SHOCK
Shock is a pathophysiologic state triggered by failure to adequately deliver
oxygen to the cellular level and perpetuated by the cellular response to ischemia.
Shock can be caused by a wide variety of conditions and, once initiated, can
become a rapidly fatal downward spiral. Shock is a leading cause of both early
and late mortality following traumatic injury. Although shock is easily diagnosed
in the clinical setting, effective treatment is complex and dynamic and may
require the utmost resources of the hospital and its personnel
DEFINITION
Shock is a clinical condition characterised by failure to adequately perfuse and
oxygenate vital organs.
OR - Shock is a life-threatening condition that occurs when the body is not getting
enough blood flow.
CLINICAL FEATURES
HYPOTENSION – Generally systolic BP < 90mmHg in adults
TARCHYCARDIA- > 100/min
ALTERED CONSCIOUSNESS- and /fainting (especially on standing or sitting
up) may result from reduced cerebral perfusion.
POOR PERIPHERAL PERFUSION
Tachypnoea
Oliguria - no urine output
Acidosis
POOR PERFUSION - signs
Cold clammy skin
Pallor
Capillary refill > 3seconds
CLASSIFICATION OF SHOCK
HYPOVOLEAMIC SHOCK
BLOOD LOSS- CAUSES
Trauma
GI Bleeding (hematemesis melaena )
Raptured ectopic pregnancy
FLUID LOSS CAUSES
Burns
GI- losses (vomiting and dirrhoea)
Pancreatits
CARDIOGENIC SHOCK
PRIMARY CAUSES
MI
Arrythmias
Valve dysfunction
Myocarditis
SECONDARY CAUSES
Cardiac Tamponade
Massive pulmonary embolus
Tension pneumothorax
SEPTIC SHOCK
Is due to infection
A wide spread infection causing organ failure which presents with very low BP
Septic shock is a life- threatening condition caused by severe localised or system-
wide infection that requires immediate medical attention.
Exaggerated low BP could be caused by the toxins produced by the bacteria
SEPTIC SHOCK
More common in extreme ages
In patients with Diabetes
In renal and hepatic failures and
Immunocompromised (HIV, malignancy, post splenectomy and steroid therapy)
Post abortion
NOTE
- That fever, Rigors and ↑wcc may not be present
3 stages of sepsis
Stage 1. sepsis
Stage 2. severe sepsis
stage 3. septic shock
When the immune system goes into overdrive in response to an infection, sepsis may
develop as a result
Stage 1 sepsis
Signs-
fever
Rapid breathing more than 20 breaths per minute
Heart rate more than100 beats per minute
Confirmed infection
The earlier the patient receive treatment the better the chances of survival
Stage 2 sepsis
Severe sepsis happens when organ failure occurs .
Patient may have one or more of the following signs to be diagnosed with severe sepsis:
Reduced urination
Change in mental status
Low platelet count
Patches of discoloured skin
Breathing problems
Irregular heart beat
Chills
Unconsciousness
Any infection can trigger sepsis
Infection of the kidney. Abdomen, or blood stream as well as pneumonia
Stage 3- SEPTIC SHOCK
SYPTOMS are same as severe sepsis such as:
Very low Bp
Most of the patients who develop septic shock die
Small clots can form throughout the blood, this can raise the chance of organ
failure and tissue death
Causative organisms in septic shock
Include:
Gram +ve and Gram –ve (especially Staph aureus, Strep. Pneumoniae, N
meningitides – coliforms such as: enterococci and Bacteroides )
in immunocompromised, pseudomonas, viruses and fungi
ANAPHYLACTIC SHOCK
It is a generalised immunological condition of sudden onset which develops after
exposure to a foreign substance.
Mechanism may involve IgE mediated reaction to a foreign protein (sting, foods,
streptokinase )or to protein – hapten conjugate (antibiotics) to which the patient
has been previously been exposed
Clinical features of Anaphylactic shock
Sudden on set (within minute or hours)
Severity vary depending on the amount of the stimulus
Severe features are seen in asthmatic patients
Systems involVed
RESPIRATORY SYSTEM
Swelling of mouth, tongue pharynx, epiglottis, may lead to complete upper air
way obstruction
Lower airway involvement presents like Asthma:
- wheezing
- Chest tightness
- Hypoxia
- Hypercabia
SKIN
Pruritis ,
erythema
urticaria and
angio- edema
CVS
Peripheral vasodilatation
Increased vascular permeability cause plasma leakage from circulation
Reduce vascular volume
Hypotension
Chest pain
GI
Nausea
Vomiting
Abdominal cramps
NEUROGENIC SHOCK
Neurogenic shock is a devastating consequence of spinal cord injury (SCI).
Manifests with low BP, bradyarrhythmia and temperature dysregulation due to
peripheral vasodilatation following an injury to the spinal cord.
This occurs due to the sudden loss of sympathetic tone with preserved
parasympathetic function leading to autonomic instability
It is not to be confused with a spinal shock which is the flaccidity of muscles and
loss of reflexes seen following spinal injury.
Pathophysiology of neurogenic shock
Neurogenic shock is the clinical state manifested from primary and secondary
spinal cord injury.
It is a combination of both primary and secondary injuries that leads to loss of
sympathetic tone unopposed parasympathetic response driven by the vagus nerve.
Can be caused by blunt cervical spinal trauma
Treatment is focused on heamodynamic stabilisation
Iv fluids
Vasopressors if not improving on iv fluids
CATEGORIES OF SHOCK
There are mainly 4 categories of shock:
DISTRIBUTIVE SHOCK
HYPOVOLEMIC SHOCK
CARDIGENIC SHOCK
OBSTUCTIVE SHOCK
1.DISTRIBUTIVE SHOCK
Characterised by peripheral vasodilatation.
Types of shock in distributive category include:
-i. Septic shock – characterised by systemic inflammatory response syndrome of
various inflammatory response caused by either infection or non infectious causes
ii. Anaphylactic shock
iii. Neurogenic shock
2. Hypovolaemic
Hypovolemic shock
Haemorrhagic shock
CARDIOGENIC SHOCK
Intracardiac causes leading to decreased cardiac output and systemic
hypoperfusion: includes
Cardiomyopathes
Arrhythmia
obstructive
Pulmonary vascular- due to impaired blood flow from the right heart to the left
heart. E.g pulmonary embolism.
Mechanical – impaired filling of right heart or due to decreased venous return to
the right heart due to extrinsic compression. Eg. Tension pneumothorax,
pericardial tamponade
3 Phases OF SHOCK
Phase 1. COMPENSATED - body is able to compensate for absolute or relative
fluid loss. At this stage Bp may be normal and brain well perfused
Phase 2.DECOMPESATED- late phase of shock body mechanisms such as
vasoconstriction fail.
phase 3. IRREVERSIBLE SHOCK- terminal phase of shock
Management of shock
Investigations and treatment should occur simultaneously
Get senior help immediately
Management cont-
Address the Priorities (A, B, C,D)
Give high flow Oxygen by mask
Secure adequate venous access and take blood for FBC, U&Es, lactate, glucose,
LFT, coagulation screen, and, if appropriate, blood cultures
Monitor vital signs, including pulse, BP, SaO2 and respiratory rate
Check ABG
MONITOR ECG and obtain 12 lead ECG and CXR
Insert a urinary catheter and monitor urine output hourly
For shock associated with increase effective circulating blood volume:
- Give IV Crystalloid (0.9% saline ) – 20ml/kg as bolus, give further iv fluids
including colloid +/- blood
- Aim for Hct >30 %) according to aetiology and clinical response (in particular,
pulse. BP, CvP, and urine out).
- Use caution with IV fluid infusion in shock related cardiogenic causes
- Look for, treat specifically, the cause(s) of the shock.
- ECHO, USS, CT and/or surgical intervention
SPECIFIC TREATMENTS
May include:
Laparotomy for Raptured ectopic pregnancy, splenic rapture, injury to the liver and intra-
abdominal sepsis
Pericardiocenthesis/
Antidotes for certain poisons
Antibiotics for sepsis.
Inotropic and vasoactive therapy
Assisted ventilation
Invasive monitoring (including arterial and CVP lines) are often needed as part of goal
directed therapy.
In critical condition monitor in ICU
