This document defines and describes shock, including its pathophysiology, types, clinical features, management, and monitoring. Shock is defined as a systemic state of low tissue perfusion due to inadequate oxygen and glucose delivery. The main types of shock discussed are hypovolemic, cardiogenic, obstructive, distributive, and endocrine shock. Clinical features vary based on shock severity from mild tachycardia to profound hypotension and coma. Management involves treating the underlying cause, improving cardiac function and tissue perfusion through fluid resuscitation and vasopressors/inotropes as needed. Close monitoring of vital signs and other parameters is important for patients in shock.

1. SHOCKArranged by :
Dunya Arsalan
Abdullah M. Muslih
Mohammad Najdat
Supervised by :
Dr.Nadim Haddad

2. Definition
 Systemic state of low tissue perfusion ,
which is inadequate for normal cellular
respiration.
 Insufficient delivery of O2 and glucose
 Cells switch from aerobic to an anaerobic
metabolism .

3. Cellular respiration

4. Pathophysiology

5. Systemic
Cardiovascular :
Preload and afterload
sympathetic activity
release of catecholamines into circulation
Tachycardia and systemic vasoconstriction

6. Respiratory :
Acidosis and sympathetic response
respiratory rate Increase excretion of
CO2 respiratory alkalosis .

7. Renal :
 Decreased perfusion pressure in the kidney
leading to reduced filtration at the glomerulus
and decreased urine output .
RAAS stimulation result in further
vasoconstriction and increase in Na and water
reabsorption by the kidneys .

8. Endocrine
 Vasopressin : released from hypothalamus
resulting in vasoconstriction and water
reabsorption .
 cortisol :released from adrenal contributing to the
Na and water reabsorption and sensitizing the cells
to catecholamines .

9.  Classification of shock :
1) Hypovolemic shock
2) Cardiogenic shock
3) Obstructive shock
4) Endocrine shock
5) Distributive shock

10. Hypovolemic shock
 may be due to :
hemorrhagic (common) .
non hemorrhagic .
-poor fluid intake .
-excessive fluid loss .
-evaporation and third
space

11. Cardiogenic shock
 MI
Cardiac dysrhythmia
Valvular heart disease
Blunt myocardial injury
Cardiomyopathy

12. 0bstructive shock
Cardiac tamponade .
Tension pneumothorax .
Massive pulmonary embolism.

13. Distributive shock
• Describes the pattern of cardiovascular responses
characterized by variety of conditions including :
Septic shock
Anaphylactic shock
Spinal cord injury
• Inadequate organ perfusion is accompanied by
vascular dilation with hypotension , low systemic
vascular resistance , inadequate afterload and
resulting in abnormally high cardiac output .

14.  septic shock
Bacterial , fungal & viral infection .
Release of endotoxins and activation of cellular and
humoral components . There is mild distribution of
blood flow at a microvascular level with
arteriovenous shunting and dysfunction of the
cellular utilization of O2 .
 In later stage fluid loss into the interstitial spaces
there will be hypotension and concomitant
myocardial depression .

15. Anaphylactic shock
-Medications , Food,
insect stings & latex .

16. Spinal cord injury :
In high spinal cord injury there is failure of
sympathetic outflow and adequate vascular
tone (neurogenic shock) .

17. • Endocrine shock :
 It may present as a combination of
hypovolemic , cardiogenic and distributive
shock .
cause : hypo/hyperthyroidism and adrenal
insufficiency .

18. Hypothyroidism :
 Causes shock similar to neurogenic shock as a
result of disorders of vascular and cardiac
responsiveness to circulatory catecholamines .

19. Thyrotoxicosis :
 Cause high output cardiac failure .

20. • Adrenal insufficiency:
Result in hypovolemia and a poor response to
circulating and exogenous catecholamines .
May result from pre existing Addison's disease
.

21. Severity of shock
Compensated shock (occult hypoperfusion) : --
There is adequate compensation to maintain
the central blood volume and preserve flow to
kidney , lung and brain .
 Cardiovascular state is only maintained by
reducing perfusion to the skin , muscle & GIT.
 If it lasts for more than 12hrs , it will have
significantly higher mortality rate , infection
rate and incidence of multiple organ failure .

22.  Decompensation :
 Further loss of circulating volume overload
(30%-40%) , the body's compensatory
mechanism fails, there is progressive renal ,
respiratory and cardiovascular
decompensation.

23. Clinical features of shock
Depend on severity of shock :
Mild shock : tachycardia , tachypnea , mild
anxiety , peripheries are cool and sweaty .
Moderate shock : urine output becomes below
0,5ml/kg/hr , there is further tachycardia, BP
starts to fall, and patient becomes drowsy &
mildly confused .
Sever shock : anuria , profound tachycardia ,
labored respiration ,hypotension , comatose .

24. Capillary refill : most patients with hypovolemic
shock will have cool and pale peripheries with
prolonged capillary refill time , except in septic
shock.

25. Tachycardia : may not always accompany shock,
patient on B.blocker or who have pacemaker
unable to mount tachycardia .
BP: is one of the last signs . Children and fit
young adults are able to maintain BP by
increasing stroke volume and peripheral
vasoconstriction .These patients can be in
profound shock with a normal BP .

26. Consequences
Unresuscitable shock :
Cell death from cellular ischemia , and the
ability of body to compensate is lost.
Multiple organ failure :
two or more organ systems fail and carries a
mortality rate of 60% .

27. Management
Guidelines
Treat the cause .
Improve cardiac function .
Improve tissue perfusion.

28. Principles of resuscitation
Ensure patent airway , adequate oxygenation and
ventilation , once A&B controlled attention is
directed to cardiovascular resuscitation .

29. Rapid clinical examination will provide adequate
clue to make an appropriate first determination.
• This involves from head to toe examination .
• Pelvic examination in obstetric patient.
Monitoring the vital signs

30. Fluid therapy
• First line therapy : IV access and administration
of IV fluid .

31. Types of fluid
Crystalloid solutions
-Normal saline
-Ringer’s lactate solutions
Colloid solutions
Blood transfusion

32. Dynamic fluid response
The shock status can be determined dynamically
by cardiovascular response to rapid
administration of a fluid bolus .
250-500 ml is rapidly given (over 5-10 min) and
HR , BP ,CVP are observed .
-responder .
-transient responder .
-non responder .

33. Vasopressors and inotropic support
Vasopressor (phenylephrine –norepinephrine)
indication :
Distributive shock ( sepsis and neurogenic
shock )
 inotropic agents ( dobutamine)
indication :
cardiogenic shock

34. Monitoring for patient in shock
 Minimum :
1) ECG
2) Pulse oximetry
3) Blood pressure
4) Urine output

35. Additional monitoring :
1) CVP
2) Invasive blood pressure
3) Cardiac output
4) Base deficit and serum lactate

36. Thank you