By

Dr. Sania Shahid

House officer, Surgery Ward -21
 OBJECTIVES:
• What is shock?
• It’s pathophysiology.
• Types of shock.
• Signs and symptoms.
• Management of shock.
What is shock?
Shock is a systemic state of low tissue perfusion and tissue
oxygenation which is inadequate for normal cellular respiration.
It’s a clinical diagnosis and is an emergency situation.
Generally patients are seen with following clinical findings:
Tachycardia
Decreased capillary refill time.
Hypotension.
Tachypnea.
Decreased U/O.
Changes in mental state.
Pathophysiology
 Cellular:
• Due to insufficient delivery of oxygen and glucose, cells switch
from aerobic to anaerobic metabolism.
• Leading to production of lactic acid.
• Accumulation of which causes metabolic acidosis.

• Hypoxia and acidosis leads to leaky capillaries which in turn activates

immune and coagulation systems.
• Leaky capillaries causes tissue edema which exacerbates hypoxia
 Systemic:
• Cardiovascular:
• Tachycardia.
• Systemic vasoconstriction except in distributive where vasodilation
occurs.
• Respiratory:
• Compensatory respiratory alkalosis, causing hyperventilation.
• Renal:
• Decreased perfusion pressure causes decreased GFR
which in turn results in decreased urinary output.

• Above condition stimulates renin-angiotensin-

aldosterone axis resulting in further vasoconstriction
and increased sodium and water reabsorption by
kidney.
Lethal Triad
Types Of Shock
 Hypovolemic Shock:

Hypovolemic shock is due to reduced circulating

volume i.e. hypovolemia. It’s the most common form
of shock.
Causes Of Hypovolemic Shock:
• Haemorrhagic:
• Internal bleeding.
• External bleeding.
• Non-hemorrhagic:
• Dehydration.
• Excessive fluid loss due to:
1)Vomiting.
2)Diarrhea.
3)Urinary loss as in diabetes insipidus and
diabetic ketoacidosis.
4)Third spacing e.g. in pancreatitis or bowel
obstruction.
5)Burns.
Signs And Symptoms:
• A rapid, weak, thready pulse due to decreased blood flow
combined with tachycardia.
• Cool, clammy skin due to vasoconstriction.
• Rapid and shallow breathing due to sympathetic nervous
system stimulation and acidosis.
• Hypothermia due to decreased perfusion and
evaporation of sweat.
• Thirst and dry mouth, due to fluid depletion.
• Cold and mottled skin (Livedo reticularis),
especially extremities, due to insufficient perfusion
of the skin.
• Oliguria.
• Increased SVR.( 700-1600 dyne-sec/cm5)
Grades Of Hemorrhagic Shock:
 Systemic index:

• The shock index (heart rate divided by systolic blood

pressure) is a stronger predictor of the impact of blood
loss than heart rate and blood pressure alone.
• Normal range 0.5-0.8
• If increased, indicates shock.
 Cardiogenic Shock:

Cardiogenic shock is caused by the failure of the heart

to pump blood effectively to the tissues.
Causes Of Cardiogenic Shock:
1)Myocardial infarction (most common)
2)Cardiac dysrhythmias.
3)Valvular heart disease.
4)Blunt myocardial injury.
5)Cardiomyopathy.
6)Endogenous factors like in sepsis.
7)Exogenous factors such as pharmaceutical agents
or drug abuse.
Signs And Symptoms:
• Distended jugular veins due to increased jugular venous
pressure
• Weak or absent pulse
• Arrhythmia, often tachycardia
• Reduced blood pressure
• Decreased cardiac output.
• Oliguria <30ml/hr.
• Tachypnea, crackles.
• Increased SVR.
 Obstructive Shock:
In obstructive shock there is a reduction in preload
due to mechanical obstruction of cardiac filling.
OR
Blood flow in the heart or great vessels becomes
blocked.
Causes Of Obstructive Shock:

1)Cardiac tamponade.
2)Tension pneumothorax.
3)Massive pulmonary embolus.
4)Air embolus.
5)Aortic stenosis.
Signs And Symptoms:
• Tachycardia.
• Anxiety.
• Shortness of breath, Tachypnea.
• Pallor to cyanosis around mouth or nose.
• Chest pain with clear lung sounds.
• Possible syncope.
• Dysrhythmias (A-fib is common) can lead to sudden cardiac
arrest.
 Distributive Shock:

It occurs when the pooling of blood in the peripheral

blood vessels results in the decreased venous return
of blood to the heart.
Types Of Distributive Shock.

• Neurogenic.
• Anaphylactic.
• Septic.
 Neurogenic Shock:
Neurogenic shock is due to a loss of sympathetic
tone causing vasodilation in peripheral vessels.
resulting in low blood pressure, occasionally with a
decreased heart rate.
It can occur after damage to the central nervous
system such as spinal cord injury.
Signs And Symptoms:
• Hypotension.
• Bradycardia
• Warm, dry skin.
• Venous and arterial vasodilation.
• Loss of sympathetic tone.
• Decreased SVR.
 Anaphylactic Shock:

An extreme, often life-threatening allergic reaction

to an antigen to which the body has become
hypersensitive.
Signs And Symptoms:
• Hypotension.
• Tachycardia.
• Cough and dyspnea, wheezing.
• Pruritus and Urticaria.
• Restlessness.
• Decreased LOC.
• Swelling of lips, tongue and throat.
 Septic Shock:
Septic shock is a serious medical condition that
occurs when sepsis, which is organ injury or damage
in response to infection, leads to dangerously low
blood pressure and abnormalities in cellular
metabolism.
 SIRS
• It stands for systemic inflammatory response syndrome
• There are Four SIRS criteria.
1)Body temperature <36 *C or >38*C
2)Heart rate >90 bpm.
3)Tachypnea >20 breaths per min, or PCO2 <32mm
Hg.
4)WBC<4,000 cells/mm3 or >12,000 cells/mm3.
• 2 criteria =SIRS
• 2 criteria + source of infection = Sepsis.
• 2 criteria + source of infection + organ
dysfunction = Severe sepsis.
• 2 criteria = source of infection + organ
dysfunction + hypotension =Septic shock.
Signs And Symptoms:
• Hypotension.
• Tachycardia.
• Full bounding pulse.
• Tachypnea, productive cough.
• Pink, warm, flushed skin.
• Decreased urine output, hematuria in severe cases.
• Fever, chills, myalgia, fatigue.
• Decreased SVR.
Severity Of Shock:
Management Of Shock:
Hypovolemic Shock:
• A:Airway.
• B: Breathing: Give oxygen if required.
• C:Circulation: Establish 2 large bore I/V cannula 16 gauge or
larger, or a central line (internal jugular and subclavian vein
catheterization.)
• Crystalloids: N/S or R/L.
• Do not give I/V solutions containing glucose. (D/W)
• Initially give 20 ml/kg of fluid followed by re-assessment.
• No change in vital signs then repeat the bolus.
• The aim is to restore B.P and pulse towards normal values
• Maintenance :Total of 2-3 litres/24 hrs.
• If the patient has travelled from a remote area where fluids were
unavailable so the patient may need to “catchup” on maintenance
fluid i.e. 125 ml / hour elapsed.
• Send Labs i.e. CBC and SUCE.
• Packed RBCs: O –ve or cross matched, if blood loss is more than
10% of blood volume i.e. (7ml/kg in adults).
• U/O should be > 0.5 ml/kg in adults and 1 ml/kg in children.

• D: Deformities: Treat the fracture or control any bleeding (apply

pressure).
• E: Exposure: Properly check the patient and keep the patient
warm.
• Massive Transfusion:
• Indication: 1)Penetrating injury.
2)B.P <90mm Hg.
3)Heart rate >120
4)Positive FAST.
• MTP (Massive transfusion protocol):
• Stop the bleeding
• Arrange 4 units of red cells urgently and transfuse. Prepare FFPs and platelets
if available.
• Or arrange 4 units of whole blood.
• Give Tranexamic acid 1g over 10 mins then 1 g over 8 hrs.
• Consider immediate damage control surgery.
• Maintain B.P of 65 mmHg if no head injury.
• Monitor vitals, U/O and clotting parameters, ABG’s and lactate, if possible.
Cardiogenic Shock:
• A,B,C: Same as previously mentioned.
• ECG, Echo, CXR, Cardiac biomarkers.
• Pulse oximetry: SaO2: >92-98%.
• Pulmonary artery catheterization/ Swan-Ganz catheterization.
• Normal values: Systemic vascular resistance (SVR)= 700-1600
dyne-sec/cm5
Pulmonary capillary wedge pressure (PCWP) = 4-
12 mm of Hg.
PVR: 20-130 dyne-sec/cm5
• Positive Inotropic drugs:
• Dobutamine: Drug of choice in mild shock.
• Dose:2.5-20 mcg/kg/min, avg. 5
ug/kg/min(renal dose)
1 amp= 250 mg/5ml solution.
• Dopamine: Drug of choice in severe shock.
Dose: 2.5-20 mcg/kg/min.
1 amp= 40mg/ml in 5ml solution.
• Nor-epinephrine (levophed): Dose: 8-12 mcg/kg/min.
1 amp= 4mg/4ml solution.
• Diamorphine 2.5-5mg I/V for pain and anxiety.
• If PCWP<15mg Hg: Give a plasma expander i.e. 100ml every
15 min I/V.
Aim for PCWP of 15-20 mmHg.
• If PCWP>15 mmH: Inotropic support. E.g. Dobutamine 2.5-
10 mcg/kg/min I/V.
Aim for systolic B.P >80 mmHg.
• Treat the underlying cause.
 Obstructive Shock:
• Pulmonary embolus:
• Thrombolytics.
• Pericardial tamponade:
• I/V Fluids.
• Pericardiocentesis.
• Pneumothorax:
• Chest tube.
• Pulmonary hypertension:
• Vasodilators example Nitroglycerine.
Neurogenic Shock:
• A,B,C: remember cervical spine precautions i.e. immobilize it with collar/sand
bag.
• Keep the patient lying flat on the back in neutral position.
• Pain relief and anti-nausea medication.
• Keep temperature stable.
• Fluid resuscitation: Keep MAP 85-90 mm of Hg for 7 days.
• Catheterize the patient.
• Minimize secondary cord injury.
• For bradycardia: Atropine.
Anaphylactic Shock:
Septic Shock:
• A,B,C.
• 2 large bore N/S bolus 1-2 L.
• Steroids: Hydrocortisone 200-100 mg I/V loading dose followed
by 50 mg q.i.d I/V for 5 days.
• Antibiotics: After sampling for microbiology start empiric
antibiotic therapy as soon as possible(within an hour). Start
broad spectrum antibiotics e.g. Moxifloxacin, Tetracycline,
Amoxicillin, Azithromycin, Augmentin.
• Inotropic support: Levophed is the drug of choice, dobutamine.
Summary: