This document provides an overview of shock, including definitions, types, and stages, as well as initial assessment and management strategies. Key points include the importance of early intervention to reduce mortality, the critical components of assessment (ABC), and common features of shock such as hypotension and altered mental status. The document also outlines a general approach to managing shock by optimizing oxygen content, cardiac output, and blood pressure.

1. Approach to
Shock
Dr Abdullah Ansari
Senior Resident (Medicine)
Aligarh Muslim University, Aligarh

2. Overview
• Definitions
• Initial Assessment – ABC
• Types of Shock
• Stages of Shock
• Physiologic Determinants of Shock
• Common Features of Shock
• Work-up
• General Approach to Management
• Take Home Points

3. Definition of Shock
• Inadequate perfusion and oxygenation of cells
• Compromises cellular metabolic activity and
organ function
• Hypotension is not a requirement

4. Why should you care ?
• High mortality of 20-90%
• Early effects of O2 deprivation on the cells are
REVERSIBLE
• Early intervention reduces mortality

5. Remember!
• Assessment, Intervention & Monitoring,
all simultaneously in acute scenarios

6. Initial Assesment - ABC
Airway:
• Does pt have mental status to protect airway?
• GCS less than “eight” means “intubate”
• Airway is compromised in anaphylaxis
Breathing:
• If pt is conversing, A & B are fine
• Place patient on oxygen
Circulation:
• Vitals (HR, BP)
• 2 large bore 16G IV catheter, start fluids (careful if
cardiogenic shock)

7. ABC “DE”
In trauma, perform ABCDE, not just ABC
Deficit or Disability
• Assess for obvious neurologic deficit
• Moving all four extremities? Pupils?
• Glascow Coma Scale (E4, M6, V5)
Exposure
• Remove all clothing on trauma patients

9. Additional Compensatory Mechanisms
• Renin-Angiotensin-Aldosterone Mechanism
▫ AII components lead to vasoconstriction
▫ Aldosterone leads to water conservation
• ADH leads to water retention and thirst
• Inflammatory cascade

13. Common Features of Shock
• Hypotension (not an absolute requirement)
▫ SBP < 90mm Hg, not seen in “preshock”
• Cool, clammy skin
▫ Vasoconstrictive mechanisms to redirect blood
from periphery to vital organs
▫ Exception is warm skin in early distrib. shock
• Oliguria (↓kidney perfusion)
• Altered mental status (↓brain perfusion)
• Metabolic acidosis

14. Work-up
History
• Dehydration (diarrhea, vomiting, burns)
• Bleeding (recent surgery, trauma, GI bleed)
• Fever or sepsis
• Allergies or prior anaphylaxis
• CAD, MI, current chest pain/diaphoresis

15. Work-up cont…
Examination
• Mucous membranes, JVP, lung sounds, cardiac
exam, abdomen, rectal (blood), neurological
exam, skin (cold & clammy or warm)
Investigations
• Routine tests
• Tests directed toward suspected dx’s

16. GENERIC APPROACH TO MANAGEMENT
OF SHOCK
1. Optimize Oxygen Content
2. Optimize Cardiac Output
3. Optimize Blood Pressure

17. • The oxygenated blood of cardiac output has to
reach the Vital organs
• This requires
▫ A good pressure gradient
▫ Low organ vascular resistance

18. OPTIMISE OXYGEN CONTENT
• Hb
▫ Check for pallor
▫ Check Hb and coagulation status
• SaO2
▫ Pulse oximetry
▫ Check SaO2 on ABG

19. OPTIMISE CARDIAC OUTPUT
CO = Stroke volume x Heart rate
STROKE VOLUME depends on
• Preload
• Contractility
• Afterload

20. Preload
Central venous pressure (CVP)
• An approximation of right atrial pressure and
therefore preload
• Measured from an internal jugular or subclavian
venous catheter

21. Preload cont…
• Look at response to fluid bolus
• If BP improves, could be suggestive of
decreased preload (volume) and a reasonable
contractility.
• If no improvement or worsening BP could
be suggestive of a contractility problem

22. Contractility
• Check any history suggestive of Ischaemic
disease or CCF
• Check ECHO and ECG results
• A high systolic pressure could be
suggestive of good contractility

23. Afterload
• Check Echo if suggestive of any obstructive
features
• If increased vascular resistance,
▫ Peripheries are cold
▫ Diastolic BP is low
• If decreased vascular resistance,
▫ Peripheries are warm
▫ Diastolic BP is high

24. OPTIMISE BLOOD PRESSURE
BP=Cardiac output x peripheral resistance
• Optimal use of inotropics and vasopressors

25. Drugs
Vasopressors
• Norepinephrine
• Dopamine
• Epinephrine
• Phenylephrine
• Vasopressin
Inotrope
• Dobutamine

26. Auto regulation range
• Kidneys : MAP 80-180 mmHg
• Brain : MAP 65-130 mmHg
• Heart : MAP 50-150 mmHg
• Try to match Renal auto regulation range

27. Thank you

28. Take home message
• Shock = poor tissue perfusion/oxygenation
• Types:
▫ Hypovolumic due to decreased preload
▫ Cardiogenic due to decreased SV or CO
▫ Distributive due to decreased SVR
• The common signs a/w shock
▫ Hypotension, tachycardia, oliguria, cool/clammy
skin, altered sensorium
• Work-up & management starts with ABC
• Aggressive resuscitation except if cardiogenic
• Vasopressors if hypotensive despite fluids