SHOCK

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 Definition of Shock
 Shock is a term used to refer to a group of
signs & symptoms that can be caused by a
variety of problems.
 Shock is an abnormal physiologic state in
which there is a disproportion between the
circulating blood volume and the size of the
vascular bed resulting in circulatory failure
and anoxia.
 Description of Shock
 Supply of blood flow to tissues inadequate
 Nutrient requirements are not filled
 Toxic metabolites not removed
 Shock occurs when the body’s physiologic
responses to increase organ perfusion are
inadequate in meeting the tissue demands
 Essentials of Diagnosis
 Hypotension and tachycardia
 Peripheral hypoperfusion
 Peripheral vasoconstriction in most
 Altered mental status
 Oliguria or anuria
 Metabolic acidosis in most
 Classification of Shock
 Hypovolemic
 Septic/Inflammatory
 Cardiogenic (Compressive & Obstructive)
 Neurogenic
 Anaphylactic
 Clinical Markers of Shock
Brachial systolic blood pressure: <110mmHg
Sinus tachycardia: >90 beats/min
Respiratory rate: <7 or >29 breaths/min
Urine Output: <0.5cc/kg/hr
Metabolic acidemia: [HCO3]<31mEq/L or base deficit>3mEq/L
Hypoxemia: 0-50yr: <90mmHg; 51-70yr:
K <80mmHg;
>71yo<70mmHg; l
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Cutaneous vasoconstriction vs. vasodilation.
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Mental Changes: anxiousness, agitation, indifference, lethargy,

obtundation
 Hypovolemic Shock
Decreased preload->small ventricular end-diastolic
volumes -> inadequate cardiac generation of pressure
and flow
Causes:
-- bleeding: trauma, GI bleeding, ruptured aneurysms,
hemorrhagic pancreatitis
-- protracted vomiting or diarrhea
-- adrenal insufficiency; diabetes insipidus
-- dehydration
-- third spacing: intestinal obstruction, pancreatitis,
cirrhosis
 Hypovolemic Shock
 Signs & Symptoms: Hypotension, Tachycardia,
MS changes, Oliguria, Diminished Pulses.
 Markers: monitor UOP,CVP, BP, HR, Hct, MS,
CO, lactic acid and PAWP
 Treatment: ABCs, IVF (crystalloid), Transfusion
Stem ongoing Blood Loss
 Patients on β-blockers, w/ spinal shock &
athletes may not be tachycardic
 Septic/Inflammatory Shock
Mechanism: release of inflammatory mediators leading to
1. Disruption of the microvascular endothelium
2. Cutaneous arteriolar dilation and sequestration of blood in
cutaneous venules and small veins
Causes:
1. Anaphylaxis, drug, toxin reactions
2. Trauma: crush injuries, major fractures, major burns.
3. Infection/sepsis: G(-/+ ) septicemia, pneumonia,
peritonitis, meningitis, pyelonephritis, necrotic tissue,
pancreatitis, wet gangrene, toxic shock syndrome, etc.
 Septic/Inflammatory Shock
Signs: Early– vasodilatation, often adequate urine
output, febrile, tachypneic.
Late-- vasoconstriction, hypotension, oliguria,
altered mental status.

Monitor/findings: Early—hyperglycemia, respiratory

alkalosis, hemoconcentration,
WBC typically normal or low.
Late – Leukocytosis, lactic acidosis
Very Late– Disseminated Intravascular
Coagulation & Multi-Organ
System Failure.
Tx: ABCs, IVF, Blood cx, ABX, Drainage (ie abscess) .
 Cardiogenic Shock
Mechanism: Intrinsic abnormality of heart -> inability to
deliver blood into the vasculature with adequate power
Causes:
1. Cardiomyopathies: myocardial ischemia, myocardial infarction,
cardiomyopathy, myocardiditis, myocardial contusion
2. Mechanical: cardiac valvular insufficiency, papillary muscle
rupture, septal defects, aortic stenosis
3. Arrythmias: bradyarrythmias (heart block), tachyarrythmias
(atrial fibrillation, atrial flutter, ventricular fibrillation)
4. Obstructive disorders: PE, tension peneumothorax, pericardial
tamponade, constrictive pericaditis, severe pulmonary
hypertension
 Cardiogenic Shock
 Characterized by high preload (CVP) with low CO
 S&S: Dyspnea, rales, low BP, oliguria
 Monitor/findings: CXR pulmonary venous congestion,
elevated CVP, Low CO.
 Tx: CHF– diuretics & vasodilators +/- pressures.
LV failure – pressures, decrease after load,
intraaortic balloon pump &
ventricular assist device.
 Cardiovascular Performance
Cardiac Output (CO) = HR x SV (L/min)
Normal CO = 4 to 8 L/min

Cardiac Index (CI) = CO/BSA (L/min/m2)

Normal CI = 2.5-4.2 L/min/m2

Stroke Volume Index (SVI): CI/HR (ml/beat/m2)

Normal SVI = 40-85 ml/beat/m2

Systemic Vascular Resistance = MAPK– CVP / CO x 80

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Normal SVR = 900-1600 dynes/sec/cm -5
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Systemic Vascular Resistance Index = MAP – CVP / CI x 80

Normal SVRI = 1970-2390 dynes/sec/cm-5
 Neurogenic Shock
Mechanism: Loss of autonomic innervation of the
cardiovascular system (arterioles, venules, small
veins, including the heart)

Causes:
1. Spinal cord injury
2. Regional anesthesia
3. Drugs
4. Neurological disorders
 Neurogenic Shock
 Characterized by loss of vascular tone & reflexes.

 Signs: Hypotension, Bradycardia, Accompanying

Neurological deficits.

 Monitor/findings: hemodynamic instability, test bulbo-

carvernous reflex

 Tx: IVF, vasoactive medications if refractory