Shock

Definition Return to top

Shock is a life-threatening condition that occurs when the body is not getting enough blood flow.
This can damage multiple organs. Shock requires IMMEDIATE medical treatment and can get
worse very rapidly.

Considerations Return to top

Major classes of shock include:

 Cardiogenic shock (associated with heart problems)

 Hypovolemic shock (caused by inadequate blood volume)
 Anaphylactic shock (caused by allergic reaction)
 Septic shock (associated with infections)
 Neurogenic shock (caused by damage to the nervous system)

Causes Return to top

Shock can be caused by any condition that reduces blood flow, including:

 Heart problems (such as heart attack or heart failure)

 Low blood volume (as with heavy bleeding or dehydration)
 Changes in blood vessels (as with infection or severe allergic reactions)

Shock is often associated with heavy external or internal bleeding from a serious injury. Spinal
injuries can also cause shock.

Toxic shock syndrome is an example of a type of shock from an infection.

Symptoms Return to top

A person in shock has extremely low blood pressure. Depending on the specific cause and type
of shock, symptoms will include one or more of the following:

 Anxiety or agitation
 Confusion
 Pale, cool, clammy skin
 Low or no urine output
 Bluish lips and fingernails
 Dizziness, light-headedness, or faintness
 Profuse sweating, moist skin
 Rapid but weak pulse
 Shallow breathing
 Chest pain
 Unconsciousness

First Aid Return to top

 Call 911 for immediate medical help.

 Check the person's airway, breathing, and circulation. If necessary, begin rescue
breathing and CPR.
 Even if the person is able to breathe on his or her own, continue to check rate of
breathing at least every 5 minutes until help arrives.
  If the person is conscious and DOES NOT have an injury to the head, leg, neck, or
spine, place the person in the shock position. Lay the person on the back and elevate
the legs about 12 inches. DO NOT elevate the head. If raising the legs will cause pain
or potential harm, leave the person lying flat.
 Give appropriate first aid for any wounds, injuries, or illnesses.
 Keep the person warm and comfortable. Loosen tight clothing.

IF THE PERSON VOMITS OR DROOLS

 Turn the head to one side so he or she will not choke. Do this as long as there is NO
suspicion of spinal injury.
 If a spinal injury is suspected, "log roll" him or her instead. Keep the person's head,
neck and back in line and roll him or her as a unit.

Do Not Return to top

 DO NOT give the person anything by mouth, including anything to eat or drink.
 DO NOT move the person with a known or suspected spinal injury.
 DO NOT wait for milder shock symptoms to worsen before calling for emergency
medical help.

Call immediately for emergency medical assistance if Return to top

Call 911 any time a person has symptoms of shock. Stay with the person and follow the First
Aid steps until medical help arrives.

Prevention Return to top

Learn ways to prevent heart disease, falls, injuries, dehydration, and other causes of shock. If
you have a known allergy (for example, to insect bites or stings), carry an epinephrine pen. Your
doctor will teach you how and when to use it.

Once someone is already in shock, the sooner shock is treated, the less damage there may be
to the person's vital organs (like the kidney, liver, and brain). Early first aid and emergency
medical help can save a life.

References Return to top

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical
Practice. 5th Ed. St. Louis, MO: Mosby; 2002.

Goldman L, Ausiello D, eds. Cecil Textbook of Medicine, 22nd Ed. Philadelphia, PA: Saunders;
2004.
Shock is a serious medical condition where the tissue perfusion is insufficient to
meet the required supply of oxygen and nutrients. This hypoperfusional state is
a life-threatening medical emergency and one of the leading causes of death in
a critically ill person.[1] [2] [3] [4] [5]

Contents
[hide]
 1 Stages of shock
 2 Types of shock
 3 Signs and symptoms
 4 Treatment
o 4.1 First aid
o 4.2 In-hospital management
 4.2.1 Hypovolaemic shock
 4.2.2 Cardiogenic shock
 4.2.3 Distributive shock
 4.2.4 Obstructive shock
 4.2.5 Endocrine shock
 5 Prognosis
 6 See also
 7 Notes
 8 References
 9 External links

Stages of shock
There are four stages of shock.
[6]
Initial - This is where the hypoperfusional states causes hypoxia, leading to
the mitochondria being unable to produce adenosine triphosphate. Due to this
lack of oxygen, the cell membranes become damaged and the cells perform
anaerobic respiration. This causes a build-up of lactic and pyruvic acid which
results in systemic metabolic acidosis. The process of removing these
compounds from the cells by the liver requires oxygen, which is absent.

Compensatory - This stage is characterised by the body employing

physiological mechanisms, including neural, hormonal and bio-chemical
mechanisms in an attempt to reverse the condition. As a result of the acidosis,
the person will begin to hyperventilate in an attempt to inspire more oxygen.
The baroreceptors in the arteries detect the resulting hypotension, and cause
the release of adrenaline and noradrenaline. These cause widespread
vasoconstriction resulting in an increase in not only blood pressure but heart
rate. Also, these hormones cause the vasoconstriction of the kidneys,
gastrointestinal tract, and other organs to divert blood to the heart, lungs and
brain. The lack of blood to the renal system causes the characteristic low urine
production.

Progressive - Should the cause of the crisis not be successfully treated, the
shock will proceed to the progressive stage and the compensatory mechanisms
begin to fail. Due to the decreased perfusion of the cells, sodium ions build up
within while potassium ions leak out. As anaerobic metabolism continues,
increasing the body's metabolic acidosis, the arteriolar and precapillary
sphincters constrict such that blood remains in the capillaries. Due to this, the
hydrostatic pressure will increase and, combined with histamine release, this
will lead to leakage of fluid and protein into the surrounding tissues. As this fluid
is lost, the blood concentration and viscosity increase, causing sludging of the
micro-circulation. The prolonged vasoconstriction will also cause the vital
organs to be compromised due to reduced perfusion.

Refractory - At this stage, the vital organs have failed and the shock can no
longer be reversed. Brain damage and cell death have occurred. Death will
occur imminently.

Shock is a complex and continuous condition and there is no sudden transition

from one stage to the next.
Types of shock
In 1972 Hinshaw and Cox suggested the following classification which is still
used today.[1] It uses four types of shock: hypovolaemic, cardiogenic, distributive
and obstructive shock: [2] [4] [3] [5] [7]

Hypovolaemic shock - This is the most common type of shock and based on
insufficient circulating volume. Its primary cause is loss of fluid from the
circulation from either an internal or external source. An internal source may be
haemorrhage. External causes may include extensive bleeding, high output
fistulae or severe burns.

Cardiogenic shock - This type of shock is caused by the failure of the heart to
pump effectively. This can be due to damage to the heart muscle, most often
from a large myocardial infarction. Other causes of cardiogenic shock include
arrhythmias, cardiomyopathy, congestive heart failure (CHF), contusio cordis or
cardiac valve problems.

Distributive shock - As in hypovolemic shock there is an insufficient

intravascular volume of blood. This form of "relative" hypovolemia is the result
of dilation of bloodvessels which diminishes systemic vascular resistance.
Examples of this form of shock are:

Septic shock - This is caused by an overwhelming infection leading to

vasodilation, such as by Gram negative bacteria i.e. Escherichia coli which
releases an endotoxin which produces adverse biochemical, immunological and
occasionally neural mechanisms which are harmful to the body.

Anaphylactic shock - Caused by a severe anaphylactic reaction to an allergen,

antigen, drug or foreign protein causing the release of histamine which causes
widespread vasodilation. Leading to hypotension and increased capillary
permeability.

Neurogenic shock - Neurogenic shock is the rarest form of shock. It is caused

by trauma to the spinal cord resulting in the sudden loss of autonomic and
motor reflexes below the injury level. Without stimulation by sympathetic
nervous system the vessel walls relax uncontrolled, resulting in a sudden
decrease in peripheral vascular resistance, leading to vasodilation and
hypotension.

Obstructive shock - In this situation the flow of blood is obstructed which

impedes circulation and can result in circulatory arrest. Several conditions result
in this form of shock.

Cardiac tamponade in which blood in the pericardium prevents inflow of blood

into the heart (venous return). Constrictive pericarditis, in which the pericardium
shrinks and hardens, is similar in presentation.
Tension pneumothorax. Through increased intrathoracic pressure, bloodflow to
the heart is prevented (venous return).

Massive pulmonary embolism is the result of a thromboembolic incident in the

bloodvessels of the lungs and hinders the return of blood to the heart.

Aortic stenosis hinders circulation by obstructing the ventricular outflow tract

Recently a fifth form of shock has been introduced:[1]

Endocrine shock based on endocrine disturbances.

Hypothyroidism, in critically ill patients, reduces cardiac output and can lead to
hypotension and respiratory insufficiency.

Thyrotoxycosis may induce a reversible cardiomyopathy.

Acute adrenal insufficiency is frequently the result of discontinuing corticosteroid

treatment without tapering the dosage. However, surgery and intercurrent
disease in patients on corticosteroid therapy without adjusting the dosage to
accommodate for increased requirements may also result in this condition.

Relative adrenal insufficiency in critically ill patients where present hormone

levels are insufficient to meet the higher demands.

Signs and symptoms

Hypovolaemic shock

Anxiety, restlessness, altered mental state due to decreased cerebral

perfusion and subsequent hypoxia.

Hypotension due to decrease in circulatory volume.

A rapid, weak, thready pulse due to decreased blood flow combined with
tachycardia.

Cool, clammy skin due to vasoconstriction and stimulation of sweat glands.

Oliguria (low urine output) due to renal artery vasonconstriction.

Rapid and deep respirations due to sympathetic nervous system stimulation

and acidosis.

Hypothermia due to decreased perfusion and evaporation of sweat.

Thirst and dry mouth, due to fluid depeletion.

Fatigue due to inadequate oxygenation.

Cold and mottled skin (cutis marmorata), especially exteremities, due to

insufficient perfusion of the skin.

Cardiogenic shock, similar to hypovolaemic shock but

in addition:
Distended jugular veins due to increased jugular venous pressure.

Absent pulse due to tachyarrhythmia.

Obstructive shock, similar to hypovolaemic shock but in addition:

Distended jugular veins due to increased jugular venous pressure.

Pulsus paradoxus in case of tamponade

Septic shock, similar to hypovolaemic shock except in

the first stages:
Pyrexia and fever, or hypothermia, due to overwhelming bacterial infection.

Vasodilation and increased cardiac output due to sepsis.

Neurogenic shock, similar to hypovolaemic shock in its

presentation.
Anaphylactic shock
Skin eruptions and large weals.

Localised edema, especially around the face.

Weak and rapid pulse.

Breathlessness and cough due to occlusion of airways and swelling of the

throat.

In the early stages, shock requires immediate intervention to preserve life.

Therefore, the early recognition and treatment depends on the transfer to a
hospital.
Treatment
First aid

First aid treatment of shock includes:

Immediate reassurance and comforting the casualty if conscious.

If alone, go for help. If not, send someone to go for help and someone stay with
the casualty.

Ensure the patency of the airway and assess breathing. Position in the recovery
position if able.

Attempt to stem any obvious haemorrhaging.

Cover the patient with a blanket or jacket, but not too thick to cause
vasodilation.

Do not give a drink, moisten lips if requested.

Prepare for cardiopulmonary resuscitation.

Give as much information when the ambulance arrives.

The management of shock requires immediate intervention, even before a

diagnosis is made. Re-establishing perfusion to the organs is the primary goal
through restoring and maintaining the blood circulating volume ensuring
oxygenation and blood pressure are adequate; achieving and maintaining
effective cardiac function and preventing complications. Patients attending with
the symptoms of shock will have, regardless of the type of shock, their airway
managed and oxygen therapy initiated. In case of respiratory insufficiency (i.e.
diminished levels of consciousness, hyperventilation due to acid-base
disturbances or pneumonia) intubation and mechanical ventilation may be
necessary. A paramedic may intubate in emergencies outside the hospital,
whereas a patient with respiratory insufficiency in-hospital will be intubated
usually by a physician.

The aim of these acts is ensure survival during the transportation to the
hospital; they do not cure the cause of the shock. Specific treatment depends
on the cause.

A compromise must be found between:

raising the blood pressure to be able to transport "safely" (when the blood
pressure is too low, any motion can lower the heart and brain perfusion, and
thus cause death);
respecting the golden hour. If surgery is required, it should be performed within
the first hour to maximise the patient's chance of survival.
In-hospital management

Hypovolaemic shock
In hypovolemic shock, caused by bleeding, it is necessary to immediately
control the bleeding and restore the victim's blood volume by giving infusions of
balanced salt solutions. Blood transfusions are necessary for loss of large
amounts of blood (e.g. greater than 20% of blood volume), but can be avoided
in smaller and slower losses. Hypovolemic shock due to burns, diarrhea,
vomiting, etc. is treated with infusions of electrolyte solutions that balance the
nature of the fluid lost. Sodium is essential to keep the fluid infused in the
extracellular and intravascular space whilst preventing water intoxication and
brain swelling. Metabolic acidosis (mainly due to lactic acid) accumulates as a
result of poor delivery of oxygen to the tissues, and mirrors the severity of the
shock. It is best treated by rapidly restoring intravascular volume and perfusion
as above. Inotropic and vasoconstrictive drugs should be avoided, as they may
interfere in knowing blood volume has returned to normal. [1] [2] [4] [3]

Regardless of the cause, the restoration of the circulating volume is priority. As

soon as the airway is maintained and oxygen administered the next step is to
commence replacement of fluids via the intravenous route.

Opinion varies on the type of fluid used in shock. The most common are:

Crystalloids - Such as sodium chloride (0.9%), dextrose (5%) or Hartmann's

solution.

Colloids - For example, synthetic albumin (Dextran™), polygeline

(Haemaccel™), succunylated gelatin (Gelofusine™) and hetastarch
(Hepsan™).

Combination - Some clinicians argue that individually, colloids and crystalloids

can further exacerbate the problem and suggest the combination of crystalloid
and colloid solutions.

Blood - Essential especially in haemorrhagically shocked patients, often pre-

warmed and rapidly infused.

Administration of vasoconstrictors such as adrenaline, noradrenaline and

dopamine might be indicated if fluid replacement is insufficient to raise the blood
pressure satisfactorily. Also, while attempting to stabilise the patient it is
essential to find the source of the hypovolaemia.

In cardiogenic shock: depending on the type of myocardal infarction one can

infuse fluids or in shock refractory to infusing fluids, inotropic agents. Inotropic
agents, which enhance the heart's pumping capabilities, are used to improve
the contractility and correct the hypotension. Should that not suffice an Intra-
aortic balloon pump -which reduces workload for the heart, and improves
perfusion of the coronary arteries- can be considered or a left ventricular assist
device -which augments the pump-function of the heart. [1] [2] [4] [3]
The main goals of the treatment of cardiogenic shock are the re-establishment
of circulation to the myocardium, minimising heart muscle damage and
improving the heart's effectiveness as a pump. This is most often performed by
percutaneous coronary intervention and insertion of a stent in the culprit
coronary lesion or sometimes by cardiac bypass.

Although this is a protection reaction, the shock itself will induce problems; the
circulatory system being less efficient, the body gets "exhausted" and finally, the
blood circulation and the breathing slow down and finally stop (cardiac arrest).
The main way to avoid this deadly consequence is to make the blood pressure
rise again with

Cardiogenic shock

fluid replacement with intravenous infusions;

use of vasopressing drugs (e.g. to induce vasoconstriction);

use of antishock trousers that compress the legs and concentrate the blood in
the vital organs (lungs, heart, brain).

use of blankets to keep the patient warm - metallic PET film emergency
blankets are used to reflect the patient's body heat back to the patient.

Distributive shock
In distributive shock caused by sepsis the infection is treated with antibiotics
and supportive care is given (i.e. inotropica, mechanical ventilation, renal
function replacemnent). Anaphylaxis is treated with adrenaline to stimulate
cardiac performance and corticosteroids to reduce the inflammatory response.
In neurogenic shock because of vasodilation in the legs, one of the most
suggested treatments is placing the patient in the Trendelenburg position,
thereby elevating the legs and shunting blood back from the periphery to the
body's core. However, since bloodvessels are highly compliant, and expand as
result of the increased volume locally, this technique does not work. More
suitable would be the use of vasopressors. [1] [2] [4] [3]

Obstructive shock
In obstructive shock the only therapy consist of removing the obstruction.
Pneumothorax or haemothorax is treated by inserting a chest tube, pulmonary
embolism requires thrombolysis (to reduce the size of the clot), or embolectomy
(removal of the thrombus), tamponade is treated by draining fluid from the
pericardial space through pericardiocentesis. [1] [2] [4] [3]

Endocrine shock
In endocrine shock the hormone disturbances are corrected. Hypothyroidism
requires supplementation by means of levothyroxine, in hyperthyroidism the
production of hormone by the thyroid is inhibited through thyreostatica, i.e.
methimazole (Tapazole®) or PTU (propylthiouracil). Adrenal insufficiency is
treated by supplementing corticosteroids. [1]