University Of Santo Tomas

Faculty Of Pharmacy

Health Intervention
Specific Emergency Situation

Shock
• Life-threatening medical condition whereby the body suffers from insufficient blood flow throughout
the body.
• Medical shock is a medical emergency and can lead to other conditions such as lack of oxygen in the
body's tissues (hypoxia), heart attack (cardiac arrest) or organ damage.
• Medical shock is different than emotional, or psychological, shock that can occur following a traumatic
or frightening emotional event.
• The connotation by the public is an intense emotional reaction to a stressful situation or piece of news.
• Medically, shock is defined as a condition where the tissues in the body don't receive enough oxygen and
nutrients to allow the cells to function. This ultimately leads to cellular death, progressing to organ failure
and finally, to whole body failure and death.

Classification

1. Hypovolemic Shock

If the body becomes dehydrated because water is lost or fluid intake is inadequate, the body tries to maintain cardiac output
by making the heart beat faster. But as the fluid losses mount, the body's compensation mechanisms fail, and shock will occur.
Hypovolemic (hypo=low + volemic=volume) shock due to water loss can be the endpoint of many illnesses, but the common element
is the lack of fluid within the body.
Gastroenteritis can cause significant water loss from vomiting and diarrhea, and is a common cause of death in third world
countries. Heat exhaustion and heat stroke is caused by excessive water loss through sweating as the body tries to cool itself. Patients
with infections can lose significant amounts of water from sweating. People in diabetic ketoacidosis lose significant water because of
because of elevated blood sugars.
Ultimately in hypovolemic shock, the patient cannot replace the amount of fluid that was lost by taking in enough water, and
the body is unable to maintain blood pressure and cardiac output. In all shock states, when cells start to malfunction waste products
build up, a downward spiral of cell death begins, increased acidosis occurs, and a worsening body environment leads to further cell
death - and ultimately organ failure.

2. Hemorrhagic Shock

Can occur in various medical conditions:

• Bleeding from the gastrointestinal tract is common; examples include stomach or duodenal ulcers, colon cancers or
diverticulitis.
• In women, excessive bleeding can occur from the uterus.
• People with cancers or leukemia have the potential to bleed spontaneously from a variety of sources if their bone marrow
does not make enough clotting factors.
• Patients who are taking blood thinners (anticoagulant medications) can bleed excessively as well.
The treatment of hemorrhagic shock depends on the cause. Finding and controlling the source of bleeding is of paramount
importance. Intravenous fluids are used to help with resuscitation to increase the fluid volume within the blood vessel space, but blood
transfusion is not always mandatory. If the bleeding is controlled and the patient becomes more stable, the bone marrow may be
allowed to replenish the red blood cells lost.
If the red blood cell count in the blood decreases gradually over time, either because of bleeding or the inability of the body to
make enough new red cells, the body can adjust to the lower levels to maintain adequate cell perfusion but the individual's exercise
tolerance may decrease. This means that they may do well in normal daily activities but find that routine exercise or household
activities bring on weakness or shortness of breath. The treatment depends on the underlying diagnosis, since it isn't a total fluid
problem like in hypovolemic shock.
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3. Cardiogenic Shock

When the heart loses its ability to pump blood to the rest of the body, blood pressure falls. Although there may be enough red
blood cells and oxygen, they can't get to the cells that need them.
The heart is a muscle itself and needs blood supply to work. When a heart attack occurs, the blood supply to part of the heart is
lost, and that can stun and irritate the heart muscle so that it isn't able to beat with an appropriate squeeze to push blood to the rest of
the body. This decreases stroke volume, and cardiac output falls.
Treatment includes trying to restore blood supply and the use of medications to support blood pressure. In more dire
circumstances, machines can be used to assist the heart to support blood pressure.

4. Neurogenic shock

If your blood vessels didn't squeeze a little tighter, gravity would make the blood flow to your feet, the lowest part of your
body, away from your brain, and you might pass out. The squeeze is maintained by signals from nerves in the sympathetic trunk, a
long bundle of fibers running from the skull to the tailbone alongside the vertebral column.
In brain or spinal injury, the sympathetic trunk stops working and blood vessels dilate and result in blood pooling away from
the heart. Since there isn't enough blood returning to the heart, the heart has a hard time pumping blood around the body.
This situation looks like hypovolemic shock, since effectively there isn't enough fluid to fill the blood vessels, but because
there isn't enough sympathetic tone or adrenaline release, the heart rate does not show a compensatory increase to increase cardiac
output.
Treatment includes fluids and medications to increase the tone in the blood vessel walls.

5. Hypoglycemic Shock and Hyperglycemia

If not enough food is ingested, then the blood sugar drops (hypoglycemia) and no glucose is available to enter the cells, even
if there is enough insulin to permit glucose to enter the cells. The brain is very susceptible to low blood sugars, and coma has a very
quick onset.
Treatment is providing sugar. If the person is awake enough to swallow, a sugar solution by mouth is used, otherwise,
intravenous fluids containing glucose are provided. If the lack of sugar was of short duration, the person will awaken almost
immediately after treatment. If blood sugars remain low for prolonged periods of time, the brain's ability to recover is potentially lost.
When blood sugar levels spiral high out of control, there is risk of significant dehydration (see below) and shock. If there is
not enough insulin in the blood stream, cells cannot use the glucose that is present and instead turn to an alternative anaerobic
metabolism to generate energy. Since glucose can't enter cells to be used, hyperglycemia (hyper= high + gly=sugar = emia) occurs as
the glucose level build in the blood stream. The kidneys try to excrete excess sugar, but because of chemical concentration gradients
between blood and urine, significant amounts of water are lost as well. The body quickly becomes dehydrated and blood pressure
drops, decreasing blood flow to cells. Cells which are now lacking glucose inside them are now starved of oxygen and turn to
anaerobic metabolism, causing acid waste product build up. Excess acid in the body changes the metabolism for all organs, making it
more difficult for oxygen to be used. This downward spiral will continue until insulin and significant fluids are given.

6. Septic shock

It results from bacteria multiplying in the blood and releasing toxins. Common causes of this are pneumonia, intra-abdominal
infections (such as a ruptured appendix) and meningitis.

7. Anaphylactic shock

It is a type of severe hypersensitivity or allergic reaction. Causes include allergy to insect stings, medicines or foods (nuts, berries,
seafood) etc.

Causes
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 If cells are deprived of oxygen, instead of aerobic (with oxygen) metabolism, the cells use the anaerobic
(without oxygen) pathway to produce energy. Unfortunately, lactic acid is formed as the by product of
anaerobic metabolism. This acid changes the acid-base balance in the blood and leads to a downward
spiral where cells start to leak toxic chemicals into the bloodstream, cause blood vessel walls to become
damaged, and this process ultimately leads to the death of the cell. If enough cells die, then organs start
to fail, and the body dies.

 The oxygen delivery system to the body's cells can fail in a variety of ways.

 The amount of oxygen in the air that is inhaled can be decreased.

Examples include breathing at high altitude or carbon monoxide poisoning.

 The lung may be injured and not be able to transfer oxygen to the blood stream. Causes of this may
include, among others:
a. pneumonia (an infection of the lung),
b. congestive heart failure where the lung fills with fluid
c. trauma with collapse or bruising of the lung.

 The heart may not be able to adequately pump the blood to the tissues of the body. Cases of this may
include, among others:
a. heart attack, where muscle tissue is lost, or by a rhythm disturbance of the heart, when the
heart can't beat in a coordinated way.
b. of heart inflammation due to infection or other causes, again where the effective beating
capabilities of the heart are lost.

 There may not be enough red blood cells in the blood. If there aren't enough red blood cells (anemia),
then not enough oxygen can be delivered to the tissues with each heart beat. Causes may include:
a. acute or chronic bleeding,
b. inability of the bone marrow to make red blood cells
c. the increased destruction of red blood cells by the body (an example includes sickle cell
disease).

 There may not be enough other fluids in the blood vessels. The blood stream contains the blood cells
(red, white, and platelets), plasma (which is more than 90% water), and many important proteins and
chemicals. Loss of body water or dehydration can cause shock.

 The blood vessels may not be able to maintain enough pressure within their walls to allow blood to be
pumped to the rest of the body. Normally, blood vessel walls have tension on them to allow blood to be
pumped against gravity to areas above the level of the heart. This tension is under the control of the
unconscious central nervous system, balanced between the action of two chemicals, adrenaline
(epinephrine) and acetylcholine. If the adrenaline system fails, then the blood vessel walls dilate and
blood pools in the parts of the body closest to the ground and may have a difficult time returning to heart
to be pumped around the body.
 Dehydration

 Infection
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 Severe allergic reaction

 Spinal injuries

 Burns

 Persistent vomiting or diarrhea

Signs and Symptoms

Shock is defined as abnormal metabolism at the cellular level. Since it is not easy to directly measure
cellular problems, the symptoms of shock are indirect measurements of cellular function. Shock is the end stage
of all diseases, and symptoms will often be dependant on the underlying cause.

 There may be a slight rise in the heart rate (tachycardia = tachy or fast + cardia or heart).

 The breathing rate gets faster and the tachycardia increases as the body tries to pack as much oxygen
onto the remaining red blood cells as possible and deliver them to the cells.

 Blood pressure starts to fall (hypotension=hypo or low + tension= pressure) as compensation

mechanisms fail.

 Cells don't get enough oxygen and the organs that they comprise start to fail. All organs may be affected.

 As the brain is affected, the patient may become confused or lose consciousness (coma).

 There may be chest pain as the heart itself doesn't get an adequate oxygen supply.

 Diarrhea often occurs as the large intestine becomes irritated due to hypotension.

 Kidneys may fail and the body may stop making urine.

 The skin becomes clammy and pale.

 Rapid, shallow breathing

 Eyes appear to stare

 Anxiety or agitation

 Confusion or unresponsiveness

 Bluish lips and fingernails

 Sweating
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Treatment

Self-Care at Home
 If you come upon a person in shock, the initial response should be to call 911 or any hospital emergency
hotline and activate the emergency response system.
 Lay the person down in a safe place and try to keep them warm and comfortable.

Medical Treatment
 EMS personnel are well trained in the initial assessment of the patient in shock. The first course of
action is to make certain that the ABCs have been assessed. The so-called ABCs are:
a.) Airway: assessment of whether the patient is awake enough to try to take their own breaths and/or
if there is there anything blocking the mouth or nose.
b.) Breathing: assessment of the adequacy of breathing and whether it may need to be assisted with
mouth-to-mouth resuscitation or more aggressive interventions like a bag and mask or intubation
with an endotracheal tube.
c.) Circulation: assessment of the adequacy of the blood pressure adequate and determination of
whether intravenous lines are needed for delivery of fluid or medications to support the blood
pressure.

 If there is bleeding that is obvious, attempts to control it with direct pressure will be attempted.

 A fingerstick blood sugar will be checked to make certain that hypoglycemia (low blood sugar) does not
exist. Many people can appear to be on death's door, but wake up and remain normal when given sugar.

In the Emergency Department, diagnosis and treatment will happen at the same time.
 Patients will be treated with oxygen supplementation through nasal cannulae, a face mask, or
endotracheal intubation. The method and amount of oxygen will be titrated to make certain enough
oxygen is available for the body to use. Again, the goal will be to pack each hemoglobin molecule with
oxygen.

 Blood may be transfused if bleeding (hemorrhage) is the cause of the shock state. If bleeding is not the
case, intravenous fluids will be given to bolster the volume of fluids within the blood vessels.

 Intravenous drugs can be used to try to bolster blood pressure (vasopressors). They work by stimulating
the heart to beat stronger and by squeezing blood vessels to increase the flow within them.

Follow-up
 Patients in shock are critically and will be admitted to an intensive care unit. Depending on the
underlying condition, a variety of specialists will be involved with their care. Nurses with advanced
training, respiratory therapists, and pharmacists will be added to the team of doctors assigned to one
patient.

 When the body is in a stressed state, it becomes more susceptible to infection. As well, having tubes in
one's body for prolonged periods lead to higher infection risk. While in the hospital, the staff will be
vigilant in trying to prevent nosocomial (hospital-borne) infections.
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 Extended nursing care is often needed if one survives shock. Rehabilitation may take a prolonged period
of time as different organs recover their function. The amount of time the body was in a shock state
often determines the extent of organ damage, and full recovery may never be complete. Brain injury can
lead to stroke and thought impairment. Heart and lung damage can lead to significant disabilities that
may include reduced exercise tolerance. Kidney damage can lead to the need for dialysis.

Sources:
http://www.emedicinehealth.com/shock/article_em.htm
http://www.medicinenet.com/shock/page4.htm

Prepared By:

SHOCK Group 1DPH

40 Rubico, Fritzie
41 Sagmon, Kristine
42 See, Carelle
43 Sulio, Cris
44 Tabaong, Mara

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