SHOCK
BY Muhammad Sani Adam RN, BNSC, PDE
This is a life threatening conditions characterised by low blood
perfusion to tissues resulting in cell injury and inadequate tissue
functions.
In a normal person a shock index of 0.5 -0.8 is usually within normal
limit. But an increase in the number raises the suspicion of shock.
Shock index can be calculated by dividing heart rate with systolic
pressure. It’s a very good and sometimes accurate diagnostic tool. It’s
even more useful than hypotension and tachycardia.
Circulatory shock is often used interchangeably with emotional state
of shock but they are not related. Shock can produce variety of effects
but with similar outcome. Overall shock relates with a problem in the
body circulatory system
Worthy of note is the danger poses by shock as it progresses through a
positive feedback mechanism. Poor blood supply can result in cell
damage, cell damage will produce inflammatory response, and
inflammatory response will increase blood supply to the area. Under
normal circumstances this is useful as it matches tissue demand with
supply.
However, in shock if the area of the damage is much, it will deprive
vital nutrients to other parts of the body. Other parts of the body May
also respond in the same way further complicating the problem.
In view of the above, prompt identification, diagnosis and treatment
of shock is crucial to the survival of an individual.
SIGN AND SYMPTOMS
The sign and symptoms varies, with some people experiencing
minimal symptoms
Weakness
Confusion
Low blood pressure
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Tachycardia
Cool clammy skin
Rapid shallow breathing
Hypothermia.
CLASSIFICATION
It is classified into the following types based on the underlying
cause
HYPOVOLEMIC SHOCK: This is the most common type
of shock caused by decrease in circulating volume. The
decrease could be due to haemorrhage, loss of fluids from
the circulation, vomiting, diarrhoea, burns, exposure to
extreme temperatures, excess water loss via urine seen in
DKA and diabetes inspidus.
CARDIOGENIC SHOCK: It is due to the failure of the
heart to pump efficiently. This cardiac inefficiency could
be due to myocardial infarction, dysthymia,
cardiomyopathy, valvular heart diseases, etc.
OBSTRUCTIVE SHOCK: This mostly due to the
blockage of blood flow outside of the heart. Cardiac
tamponade, constrictive pericarditis, tension
pneumothorax, pulmonary embolism, aortic stenosis,
hypertrophic aortic stenosis.
DISTRIBUTIVE SHOCK: This is due to improper use of
oxygen and energy output by the cell. Its subtype includes:
a. Septic shock- due to systemic infection which results
in vasodilation leading to hypotension.
b. Anaphylactic shock- it is caused by severe
anaphylactic reaction to an antigen, drug, allergen,
etc. They tend to precipitate the release of histamine
a potent vasodilator. Histamine also causes capillary
permeability all of which lead to hypotension.
PATHOPHYSIOLOGY:
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Four stages are involved in the pathophysiology of shock. Oxygen
demand outweighs oxygen supply.
1. Initial stage – Normally, cell undergoes aerobic
metabolism, but due to reduce oxygen supply,
the cell start to undergo anaerobic metabolism
the end product of which produce lactic acid
2. Compensatory stage- the body employs its
homeostatic mechanism to compensate .Neural,
hormonal, and biochemical mechanisms are
activated. The person will begin to ventilate as
a result of acidosis in order to get rid of excess
CO2 .Co2 indirectly makes blood acidic
removing it will raise the PH of the blood.
Pressure receptors in the arteries respond to
hypotension by causing the release of
epinephrine which increases heart rate and
norepinephrine which causes vasoconstriction.
Their combined effects will result into an
increase in blood pressure. ADH is release to
spare water by the kidney. FIT and other organs
divert blood to heart, lungs, and brain.
3. Progressive stage- in this stage most of the
homeostatic mechanism fail to restore balance
and due to sustained hypotension sodium ions
accumulate within the cell and potassium ions
leak out of the cell. Continued anaerobic
metabolism will further produce lactic acid that
further worsen the vasodilation. Fluid and
plasma proteins are lost from the circulation
making the pressure to drop further and the
blood to become viscous causing sluggish
circulation.
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4. Refractory stage- In this stage vital organ
failure results and the process could not be
reverse
DIAGNOSIS.
Cardiac output
Shock index
Wide and narrow pulse pressure
ABG(arterial blood gases) analysis
Complete blood count
Chest x-ray
MANAGEMENT
Airway management
Oxygen supplementation
Aggressive fluid infusion 1-2 litre in
20 minutes
Blood transfusion
Use of adrenaline
Use of antibiotics
Urine output greater than 0.5ml/ kg/ hour
is a goal of management. Mean arterial
pressure of 65- 95 is also desirable.
Arrests of bleeding by surgical
intervention is also important.
NURSING MANAGEMENT
Assess for shock
Recognising early signs of
compensation
Identifying the cause
Administration of IV fluids
Administration of oxygen
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Obtaining lab results
Administration of prescribed
medications
Monitor vital signs
