SHOCK

Stages of shock
• Stage I: Compensated Shock
• Stage II: Decompensated Shock
• Stage III: Irreversible Shock
 Compensatory stage
When low blood flow (perfusion) is first detected by the body.
A number of systems are activated in order to maintain/restore
perfusion.
May have ACCEPTABLE BLOOD PRESSURE.
TACHYCARDIA, VASOCONSTRICTION, and the kidney works to retain fluid in
the circulatory system to ENSURE ADEQUATE PERFUSION OF VITAL ORGANS.
The patient in this stage of shock has very few symptoms, and
aggressive treatment may slow or stop progression to stage II
shock.
Decompensated stage
• State when inadequate end organ perfusion.
• HYPOTENSION, TACHYCARDIA, TACHYPNEA, POOR
PERIPHERAL PULSES
 Irreversible stage
• The length of time that poor perfusion has existed begins to take a permanent
toll on the body's organs and tissues.

• The heart's functioning continues to spiral downward, and the kidneys usually
shut down completely. NOT ABLE TO RECOVER EVEN WITH ADEQUATE
PERFUSION.

• Cells in organs and tissues throughout the body are injured and dying.

• REFRACTORY ACIDOSIS, MYOCARDIAL AND BRAIN ISCHEMIA.

• The endpoint of Stage III irreversible shock, is patient’s death.

HYPOVOLEMIC SHOCK
Definition
• Any condition provoking a major reduction in
blood volume that causes failure of oxygen
delivery (DO2) to meet the metabolic
requirement of the tissues.
Causes
Causes
Classification
 History of Presenting Illness
• Any vascular disorders, recent trauma (eg. Motor vehicle accident)-
may indicates presence of internal bleeding.
• GI bleeding, inquiry about hematemesis, melena, alcohol drinking
history, excessive NSAIDS use, and coagulopathies
• Presence of weakness, lethargy, dizziness.
• Presence of pain- vascular disease.
• Thoracic aneurysm-- tearing pain radiating to the back.
• Abdominal aortic aneurysms-- abdominal, back pain, or flank pain.
• Comorbidities: Hypertension, Dyslipidemia, Diabetes Mellitus.
• Family history of coagulation disorders or vascular disorders.
Examination
Initial symptoms of shock include:
• Cold, clammy hands and feet
• Pale or blue-tinged skin tone (Peripheral cyanosis)
• Weak, fast pulse rate (tachycardia)
• Fast breathing rate (tachypnea)
• Low blood pressure (hypotension)
A variety of other symptoms may be present, but they are dependent on the
underlying cause of the shock state.
1. Mental states
•Restlessness

•Anxiety

•Altered mental status

2. Peripheral perfusion
•Delayedcapillary refill greater than 2 seconds in normal ambient air
temperature infant and child patients only
•Weak, thready or absent peripheral pulses
•Pale, cool, clammy skin
3. Vital signs
•Decreased blood pressure (late sign)
•Increased pulse rate (early sign) - weak and thready
•Increased breathing rate (1) Shallow (2) Labored (3) Irregular

4. Other signs and symptoms include

•Dilated pupils
•Thirst

•Nausea and vomiting

•Pallor with cyanosis to the lips
Complications
• ARDS
• Acute kidney injury
• Coma
• Sepsis
• Disseminated Intravascular Coagulation (DIC)
Management
• Initial assessment (ABCDE)
• Airway: check any signs of obstruction, establish a patent airway (Open
mouth and prevent the tongue from blocking the airway--- turn patient to
left lateral position.
• Breathing: Respiratory rate, bilateral chest movement, Percussion and
auscultation. If no respiratory effort, intubate and ventilate.
• Circulation: check pulse and blood pressure, CRT, ECG. Large bore IV access
x2 for each arm for rapid administration.
• Disability: level of conscious (alert, respond to voice, respond to pain,
unresponsive), check pupils size, equality and reactions
• Exposure: check for other wounds
• Hypovolemic shock (fluid loss)
 Identify and treat underlying cause. Raise the legs.
 Give fluid bolus 10-15ml/kg crystalloid (lactated Ringer solution
or normal saline) or 3-5ml/kg colloid
 If shock improves, repeat, titrate to heart rate (aim <100bpm) ,
BP (SBP >90mmHg) and urine output (>0.5mg/kg/h)
 If no improvement after 2 boluses, referral to ICU
• Haemorrhagic shock
 Control and stop the bleeding
 If still shocked despite 2L crystalloid or present with class
3/ 4 shock, then cross match blood ( request O Rh-ve in
an emergency)
 Give fresh frozen plasma alongside packed red cells (1:1
ratio)
 Management
• Monitor patient
• CIRCULATION
1. ECG
2. BP
3. Urine output
4. Central Venous pressure – assess the need and rate of intravascular fluid
replacement (Normal-0-5mmhg)
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5. PAWP (pulmonary artery catheterization)- pulmonary htn/right ventricular
dysfunction cause increase CVP even if the patients is in hypovolemic shock
6. Oesophageal Doppler ultrasonography – check for Cardiac Output
7. Peripheral skin temperature

• RESPIRATORY
1. SpO2
2. ABGs ( can consider insert arterial cannula)
3. Lung function
CARDIOGENIC SHOCK
Definition
• Defined as a state of critical end-organ hypoperfusion due to
reduced cardiac output.
• Established criteria for the diagnosis of CS are:
• (i) systolic blood pressure <90 mmHg for >30 min or vasopressors
required to achieve a blood pressure ≥90 mmHg;
• (ii) pulmonary congestion or elevated left-ventricular filling
pressures;
• (iii) signs of impaired organ perfusion with at least one of the
following criteria:
• (a) altered mental status;
• (b) cold, clammy skin;
• (c) oliguria;
• (d) increased serum-lactate.
Signs and Symptoms

• Hypotension

• Absence of hypovolemia
• Clinical
signs of poor tissue perfusion such as oliguria,
cyanosis, cool extremities, altered mentation
• Skin --- cyanotic and cool, extremities are mottled
• Peripheral pulses --- rapid and faint and may be irregular
 Signs and Symptoms
• Jugularvenous distention and crackles in the lungs are usually
present; peripheral edema
• Heart
sounds are usually distant, and third and fourth heart sounds
may be present
• Low pulse pressure , and patients are usually tachycardic
• Signsof hypoperfusion, such as altered mental status and decreased
urine output
• Systemichypotension (ie, systolic blood pressure below 90 mm Hg or
a decrease in mean blood pressure by 30 mm Hg)
History of Presenting Illness (HOPI)
• Presence of chest pain radiating to the left arm or neck.
• Character: sharp/ burning/ stabbing pain
• Associating symptoms: SOB, orthopnea, paroxysmal
nocturnal dypsnea, syncopal attack, palpitation.
• Previous history of Heart disease– Myocardial Infarction.
• Comorbidities: Hypertension, Dyslipidemia, Diabetes
Mellitus.
• Family history of heart diseases-- Coronary Artery Disease
 Examination
• Low Cardiac Output: Hypotension, oliguria, confusion and cold
clammy peripheries.

• Pulmonary edema: breathlessness, hypoxaemia, cyanosis and

inspiratory crackles at the lung bases.

• A chest X-ray may reveal signs of pulmonary congestion when

clinical examination is normal.
 Diagnosis
• Biochemical profile
• CBC
• Cardiac enzymes (creatine kinase and CK-MB, troponins,
myoglobin, LDH)
• Arterial blood gases
• Lactate
• Brain natriuretic peptide
 Management
• Needs immediate resuscitative therapy before shock irreversibly
damages vital organs.
• Early and definitive restoration of coronary blood flow is the most
important intervention for achieving an improved survival rate ——>
represents standard therapy for patients with cardiogenic shock due to
myocardial ischemia.
• Correction of electrolyte and acid-base abnormalities, such as
hypokalemia, hypomagnesemia, and acidosis, is essential in
cardiogenic shock.
• Vasopressors augment the coronary and cerebral blood flow during
the low-flow state associated with shock.
• Alpha- and beta-adrenergic. Dopamine and dobutamine are the drugs
of choice to improve cardiac contractility, with dopamine the
preferred agent in patients with hypotension.
• Vasodilators relax vascular smooth muscle and reduce the Systemic
Venous Return, allowing for improved forward flow, which improves
cardiac output.
• Diuretics are used to decrease plasma volume and peripheral edema.
 Percutaneous Coronary Intervention
• The SHOCK trial demonstrated that either PCI or CABG is the
treatment of choice for cardiogenic shock and that each has been shown
to markedly decrease mortality rates at 1 year.
• A fine guidewire is passed through and locate the coronary stenosis
under radiographic guidance, a balloon or stent is inflated to dilate the
stenosis.
• PCI should be initiated within 90 minutes of presentation.
• However, it remains helpful, as an acute intervention, within 12 hours
of presentation.
 Coronary Artery Bypass Grafting (CABG)
• A surgical procedure that diverts the flow of blood around a section
of a blocked or partially blocked artery in the heart.

• Vessels that are routinely used:

• Reversed segment of Great saphenous vein
• Internal mammary artery (left more common than right)
• Radial artery

• After the CABG, one should

• Take Aspirin, clopidogrel and
• Lipid lowering therapy
• Lifestyle modification: stop smoking, exercise
ANAPHYLACTIC SHOCK
Definition
• Inappropriate vasodilation triggered by an
allergen, often associated with endothelial
disruption and capillary leak.
 HISTORY OF PRESENTING ILLNESS
• Does the patient having warm or cold peripheries.
• Episode of shortness of breath.
• Does patient have palpitation.
• Difficulty in speaking.
• Any recent drug or exposure to an allergen (bee stung).
• Nausea, vomiting, abdominal cramps, diarrhoea.

Ask the patient having any allergy history.

PHYSICAL EXAMINATION
• Pallor.
• Peripheral cyanosis.
• Tachycardia.
• Respiratory distress.
• Bounding pulses.
• Wheezing.
• Urticarial rash.
• Angioedema.
• Acceptable systolic blood pressure, low diastolic blood
pressure.
INVESTIGATION
• Serum or plasma total tryptase.
• 10 mL of clotted blood should be taken within 45–60
minutes after the reaction for confirmation of the
diagnosis.
 TREATMENT
• 0.2-0.5 ml subcutaneous of epinephrine administered
immediately, repeated dose every 20 minutes.
Or
• Epinephrine administered by continuous infusion of 30-60
ml/h in severe reactions.
• Diphenhydramine 50-80 mg intramuscular or intravenous for
urticaria or angioedema.