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2. It is a Syndrome characterized by decreased
tissue perfusion and impaired cellular
metabolism
Imbalance between the supply and demand for
O2 and nutrients

3. 1. Low blood flow
Cardiogenic
Hypovolemic
2. Maldistribution of blood flow
Septic
Anaphylactic
Neurogenic

5. Cardiogenic shock is a condition in which heart
suddenly can't pump enough blood to meet body's
metabolic needs

6. Primary dysfunction of one ventricle or the other.
Dysfunction may be due to
Myocardial infarction
Cardiomyopathy
Blunt cardiac injury
Severe systemic or pulmonary hypertension
Cardiac tamponade
Myocardial depression from metabolic problems

7. PATHOPHYSIOLOGY

9.  Early manifestations
 Tachycardia
 Hypotension
 Narrowed pulse pressure
 ↑ Myocardial O2 consumption
 Late manifestations
 Anxiety, restlessness, altered mental state due to decreased
blood flow to the brain and subsequent hypoxia.
 Low blood pressure due to decrease in cardiac output.

10.  A rapid, weak, thready pulse due to decreased
circulation combined with tachycardia.
 Cool, clammy, and mottled skin (cutis marmorata)
due to vasoconstriction and subsequent
hypoperfusion of the skin.
 Distended jugular veins due to increased jugular
venous pressure.
 Oliguria (low urine output) due to inadequate blood
flow to the kidneys if the condition persists.

11.  Rapid and deeper respirations (hyperventilation) due
to sympathetic nervous system stimulation and
acidosis.
 Fatigue due to hyperventilation and hypoxia.
 Absent pulse in fast and abnormal hear rhythms.
 Pulmonary edema, involving fluid back-up in the
lungs due to insufficient pumping of the heart.

12. Electrocardiogram
 An electrocardiogram helps establishing the exact
diagnosis and guides treatment, it may reveal:
 Abnormal heart rhythms
 myocardial infarction
 Signs of cardiomyopathy

13.  Echocardiography may show poor ventricular
function, rupture of the interventricular septum, an
obstructed outflow tract or cardiomyopathy.
 Swan-Ganz catheter
The Swan-Ganz catheter or pulmonary artery
catheter may assist in the diagnosis by providing
information on the hemodynamics.

14.  Biopsy
When cardiomyopathy is suspected as the cause of
cardiogenic shock, a biopsy of heart muscle may
be needed to make a definite diagnosis.

15. GOAL OF MANAGEMENT :
 Treat reversible causes
 Protect ischemic myocardium
 Improve tissue perfusion

16.  Early assessment & treatment!!!
 Optimizing pump by:
 Increasing myocardial O2 delivery
 Maximizing CO
 Decreasing LV workload (Afterload)

17. Limiting/reducing myocardial damage during
Myocardial Infarction:
 Increased pumping action & decrease workload of the
heart
 Inotropic agents
 Vasoactive drugs
 Intra-aortic balloon pump
 Cautious administration of fluids
 Transplantation
 Consider thrombolytics, angioplasty in specific cases

18. OPTIMIZING PUMP FUNCTION:
 Pulmonary artery monitoring is a necessity !!
 Aggressive airway management: Mechanical Ventilation
 Judicious fluid management
 Vasoactive agents
 Dobutamine
 Dopamine
 Morphine as needed (Decreases preload, anxiety)
 Cautious use of diuretics in CHF
 Vasodilators as needed for after load reduction
 Short acting beta blocker, for refractory tachycardia

20.  Occurs from inadequate circulating blood volume
 Major effects are due to decreased cardiac output
and low intra cardiac pressure
 Severity of clinical features depends on degree of
blood volume lost

21.  Hypovolemic shock, also known as
hemorrhagic shock, is a life-threatening condition
that results from lose of more than 20 percent
(one-fifth) of body's blood or fluid supply. This
severe fluid loss makes it impossible for the heart
to pump a sufficient amount of blood to the body.

22.  Relative hypovolemia
 Results when fluid volume moves out of the vascular
space into extravascular space (e.g., interstitial or
intracavitary space)
 Termed third spacing

23. Internal or External fluid loss
Intracellular and extracellular compartments
Most common causes:
Hemmorhage
Dehydration

24.  External loss of fluid
Fluid loss: Dehydration
Nausea & vomiting, diarrhea, massive diuresis
extensive burns
Blood loss:
trauma: blunt and penetrating

25.  Internal fluid loss
 Loss of Intravascular integrity
 Increased capillary membrane permeability
 Decreased Colloidal Osmotic Pressure
(third spacing)

26. Hemorrhagic:
trauma
gastrointestinal bleeding
Non-hemorrhagic: external fluid loss
 diarrhoea
 vomiting
 polyurea
 fluid redistribution
 Burns
 anaphylaxis

27.  PATHOPHYSIOLOGY

29. SIGNS AND SYMPTOMS
AND STAGES

30. Stage 1 Stage 2 Stage 3 Stage 4
Blood loss
Up to 15%
(750mL)
15–30% (750–
1500mL)
30–40%
(1500–
2000mL)
Over 40% (over
2000mL)
Blood
pressure
Normal
(Maintained
by vasoconstric
tion)
Increased diastoic
BP
Systolic
BP <100
Systolic BP <
70
Heart rate Normal
Slight tachycardia
(> 100bpm)
Tachycardia
(> 120bpm)
Extreme
tachycardia (>
140bpm) with
weak pulse
Respiratory
rate
Normal Increased (> 20)
Tachypneic (>
30)
Extreme tachyp
nea
Mental status Normal
Slight anxiety,
restless
Altered
confused
Decreased LOC
, lethargy, coma

31. Stage 1 Stage 2 Stage 3 Stage 4
Skin Pallor
Pale, cool,
clammy
Increased di
aphoresis
Extreme diap
horeis;
Capillary
refill
Normal Delayed Delayed Absent
Urine
output
Normal 20–30mL/hr 20ml/hr Negligible

32.  Tachycardia and tachypnea
 Weak, thready pulses
 Hypotension
 Skin cool & clammy
 Mental status changes
 Decreased urine output: dark & concentrated

33. Management goal: Restore circulating
volume, tissue perfusion, & correct cause:
 Early Recognition- Do not relay on BP! (30% fluid
loss)
 Control hemorrhage
 Restore circulating volume
 Optimize oxygen delivery
 Vasoconstrictor if BP still low after volume loading

34.  Inotropic therapy (Dopamine, Noradrenaline)
which increase the contractility of the heart muscle
 Fresh frozen plasma or whole blood

36.  Neurogenic shock is a distributive type
of shock resulting in low blood pressure,
occasionally with a slowed heart rate, that is
attributed to the disruption of the autonomic
pathways within the spinal cord. It can occur after
damage to the central nervous system such as spinal
cord injury.

37.  Neurogenic shock can result from severe central nervous
system damage
- brain injury,
- cervical or high thoracic spinal cord).
 Neurogenic shock results from damage to the spinal cord
above the level of the 6th thoracic vertebra.

38. PATHOPHYSIOLOGY

40.  Hypotension
 Bradycardia
 Temperature dysregulation
(resulting in heat loss)
 Dry skin
 Poikilothermia (taking on the
temperature of the environment)

41. PATIENT
ASSESSMENT
 Hypotension
 Bradycardia
 Hypothermia
 Warm, dry skin
 CO
 Flaccid paralysis below
level of the spinal
MEDICAL
MANAGEMENT
 Goals of Therapy are
to treat or remove the
cause & prevent
cardiovascular
instability, & promote
optimal tissue
perfusion

42.  Dopamine (Intropin) is often used either alone or
in combination with other inotropic agents.
 Vasopressin (antidiuretic hormone [ADH])
 Certain vasopressors (ephedrine, norepinephrine).
Phenylephrine may be used as a first line
treatment, or secondarily in people who do not
respond adequately to dopamine.
 Atropine is administered for slowed heart rate.

43.  A type of distributive shock that results from
widespread systemic allergic reaction to an antigen
 Anaphylactic shock is a severe, potentially life-
threatening allergic reaction. It can occur within
seconds or minutes of exposure to allergen.

44.  certain medications such as penicillin
 insect stings
 foods such as tree nuts, shellfish, milk, and eggs
 agents used in immunotherapy
 latex

46.  Skin
⁻ Generalized hives.
⁻ Itching or flushing.
⁻ Swollen lips-tongue-uvula.
⁻ Per-orbital edema.
 Respiratory
⁻ Nasal discharge and congestion.
⁻ Change in voice quality.
⁻ Sensation of throat closure or choking.
⁻ Tridor or wheeze.
⁻ Shortness of breath and cough.

47. Gastrointestinal:
⁻ Nausea.
⁻ Vomiting.
⁻ Diarrhea.
⁻ Crampy abdominal pain.
Cardiovascular:
⁻ Hypotonia (collapse).
⁻ Syncope.
⁻ Dizziness.
⁻ Tachycardia.
⁻ hypotension.

48.  Epinephrine
 IM 0.3mg , 1:1000
 IV 0.15mg , 1:10,000
 Antihistamine
 Corticosteroid
 Bronchodilator
 Oxygen
 Fluids and vasopressors

49.  Sepsis: Systemic inflammatory response to
documented or suspected infection
 Severe sepsis = Sepsis + Organ dysfunction

50.  Systemic Inflammatory Response (SIRS) to
INFECTION manifested by : two or > of
following:
 Temp > 38 or < 36 centigrade
 HR > 90
 RR > 20 or PaCO2 < 32
 WBC > 12,000/cu mm or < 4,000
> 10% Bands (immature wbc)
 Sepsis syndrome: SIRS with confirmed
infectious process associate with organ failure
or hypotention

51.  Age
 Malnutrition
 General debilitation
 Use of invasive catheters
 Traumatic wounds
 Drug Therapy

53.  Two phases:
1.“Warm” shock - early phase
 hyperdynamic response,
 VASODILATION
2.“Cold” shock - late phase
 hypodynamic response
 DECOMPENSATED STATE

54. Pink, warm,
flushed skin
Increased Heart
Rate
Tachypnea
Massive
vasodilation
Increased CO
Crackles

55.  Vasoconistriction
 Skin is pale & cold
 Tachycardia
 Decrease BP
 Change LOC
 Decrease UOP
 Decrease CO
 Metabolic &
respiratory acidosis
with hypoxemia

56.  Prevention !!!
 Find and kill the
source of the infection
 Fluid Resuscitation
 Vasoconstrictors
 Inotropic drugs
 Maximize O2
delivery Support
 Nutritional Support
 Comfort &
Emotional support