This document provides an overview of shock, including its pathophysiology and classification. It discusses the main types of shock: hypovolemic, cardiogenic, distributive, and obstructive. For each type, it describes the causes, characteristics, and treatment approaches. It also covers fluid resuscitation, vasopressors, inotropic drugs, and mechanical ventilation as general treatment strategies for shock.
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General Mechanisms of Action
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Cardiogenic shock is a condition of diminished cardiac output that severely impairs cardiac perfusion. In this condition in which the heart suddenly can't pump enough blood to meet the body's needs.
a clinical syndrome that results from inadequate tissue perfusion.
Hypovolemic shock - Blood or fluid loss, both leading to a decreased circulating blood volume, diastolic filling pressure, and volume.
Cardiogenic shock - due to cardiac pump failure related to loss of myocardial contractility/functional myocardium or structural/mechanical failure of the cardiac anatomy and characterized by elevations of diastolic filling pressures and volumes
Extra-cardiac/obstructive shock - due to obstruction to flow in the cardiovascular circuit and characterized by either impairment of diastolic filling or excessive afterload
Distributive shock - caused by loss of vasomotor control resulting in arteriolar/venular dilatation leading to a decrease in preload, with decreased, normal, or elevated cardiac output, depending on the presence of myocardial depression.
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Pathophysiology, Pharmacology and Treatment of Shock
1. CV Pharmacology-
Pathophysiology and Treatment of Shock
Recommended Reading:
Autonomic pharmacology
Formatives:
Practice Question Set #1
Clinical:
E-Medicine Articles
Shock, Cardiogenic
Shock, Hypovolemic
Shock, Septic
Prepared and presented by:
Marc Imhotep Cray, M.D.
BMS / CK-CS Teacher
http://www.imhotepvirtualmedsch.com/
2. 2
Shock (circulatory) See: Shock (circulatory)
Effects of inadequate perfusion on cell function
From: http://en.wikipedia.org/wiki/Shock_%28circulatory%29
3. 3
Shock, Circulatory Defined
Circulatory shock, commonly known as just shock, is a
serious, life-threatening medical condition where insufficient
blood flow reaches body tissues
As blood carries oxygen and nutrients around body,
reduced flow hinders delivery of these components to
tissues, and can stop tissues from functioning properly
The process of blood entering tissues is called perfusion, so
when perfusion is not occurring properly this is called a
hypoperfusional (hypo = below) state
See: Shock: An Overview PDF by Michael L. Cheatham, MD, Ernest F.J. Block, MD, Howard G. Smith, MD,
John T. Promes, MD, Surgical Critical Care Service, Department of Surgical Education, Orlando
Regional Medical Center Orlando, Florida
4. 4
The problem in shock
Altered circulatory parameters
Compromised microcirculation
Persistent severe hypoxia
Multiple organ failure
From: http://www.cvpharmacology.com/clinical
topics/hypotension.htm
6. 6
Classification
In 1972 Hinshaw and Cox suggested
the following classification which is
still used today
It uses four types of shock:
1. hypovolemic,
2. cardiogenic,
3. distributive and
4. obstructive shock
7. 7
Classification
(based on cardiovascular characteristics, which was
initially proposed in 1972 by Hinshaw and Cox)
Hypovolaemic
Hemorrhagic, Fluid
depletion, Increased
vascular capacitance
Cardiogenic
Myopathic,
Mechanical,
Arrhythmic
Distributive
Septic, etc.
Obstructive
PE, pericarditis,
pnumothorax etc.
8. 8
Hypovolemic shock
Hypovolemic shock –
This is the most common type of shock and
based on insufficient circulating volume.
Its primary cause is loss of fluid from the
circulation from either an internal or external
source.
An internal source may be haemorrhage.
External causes may include extensive
bleeding, high output fistulae or severe
burns.
9. 9
Cardiogenic shock
Cardiogenic shock –
This type of shock is caused by the failure of
the heart to pump effectively.
This can be due to damage to the heart
muscle, most often from a large myocardial
infarction.
Other causes of cardiogenic shock include
arrhythmias, cardiomyopathy, congestive
heart failure (CHF), and cardiac valve
problems.
10. 10
Distributive shock
Distributive shock –
As in hypovolaemic shock there is an insufficient
intravascular volume of blood.
This form of "relative" hypovolaemia is the result of
dilation of blood vessels which diminishes
systemic vascular resistance. Examples of
this form of shock are:
1. Septic shock
2. Anaphylactic shock
3. Neurogenic shock
11. 11
Obstructive shock
Obstructive shock –
In this situation the flow of blood is
obstructed which impedes circulation and can
result in circulatory arrest.
Several conditions result in this form of
shock.
1. Cardiac tamponade
2. Tension pneumothorax
3. pulmonary embolism
4. Aortic stenosis
12. 12
Endocrine shock
based on endocrine disturbances.
Recently a fifth form of shock has been introduced:
Hypothyroidism, in critically ill patients, reduces cardiac output and
can lead to hypotension and respiratory insufficiency
Thyrotoxicosis may induce a reversible cardiomyopathy
Acute adrenal insufficiency is frequently the result of discontinuing
corticosteroid treatment without tapering the dosage
However, surgery and intercurrent disease in patients on
corticosteroid therapy without adjusting the dosage to accommodate
for increased requirements may also result in this condition
Relative adrenal insufficiency in critically ill patients where present
hormone levels are insufficient to meet the higher demands
13. 13
Comparison of types of shock
(Early stage)
Vasoconstrictive Vasodilatative
Hypovolamic Cardiogenic Circulatory Septic
Cardiac
index
Cardiac
index
Peripheral
resistance
Peripheral
resistance
Blood
Volume
Blood
Volume
Malperfusion and organ dysfunction are the ultimate end point of any shock stage
14. 14
Decreased cardiac output
Decreased blood pressure
Decreased tissue perfusion
Decreased coronary perfusion
Decreased myocardial function
Microcirculatory
obstruction
Cellular aggregation
Microcirculatory demage
Cell hypoxia
Metabolic
acidosis
Decreased
myocardial
contraction
Inracellular
fluid
loss
Decreased
venous return
BP = CO x SVR
Pathophysiology Concept Map
15. 15
Hypovolemic Shock
loss in circulatory volume
Decreased venous return
Decreased filling of the cardiac chambers
Decreased cardiac output
increase in the systemic vascular resistance (SVR).
low central venous pressure (CVP), a low pulmonary capillary wedge pressure (PCWP), low
cardiac output (CO) and cardiac index (CI), and high SVR. The arterial blood pressure may be
normal or low.
17. 17
Cardiogenic Shock
dependent on poor pump function
acute catastrophic failure of left
ventricular pump function
high PCWP, low CO and CI, and generally a high SVR
21. 21
Extracardiac obstructive shock
Impaired diastolic filling (decreased
ventricular preload)
a physical impairment to adequate forward circulatory flow involving
mechanisms (different than primary myocardial or valvular dysfunction)
Frank decrease in filling pressures (as in mediastinal compressions of
great veins) or
trends towards equalization of pressures in the case of cardiac
tamponade or
markedly increased right ventricular filling pressures
High CVP, low PCWP Cardiac output is usually decreased with increased SVR.
24. 24
Enhance compensatory phase
of the shock
Maintenance of mean circulatory pressure
Maximizing cardiac function
Redistributing perfusion to vital organs
Optimizing unloading of oxygen at tissues
25. 25
Maintain Volume
-Fluid redistribution to
vascular space
From interstitium
(Starling effect)
From intracellular
space (Osmotic
effect)
-Decreased renal fluid
losses
Decreased
glomerular filtration
rate (GFR) Increased
aldosterone
Increased
vasopressin
28. 28
Early mechanical ventilation
allows blood flow to be redistributed
tends to reverse lactic acidosis
supports the patient until other
therapeutic measures can be effective
Tidal volumes in the order of 7-10 mlkg-1 of lean body mass, an O2
concentration that results in arterial saturation not less than 92%, adequate
ventilator rate and sedation to minimize the work of breathing.
29. 29
Fluid resuscitation
IV line
Large bore cannula
More iv line
Choice of infusion
Lactated Ringer's
solution (initial
bolus: 10-25 ml/kg
/ 10 min.)
Colloids
Dextrane
Hydroethylstrach
Gelatine
Small volume resuscitation
Rate, amount
General conditions
parameters ( BP, Pulse,
CVP, SatO2 etc)
33. 33
Reference Resource
Joynt, Gavin (April 2003). "Introduction to
management of shock for junior ICU trainees and
medical students". The Chinese University of
Hong Kong. Retrieved on 9 October, 2006.