CIRCULATORY COLLAPSE

SHOCK

DEFINITION
physiologic

state characterized
by a significant reduction of
systemic tissue perfusion,
resulting in decreased oxygen
delivery to the tissues

Inadequate

perfusion
cellular dysfunction
organ dysfunction

Causes
Cardiogenic
Hypovolemic
Distributive

(vasodilatory )
Obstructive (e.g
pulmonary embolism
tensin pneumothorax)

Cardinal features
Hypotension

(systolic BP < 90) or

relative (drop in systolic BP > 40
mmhg from baseline)
Oliguria :
Mental status changes agitation
initially then delerium and
confusion >> coma

Approach to patient
ABCs
Vital

signs
BP: repeat BP to make sure of
the reading
PR and rhythm :both
tachyarrythmia and
bradyarrythmias can be
associated with hypotension
Tachycardia can be associated
with any cause of shock

Approach to patient
Wide

pulse volume associated

with distributive shock
Temperature: fever is associated
with septic shock however
hypothermia can also occur
Respiration :respiratory distress
is associated with cardiogenic
shock , PE,anaphylaxis as well as
sepsis due to pneuomina

Approach to patient
Tachypnea

can be
compensatory mechanism for
metabolic acidosis due to tissue
hypoperfusion

Assessment

and
resuscitation occur
simultaneously

Approach to patient /focused history

Volume loss (diarrhea/ vomiting)

or bleeding
Hidden bleeding intraabdominal
or GI (malena)
Fever, ?? Focus of infection >>
septic shock
Chest pain, breathlessness >> ??
cardiogenic /PE

Approach to patient /focused history

Recent

complaints and recent

activities may hold valuable (e.g.
surgery )

Food

and medicine allergies,

recent changes in medications.

Skin

rash/ itching

Approach to patient /focused exam

JVP:

raised go with cardiogenic

shock while reduced in other types
of shock
Reduce heart sounds >?? Pericardial
tamponade
Chest auscultation: pulmonary
edema going with cardiogenic
shock, diffuse wheezes can be
associated with anaphylaxis

Approach to patient /focused exam

Reduced

breath sound on one

side plus increased resonance
>>> tension pneumothorax
Abdominal tenderness may
suggest intraabdominal bleeding
Uriticaria ?? Anaphyalxis
Unilateral leg swelling may
suggest PE
Capillary refilling

Management
Rapid

assessment and
early resuscitation is
of paramount
importance

Time

is tissue
Delaying management
>> poor outcome

Management
Maintain

airway

Give

supplementary
oxygen if required
Consider
intubation if
extreme distress
Elevate the feet of
bed
IV access and

Management
Blood

test

CBC
Basic screening
bicarbonate
Anion gap
Coagulation profile
Blood grouping
Blood culture
Cardiac enzymes
Lactic acid

Management
CXR
ECG
Echocardiograph

Management
Management

needs to
be individualized
according to type of
shock
Generally IV fluid bolus
can be good initial
management for all
types of shock (need to
be caution in
cardiogenic)

Management (individulazied)
Hypovolemia
IV

fluid (normal saline ringer

lactate ) +\- inotropic agent
(norepinephrine and dopamine)
Septic shock
Same as above plus empirical
antibiotics (delay use of
antibiotics is associated with
increased mortality )

Management (individulazied)
Anaphylactic

shock
>>> subcutaneous or IM
epinenphrince (0.5-1 ml )
+\- anithistamine and
corticosteroids

Cardiogenic

shock
use of inotropes
DC shock if unstable
tachyarrythmia

Management (individulazied)
Obstructive
Removal

of obstruction
PE thrombolysis
Tension Pneumothorax
Pericardial tamponade

Management
Monitoring

response to
treatment using
parametrs
Blood pressure
Urine output (need
insertion of foleys
catheter )
Consciousness level
Invasive monitoring
such as CVP and intra-

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YOU