SHOCK

Definition
Classification
Pathophysiology
Clinical features
Management
 Inadequate tissue perfusion resulting in
cellular injury ie, the tissues in the body dont
receive enough O2 and nutrients to allow the
cells to function cellular death organ
failure whole body failure & death.
Can be due to an impaired cardiac pump,
circulatory system &/or volume
A common problem encountered in ICU & ER.
1. HYPOVOLEMIC SHOCK
 Most common type
Results from loss of blood or fluid.
Circulating blood volume diastolic
filling pressure and volume Cardiac
output Hypotension Shock
Causes:
i.) BLOOD LOSS
Revealed: External bleeding ( Major injuries,
surgery) Hemorrhagic shock
 Concealed Retroperitoneal bleeding,
bleeding into pelvic cavity as in pelvic #, #
shaft of femur
ii.) FLUID LOSS:
Exogenous Burns, diarrhea, diuresis,
excessive sweating, DKA
Endogenous fluid lost in body cavities as in
Intestinal obstruction, peritonitis.
iii) IATROGENIC CAUSES:
Poor fluid prescription, inappropriate use of
diuretics, mechanical bowel preparation,
prolonged fasting before surgery.
 2. CARDIOGENIC SHOCK
Caused by failure of heart to pump effectively due to direct
damage of myocardium or any mechanical heart abnormality
leading to in C.O and BP
Causes are:
Massive myocardial infarction damage to
heart Muscles
Arrhythmias
Cardiomyopathy
Congestive heart failure
Cardiac valve problems
Myocardial contusion
VSD
Drugs ( Anthracycline cardiotoxicity, CCB)
3. DISTRIBUTIVE SHOCK
 Due to systemic vasodilatation relative
hypovolemia preload hypotension
1) SEPTIC SHOCK: severe infection triggers
massive inflammatory response profound
vasodilation, capillary permeability &
myocardial depression shock
2) ANAPHYLACTIC SHOCK: severe anaphylactic
reaction to an allergen release of
histamine, wide spread vasodilatation
hypotension & capillary permeability.
3) NEUROGENIC SHOCK: rarest form.
Causes are: Trauma to S.C above T6 level, Deep
General anaesthesia (depresses VMC), High
spinal anaesthesia, Brain damage(stroke,
contusion etc)
Trauma to SC sudden loss of autonomic &
motor reflexes below injury level. Without
normal stimulation by SNS the vessel wall
relaxes uncontrollably sudden in PVR
vasodilatation & hypotension shock
4) ENDOCRINOLOGICAL
eg: Adrenal crisis

5) THYROID STORM

6) DRUGS:
Eg: Nitroprusside, Bretylium
4. OBSTRUCTIVE SHOCK (extra cardiac)
Results secondary to obstruction to flow in the
cardiovascular circuit which impedes circulation
circulatory arrest

Impaired diastolic filling: RV or LV afterload

Cardiac tamponade Pulmonary embolism
Constrictive Acute pulmonary
pericarditis hypertension
Tension Aortic dissection
pneumothorax
Systemic embolism
Compression of great
Severe aortic stenosis
vessels by mediastinal
masses
 5. MIXED SHOCK
Occurs when 2 or more processes occur
simultaneously
Eg. Myocardial depression seen in septic
shock.
 SHOCK PATHOPHYSIOLOGY
Inadequate perfusion cellular hypoxia
Cells switch from aerobic to anaerobic
metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impaired
mitochondria damage
cell death
 Investigations
Complete blood count: Hb, TC, DC, Plt count
S. lactate
S. Creatinine
ABG
 MANAGEMENT
Shock is a life threatening emergency that
must be recognized immediately & treated
aggressively
Aim is to achieve MAP > 60mmHg.
Treatment protocol is based on the type of
shock
 Physiological basis of treatment
1) Head down position useful in most types of
shock, promote venous return and C.O
2) O2 Therapy: helps because basically there is
O2 delivery to tissues
3) Replacement of losses:
Blood loss iv fluids (colloids/crystalloids) &
blood
Plasma loss plasma
Dehydration electrolyte solution
4) Sympathomimetic drugs (Adrenaline,
Noradrenaline)- mimics sympathetic stimulation
and tend to restore circulatory function. Useful
in neurogenic shock & anaphylactic shock
5) Glucocorticoids
TREATMENT OF CARDIOGENIC SHOCK
Goals: Treat reversible causes
Protect ischemic myocardium
Improve tissue perfusion
Increase pumping action & workload of
heart:
Inotropic agents Digoxin, dobutamine,
Amrinone, Milrinone
Vasoactive agents Dopamine, dobutamine
Morphine ( preload and anxiety)
Diuretics (prevent fluid retention)
 Vasodilators ( afterload)
Beta blockers (for refractory tachycardia)
Cautious administration of iv fluids
Intraaortic balloon pump
Heart transplantation
Consider thrombolytics or angioplasty in
specific cases.
 TREATMENT OF SEPTIC SHOCK
Administer pure oxygen
Start I.v. line, and take bloods for culture
Broad spectrum antibiotics urgently
Attempt to identify source of sepsis