Shock is a pathophysiological state characterized by inadequate oxygen delivery to tissues, leading to organ dysfunction and potentially death. Effective management includes recognizing physiological compromise, identifying causes, resuscitating, and treating underlying issues; early signs and interventions are critical. Types of shock include hypovolemic, distributive, cardiogenic, and obstructive, with treatment strategies varying according to the specific cause and severity.

1. SHOCK
MANAGEMENT
Dr. GT Wijesinghe, MBBS

2. Irrespective of the cause the inadequate delivery of oxygen to tissues results in a
failure of aerobic metabolism leading to end organ dysfunction, and ultimately the
death.
Oxygen delivery Oxygen demand SHOCK
What do you mean by SHOCK ?
• Shock is defined as pathophysiological state in which there is an inadequate supply or inappropriate
use of metabolic substrate (particularly oxygen) by peripheral tissues

3. Importance of Oxygen delivery
For practical purposes global oxygen delivery can be calculated as:
Cardiac output (HR x SV) x [Hb]g/dl x 10 x 1.34 x Saturation(sO2) ml/l
• ATP is the fuel of body ( energy source in cellular metabolism )
• ATP is produced by glucose metabolism
• Oxygen is needed in this reaction, but limited reaction also possible without oxygen (anerobic)
• Glucose Pyruvate Lactate + CO2
• Limitation of oxygen result in altered cellular activities leading to organ dysfunction
Aerobic >>> Anerobic ( 18 times higher efficacy )

4. MANAGEMENT STEPS...
1. Recognition of the degree of physiological compromise
2. Identification of the cause
3. Correction of the physiological deficit
4. Treatment of the underlying cause
ABCDE approach
Focused history simultaneous resuscitation
Examination

5. Normal Early signs Late signs Irreversible state, death
Identify the shock… and Intervene
• Early signs - Results of compensatory mechanisms
• Late signs - Secondary to organ dysfunction
1 2
3
Time is an important factor !

6. Heart rate
Absence of tachycardia does not rule out hemorrhagic
shock
Skin
Cold / clammy - Hypovolemic
Warm - Neurogenic / Early sepsis
Erythema / Urticaria / Angioedema - Anaphylaxis
Respiratory rate
excellent marker of physiological compromise
Secondary to hypoxia / Metabolic acidosis
Blood pressure
Normal at early stages
Pulse pressure drops prior to BP
MAP > 65 mmHg important
GCS
Lack of cerebral perfusion
Urine Out Put
Reduced UOP is a Late sign, useful in assessment of
resuscitation in shocked patients
May be misleading ; Eg: Diabetic ketoacidosis
LOOK FOR THESE…

7. Seemingly normal physiology may be concealing a
significantly compensated shock !!!

8. Investigations
Target to identify the cause
FAST / CT - trauma
ECG - cardiogenic shock
Echo - Pulmonary embolism
Blood lactate
Product of anaerobic respiration
> 4 mmol/l is associated with increased ICU admission and mortality in normotensive patients with sepsis
higher lactate clearance at 6 hours have an improved outcome
SVO2
Normaly about 70 %
reduced in shock due to inadequate oxygen delivey
Falsely negative in uncompensated septic shock
ABG – SaO2 / Base excess / HCO3 / Anion gap

9. High flow
supplementary
oxygen
Once a shock state is recognized, treatment must focus on:
1. Reversing the physiological deficit (resuscitation)
2. Treating the cause
+/-Fluid resuscitation
Blood, colloid, Crystalloid
Inotropes
Frequent clinical re-assessment Response ? Accuracy of diagnosis | Need of intervention
Surgical intervention
Antibiotics
Intubation & Ventilation

10. Effect on oxygen delivery Intervention Increase in oxygen delivery
Greatest
Increasing [Hb] from 6g/dl to
9g/dl
50%
Increasing cardiac output by
20% with crystalloid boluses
20%
Increasing oxygen saturation
from 91% to 100% with
supplemental oxygen
10%
Least
Increasing PaO2 from 12kPa to
40kPa with supplemental
oxygen
<1%
Incresing Hb - Blood transfusion – Not more / not less
Increasing Cardiac Output - Crystalloids | Colloids | Inotropes
Increasing oxygen saturation - Supplementary Oxygen | Intubation and Ventilation
GOAL of resuscitation

11. Types of shock...
(Causes)
Hypovolemic
Distributive
Cardiogenic
Obstructive
Combination ? ?

12. • Place of surgical intervention
with uncontrolled haemorrhage temporary or definitive haemostasis (even in the presence of hypotension)
should be performed first, followed by intravascular fluid replacement
• Crystalloids
 250 ml bolus over 5 – 10 min
 Reassess after each
 There is no evidence that ordinary crystalloid ( Normal saline or Hartmanns ) is inferior to colloid
 Reduction in the hemoglobin by approximately 1g/dl per 500 ml of colloid or crystalloid solution
remaining in the vascular compartment
 Place of hypertonic saline?
• Blood
Target Hb 8 – 9 g/dl
Judicious transfusion, avoid fluid overload
• Role of passive leg raising
only 100-150 mL are transferred to the intravascular space by this method

13. Role of Inotropes
Exactly which inotrope in which setting is a subject of vigourous ongoing debate
Considered in unresponsive shock for resuscitation
Norepinephrine is considered firstline in Septic shock
Dobutamine increase contractility but vasodilate; worsen the septic or anaphylactic shock if give early.
Useful in cardiogenic shock
Intubation & Ventilation
Early intubation and ventilation may needed
Oxygen consumption can be dramatically reduced by taking over the work of breathing
Need to consider intubation once fluid resuscitation exceeds 40-60 ml/kg in children due to risk of
pulmonary edema
Role of Low dose steroids ??
Initial enthusiasm for low dose steroids in sepsis is now waning
[ exception in adrenal insufficiency (Addisonian crisis) ]

14. Take home message
Shock is not a diagnosis , it is a pathophysiological state secondary to many
disease conditions
Inadequate oxygen delivery to tissues is the main problem
Do not rely simply on heart rate and blood pressure while tackling with a patient
who is carrying the possibility of shock, because initial compensation may mask
the imminent decompensation
Increased respiratory rate is an excellent early clinical indicator of ongoing shock
Serum lactate level > 4 mmol/ l is a good early indicator
Prompt early resuscitation +/- surgical intervention(when necessary) and
definitive treatment for underlying pathology is the mainstay of management
Intubation and ventilation will help to minimize the work load needed for
breathing