1. Shock is a life-threatening condition caused by an imbalance between oxygen supply and demand in tissues. It can lead to organ dysfunction if left untreated. 2. There are four main types of shock based on the underlying pathophysiology: distributive, cardiogenic, obstructive, and hypovolemic. Distributive shock is most often caused by sepsis. 3. The goals of treatment are to restore adequate tissue perfusion and oxygen delivery through rapid fluid resuscitation and vasopressor support if needed. Early recognition and treatment of shock is critical to prevent irreversible organ damage.

1. APPROACH TO SHOCK
MODERATOR: DR JAI GAWLI SIR
PRESENTER: DR AYUSHI MUNGAD

2. DEFINITION
• Shock is clinical condition of organ dysfunction resulting from imbalance between cellular oxygen
supply and demand.
• Life threatening condition.
• Organ dysfunction in early shock is reversible.
• If left untreated, goes in irreversible phase and death occur from multisystem organ dysfunction.

3. PATHOPHYSIOLOGY OF SHOCK
• Most commonly related to impaired oxygen delivery in the setting of
circulatory failure.
• Can also develop during states of increased oxygen consumption or impaired
oxygen utilization.

5. • Normal oxygen content in mitochondria is 10 mmHg.
• Critical value in mitochondria is 1-2 mmHg, Below this anerobic
respiration sets in.
• Major oxygen consumers are LIVER, BRAIN, HEART, SKELETAL
MUSCLE, KIDNEY, SKIN.

6. INSUFFICIENT OXYGEN SUPPLY
ANAEROBIC METABOLISM
INADEQUATE ATP SUPPLY
OSMOTIC, IONIC DISRUPTION
CELLULAR
SWELLING
CELL DEATH

7. CLASSIFICATION OF SHOCK
• Based on the primary physiologic derangement, shock is classified in
four major types:
1. DISTRIBUTIVE
2. CARDIOGENIC
3. OBSTRUCTIVE
4. HYPOVOLEMIC

8. PATHOPHYSIOLOGIC CLASSIFICATION OF SHOCK
1. DISTRIBUTIVE SHOCK
• SEPTIC SHOCK
• ANAPHYLACTIC SHOCK
• NEUROGENIC SHOCK
2. CARDIOGENIC SHOCK
• MYOCARDIAL INFARCTION
• VALVULAR INSUFFICIENCY
3. OBSTRUCTIVE SHOCK
• TENSION PNEUMOTHORAX
• INTRATHORACIC TUMOR
• PULMONARY EMBOLISM
4. HYPOVOLEMIC SHOCK
• BURNS
• GI LOSSES
• HEMORRHAGE
• DIABETIC KETOACIDOSIS
• DIABETIC INSIPIDUS

9. DISTRIBUTIVE SHOCK
• It is the condition of reduced systemic vascular resistance.
• It is unique among the types of shock because there is compensatory
increase in cardiac output.
• Most common cause of distributive shock is sepsis.

10. • Sepsis: A life threatening organ dysfunction caused by
dysregulated host response to infection.
• Septic shock: Suspected infection (or documented) plus
vasopressor therapy to maintain MAP >65mmHg and serum
lactate >2mmol/L despite adequate fluid resuscitation.

11. SYSTEMIC INFLAMMATORY RESPONSE SYNDROME
SEPSIS
SEPTIC SHOCK
MULTI ORGAN DYSFUNCTION SYNDROME

14. • ANAPHYLACTIC SHOCK: Predominantly IgE mediated allergic reaction
rapidly develop after exposure to an ALLERGEN.
• It is mediated through histamine release.
• Both arterial and venous vasodilation occur.

15. NEUROGENIC SHOCK
• In high spinal injuries there is failure of sympathetic outflow.
• Vasodilation
• Pooling of blood
• Decrease venous return
• Decrease cardiac output
• It is sudden in onset.

16. HYPOVOLEMIC SHOCK
• It is due to reduce cardiac output(and oxygen delivery) via a
reduction in preload.
• Most commonly related to hemorrhage, may be external or internal.
• Non-hemorrhagic processes(GI, Renal, Skin loss) can also lead to
hypovolemic shock.

17. CLASSIFICATION OF HYPOVOLEMIC SHOCK
I II III IV
% OF VOLUME
LOSS
0-15% 15-30% 30-40% >40%
AMOUNT OF
BLOOD LOSS
400-500mL 500-1500mL 1500-2000mL >2000mL
HR NORMAL NR
SBP NORMAL NORMAL NR
DBP NORMAL NR
RR NORMAL NORMAL
UO NORMAL NORMAL/ ANURIA

18. I II III IV
MENTAL STATUS NORMAL ANXIOUS AND
THIRSTY
CONFUSED COMA
MANGEMENT ORAL LIQUIDS IV CRYSTALLOIDS IV CRYSTALLOIDS
+ COLLOIDS
MASSIVE BLOOD
TRANFUSION

19. CARDIOGENIC SHOCK
• It is characterized by reduced oxygen delivery related to
reduction in cardiac output owing to a primary cardiac problem.
• When affects LV, PCWP will be elevated.
• When affects RV, CVP will be elevated.

20. OBSTRUCTIVE SHOCK
• Reduction in oxygen delivery is related to reduced CO due to an
extracardiac process impairing blood flow.
• Some process can impede venous return and other obstruct cardiac
flow.

21. • MIXED SHOCK: Patient will present with more than one type of
shock.
• UNDIFFERENTIATED SHOCK

22. HEMODYNAMIC CHARACTERISTIC OF MAJOR TYPES
OF SHOCK
TYPE OF SHOCK CVP PCWP CARDIAC
OUTPUT
SYSTEMIC
VASCULAR
RESISTANCE
DISTRIBUTIVE DECREASE DECREASE INCREASE DECREASE
CARDIOGENIC INCREASE INCREASE DECREASE INCREASE
OBSTRUCTIVE INCREASE INCREASE OR
DECREASE
DECREASE INCREASE
HYPOVOLEMIC DECREASE DECREASE DECREASE INCREASE

23. STAGES OF SHOCK
COMPENSATED
SHOCK
(PRESHOCK)
DECOMPENSATED
SHOCK
IRREVERSIBLE
SHOCK

24. EVALUATION OF PATIENT WITH SHOCK

25. KEY PRINCIPLES IN THE TREATMENT OF SHOCK
1. RECOGNIZE SHOCK EARLY..
2.ASSESS FOR THE TYPE OF SHOCK PRESENT
3. INITIATE THERAPY SIMULTANEOUS WITH THE EVALUATION INTO ETIOLOGY OF SHOCK.
4. RESTORATION OF OXYGEN DELIVERY IS THE AIM OF THERAPY.
5. IDENTIFY ETIOLOGIES WHICH REQUIRE ADDITIONAL LIFE SAVING INTERVENTIONS

26. HISTORY TAKING
• In some cases, the type of shock is apparent from history.
• The most easily identified new organ dysfunction is presence of altered
mental status or decrease renal function.

27. • DISTRIBUTIVE SHOCK FROM SEPSIS- FEVER, FOCAL SITE OF INFECTION.
• DISTRIBUTIVE SHOCK FROM ANAPHYLAXIS- DYSPNEA, NEW FACIAL EDEMA, PRURITIS AFTER
EXPOSURE TO ALLERGEN.
• CARDIOGENIC SHOCK: EXERTIONAL CHEST DISCOMFORT, PALPITATION, CHEST PAIN.

28. • HYPOVOLEMIC SHOCK: History of trauma or GI bleed.
• OBSTRUCTIVE SHOCK: Tearing chest or back pain with history of HTN or
acute onset chest pain with dyspnea in the setting of immobility.

29. PHYSICAL EXAMINATION
Physical examination should be conducted with aim of
answering 2 questions:
1.IS SHOCK PRESENT?
2. WHAT TYPE OF SHOCK PRESENT?

30. • DURING COMPENSATED PHASE: TACHYCARDIA, TACHYPNEA.
• HYPOTENSION MAY ALSO BE PRESENT.
• CNS, KIDNEY AND SKIN ARE THE ORGAN MOST EASILY ASSESED FOR EVIDENCE OF
DYSFUNCTION.

31. • WARM EXTREMITIES: DISTRIBUTIVE SHOCK.
• COLD EXTREMITIES: HYPOVOLEMIC SHOCK, OBSTRUCTIVE SHOCK, CARDIOGENIC SHOCK.
• URINARY OUTPUT SHOULD BE ASSESED.

32. • JVP AND PERIPHERAL EDEMA can provide insight into right side cardiac
pressure.
• PULMONARY AUSCULTATION can identify signs of left sided cardiac
dysfunction.
• Examination may demonstrate site of untreated infection, large
ecchymosis.

33. SCORING SYSTEM
• SHOCK INDEX (SI)= HR/ SYSTOLIC BLOOD PRESSURE
• NORMAL SI IS 0.5-0.7.
• SI >0.9 IS MORE SENSITIVE INDICATOR OF TRANSFUSION REQUIREMENT.

34. QSOFA
• IT IS A RAPID ASSESSMENT SCALE THAT ASSIGNS A POINT FOR
1. SBP <1OO mmHg.
2. RR >22/MIN.
3. ALTERED MENTAL STATUS.
• qSOFA OF >2 IS ASSOCIATED WITH SIGNIFICANTLY GREATER RISK OF
PROLONGED ICU STAY OR DEATH.

35. INITIAL LABORATORY EVALUATION OF
UNDIFFERENTIATED SHOCK
1. LACTATE
2. RENAL FUNCTION TEST
3. LIVER FUNCTION TEST
4. CARDIAC ENZYMES
5. COMPLETE BLOOD COUNT
6. PT, INR
7. URINALYSIS
8. ABG
9. ECG

36. INITIAL TREATMENT OF SHOCK
• VOLUME RESUSCITATION
• VASOPRESSOR AND INOTROPIC SUPPORT
• OXYGEN AND VENTILLATION SUPPORT
• ANTIBIOTIC SUPPORT

37. VOLUME RESUSCITATION
• Aim is to restore tissue perfusion .
• Patient with suspected septic shock, minimum 30ml/kg is
recommended by surviving sepsis campaign in 1 hr.
• Most commonly volume resuscitation begin with crystalloid.

38. RINGER LACTATE
INDICATIONS:
1. SEVERE HYPOVOLEMIA
2. DIARRHOEA INDUCED HYPOVOLEMIA WITH HYPOKALEMIC METABOLIC ACIDOSIS
3. DIABETIC KETOACIDOSIS
CONTRAINDICATION:
1. LIVER DISEASE
2. ALONG WITH BLOOD TRANSFUSION (CALCIUM BINDS CITRATE)
3. SEVERE CHF
4. DRUGS (DOXYCYCLINE, AMPICILLINE)

39. ISOTONIC SALINE
(0.9% NACL)
• INDICATIONS:
1. HYPOVOLEMIC SHOCK
2. ALKALOSIS WITH DEHYDRATION (VOMITING)
3. INITIAL THERAPY IN DKA
CONTRAINDICATIONS:
1. AVOID IN HTN, RENAL DISEASE.
2. DEHYDRATION WITH SEVERE HYPOKALEMIA

40. DEXTROSE SALINE(DNS)
• 5% DEXTROSE WITH 0.9% NaCl
• INDICATIONS:
1. CORRECTION OF SALT DEPLETION, HYPOVOLEMIA WITH ENERGY SUPPLY
2. COMPATIBLE WITH BLOOD TRANSFUSION.
CONTRAINDICATIONS:
1. SEVERE HYPOVOLEMIC SHOCK
2. ANASARCA OF CARDIAC, HEPATIC, RENAL DISEASE

41. MONITORING FLUID THERAPY
• Skin, tongue
• Weight
• Sensorium
• Urine output
• Pulse
• Blood pressure
• CVP

42. • In patient with hypovolemic shock with ongoing hemorrhage, volume
replacement with PRBC is recommended.
• In case of massive transfusion, Platelets and FFP should be provided.
• Most commonly used parameter to assess adequacy of volume
resuscitation are IVC DIAMETER, IVC COLLAPSE.

43. VASOPRESSOR AND INOTROPIC
SUPPORT
• In patient with distributive shock, norepinephrine is
the first choice vasopressor.
• Vasopressin is safe and used as second agent for
hypotension in septic shock.
• Dobutamine is first line agent in cardiogenic shock.

44. • CASE SCENARIO
• An 82-year-old man is admitted after being involved in a motor
vehicle collision. He has severe chest and abdominal injuries.
His head and extremities are only minimally traumatized. He
undergoes surgery for a splenic rupture. After eight hours, he
becomes hypotensive and febrile, and is intubated because of
respiratory failure. He rapidly develops disseminated
intravascular coagulation (DIC). Which of the following is the
most likely diagnosis?

45. • CASE SCENARIO
• A 81 year male, comes to the emergency department looking weak,
lethargic, he’s able to state he is under chemotherapy for
a pancreatic tumor and he has had nausea, vomiting, watery
diarrhea for the last 2 days.
• On inspection: Poor skin turgor, dry mucous membranes.
• His vital signs are: HR 130 beats/minute and regular, BP 62/30 mm
Hg,, RR26 breaths/minute, Temp: 37° C.

46. THANK YOU