Shock

Rasika Kotakadeniya
24.10.2011

At the end of this lecturer you

should be able to..

define what shock means

list different types of shock
describe the pathophysiology of each
type
understand the principles of
management of shock

What is shock?
..deficiency of oxygen delivery
to mitochondria of cells..
..inadequate organ perfusion
and tissue oxygenation.

What are the types of shock?

Hypovolemic
Septic
Cardiogenic
Neurogenic

1. Hypovolemic shock
Hypovolemia is caused by loss of
intravascular volume due to..
Bleeding
dehydration
Vomiting & diarrhoea
.and also impaired venous
return/ventricular filling by tension
pneumothorax/cardiac tamponade

1. Hypovolemic shockpathophysiology
Blood volume-

7-8 % of body weight

A 70 kg man has
5L of blood

When 1000ml of blood volume is lost from

a healthy adult (10%)
BP remains unchanged

hormonal & neural compensatory

mechanisms operate
transcapillary refill increases
intravascular volume

Classification of Hemorrhagic
Shock

Compensated Mild

Moderate

severe

Blood Loss
(ml)

<1000

1000-1500

1500-2000

>2000

HR

<100

>100

>120

>140

normal

Postural
drop

Marked fall

profound
fall

delayed

always
delayed

Moderate
tachypnoea

marked

confused

obtunded

BP
capillary
refill
RR

normal

may be
delayed
mild
increase

mental
status

normal/agita
ted

agitated

normal

1. Hypovolemic shock- diagnosis

History
Mechanism
Blood at the scene, cloths..

Examination

extremities
Pulse, BP
Occult bleeds- intrathoracic, intra-abdominal,
pelvis, #long bones

investigation

1. Hypovolemic shock management

ABCDE
Stop ongoing bleeding
Crystalloids, colloids, blood
Damage control measures

2. Septic shock
What is SIRS (Systemic Inflammatory Response
Syndrome)?
Two or more of,
Temperature >38C or <36C
Pulse >90/min
Respiratory rate >20/min
WBC >12x109 or <4x109 per liter
What is sepsis?
SIRS with demonstrable infection

 .Its our response to their presence

that make the disease. Our arsenals for

fighting off bacteria are so
powerful..that we are more in danger
from them than the invaders(Thomas
L. Germs. N Engl J Med 1972;287:5535.)

Systemic inflammatory response

syndrome that occur during infection

(Bone RC et al, chest 1992;101:1644-55)

 Septic shock is a state of hyperdynamic

circulation

tachycardia
High cardiac output
Warm peripheries
Hypotension

 Hypoxia can develop with a normal or

high oxygen delivery rates because
tissue oxygen demand is high and
oxygen uptake by cells is impaired.

Endotoxins from gram negative

organisms impair energy utilization at a

cellular level.

 Leaky capillaries may lead towards

hypovolemia

Endotoxins have a negative inotropic

action on the myocardium

2. Septic shock - management

IV fluids
Adrenergic & dopaminergic agents
To improve cardiac functions
To cause vasoconstriction

Removal/treatment of septic focus

Antiinflammatory agents?

3. Cardiogenic shock
4. Neurogenic shock
5. Anaphylactic shock
6. Vasovagal shock

Fluid compartments

Adult male 60% water

Adult female 55% water
Newborn 75% water

Fluid compartments
Intracellular fluid (ICF) 55%
Extracellular fluid (ECF) 45%

Plasma 7.5%
Interstitial fluid 20%
Transcellular fluid 2.5%
Water associated with bone and dense
connective tissue 15%

 If 1L of 5% dextrose is infused
Only 7.5% remains intravascular
Therefore 13L of 5% dextrose needs to
be infused in order to increase
intravascular compartment by 1L

 If 1L of 0.9% Saline is infused.

This will get distributed in extracellular
compartment and hence 1/6 remains
intravascular
Therefore 6l of N saline is needed to
increase intravascular compartment by
1L

 If 1L of colloid is infused..
The whole litre of colloid remains
intravascular!

define what shock means

list different types of shock
describe the pathophysiology of each
type
understand the principles of
management of shock