Shock

Max Harry Weil and Eric C. Rackow

INTRODUCTION
Shock is a clinical syndrome characeri!ed "y #roraced #rosraion$ #allor$ coolness and moisness o% he
skin$ colla#se o% he s&#er%icial 'eins$ aleraion o% menal sa&s$ and s&##ression o% &rine %ormaion. The "asic
de%ec ha &nderlies shock is a red&cion in e%%eci'e #er%&sion o% iss&es wih decreased oxy(en deli'ery o he
ca#illary "ed. The sysolic arerial #ress&re is &s&ally less han )* mm H( or has declined "y more han +* mm H(
%rom a #re'io&s hy#erensi'e le'el. , -normal. "lood #ress&re may re%lec excessi'e 'asoconsricion e'en when
"lood %low is criically red&ced.
Shock may "e re(arded as a hemodynamic de%ec o% s&ch se'eriy ha deli'ery o% oxy(en is no ade/&ae
o mee he mea"olic needs o% he iss&es 012. 3iochemical dis&r"ances %ollow ischemic in4&ry o iss&es. These
incl&de he li"eraion o% lysosomal en!ymes$ hisamine$ seroonin$ kallikrein$ and #rosa(landins5 aleraions in
"lood cloin( wih cons&m#ion coa(&lo#ahies and disseminaed inra'asc&lar coa(&laion5 red&cion in
reic&loendohelial aci'iy5 and he release o% #roein "reakdown #rod&cs$ es#ecially &ric acid$ &rea$ and
creainine. ,cidemia %rom an excess o% hese acids$ as well as lacic and #yr&'ic acid$ %ay acids$ keones$ and
amino acids$ ens&es. Si(ns o% di%%&se in4&ry a##ear$ incl&din( increases in ser&m ransaminase and lacic
dehydro(enase. Indocyanine (reen clearance "y he li'er is im#aired$ re%lecin( a decrease in he#aocell&lar
%&ncion.
When inracell&lar oxy(en is criically red&ced$ miochondrial %&ncion and he re(eneraion o% hi(h6ener(y
#hos#hae com#o&nds are im#aired 072. Cell&lar mem"rane #ermea"iliy is increased$ and he sodi&m6#oassi&m
#&m# is dama(ed. ,ccordin(ly$ inracell&lar #oassi&m is red&ced$ sodi&m concenraion is increased$ and he cell
swells. Inracell&lar acidosis and lysosomal lysis wih release o% lysosomal hydrolases iniiae a&odi(esion o% cell
#arenchyma wih &limae cell deah 082. Im#airmen o% aero"ic mea"olism ri((ers a less e%%icien anaero"ic
#ahway o% ener(y #rod&cion wih acc&m&laion o% lacic acid$ which has "een correlaed wih se'eriy and s&r'i'al
09$+$:$; and <2 0=i(. 7>1.12.
=i(&re 7>1.1. The #ro"a"iliy c&r'e indicain( he likelihood o% s&r'i'al "ased on a (i'en 'al&e o% arerial "lood
lacae in #aiens wih circ&laory shock. 0Re#rod&ced wih #ermission %rom Weil MH$ ,%i%i ,,? Circ&laion
1);*591?)<).2
We "elie'e ha he lacae concenraion c&rrenly ser'es as he "es sin(le meas&remen o% he #resence and he
se'eriy o% shock saes 0)2.
HEMOD@N,MIC MECH,NISMS O= SHOCA
The hemodynamic mechanisms o% shock are "es 'iewed in relaionshi# o he %&ncional com#onens o% he
cardio'asc&lar sysem.
The %irs com#onen is he oal 'ol&me o% "lood conained wihin he 'asc&lar com#armen.
The second com#onen is he hear$ which ser'es as he #&m# #ro'idin( hydra&lic #ower %or circ&laion.
The hird com#onen is he resisance circ&i$ which incl&des areries and arerioles$ hro&(h which "lood ra'els o
he ca#illary exchan(e "eds.
The %o&rh com#onen is he ca#illary "ed$ which is he sie o% n&rien exchan(e and %l&id %ilraion "eween he
inra'asc&lar and inersiial %l&id com#armens. 3lood %low and %l&id %ilraion hro&(h hese ca#illary "eds are
re(&laed "y h&moral and ne&ro(enic conrols on he #reca#illary arerioles and #osca#illary 'en&les.
The #osca#illary 'en&les are he %i%h com#onen$ ser'in( as a sie %or 'eno&s #oolin(.
The sixh com#onen is he 'eno&s ca#aciance "ed$ which is he #rimary sora(e reser'oir$ accommodain( &# o
<*B o% he oal "lood 'ol&me. Chan(es in 'eno&s ca#aciance ser'e o increase or decrease he circ&lain( "lood
'ol&me and$ here%ore$ he #reload$ which may "e re#resened as he 'eno&s re&rn o% "lood o he hear.
The mearerioles are he se'enh com#onen. These 'essels "rid(e he resisance 'essels and he #osca#illary
'eno&s "eds$ "y#assin( he ca#illary circ&i$ and ser'e as -sh&ns..
The mainsream channels are he ei(hh com#onen$ cond&cin( "lood o and %rom he hear.
Hemodynamic mechanisms o% shock are relaed o he dys%&ncion o% one or more com#onens o% he sysem
0Ta"le 7>1.12.
Ta"le 7>1.1. Hemodynamic Mechanisms o% Shock
,lho&(h a sin(le hemodynamic a"normaliy may iniiae he low6%low sae$ he #ro(ression o% shock is
y#ically relaed o he com"ined e%%ec o% se'eral ca&ses. =or insance$ a criical red&cion in inra'asc&lar 'ol&me
acco&ns %or hy#o'olemic shock$ "& #ro(ression o% he shock sae is also relaed o increased arerial and 'en&lar
resisance$ 'eno&s #oolin($ cardiac %ail&re$ and inra'asc&lar coa(&laion wih 'asc&lar o"sr&cion. In cardio(enic
shock$ %acors ha may acco&n %or he #ro(ression o% shock incl&de hy#o'olemia$ disri"&i'e de%ecs associaed
wih increased areriolar and 'en&lar resisance$ and e'en o"sr&ci'e de%ecs %rom hrom"osis and em"oli!aion.
Circ&laory com#eence and oxy(en deli'ery o he iss&es is mainained "y an ine(raed %&ncionin( o% he
cardio'asc&lar sysem$ incl&din( 01*2 he hear$ which ser'es as a #&m#5 0112 he arerial ree$ as he resisance
"ed$ which ser'es as he cond&i ha deli'ers "lood o he ca#illaries hro&(h which mea"olies are exchan(ed5
0172 he low6#ress&re 'eins as he re&rn sysem$ which also ser'es as he ca#aciance "ed5 and 0182 he "lood
'ol&me.
Shock is classi%ied as? 0a2 hy#o'olemic$ 0"2 cardio(enic$ 0c2 o"sr&ci'e$ 0d2 or disri"&i'e 0Ta"le 7>1.72.
The #rimary de%ec &nderlyin( all ac&e circ&laory %ail&re is red&cion o% e%%eci'e "lood %low wih inade/&ae iss&e
#er%&sion. Cacic acid acc&m&laes "eca&se o% anaero"ic mea"olism and can #ro'ide a /&aniai'e meas&re o%
#er%&sion %ail&re and oxy(en de%ici. D&lmonary hydrosaic #ress&re and colloid osmoic #ress&re are im#oran in
he #rod&cion o% #&lmonary edema. When ca&sed "y le% 'enric&lar %ail&re$ #&lmonary edema re#resens a %orm o%
shock ha may e'en re/&ire %l&id re#leion o resore he e%%eci'eness o% inoro#ic and 'asodilaor dr&(s.
Ta"le 7>1.7. Classi%icaion o% Shock
H@DOEOCEMIC SHOCA
Ne&roh&moral Res#onses
The res#onse o hy#o'olemic hy#oension in an oherwise healhy #erson is re#rod&ci"le 0=i(. 7>7.12. , %all
in "lood 'ol&me iniiaes increased aci'iy %rom he caroid and aoric arch "arorece#ors$ and %rom
mechanorece#ors wihin he ri(h ari&m. , ne&roh&moral res#onse is iniiaed ha incl&des increased sym#aheic
ner'o&s sysem aci'iy wih direc cardiac sim&laion and #eri#heral 'asoconsricion$ increased #i&iary release
o% adrenocoricoro#ic hormone 0,CTH2 and anidi&reic hormone 0,DH2$ increased adrenocorical release o%
e#ine#hrine and corisol$ and increased renin6an(ioensin6aldoserone secreion. The ne e%%ec is an ine(raed
res#onse o mainain "lood #ress&re and "lood 'ol&me. Wih se'ere hy#o'olemia$ howe'er$ hese com#ensaory
mechanisms are ine%%eci'e and or(an %&ncion deerioraes. Oher hormones "esides caecholamines ha'e
'asoaci'e #ro#eries and are released ino he circ&laion d&rin( shock. Imm&ne sysem %acors #rod&cin(
in%lammaion are also released 012. The res&l alers myocardial %&ncion$ cloin( mechanisms$ and increase
in%lammaory res#onse o name 4&s a %ew. , loss o% more han 8*B o% #lasma 'ol&me hreaens immediae s&r'i'al
and elicis a #ro%o&nd "ody reacion as descri"ed #re'io&sly.
=i(&re 7>7.1. Ex#eced ne&roh&moral res#onse o hy#o'olemia.
Ca&ses o% shock deermine "ody res#onse. =or exam#le$ in%arced myocardi&m is lar(ely &nres#onsi'e o
adrener(ic sim&laion$ and cardiac sim&laion is here"y limied as an early com#ensaory mechanism d&rin(
cardio(enic shock. Deri#heral 'asoconsricion$ which may "e &se%&l d&rin( hy#o'olemic shock$ can "e
co&ner#rod&ci'e d&rin( cardiac shock$ es#ecially in he #resence o% an already weakened myocardi&m$ "y
increasin( cardiac a%erload. ,lernai'ely$ d&rin( se#ic shock$ #eri#heral 'asoconsricion is o%en a"sen or
ine%%eci'e$ and myocardial dys%&ncion is he res&l o% coronary hy#o#er%&sion or circ&lain( de#ressan %acors.
SDECI=IC ORF,N INEOCEEMENT IN SHOCA ,ND TRE,TMENT TO REDUCE ISCHEMIC D,M,FE
When coronary #er%&sion is com#romised$ as i is d&rin( sysemic hy#oension$ es#ecially wih &nderlyin(
coronary disease$ cardiac %&ncion s&%%ers. Myocardial de#ressan %acors may also "e #resen in some %orms o%
shock 07$82$ and cardiac o&#& can "e com#romised "y dysrhyhmias ca&sed "y coronary ischemia$ hy#oxemia$
adrener(ic sim&laion$ dr&( oxiciies$ hy#oxemia$ or acidosis.
In he a"sence o% coronary senosis$ myocardial necrosis #er se 0as e'idenced "y release o% he M3 %racion o%
creaine kinase$ ro#onin I$ or elecrocardio(ra#hic ST6se(men ele'aion and G wa'e de'elo#men2 is &n&s&al in
shock. Raher$ &nless shock is o% cardiac ori(in$ he hear &s&ally #lays a #arici#aory role in which i is &na"le o
com#ensae %&lly %or arerial hy#oension ca&sed "y hy#o'olemia$ 'asodilaion$ or oher %acors.
Ordinarily$ cere"ral #er%&sion is ke# relai'ely consan o'er a wide ran(e o% #er%&sion #ress&res.
E'en&ally$ howe'er$ cere"ral #er%&sion decreases i% #er%&sion #ress&re %alls "elow a"o& :* o ;* mm H(. 3rain
%&ncion can also "e si(ni%icanly a%%eced "y re(ional decreases in #er%&sion im#osed "y &nderlyin(
cere"ro'asc&lar disease.
Renal Function and Tubular Necrosis
Oli(&ria is a cardinal mani%esaion o% shock. In %ac$ he dia(nosis sho&ld "e serio&sly /&esioned i% oli(&ria
is no #resen. Ne'erheless$ he #aho(enesis o% shock6relaed oli(&ria is com#lex. I is no sim#ly ca&sed "y renal
hy#o#er%&sion. Red&ced cardiac o&#&$ sym#aheic sim&laion$ circ&lain( caecholamines$ an(ioensin$ and
locally #rod&ced #rosa(landins all conri"&e o renal a%%eren areriolar 'asoconsricion and o he redisri"&ion o%
"lood %low away %rom corical (lomer&li oward he med&lla. The ne e%%ec o% hese chan(es is a decrease in
(lomer&lar %ilraion rae.
These re%lex res#onses$ all o% which ca&se oli(&ria can also "e alered "y hera#y 0e.(.$ he &se o%
'asoconsricin( caecholamines2 and "y in4&ry o he ne#hron. Three #aholo(ic chan(es are %re/&enly o"ser'ed?
&"&lar necrosis wih "ack6di%%&sion o% (lomer&lar in%ilrae$ &"&lar o"sr&cion "y cass or oher cell&lar de"ris$ and
&"&lar e#ihelial dama(e wih conse/&en inersiial edema and &"&lar colla#se.
This mix&re o% re%lex res#onses and #rimary ischemic dama(e may ex#lain he 'aria"le res#onse o
hera#y %or oli(&ria. When a%%eren areriolar 'asoconsricion #redominaes$ do#amine$ in low doses$ may hel# o
#reser'e &rine o&#& "y o##osin( 'asoconsricion. ,s #aholo(ic chan(es occ&r$ inra'asc&lar 'ol&me ex#ansion
com"ined wih a loo# di&reic or manniol may diminish &"&lar o"sr&cion "y mainainin( &rine %low. Once
o"sr&cion or &"&lar necrosis is #resen$ reamen "ecomes "asically conser'ai'e$ s&##ored "y dialysis$ while
cell&lar re#air and reco'ery ake #lace.
Urine ha is #rod&ced d&rin( shock o%en re%lecs hese #aho#hysiolo(ic chan(es in he kidney. When
re%lex 'asoconsricin( mechanisms #redominae 0hy#o'olemic and cardio(enic shock2$ he &rine is lar(ely %ree o%
sal and hi(hly concenraed. In conras$ when ischemic dama(e is #rominen$ &"&lar %&ncion$ sal reenion$ and
&rine osmolaliy decrease. E'en so$ &rine chemisries are no hi(hly s#eci%ic$ and ca&ion m&s "e &sed o a'oid
o'eriner#reaion. Osmoic a(ens 0e.(.$ manniol or di&reics H%&rosemideI2 ha'e "een &sed "ased on animal
ex#erimens showin( #roecion a(ains ischemic in4&ry. While #roo% o% o&come im#ro'emen is sill lackin( we
s&((es he &se o% osmoic a(ens o increase &rine %low.
Other Organ Systems: Heart, Lungs, Liver, Gut
Oher or(an sysems are a%%eced "y shock. D&lmonary edema is common d&rin( shock$ and may "e he
res&l o% cardiac %ail&re$ o'erly a((ressi'e inra'asc&lar 'ol&me ex#ansion$ or increased #&lmonary 'asc&lar
#ermea"iliy 092. Wih he#aic ischemia 0-shock li'er.2$ characerisic en!ymes 0ser&m (l&amic6oxaloaceic
ransaminase H,CTI and ser&m (l&amic6#yr&'ae ransaminase H,STI2 are released. Occasionally$ an o"sr&ci'e
#ic&re wih ele'aed "ilir&"in and alkaline #hos#haase #redominaes.
Ischemic in4&ry o he (& is mani%esed #rimarily "y inersiial %l&id se/&esraion$ hemorrha(e$ or necrosis
o% he m&cosal linin(. Ulcer %ormaion wih exsan(&inain( hemorrha(e can occ&r$ o%en se'eral days a%er normal
hemodynamic %&ncion has "een resored. The ischemic lesions ha de'elo# in he (& &s&ally are mos #rominen
in he somach$ wih he res o% he (asroinesinal rac less %re/&enly a%%eced. 3reakdown o% he (& e#iheli&m
also creaes a #oral %or enry o% "aceria or oher deleerio&s "acerial #rod&cs.
DREHOSDIT,C ,SSESSMENT ,ND ST,3ICIJ,TION
The mos im#oran o"li(aion o% %ield #ersonnel is o reco(ni!e ha shock or a #reshock sae is #resen.
In'aria"ly$ his assessmen "e(ins wih acc&rae 'ial si(ns. , com"inaion o% sysolic "lood #ress&re less han )*
mm H($ com"ined wih eiher "radycardia or achycardia and an alered menal sa&s$ sho&ld "e considered shock
&nil #ro'en oherwise. ,lho&(h 'ir&ally all #aiens in shock ha'e an im#aired le'el o% conscio&sness$ in #reshock
saes hese chan(es can "e s&"le. When shock is associaed wih #eri#heral 'asoconsricion$ he skin will %eel
cool and clammy$ and ca#illary re%ill will "e #rolon(ed 0K7 seconds2. Wih %e'er or se#sis$ his si(n may no "e
#resen. Wih hy#oxemia$ cyanosis may "e a##aren$ "& only i% s&%%icien red&ced hemo(lo"in is #resen.
Once shock is reco(ni!ed$ reamen de#ends (realy on se'eriy and he &nderlyin( ca&se. Se'eriy can "es "e
4&d(ed in he %ield "y he e%%ecs on cardiac and "rain %&ncion. I% menal sa&s is reasona"ly normal and
elecrocardio(ra#hic mani%esaions o% ischemia are a"sen$ a((ressi'e hera#y can &s&ally "e de%erred &nil arri'al
a he hos#ial. Oherwise$ some %orm o% res&sciaion sho&ld "e aem#ed immediaely$ i% #ossi"le$ as indicaed "y
he mos likely ca&se.
Cerain meas&res are rele'an o any #aien.
1. Ens&re ade/&ae (as exchan(e
7. ,ll #aiens sho&ld recei'e s&##lemenal oxy(en.
8. Those in res#iraory disress or wih inade/&ae 'enilaory e%%or sho&ld "e in&"aed hro&(h he rachea$ i%
#ossi"le or oherwise aided wih 'enilaion &nil ED arri'al.
9. Eeno&s access sho&ld "e aem#ed. Dlace one or wo lar(e6"ore 01< (a&(e or lar(er2 #eri#heral
inra'eno&s caheers i% rans#or will no "e delayed. I% cardio(enic shock can "e excl&ded wih con%idence 0%or
insance$ when ra&ma or hemorrha(e is he o"'io&s ca&se2$ sar inra'eno&s %l&ids$ es#ecially i% he neck
'eins are %la. , "alanced isoonic sal sol&ion sho&ld "e in%&sed a a ra#id rae. , c&rren conro'ersy in'ol'es
wheher ra#id in%&sions may increase "leedin( 09,2. ,%er arri'al in he emer(ency de#armen$ hese raes can
"e ad4&sed as a##ro#riae.
The #aien sho&ld "e ke# warm wih "lankes$ es#ecially i% am"ien em#era&res are low or he #aien is
shi'erin(. O"'io&sly$ (ross exernal hemorrha(e sho&ld "e so##ed i% #ossi"le. The ime s#en in he %ield$
howe'er$ sho&ld "e ke# o a minim&m. Do no #ersis in #rolon(ed &ns&ccess%&l aem#s a in&"aion or
inra'eno&s caheeri!aion. Us&ally wo or hree aem#s a eiher #roced&re deermine he likely %easi"iliy o%
addiional e%%or.
CCINIC,C DRESENT,TIONS O= SHOCA
3eca&se #er%&sion is direcly relaed o #ress&re$ a %all in sysemic "lood #ress&re is a cardinal
mani%esaion o% shock 0Ta"le 7>7.12. Chan(es in re(ional 'asc&lar resisance can$ howe'er$ com#ensae %or
modes decreases in #er%&sion #ress&re$ here"y mainainin( #er%&sion o 'ial or(ans. Th&s$ a %all in arerial
#ress&re can "e a har"in(er o% #oenial shock$ as well as a common mani%esaion o% shock isel%$ "& a -normal.
"lood #ress&re is sill #ossi"le d&rin( he early #hases o% com#ensaed shock 0-#reshock.2. Indeed arerial
hy#oension can o%en "e reaed "e%ore 'ial or(an dys%&ncion is clinically o"'io&s. This #res&ma"ly #re'ens
irre'ersi"le or(an dys%&ncion or a leas amelioraes is se'eriy.
Ta"le 7>7.1. Disin(&ishin( Clinical =ea&res in he Iniial Dresenaion o% Shock
,n acc&rae "lood #ress&re is necessary when reamen is iniiaed$ es#ecially o a'oid %alse low readin(s.
Deri#heral 'asc&lar disease$ achycardia wih a small #&lse #ress&re$ and irre(&lar rhyhms s&ch as arial %i"rillaion
can ca&se he a&sc&laory "lood #ress&re o "e &nderesimaed. Do##ler de'ices o%en$ "& no always$ im#ro'e
#ress&re deecion.
ostural !hanges in "lood ressure
Dos&ral chan(es in "lood #ress&re and hear rae can "e hel#%&l in deecin( mild o moderae de(rees o%
hy#o'olemia 0+2. Orhosasis normally ca&ses he sysolic #ress&re o decrease sli(hly$ he diasolic #ress&re o
increase or say &nchan(ed$ and he #&lse rae o increase "y less han 1* o 7* "eas #er min&e. Wih
hy#o'olemia$ a %all in diasolic "lood #ress&re (reaer han 1+ o 7* mm H( when he #aien is siin( or sandin( is
almos always a"normal$ es#ecially i% accom#anied "y an increase in #&lse rae (reaer han 7* o 8* "eas #er
min&e. Si(ni%ican di!!iness or li(hheadedness on siin( or sandin($ e'en in he a"sence o% si(ni%ican #&lse and
"lood #ress&re chan(es$ is sill consisen wih hy#o'olemia$ "eca&se some #aiens mainain "lood #ress&re a he
ex#ense o% cardiac o&#&. Chan(es in sysolic "lood #ress&re are more 'aria"le and h&s less hel#%&l in e'al&ain(
orhosasis. In conras$ dan(ero&s hy#o'olemia is essenially excl&ded i% si(ni%ican di!!iness or chan(es in "lood
#ress&re or #&lse %ail o occ&r on he #aienLs ass&min( he sandin( #osiion.
Shock #$$ecting "rain, Heart, and %idney
The "rain$ hear$ and kidneys are he 'ial or(ans mos o%en a%%eced "y shock. There%ore$ red&cin( he
e%%ec o% shock on hese or(ans is he key o reamen. The se'eriy o% or(an dys%&ncion and clinical #resenaion$
howe'er$ 'aries wih #re'io&s le'els o% or(an %&ncion$ com#ensaory mechanisms$ and ca&se.
The mos common clinical mani%esaion o% cere"ral dys%&ncion is an ac&e chan(e in menal sae$ 'aryin(
%rom mild chan(es in menal ac&iy o %rank coma. =ocal ne&rolo(ic de%icis are no ex#eced. When hey are
#resen$ an associaed #rimary ne&rolo(ic #ro"lem sho&ld "e ass&med.
The mos common #resenaion o% cardiac dys%&ncion is achycardia. The #&lse is %re/&enly -hready$.
indicain( a low cardiac sroke 'ol&me. Wih coronary ischemia$ more com#lex rhyhm dis&r"ances may occ&r$ and
hese can also im#air cardiac %&ncion. ,s he hear %ails$ le% 'enric&lar end6diasolic #ress&re rises$ &limaely
ca&sin( #&lmonary edema and res#iraory %ail&re. The mos common clinical sym#oms o% coronary hy#o#er%&sion
are ches #ain and dys#nea5 #hysical si(ns incl&de he a##earance o% a dyskineic a#ical cardiac im#&lse$ a new
hird or %o&rh hear so&nd$ a new m&rm&r o% miral re(&r(iaion 0re#resenin( #a#illary m&scle dys%&ncion2$ and
#&lmonary crackles. Elecrocardio(ra#hic si(ns 0ST6T wa'e chan(es2 o% myocardial ischemia can also "e
ex#eced. Occasionally$ shock can res&l %rom miral 'al'&lar dys%&ncion or #a#illary m&scle r&#&re 0:2.
Skin !hanges
When he skin is #oorly #er%&sed$ is em#era&re %alls and is color chan(es. O%en skin color is #ale and
d&sky$ re#resenin( oli(emia and 'eno&s #oolin( o% "lood desa&raed o% oxy(en. Wih concomian hy#oxemia$
%rank cyanosis can "e #resen. Sym#aheic ner'o&s sysem sim&laion$ a com#ensaion %or hy#oension$ ca&ses
swea (land hy#ersecreion. The res&l is he %re/&enly o"ser'ed cool$ clammy skin o% shock. In addiion$ oher
skin mani%esaions can occ&r. =or insance$ di%%&se eryhroderma in a mensr&ain( woman s&((ess he oxic
shock syndrome. Cell&liis$ erysi#elas$ or %asciiis may "e "oh he ca&se or res&l o% se#sis. Uricaria or
an(ione&roic edema may si(ni%y ana#hylacic shock. The #resence o% #eechial hemorrha(es or ecchymoses may
indicae disseminaed inra'asc&lar coa(&laion 0DIC2 or$ more rarely$ menin(ococcemia. Em"olic lesions may
indicae endocardiis.
D&lmonary dys%&ncion is common and &s&ally re#resens #&lmonary edema %rom eiher increased
hydrosaic #ress&res 0e.(.$ cardiac shock2 or increased 'asc&lar #ermea"iliy 0e.(.$ se#ic shock2. D&rin(
ana#hylacic shock$ &##er airway o"sr&cion may res&l %rom swellin( o% he on(&e or larynx 0mani%esed "y
sridor2 and lower airway o"sr&cion %rom "ronchos#asm 0mani%esed "y whee!in(2. Whee!in( can also occ&r in
#&lmonary edema.
Ci'er %ail&re is occasionally #rominen$ as e'idenced "y eiher hy#er"ilir&"inemia or he release o% li'er
en!ymes. When shock is ca&sed "y in%ecion hy#er(lycemia and %e'er are &s&ally #resen5 #aradoxically$
hy#ohermia can also occ&r. Mea"olic 0lacic2 acidosis is ca&sed "y iss&e hy#oxia and anaero"ic mea"olism$
o%en com#licaed "y he#aic dys%&ncion and inade/&ae lacae mea"olism. The se'eriy o% acidosis 'aries (realy
and is #oorly correlaed wih o&come when all %orms o% shock are considered.
In s&mmary$ con%&sion$ achycardia$ arerial hy#oension$ and oli(&ria are he mos common early mani%esaions o%
"rain$ cardiac$ and kidney dys%&ncion$ res#eci'ely$ d&rin( shock. More se'ere de(rees o% shock res&l in coma$
myocardial ischemia$ and #&lmonary edema. Mea"olic acidosis and arerial hy#oension are %re/&en$ es#ecially
when shock is se'ere$ "& are no #rere/&isies %or dia(nosis. Oher #hysical si(ns de#end on he &nderlyin(
ca&se$ he le'el o% or(an %&ncion "e%ore he onse o% shock$ and he e%%eci'eness o% com#ensaory mechanisms.
C,USES ,ND CC,SSI=IC,TION
, &se%&l way o classi%y shock 0Ta"le 7>7.72 is "y he #rimary ca&se o% he circ&laory dis&r"ance #rod&cin( arerial
hy#oension and he e%%ecs 0Ta"le 7>7.82. Many cases o% shock o'erla# more han one cae(ory. In oher cases$
he circ&laory dis&r"ance is com#lex$ &ncerain$ or &nknown. This o&line is a 'arian o% he erms hy#o'olemic$
cardio(enic$ o"sr&ci'e$ or disri"&i'e.
Ta"le 7>7.7. Classi%icaion o% Shock
Ta"le 7>7.8. Some Common Hemodynamic Daerns in Shock
H@DOEOCEMIC SHOCA
Hy#o'olemic shock #rod&ces he #rooy#ical hemodynamic #ic&re o% shock. I is characeri!ed "y marked
decreases in cardiac %illin( #ress&res and a conse/&en decrease in sroke 'ol&me. Cardiac o&#& is #arially
mainained "y a com#ensaory achycardia. Re%lex increases in #eri#heral 'asc&lar resisance and myocardial
conraciliy iniially mainain #er%&sion o he "rain and hear. When "lood loss exceeds 7* o 7+B o% he
inra'asc&lar 'ol&me 0a"o& 1 C2$ howe'er$ hese com#ensaory mechanisms are no lon(er e%%eci'e. The decrease
in cardiac o&#& ca&ses decreased oxy(en rans#or o #eri#heral iss&es. The arerio'eno&s oxy(en conen
di%%erence widens as oxy(en exracion increases$ "& e'en&ally iss&e hy#oxia and lacic acidosis s&#er'ene.
Treamen m&s %oc&s on resorin( 'ol&me$ red cells$ and #er%&sion.
C,RDIOFENIC SHOCA
Cardio(enic shock occ&rs i% more han 9*B o% he le% 'enricle is in'ol'ed in ac&e in%arcion 0;2. Clinically$
si(ns o% #eri#heral 'asoconsricion are #rominen$ #&lmonary con(esion is %re/&en$ and oli(&ria is 'ir&ally
always #resen. The com#licaions o% myocardial in%arcion also #rod&ce characerisic si(ns. Cardiac r&#&re ino
he #ericardial sac can #rod&ce classic si(ns o% am#onade. Se#al r&#&re can #rod&ce he classic m&rm&r and
hrill o% a 'enric&lar se#al de%ec. Da#illary m&scle or chordae endineae r&#&re can #rod&ce %&lminan miral
re(&r(iaion and #&lmonary edema. Emer(ency echocardio(ra#hy can con%irm #oor le% 'enric&lar %&ncion and
can hel# excl&de s&r(ically correca"le mechanical lesions$ which may "e conri"&in( o he #ic&re o% shock 0:2.
Throm"yolyics are &se%&l i% myocardial in%arcion is he ca&se. Eario&s "y#ass ad4&ncs are ex#erimenal.
Medicaions o im#ro'e hear %ail&re are no &s&ally e%%eci'e. Moraliy is sill hi(h$ re(ardless o% reamen.
Right &entricular 'n$arction and Shock
,n im#oran 'arian o% cardio(enic shock is ha d&e o ri(h 'enric&lar 0&s&ally in%erior wall2 myocardial
in%arcion$ since reamen di%%ers markedly %rom ha indicaed %or le% 'enric&lar in%arcion 0<2. Clinically$ he l&n(s
are clear des#ie he #resence o% 4&(&lar 'eno&s disenion. Occasionally$ A&ssma&lLs si(n 04&(&lar 'eno&s
disenion d&rin( ins#iraion2 may "e o"ser'ed. Hemodynamic %indin(s are 'aria"le$ "& %re/&enly incl&de ele'aed
ri(h arial #ress&re com#ared wih he wed(e #ress&re$ ele'aed ri(h 'enric&lar diasolic #ress&re$ and
decreased #&lmonary arery #ress&re. The cardiac o&#& is decreased and$ no in%re/&enly$ e/&ali!aion o%
'asc&lar and 'enric&lar end6diasolic #ress&res is #resen. In his case$ #ericardial am#onade m&s "e excl&ded.
,(ain$ emer(ency echocardio(ra#hy can hel# wih his deerminaion$ while also demonsrain( decreased ri(h
'enric&lar %&ncion. Ce% 'enric&lar conraciliy may "e normal or a"normal$ de#endin( on wheher i is a%%eced "y
ischemia$ oo. When ri(h 'enric&lar dys%&ncion is #resen$ a #&lmonary #er%&sion or 'enilaion #er%&sion scan
may "e necessary o excl&de #&lmonary em"ol&s. Wih #&lmonary em"oli!aion$ howe'er$ #&lmonary hy#erension
almos in'aria"ly accom#anies shock.
The main %oc&s in reain( hy#oension accom#anyin( ri(h 'enric&lar in%arcion is o mainain ri(h
'enric&lar %illin( #ress&re and #reload wih inra'asc&lar 'ol&me ex#ansion. Ce% 'enric&lar %illin( #ress&re sho&ld
"e &sed alon( wih meas&remens o% cardiac o&#& as an end #oin %or %&rher %l&id adminisraion. 3eca&se he
dilaed ri(h 'enricle may ca&se he se#&m o "&l(e ino he le% 'enricle and$ here%ore$ chan(e le% 'enric&lar
diasolic com#liance 0-'enric&lar inerde#endence.2$ howe'er$ lile chan(e in cardiac o&#& may occ&r des#ie an
increase in he #&lmonary arery wed(e #ress&re. I% 'ol&me in%&sion is no s&%%icien o resore hemodynamic
%&ncion o normal$ inoro#ic hera#y sho&ld "e &sed. The inoro#ic a(ens o% choice$ s&ch as do"&amine or
do#amine$ do no increase #&lmonary 'asc&lar resisance.
SEDTIC SHOCA
Se#ic shock is ca&sed "y he #resence o% in%ecio&s a(ens or heir #rod&cs in he "lood sream. Fram6
ne(ai'e or(anisms are res#onsi"le %or he ma4oriy o% cases. Fram6#osii'e "aceria$ %&n(i$ and 'ir&ses$ howe'er$
are all ca#a"le o% #rod&cin( a clinical syndrome indisin(&isha"le %rom ha d&e o Fram6ne(ai'e "aceria. , &se%&l
de%iniion o% se#ic shock is? se#sis6ind&ced hy#oension des#ie ade/&ae %l&id challen(e wih sysolic "lood
#ress&re less han )* mm H( or red&cion o% more han 9* mm %rom "aseline alon( wih or(an #er%&sion
a"normaliies 0)$1*2.
Se#sis and se#ic shock are no idenical. Se#sis is "es considered as he hos res#onse o "aceremia$
endooxemia$ or oher "y#rod&cs o% "aceria in he "lood. This hos res#onse is characeri!ed "y clinical %ea&res
s&ch as %e'er$ achycardia$ achy#nea$ and res#iraory alkalosis. Mea"olic a"normaliies 0e.(.$ "oh hy#o(lycemia
and hy#er(lycemia$ as well as acidosis and hy#ocalcemia2 are also common in se#sis 0:2. 3aceremia or a
locali!ed in%ecio&s sie 0e.(.$ an a"scess2 are common$ "& oxic shock syndrome may no demonsrae so&rce
011$17$18 and 192$ alho&(h care%&l search is &s&ally rewardin(. 3eware o% &n&s&al ca&ses s&ch as
#oss#lenecomy se#sis$ se#sis in sickle cell disease #aiens and #se&domonas se#sis wih or wiho& he skin
chan(es o% echyma (an(renos&m 0&s&ally eemin( wih "aceria2. Menin(ococcal se#sis is #aric&larly a((ressi'e
and re/&ires ra#id reamen.
Se#ic shock is o%en descri"ed$ in is iniial #hases$ as a hy#erdynamic sae wih a hi(h cardiac o&#&$
normal o low cardiac %illin( #ress&res$ and decreased sysemic 'asc&lar resisance 01+$1:2. Indeed$ a
hy#erdynamic circ&laion in a #aien wih shock is s&%%icienly characerisic o% se#sis in which an em#irical "road
s#ecr&m ani"ioic hera#y sho&ld "e immediaely iniiaed alon( wih %l&id res&sciaion and occ&l so&rces o%
in%ecion excl&ded. Occasionally$ a hy#erdynamic #ic&re is associaed wih oher ca&ses o% shock$ incl&din( se'ere
he#aic dys%&ncion$ hy#erhyroidism$ and ra&ma.
In he erminal sa(es o% se#ic shock$ cardiac %&ncion deerioraes and he hemodynamic #aern o%en resem"les
ha o% cardio(enic shock 01;2.
E'en when cardiac o&#& is ele'aed d&rin( se#ic shock$ cardiac %&ncion and #eri#heral #er%&sion are
sill a"normal 07$8$1<$1)2. ,"normaliies in sysolic %&ncion are characeri!ed "y decreases in sroke 'ol&me and
e4ecion %racion. Ex#erimenally$ a"normaliies in myocardial conraciliy ha'e "een demonsraed. These
a"normaliies may "e ca&sed "y he #resence o% -myocardial de#ressan %acors$. or coronary ischemia. 3eca&se
conraciliy may someimes "e a"normal$ increasin( #reload 0e.(.$ wih inra'asc&lar 'ol&me ex#ansion2 may no
always increase sroke 'ol&me "& may insead exacer"ae #&lmonary edema. ,"normaliies in 'enric&lar
com#liance 0diasolic dys%&ncion2 also occ&r in se#ic shock.
, si(ni%ican decrease in sysemic 'asc&lar resisance$ o%en o& o% #ro#orion o any increase in cardiac
o&#&$ is common in se#ic shock and may "e res#onsi"le %or re%racory hy#oension in many #aiens.
In (eneral$ in mos %orms o% shock$ iss&e oxy(en cons&m#ion remains inde#enden o% oxy(en deli'ery as iss&e
oxy(en exracion increases. In se#ic shock$ howe'er$ oxy(en cons&m#ion a##ears o "e direcly #ro#orional o
oxy(en deli'ery. The clinical im#licaions o% his o%6re#eaed %indin($ howe'er$ are sill &ncerain.
O3STRUCTIEE SHOCA
Se'eral ca&ses o% shock #resen wih si(ns o% ele'aed ri(h6sided cardiac %illin( #ress&res "& no e'idence
o% #&lmonary edema$ s&((esin( normal le%6sided %illin( #ress&res. These incl&de ri(h 'enric&lar in%arcion 0see
#re'io&s descri#ion2$ #&lmonary em"ol&s$ am#onade$ and ension #ne&mohorax.
D&lmonary em"ol&s is &s&ally characeri!ed "y he s&dden onse o% ches #ain$ achy#nea$ achycardia$
ele'aed 4&(&lar 'eno&s #ress&re$ hy#oxia$ and a imes hemo#ysis. In se'ere cases$ #&lmonary arery o"sr&cion
res&ls in #&lmonary hy#erension and e'en ac&e ri(h hear %ail&re. In #aiens wih oherwise normal
cardio#&lmonary sysems$ shock ca&sed "y #&lmonary em"oli only occ&rs when a leas :* o ;+B o% he
#&lmonary circ&laion is o"sr&ced. Wih &nderlyin( cardio#&lmonary disease$ lesser de(rees o% o"sr&cion can
ca&se shock.
Cardiac am#onade can occ&r ac&ely as he res&l o% "l&n or #enerain( ra&ma$ or de'elo# chronically in
a more s&"le %ashion$ as he res&l o% #ericardiis$ renal %ail&re$ or a mali(nan #ericardial e%%&sion. Sym#oms
de#end lar(ely on he #rimary disease #rocess. Wih ches ra&ma$ ac&e cardiac am#onade is s&s#eced in any
#aien who #resens wih 3eckLs riad? ele'aed neck 'eins$ shock$ and m&%%led or disan hear so&nds. In he more
chronic e'ol&ion o% cardiac am#onade$ a %re/&enly #resen si(n is #&ls&s #aradox&s. The #aien also de'elo#s
sym#oms o% ri(h hear %ail&re wih #eri#heral edema$ dys#nea$ 'eno&s con(esion$ and achycardia. The ches
radio(ra#h demonsraes cardiome(aly wih a widened rans'erse diameer and a (lo"&lar a##earance o% he
cardiac silho&ee. ,n echocardio(ram con%irms he dia(nosis o% #ericardial e%%&sion and can s&((es he #ossi"iliy
o% hemodynamic em"arrassmen. Deriocardiocenesis is he re/&ired reamen.
Tension #ne&mohorax 0o%en associaed wih assised 'enilaion2 can also ca&se shock wih disended
neck 'eins. In ension #ne&mohorax$ howe'er$ here are no "reah so&nds on he a%%eced side$ and he
mediasin&m is shi%ed$ wih dis#lacemen o% he rachea away %rom ha side. Tension #ne&mohorax ca&ses shock
"y decreasin( "lood re&rn o he ri(h hear. Treamen can ran(e %rom ra#id needle decom#ression o &"e
horacosomy.
,N,DH@C,CTIC SHOCA
,na#hylacic shock can occ&r when a #re'io&sly sensii!ed indi'id&al is ex#osed o a s#eci%ic ani(en.
,o#ic #ersons are #aric&larly a risk. Darenerally adminisered dr&(s$ es#ecially #enicillins$ ce#halos#orins$ and
iodinaed conras media$ are common o%%enders. The hemodynamic mani%esaions o% ana#hylacic shock incl&de
decreased "lood #ress&re$ cardiac o&#&$ #reload 0#rimarily %rom 'enodilaion2$ and occasionally sysemic 'asc&lar
resisance. The laer may no "e a##aren &nil a%er %l&id res&sciaion. When sysemic 'asc&lar resisance is
decreased$ he hemodynamic #ic&re may "e con%&sed wih se#sis. The ca&se is &nclear$ "& is &s&ally ari"&ed
o 'asoaci'e mediaors. In conras o oher %orms o% hy#o'olemic shock$ 'asodilaion #rod&ces warm skin$ and
increased #ermea"iliy #rod&ces #eri#heral edema. Ra#id re'ersal re/&ires adrenaline$ %l&id s&##or$
coricoseroids$ and anihisamines.
INITI,C M,N,FEMENT O= SHOCA
Mos #aiens wih %&lly de'elo#ed shock re/&ire racheal in&"aion and mechanical 'enilaory s&##or$
e'en i% ac&e res#iraory %ail&re #er se 0dia(nosed wih arerial "lood (ases2 is no ye #resen. Tracheal in&"aion
is also indicaed i% menal sa&s chan(es makes #roecion o% he airway &ncerain$ or i% inade/&ae res#iraory
com#ensaion %or a mea"olic acidosis is li%e6hreaenin( 0=i(. 7>7.72.
=i(&re 7>7.7. Clinical al(orihm %or he iniial a##roach o he #resenaion o% a #aien wih #ossi"le shock.
0Re#rined wih #ermission %rom Emer(ency Decisions$ Dhysicians World Comm&nicaions Fro&#$ 1)<;580<;2?87>
98.2
Theoreically$ ilin( a #aien ino he head6down 0Trendelen"&r(2 #osiion di'ers "lood 'ol&me ino he
cenral circ&laion$ increasin( cardiac %illin( and a&(menin( sroke 'ol&me. Recen s&dies$ howe'er$ ha'e %ailed o
demonsrae si(ni%ican redisri"&ion o% "lood 'ol&me cenrally. =or his reason$ and "eca&se he head6down
#osiion can ca&se worsened (as exchan(e and e'en worsened cardiac %&ncion$ &se o% he Trendelen"&r(
#osiion in he emer(ency mana(emen o% shock can no lon(er "e ro&inely recommended. I% any s&ch meas&re is
desira"le$ i is s&%%icien o sim#ly raise he #aienLs le(s a"o'e he le'el o% he hear.
When "lood #ress&re re/&ires immediae reamen 0=i(. 7>7.82$ one m&s choose eiher a 'aso#ressor
a(en 0e.(.$ le'arerenol$ do#amine2 or inra'asc&lar 'ol&me ex#ansion 0wih "lood$ "lood s&"si&es s&ch as
al"&min6conainin( sol&ions or heasarch$ or isoonic crysalloid sol&ions2. O%en$ a com"inaion o% a 'aso#ressor
wih a rial o% 'ol&me ex#ansion is a##ro#riae. The conse/&ences o% inade/&ae cere"ral and coronary #er%&sion
are #oenially so disasro&s ha e'ery e%%or m&s "e made o ra#idly resore #er%&sion #ress&re o a leas )* mm
H( sysolic or :* mm H( mean. This (oal can "e achie'ed ra#idly wih a 'aso#ressor$ e'en i% shock is ca&sed "y
hemorrha(e$ as lon( as %l&ids are also (i'en sim&laneo&sly. ,lho&(h 'asoaci'e a(ens are leas e%%eci'e when
inra'asc&lar 'ol&me is de#leed$ heir &se can "e 4&si%ied "y he lehal conse/&ences o% #rolon(ed sysemic
arerial hy#oension$ namely$ irre'ersi"le cere"ral and cardiac in4&ry. Ce'arerenol is he "es iniial choice %or
raisin( "lood #ress&re. S&"se/&enly$ e'ery aem# m&s "e made o ra#idly decrease he in%&sion rae o% he
'aso#ressor$ o swich o a lower 0and less 'asoconsrici'e2 e%%eci'e dose o% do#amine$ or o disconin&e
'asoaci'e a(ens alo(eher 07*2.
=i(&re 7>7.8. Clinical al(orihm %or he iniial a##roach o he #resenaion o% a #aien wih #ossi"le shock.
0Re#rined wih #ermission %rom Emer(ency Decisions$ Dhysicians World Comm&nicaions Fro&#$ 1)<;580<;2?87>
98.
Wih noncardio(enic %orms o% shock$ es#ecially in he a"sence o% #&lmonary edema$ inra'asc&lar 'ol&me
ex#ansion sho&ld "e aem#ed. The ac&al choice o% %l&id %re/&enly re#resens a com#romise "eween wha is
readily a'aila"le and wha is re/&ired$ "ased on esimaed or o"ser'ed losses. I% "lood is he o"'io&s choice %or
hemorrha(e$ "& is no immediaely a'aila"le$ a "lood s&"si&e or isoonic crysalloid sol&ions sho&ld "e (i'en
iniially. The o&come %rom shock is #ro"a"ly no a%%eced "y he y#e o% sol&ion (i'en d&rin( he %irs ho&rs o%
res&sciaion. On he oher hand$ he rae o% adminisraion can criically a%%ec o&come. I% i is oo slow$ arerial
hy#oension or 'aso#ressor &se is &nnecessarily #rolon(ed5 i% oo %as$ he risk o% #&lmonary edema increases
ra#idly. No ar"irary %orm&la sho&ld "e adhered o do(maically$ "& a reasona"le a##roach is o adminiser +** o
;+* mC o% a "lood s&"si&e or 7*** mC o% a crysalloid sol&ion 0normal saline or Rin(erLs lacae2 d&rin( he %irs
ho&r 0no co&nin( on(oin( losses2. In hemorrha(ic shock$ e'en more ra#id adminisraion may "e necessary s&ch
as a ra#id +** mC "ol&s 0he -,TCS. challen(e2. 3lood losses can also "e occ&l 0e.(.$ %rom inernal "leedin( a%er
ra&ma or leakin( aoric ane&rysm2. 3lood adminisraion may "e &sed o s&##lemen %l&id adminisraion in oher
%orms o% shock when anemia is #resen. , all imes$ he rae o% adminisraion sho&ld "e ad4&sed %re/&enly$ &sin(
chan(es in "lood #ress&re$ &rine o&#&$ or e'idence o% emer(in( #&lmonary edema as im#oran clinical end
#oins. ,ddiional %l&id adminisraion is dicaed "y he clinical res#onse o his iniial %l&id challen(e$ or e'en&ally
"y new in%ormaion %rom hemodynamic moniorin( 0712.
,%er his iniial #eriod$ d&rin( which mainenance o% a minimally acce#a"le mean sysemic "lood #ress&re$
or(an #er%&sion$ and a rial o% inra'asc&lar 'ol&me ex#ansion are em#hasi!ed$ aenion m&s "e direced oward
ac/&irin( addiional daa$ de%inin( he ca&se$ and im#lemenin( a##ro#riae %&rher s#eci%ic mana(emen.
C,3OR,TOR@ ,ND OTHER DROCEDURES
Iniial la"oraory in'esi(aions sho&ld incl&de ser&m elecrolyes$ creainine$ and "lood &rea niro(en5 a
com#lee "lood co&n and di%%erenial5 a #laele co&n$ #rohrom"in ime$ and aci'aed #arial hrom"o#lasin ime5
and$ arerial "lood (ases i% indicaed "y oximery. =&rher cardiac en!ymes sho&ld "e aken i% here is a chance o%
cardio(enic shock. , #re(nancy es sho&ld "e #er%ormed in all women o% child"earin( a(e. ,n elecrocardio(ram
and ches radio(ra#h are always indicaed. Oher s&dies 0e.(.$ c&l&res$ addiional radio(ra#hic s&dies2 de#end on
he circ&msances and likely dia(nosis.
Moniorin( he #aien in shock iniially incl&des nonin'asi'e deerminaion o% 'ial si(ns$ #&lse oximery
cardiac rhyhm$ and &rinary o&#&. Nonin'asi'e moniorin( are easy o a##ly$ and are more &se%&l in he
emer(ency sein( 018$18,2. When hy#oension is #ro%o&nd andMor &nres#onsi'e o iniial res&sciai'e meas&res$
in'asi'e hemodynamic moniorin( 0arerial and #&lmonary arerial caheeri!aion2 is indicaed$ "& sho&ld "e
de%erred &nil he #aien has "een admied o an inensi'e care &ni.
THER,DEUTIC REFIMENS
Choice o% =l&id %or Eol&me Ex#ansion
The y#e o% %l&id o "e adminisered is a maer o% considera"le conro'ersy. Des#ie n&mero&s s&dies$ no
consisen e'idence indicaes ha any %l&id re(imen relia"ly a%%ecs o&come more %a'ora"ly han any oher$
#aric&larly i% #aiens are closely moniored %or im#ro'emen or com#licaions o% hera#y. Th&s$ %l&id re#lacemen
sho&ld incl&de 0alho&(h no necessarily "e limied o2 he kind o% %l&id "ein( los 0e.(.$ "lood or #acked red cells in
he case o% hemorrha(e$ crysalloid sol&ions in he case o% diarrhea or excessi'e di&reic hera#y2. 3lood and
colloid6conainin( sol&ions are more e%%icien and o%en more e%%eci'e in ra#idly ex#andin( inra'asc&lar 'ol&me
han are isoonic crysalloid sol&ions. Shor6erm &se o% "lood or colloid6conainin( sol&ions is sensi"le %or ra#id
ex#ansion o% inra'asc&lar 'ol&me 0as is o%en he case in shock2 when oxy(en deli'ery is com#romised 071,2. In
#racice$ #aiens %or whom a rial o% 'ol&me ex#ansion is indicaed sho&ld recei'e 1 o 7 C o% isoonic crysalloid
sol&ion or +** o 1*** mC o% a colloid6conainin( sol&ion 0or e/&i'alen2$ %ollowed "y "lood rans%&sions i% anemia
or hemorrha(e is #resen. S&"se/&enly$ colloid is rarely 4&si%ied "eca&se o% he ex#ense and he risk o%
#reci#iain( #&lmonary edema. ,ddiional %l&id adminisraion can "e handled wih any com"inaion o% "lood and
crysalloid sol&ions.
Ser&m al"&min is a'aila"le in + and 7+B sol&ions. The %ormer is he %orm &s&ally &sed o ex#and 'ol&me.
,l"&min sol&ions are sa"ili!ed and hea6reaed o kill he#aiis 'ir&s. ,l"&min has no deleerio&s e%%ec &#on
hemosasis.
R,DID USE O= 3COOD
Ty#in( and cross machin( o% "lood canno always "e achie'ed "e%ore "lood needs o "e adminisered$
es#ecially i% exsan(&inaion is imminen. The "es choice in his si&aion is y#e6s#eci%ic "lood$ which is #re%era"le
o O ne(ai'e 0&ni'ersal donor2 "lood "eca&se rans%&sin( lar(e amo&ns o% y#e O "lood can make s&"se/&en
y#in( and cross machin( o% he #aienLs "lood di%%ic&l. Howe'er$ i% here is o "e any delay in a hemorrha(ic
#aien$ i is "eer o &se he O ne(ai'e.
I% an addiional 1+ min&es are a'aila"le$ saline cross machin( can "e carried o& in addiion o y#in(. This
#ermis deerminaion o% he Rh %acor and deecs sron( ani"odies o% he minor "lood (ro&#s 0e.(.$ ani6Aell2$
a'oidin( se'ere reacions.
Wih massi'e rans%&sion$ a "lood warmer can hel# #roec he #aienLs core em#era&re and he hea6
sensii'e coa(&laion mechanism. , microwa'e o'en or inc&"aor can "e &sed %or his #&r#ose wih crysalloids
0Rin(erLs lacae can "e mainained a 9*NC in he emer(ency de#armen2. 3lood$ howe'er$ m&s "e warmed &sin(
"lood warmers. Two &nis o% %resh %ro!en #lasma and 8 o 9 &nis o% #laeles may "e necessary a%er e'ery < &nis
o% #acked cells. C&rren #racice re/&ires adminisraion only %or demonsraed coa(&lo#ahy or la"oraory
con%irmaion. Calci&m (l&conae is rarely needed &nless he in%&sion rae o% "lood is more han ;+ o 1** mCMmin
%or more han se'eral &nis.
harmacologic Su((ort o$ "lood ressure
Ce'arerenol is he "es choice in hemorrha(ic shock$ alho&(h do#amine and do"&amine are he mos
commonly &sed inoro#ic a(ens in he reamen o% cardio(enic shock 0772. Do#amine is an endo(eno&s #rec&rsor
o% nore#ine#hrine$ and has m&li#le dose6relaed e%%ecs. , low doses$ "7 and do#aminer(ic e%%ecs are e'iden$
and enhanced "lood %low o renal and s#lanchnic "eds is #rominen. , hi(her doses$ cardiac inoro#y is seen5 a
sill hi(her doses$ 'asoconsricion #redominaes. Do"&amine is a synheic con(ener o% iso#roerenol wih
#rimarily "1 0cardiac2 "& also "7 0'asodilaory2 sim&lain( #ro#eries. I has lile inde#enden 'asoconsrici'e or
renal 'asodilain( e%%ec 0Ta"le 7>7.92.
Ta"le 7>7.9. S&((esed Indicaions and Dosa(es %or Easoaci'e ,(ens in he Treamen o% Shock
When shock in'ol'es hear %ail&re$ do"&amine can o%en "e &sed o ad'ana(e. Cardiac o&#& is &s&ally
increased wiho& marked increases in hear rae$ and he #&lmonary arery wed(e #ress&re &s&ally %alls. ,
sim&laneo&s in%&sion o% low6dose do#amine 0O+ P(Mk( #er min&e2 may enhance renal #er%&sion and &rine o&#&.
Do"&amine and do#amine can e'en "e &sed in he #resence o% coronary ischemia i% hear rae is no increased
si(ni%icanly.
When shock is %rom ca&ses oher han hear %ail&re$ a 'aso#ressor a(en is &s&ally needed i% 'ol&me
re#lacemen does no correc hy#oension. Hi(h6dose do#amine may "e &sed in his sein($ alho&(h less e%%eci'e
han le'arerenol 0782. Des#ie wides#read &se o% adrener(ic 'aso#ressor a(ens$ "ene%is %rom heir &se are no
well #ro'en 079$7+2.
Oher dr&(s$ incl&din( le'odo#a$ heo#hylline$ and newer a(ens s&ch as amrinone and milrinone$ ha'e
#oen inoro#ic #ro#eries ha may someimes "e &se%&l when do#amine or do"&amine is no e%%eci'e. ,mrinone
and milrinone are also 'asodilaors$ which may a imes conraindicae heir &se in shock. The #ro#er role %or hese
dr&(s$ #rimarily in cardio(enic shock$ is no clear.
Red&cin( he sysemic 'asc&lar resisance 0-a%erload red&cion.2 wih direc6acin( 'asodilaors can "e a
'ery e%%eci'e means o% im#ro'in( cardiac o&#& in hear %ail&re$ when sysemic #ress&res are oherwise normal or
e'en ele'aed. Easodilaors$ howe'er$ are exremely dan(ero&s i% sysemic #ress&res or cardiac %illin( #ress&res
are low$ &nless shock is ca&sed "y se'ere aoric or miral 'al'&lar re(&r(iaion.
Ne&ro(enic shock res&ls %rom a se'ere mid"rain or s#inal cord in4&ry "y he loss o% 'asomoor one
hro&(h he relaxaion o% he 'asc&lar smooh m&scle. The hear rae is o%en normal and he #eri#hery warm and
#er%&sed. The dr&(s o% choice %or "lood #ress&re s&##or in his sein( are he a6adrener(ic dr&(s? #henyle#hrine$
mehoxamine$ and mearaminol.
MISCECC,NEOUS TRE,TMENTS
, mea"olic lacic acidosis is commonly #resen wih shock. Mea"olic acidosis is a known$ alho&(h no
'ery #oen$ myocardial de#ressan. These %acors$ howe'er$ are o%en &sed as a raionale %or recommendin(
a((ressi'e reamen o% lacic acidosis 07:2.
The "es reamen o% lacic acidosis is &n/&esiona"ly re'ersal o% he &nderlyin( ca&se. Howe'er$ his is
o%en no an immediaely aaina"le (oal. In s&ch cases$ inra'eno&s "icar"onae adminisraion is o%en (i'en. The
wisdom o% his %orm o% reamen has "een /&esioned 07;2.
Hi(h6dose (l&cocoricoids are no e%%eci'e in he reamen o% se#sis or se#ic shock. The res&ls o% wo
lar(e #ros#eci'e m&licener s&dies ha'e shown ha early adminisraion o% hi(h6dose coricoseroids neiher
im#ro'ed #aien s&r'i'al nor #re'ened or re'ersed shock in se#ic #aiens. Howe'er$ in seleced cases heir &se
is warraned.
On he oher hand$ (l&cocoricoids are a##ro#riae i% adrenal ins&%%iciency may "e #resen. Sress doses
01** m( o% hydrocorisone e'ery < ho&rs or is e/&i'alen2 may "e (i'en o #aiens wih an im#aired adrenal6
#i&iary axis$ or hose who re/&ire seroids %or he reamen o% an &nderlyin( imm&nolo(ic disease 0e.(.$
'asc&liis2. Hi(h6dose seroid adminisraion has also "een ad'ocaed a 'ario&s imes %or cardio(enic and
hy#o'olemic shock and %or ad&l res#iraory disress syndrome 0,RDS2 associaed wih se#ic shock. Neiher
animal nor clinical s&dies s&##or he &se o% seroids in s&ch #aiens.