SHOCK

NURUL IZZATI BINTI SAIDI

DEFINITION
A state of impaired perfusion leading to
inadequate delivery of oxygen and
nutrients and clearance of metabolites
with consequent reversible and eventual
irreversible cellular injury.

PATHOPHYSIOLOGY
Inadequate perfusion
Cell hypoxia
Energy deficit
Lactic acid accumulation and fall in pH
(anaerobic metabolism)

Metabolic acidosis
Cell membrane dysfunction and failure of sodium pump
Intracellular lysosomes release digestive enzymes
Toxic substances enter circulation
Capillary endothelial damaged, cell death and dysfunction

Metabolic acidosis
Vasoconstriction
Failure of pre-capillary spinchter
Periphery pooling of blood

HISTORY
Recent illness
Fever
Chest pain, SOB
Abdominal pain
Comorbidities
Medications
Toxins/ingestions
Recent hospitalization or surgery

PHYSICAL EXAMINATION
Vital signs
CNS mental status
Skin color, temp, rashes, sores
CVS JVP, heart sounds
Resp lung sounds, RR, oxygen saturation
Gi abd pain, rigidity, guarding, rebound
Renal urine output

CLINICAL ASSESSMENT
To recognize patient in shock and to identify type and cause of shock.
Hypotension with classical signs of hypoperfused state like pallor, cool skin,
tachycardia, sweating or altered mental status.
Patients on beta-blocker, athlete and patients with neurogenic shock may not
exhibit tachycardia.
Patients who have septic shock may have hyperdynamic circulation with
warm peripheries and bounding pulse.

INITIAL MANAGEMENT
All patients exhibiting the general features of shock should be urgently
transferred to a monitored, critical care area for assessment and stabilization.
The patient should be put on continuous cardiac monitoring, BP, HR, and
pulse oximetry monitoring.
The airway should be maintained and oxygen should be administered as far
as possible. Be prepared to intubate the patient as necessary.
Obtain IV access. Place 2 large bore IV lines (14/16G) preferably in the
antecubital fossa, if possible drawing blood for lab tests concurrently.
Begin fluid resuscitation if the patient is not suspected to be in cardiogenic
shock.

BASIC INVESTIGATIONS
FBC

BUSE/CREA
T

COAGULATI
ON PROFILE

BLOOD GAS

GXM

OTHERS
ECG, CXR

CT SCAN

ULTRASOU
ND

UPT

BLOOD
CULTURES

MANAGEMENT
Resuscitation strategies generally target 3 mechanisms to restore oxygen
delivery and repay the oxygen debt in the tissues :
Intravascular volume (preload & afterload)
Cardiac output (pump)
Oxygen carrying capacity and delivery (Hb content)

HYPOVOLAEMIC SHOCK
The main problem is inadequate volume.
Fluid resuscitation with 1 to 2 litres of crystalloids should be started. Further
resuscitation with colloids, packed RBC or whole blood maybe appropriate.
In paediatric patient, give fluid challenge with boluses of 20ml/kg body
weight of D/S.
Ensure that adequate fluid resuscitation has taken place before starting
vasopressor support.
1. Give IV Dopamine 5-20 microgram/kg/min.
2. Add IV Noradrenaline 0.5-30 microgram/min.
Placement of central venous pressure line maybe necessary for guiding fluid
therapy.

HAEMORRHAGIC SHOCK
The problem here is both inadequate volume and oxygen carrying capacity.
Remember that fluid resuscitation does not stop the haemorrhage. It might
has to be stopped surgically.
Control all external haemorrhage and obtain urgent review by surgical team.
Low versus high volume resuscitation;
-prior to definitive surgical haemorrhagic control, avoid excessive fluid
resuscitation if the patients BP is normal, as this may dislodge the blood
clots that are spontaneously limiting the haemorrhage.
-if the patient is significantly hypotensive with ongoing blood loss, obtain 6
units of GXM, and transfuse early with whole blood, or combined packed RBC,
FFP and platelets.

CARDIOGENIC SHOCK
The problem here is one of the pump.
Acute MI with left ventricular failure is the most common cause.
If the SBP is <70mmHg, start IV Dopamine 5-20microg/kg/min.
If the SBP is 70-100mmHg, start IV Dobutamine 0.2-20microg/kg/min to
reduce systemic vascular resistance & improve stroke volume.
Avoid excessive fluid resuscitation as this may worsen pulmonary oedema.
Cardiogenic shock with right ventricular failure may respond better to fluid
resuscitation. Give IV 500cc boluses with frequent review.
Further definitive mx will depend on the underlying pathology.

OBSTRUCTIVE SHOCK
The problem here is one of the pump.
Tension pneumothorax should be suspected and diagnosed clinically.
Immediate relief by needle thoracotomy followed by definitive tube
thoracotomy should be performed.
For suspected cardiac tamponade, perform a FAST examination, obtain
urgent cardiothoracic consultation and prepare for pericardiocentesis.
For massive pulmonary embolism with circulatory compromise, consider
noradrenaline, adrenaline or dopamine.

SEPTIC SHOCK
Sepsis can affect the capacitance, pump and end-organ delivery of oxygen.
Establish 2 large bores of branula and aggressively correct the hypotension
with fluid resuscitation (rapid fluid administration, 1-2L crystalloid or 2040mL/kg
Vasoactive support system maybe needed if there is no response to fluid
challenge.
Noradrenaline is the agent of choice in septic shock. Alternatively, dopamine
can be used.
Successful fluid resuscitation is indicated by stabilization of mentation, BP,
RR, PR, skin perfusion and urine output.
It is the paramount the right antimicrobial therapy is started as soon as
possible.

ANAPHYLACTIC SHOCK
The problems are the abnormally increase capacitance and decrease cardiac
contractility.
Aggressive fluid resuscitation is necessary to restore preload due to
vasodilatation. Give 1-2 of crystalloids, reassess and repeat as necessary.
Adrenaline is the vasoactive agent of choice, as it reverse many of other
effects of anaphylaxis.
Give IM or SC, 0.3mg. Repeat every 3-5 minutes according to response. If in
refractory hypotension, start IV adrenaline infusion 5-15microg/kg/min.

NEUROGENIC SHOCK
The problem is loss of sympathetic vascular tone leading to vasodilatation, as
well as loss of sympathetic input to the heart, resulting in bradycardia from
unopposed parasympathetic input.
Aggressive fluid resuscitation is necessary to restore preload due to the
vasodilatation. Give 1-2L of crystalloids, reassess and repeat to target MAP
about 90mmHg.
Vasopressor are important to counter the vasodilation.
1. IV Dopamine 5-20microgram/kg/min
2. Add IV Noradrenaline 0.5-30microgram/min if necessary.

THE END