Shock is a life threatening emergency which all physicians must know. This slide helps in the understanding of shock, it's definition/classification/pathophysiology/clinical features/investigations and assessment of shock..

1. SHOCK
BY NAWA .M.S

2. OBJECTIVES
• Definitions and terms
• Determinants of oxygen
• Classification of shock with causes
• stages of shock
• clinica features
• investigations
• summary of septic shock and shock index

3. DEFINITIONS AND TERMS
• SHOCK:
• state of cellular and tissue hypoxia due to either reduced oxygen delivery, increased oxygen
consumption or inadequate oxygen utilization.
• clinical condition of oxygen dysfunction due to an imbalance between oxygen supply and oxygen
demand.
• UNDIFFERENTIATED SHOCK: shock is recognized but cause is unknown.
• MIXED SHOCK: patient presents with more than one type of shock.
• NOTE: initially, shock is reversible with treatment but irreversible if untreated and can lead to
multisystemic organ failure.
• DETERMINANTS OF OXYGEN
• preload
• myocardial contractility
• systemic vascular resistance
• hemglobin combined with the blood(hb×1.39×Saturation of oxygen)
• oxygen dissolved in blood(partial pressure of oxygen×0.03)
• NOTE: if any of the components above are affected can lead to shock.

4. CLASSIFICATION OF SHOCK WITH CAUSES AND PHYSICAL EXAMINTION

5. TYPES OF CARDIOGENIC SHOCK
• FUNCTIONAL: associated with functional defect of heart( as in ischaemic heart disease)
• COMPRESSIVE: associated with mechanical or exteranal compression( cardiac tamponade, tension
pneumothorax, positive pressure ventilation)
• OBSTRUCTIVE: associated with obstruction to flow( valvular insufficiency, tension pneumothorax)

6. CAUSES(CONTINUED)
• CARDIOGENIC: drug overdose(calcium channel blockers, beta blockers),valvular(severe aortic/mitral
valve insufficiency)
• HYPOVOLEMIC: trauma
• PARAMETERS AFFECTED
CVP=CENTRAL VENOUS PRESSURE
PCWP=PULMONARY CAPILLARY WEDGE PRESSURE

9. TYPES OF SHOCK= A GAS STATION

11. PATHOPHYSIOLOGY OF SHOCK

12. STAGES OF SHOCK

13. • NOTE
• COMPENSATED SHOCK: Blood pressure is normal, tachycardia, mild tachypnoea, reduced capillary
refill time, orthostatic changes in bloodd pressure and pulse, irritability.
• DECOMPENDATED SHOCK: Hypotension, increased tachycardia, thin thread pulse, tachypnoea,
reduced urine output, altered mental status and cold peripheries.
CLINICAL FEATURES(GENERAL)
SYMPTOMS: symptoms of cause with dyspnoea, drowsiness, oliguria/anuria, confusion, light headness
SIGNS:
A=reduced consciousness, compressed airway
B=hypoxia, kussmal respirations
C=cold and pale extremities, capillary refill time greater than 3 SECONDS, tachycardia, oliguria/anuria
D=confusion

14. PHYSICAL EXAMINATION

15. NOTE
• DISTRIBUTIVE SHOCK: Warm extremities, bounding pulse, brisk capilly refill time
• CARDIOGENIC SHOCK: Signs of heart failure(raised jvp, peripheral oedema, s3 gallop,..)
• HYPOVOLEMIC SHOCK(CLASSES)

16. GENERAL CRITERIA FOR A SHOCK PATIENT

17. INVESTIGATIONS
• Arterial blood gas analysis
• ECG and Chest x ray
• Echocardiography
• urinalysis and urine sediments
• coagulation profile
• lactacte/renal function test/liver function test
• cardiac output, pulmonary capillary wedge pressure
• vitals: blood pressure, temperature, respiratory rate and pulse rate
• IN TRAUMA PATIENTS: pelvic x-ray, CT-TAP(thorax,abdomen,pleura), e-fast scan.
• cardiac enzymes
• full blood count/differential count

18. SUMMARY OF SEPTIC SHOCK AND SHOCK INDEX

19. • PRACTICAL DEFINITION OF SEPTIC SHOCK: Despite fluid resuscitation=
• 1.) hypotension requiring vasopressors to maintain mean arterial pressure of less than 65mmHg
• 2.) elevated lactate levels of greater than 2mmol/l
• RISK FACTORS
• Supressed immune response
• Extreme age(infant/elderly)
• People who received an organ transplant
• Surgical procedures(invasive)
• Infection/indwelling devices
• Sickness(chronic illness)-diabetes mellitus, alcoholism, liver/renal failure.
• CLINICAL FEATURES
• T-increasedor decreased temperature
• I-symptoms and signs of infection
• M-mentally declined(confused, sleepy, inability to arouse)
• E-extremely ill(severe pain,discomfort,dyspnoea)

20. ASSEMENT OF SHOCK PATIENT
• SHOCK INDEX(SI)=Heart rate over systolic blood pressure(HR/SBP)
• MODIFIED SHOCK INDEX(MSI)=Heart rate over mean arterial pressure(HR/MAP)
• shock index of:
• ≥0.6 to <1=mild shock
• ≥1 to < 1.4=moderate shock
• ≥ 1.4=severe shock
• Increased MSI/SI is seen in: hypovolemic shock, cardiogenic shock, septic shock
• Decreased MSI/SI is seen: neurogenic shock

21. REFERENCES
• MEDICINE_PREP MANUAL OF MEDICINE(5TH EDITION) NY K.GEORGE MATHEW, E’TAL..
• SHOCK BY DR SHUBHAM UPADHYAY
• APPROACH TO A SHOCK PATIENT BY DR HOPE MUTENGO
• HARRISON’S MANUAL OF MEDICINE(20TH EDITION) BY DR FAUCI, E’TAL..
• SHOCK-BASIC-PRINCIPLES IN SURGERY BY DR .B. SELVARAJ
• KUMAR AND CLARK’S CLINICAL MEDICINE(10TH EDITION) BY PROFESSOR DAME PARVEEN J
KUMAR, E’TAL...

22. • NEXT SLIDE: SOFA SCORE/QSOFA SCORE AMD
MANAGEMENT OF SHOCK
• THANK YOU.....