents with fever,
tachycardia, and tachypnoea.
• Pyrogenic response is still intact.
• Patient should be treated properly at
this stage

26. b. Hypodynamic hypovolaemic septic shock
(cold septic shock):
• Here pyrogenic response is lost. Patient is
in decompensated shock.
• It is an irreversible stage along with MODS
(multiorgan dysfunction syndrome) with
anuria, respiratory failure (cyanosis),
jaundice (liver failure), cardiac depression,
pulmonary oedema, hypoxia, drowsiness,
eventually coma and death occurs
(Irreversible stage).

27. • Correction of fluid and electrolyte by
crystalloids, blood transfusion. Perfusion is
very/most important.
• Appropriate antibiotics
• Treat the cause or septic focus
• Critical care, oxygen, ventilator support,
dobutamine/ dopamine/noradrenaline to
maintain blood pressure and urine output

28. Treatment Of Shock
• First stabilize the patient with initial
resuscitation
• Next evaluate the patient for cause and
severity
• Lastly treat the specific cause to
achieve cure.

29. • Initial acute critical care management using
• A-Airway;
• B -Breathing;
• C - Circulation;
• lnotropic agents: Dopamine, dobutamine,
adrenaline infusions- mainly in distributive
shock like septic shock.

30. • Antibiotics in patients with sepsis;
• Catheterization to measure urine output
(30-50 ml/hour or >0.5 ml/kg/hour should
be maintained).
• Hemodialysis may be necessary when
kidneys are not functioning.

31. COMPLICATIONS OF SHOCK
• Acute respiratory distress syndrome and
respiratory failure
• Disseminated intravascular coagulation
(DIC) and thrombocytopenia
• Systemic inflammatory response
syndrome and multiorgan dysfunction
syndrome (MODS)