Shock occurs when blood pressure falls to a very low level.

As blood pressure
falls, brain and other organs don't get enough blood or oxygen to function, and
they begin to fail. Shock can arise from any of a number of causes. It is a life-
threatening medical emergency and must be treated early to avoid serious
complications and even death.

The following conditions and characteristics increase the risk for shock:

• Serious injury and trauma

• Heart conditions such as heart disease or heart attack
• Surgery
• Bacterial infection that has spread to the blood
• Bleeding
• Losing large volume of fluids from severe diarrhea or vomiting
• Excessive alcohol use
• Severe anemia
• Weakened immune system
• Allergic reaction to a drug, food, or environmental exposure
• Drug overdose
• Pregnancy

Common signs and symptoms of shock include:

• Low blood pressure

• Altered mental state, including reduced alertness and awareness,
confusion, and sleepiness
• Cold, moist skin. Hands and feet may be blue or pale
• Weak or rapid pulse
• Rapid breathing and hyperventilation
• Decreased urine output
• In septic shock (from overwhelming blood infection) -- shaking chills, rapid
temperature increase, warm, flushed skin, and rapid pulse
• In shock related to heart problems -- lung congestion, rapid pulse, heart
murmur, enlarged neck veins
CAUSES

1. Loss of fluid in the bloodstream (hypovolemic shock) -- occurs after heavy

bleeding from an injury or a condition such as bleeding ulcers. Hypovolemic
shock can also occur if your body loses too much of fluids other than blood (such
as losing water after severe diarrhea or vomiting, or losing plasma after serious
burns).

2. Blood vessels become too dilated (distributive shock) -- If the blood vessels
expand too much, they are not able to keep blood circulating to all organs. Septic
shock, which occurs when bacteria invade the bloodstream, and anaphylactic
shock, which is a severe allergic reaction, are examples.

3. Heart problems (cardiogenic shock) -- In this case, the heart doesn't pump
enough blood through the body. It can be caused by a heart attack, abnormal
heart rhythm, or damage to the heart from heart disease.

CLASSIFICATION OF SHOCK

Hypovolemic shock
This is the most common type of shock and based on insufficient
circulating volume. Its primary cause is loss of fluid from the circulation (most
often "hemorrhagic shock"). Causes may include internal bleeding, traumatic
bleeding, high output fistulae or severe burns.
Direct loss of effective circulating blood volume leading to:

• Anxiety, restlessness, altered mental state due to decreased cerebral

perfusion and subsequent hypoxia
• Hypotension due to decrease in circulatory volume
• A rapid, weak, thready pulse due to decreased blood flow combined with
tachycardia
• Cool, clammy skin due to vasoconstriction and stimulation of
vasoconstriction
• Rapid and shallow respirations 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
 • Fatigue due to inadequate oxygenation
• Cold and mottled skin (cutis marmorata), especially extremities, due to
insufficient perfusion of the skin
• Distracted look in the eyes or staring into space, often with pupils dilated

Cardiogenic shock
This type of shock is caused by the failure of the heart to pump effectively. This
can be due to damage to the heart muscle, most often from a large myocardial
infarction. Other causes of cardiogenic shock include arrhythmias,
cardiomyopathy, CHF, cardiac valve problems.

Signs are similar to hypovolemic shock but in addition:

• Distended jugular veins due to increased jugular venous pressure

• Weak or absent pulse
• Arrhythmia, often tachycardic

Distributive shock
As in hypovolemic shock there is an insufficient intravascular volume of blood.
This form of "relative" hypovolemia is the result of dilation of blood vessels which
diminishes systemic vascular resistance. Examples of this form of shock are:

Septic shock. It is caused by an overwhelming systemic infection resulting

in vasodilation leading to hypotension. Septic shock can be caused by Gram
negative bacteria such as (among others) Escherichia coli, Proteus
species, Klebsiella pneumoniae which release an endotoxin which produces
adverse biochemical, immunological and occasionally neurological effects which
are harmful to the body, and other Gram-positive cocci, such
as pneumococci and streptococci, and certain fungi as well as Gram-positive
bacterial toxins. Septic shock also includes some elements of cardiogenic shock.
In 1992, the ACCP/SCCM Consensus Conference Committee defined septic
shock: ". . .sepsis-induced hypotension (systolic blood pressure <90 mm Hg or a
reduction of 40 mm Hg from baseline) despite adequate fluid resuscitation along
with the presence of perfusion abnormalities that may include, but are not limited
to, lactic acidosis, oliguria, or an acute alteration in mental status. Patients who
are receiving inotropic or vasopressor agents may have a normalized blood
pressure at the time that perfusion abnormalities are identified.

Signs are similar to hypovolemic shock except in the first stages:

• Pyrexia (fever), due to increased level of cytokines

• Systemic vasodilation resulting in hypotension (low blood pressure)
• Warm and sweaty skin due to vasodilation
• Systemic leukocyte adhesion to endothelial tissue[1]
• Reduced contractility of the hear
• Activation of the coagulation pathways, resulting in disseminated
intravascular coagulation
• Increased levels of neutrophils

Anaphylactic shock. It is caused by a severe anaphylactic reaction to

an allergen, antigen, drug or foreign protein causing the release
of histamine which causes widespread vasodilation, leading to hypotension and
increased capillary permeability.

• Skin eruptions and large bumps

• Localized edema, especially around the face
• Weak and rapid pulse
• Breathlessness and cough due to narrowing of airways and swelling of the
throat

Neurogenic shock. it is the rarest form of shock. It is caused by trauma to

the spinal cord resulting in the sudden loss of autonomic and motor reflexes
below the injury level. Without stimulation by sympathetic nervous system the
vessel walls relax uncontrollably, resulting in a sudden decrease in peripheral
vascular resistance, leading to vasodilation and hypotension. (This term can be
confused with Spinal shock which is a recoverable loss of function of the spinal
cord after injury and does not refer to the hemodynamic instability per se.)
 • As with hypovolemic shock but in high spinal injuries may also be
accompanied by profound bradycardia due to loss of the cardiac
accelerating nerve fibres from the sympathetic nervous system at T1-T4.
• The skin is warm and dry or a clear sweat line exists, above which the skin
is diaphoretic.
• Priapism due to Peripheral nervous system stimulation

Obstructive shock
In this situation the flow of blood is obstructed which impedes circulation and can
result in circulatory arrest. Several conditions result in this form of shock.

Similar to hypovolemic shock but in addition:

• Distended jugular veins due to increased jugular venous pressure

• Pulsus paradoxus in case of tamponade

Cardiac tamponade in which fluid in the pericardium prevents inflow of blood

into the heart (venous return). Constrictive pericarditis, in which
the pericardiumshrinks and hardens, is similar in presentation.

Tension pneumothorax. Through increased intrathoracic pressure, blood flow

to the heart is prevented (venous return).

Massive pulmonary embolism is the result of a thromboembolic incident in the

bloodvessels of the lungs and hinders the return of blood to the heart.

Aortic stenosis hinders circulation by obstructing the ventricular outflow tract

MANAGEMENT

When someone goes into shock, treatment is needed immediately. Treating

shock with the following guidelines to make a difference:

• Call a doctor or emergency services for medical help immediately.

• Check the person’s rate of breathing and circulation every 5 minutes. If the
person is experiencing trouble breathing, begin CPR.
• Lay the person flat on the back and raise the legs about 25 cm to help
restore the blood pressure. If the person is conscious but has trouble
breathing, place him or her in a sitting position.
• Administer first aid treatment to wounds, injuries or illnesses.
• Loosen tight clothing and keep person warm and comfortable.
• Do not give the person food or liquids to prevent inhalation of vomit.

Emergency treatment would involve the person in shock being hospitalized. To

treat him or her effectively, treating shock will include:

• Temperature control such as cooling blankets or warming devices.

• Give fluids and blood intravenously to improve the blood flow.

FLUID REPLACEMENT Is administered in all types of shocks. The type of fluids

administered and the speed of delivery vary, but fluids are given to
improve cardiac and tissue oxygenation, may include crystalloids (electrolyte solutions
that move freely between intravascular and
isterstitial space), colloids (large-molecule intravenous solutions) or
blood components.

*Close monitoring of the patients during fluid is necessary to identify side effects and
complications. The most common and serious side effect of fluid replacement are
cardiovascular overload and pulmonary edema.

• Extra oxygen is administered either by a tube in the nose, a face mask, or

an endotracheal tube and ventilator. A ventilator is used if the patient has
trouble breathing.
• To deal with underlying conditions such as heart problems, drugs are
administered or surgery may be performed. Bacterial infections will be
treated with antibiotics.
If physiological shock is left untreated, it is usually fatal. Depending on the
severity of the condition associated with shock and symptoms, some people do
recover while others may need long-term care.

Septic shock is treated with prompt administration of antibiotics depending on

the source and type of underlying infection. These patients are often dehydrated
and require large amounts of fluids to increase and maintain blood pressure.
Anaphylactic shock is treatedwith diphenhydramine (Benadryl), epinephrine (an
"Epi-pen"), steroid medications methylprednisolone (Solu-Medrol) and
sometimes a H2-Blocker medication.
Cardiogenic shock is treated by identifying and treating the underlying cause. A
patient with a heart attack may require a surgical procedure called a cardiac
catheterization to unblock an artery. A patient with congestive heart failure may
need medications to support and increase the force of the heart's beat. In severe
or prolonged cases, a heart transplant may be the only treatment.
Hypovolemic shock is treated with fluids (saline) in minor cases, but may
require multiple blood transfusions in severe cases. The underlying cause of the
bleeding must also be identified and corrected.
Neurogenic shock is the most difficult to treat. Damage to the spinal cord is
often irreversible and causes problems with the natural regulatory functions of
the body. Besides fluids and monitoring, immobilization (keeping the spine from
moving), anti-inflammatory medicine such as steroids, and sometimes surgery
are the main parts of treatment.