ShockPresented by Dr Azza Serry

Learning objectives

Definition Pathophysiology Types of shockStages of shockClinical presentationmanagement

Types of shock

Shock Shock is inadequate tissue perfusion leading to decreased oxygen delivery to tissues .

typesHypovolaemicCardiogenicObstructiveDistributive

Hypovolaemic shock

Hypovolaemic shockTissue hypoperfusion resulting from inadequate intravascular volume .

Caused by reduced circulatory volume due to haemorrhage or fluid loss .

Haemorrhage : external , internal

Fluid loss : vomiting ,diarrhea ,burns.

Haemorrhagic shock classification

Class I Class II Class III Class VI

Volume loss (ml )

0 - 750 750 - 1000 1500 - 2000 ≥ 2000

Loss % 0 - 15 15 -30 30 - 40 ≥ 40

Pulse beats / min

< 100 > 100 > 120 > 140

Blood pressure

unchanged unchanged decreased decreased

Pulse pressure

unchanged decreased decreased decreased

Urine output ml / h

> 30 20 - 30 5 -15 anuric

Respiratory rate / min

14 -20 20 - 30 30 -40 > 40

Mental state

restless Anxious Anxious - confused

confused

Fluid replacement

Crystalloid Crystalliod & colloid

Colloid & blood

Colloid & blood

Cardiogenic shock

Cardiogenic shock Inadequate blood flow to vital organs due to inadequate cardiac output despite normal blood volume .

Caused by : acute myocardial infarction ,arrhythmia , myocarditis

.

Obstructive shock

Obstructive shockReduction of preload due to mechanical obstruction of cardiac contractility .

Caused by cardiac tamponade ,tension pneumothorax , pulmonary embolism .

.

Distributive shock

Disrtributive shock there is inadequate tissue perfusion accompanied by vascular dilatation ,with hypotension and decrease peripheral vascular resistance .

Anaphylaxis : antigen antibody reaction → histamine release →

vasodilatation → ↓PVR .

.

High spinal cord injury : interruption of sympathetic outflow → VD .

Septic shock

Septic shock

Tissue hypoperfusion that occurs in the presence of systemic inflammatory response to infection .

Gram negative , gram positive bacteria .

Intraperitoneal abscess , genitourinary infections .central line infection .

hypovolemic

cardiogenic

obstructive

distributive

Cardiac output

↓ ↓ ↓ ↑

Heart rate ↑ ↑ ↑ ↑

Blood pressure

↓ ↓ ↓ ↓

Peripheral vascular resistance

↑ ↑ ↑ ↓

Venous pressure

↓ ↑ ↑ ↓

Skin temperature

↓ ↓ ↓ ↑

acidosis √ √ √ √

Stages of shockCompensated shock Early , compensatory sympathetic stimulation

Altered level of consciousness ,

Increased pulse rate

Increase respiratory rate

Pale clammy skin

Normal blood pressure

Decompensated shocklate stage

Body looses ability to compensate

Rapid weak pulse

Shallow respiration

Extreme weakness

Pallor ,cyanosis

Drop in blood pressure

oliguria

Irreversible shock

Terminal stage Organs suffer prolonged hypoxia Return of function is irreversible despite aggressive adequate intervention

Unresponsiveness Profound hypotension Severe bradycardia Apnea Fixed dilated pupils

Presentation

Shock presents by Altered mental status Hypotension Increased pulse rate Increased respiratory rateOliguriaCold pale skin ,warm skin is seen in distributive shock

Manifestation of cause

Principles of management

General management principles1. Golden hour .

2. Establish clear airway ,adequate ventilation

3. Oxygen

4. Adequate intravenous access

5. Continuous cardiac monitoring

6. Urinary catheter

7. Record fluid balance

8. Maintain optimum temperature

9. Blood gases

10.Inotropes and vasoconstrictors may be used

11.Assess the response

12.Treat underlying cause.