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Shock
Diagnosis & Treament

Dr. Nasman Puar SpAn


Shock is a serious, life-threatening
condition
What is Shock ??

Insufficient blood flow reaches the body


tissues
Medical shock should not be confused with the
emotional state of shock
Medical shock is a life-threatening
medical emergency and one
of the most common causes
of death for critically-ill people
Stages of shock
Initial
During this stage, the hypoperfusional state causes
hypoxia, leading to the mitochondria being unable to
produce adenosin triphosphate (ATP).
the cell membranes become damaged
cells perform anaerobic respiration
a build-up of lactic and pyruvic acid which results in
systemic metabolic acidosis.
Stages of shock
Compensatory (Compensating)
This stage is characterised by the body employing
physiological mechanisms
the person will begin to hyperventilate in order to rid
the body of carbon dioxide (CO2).
The baroreceptors in the arteries detect the resulting
hypotension, and cause the release of adrenaline and
noradrenaline
Stages of shock
Noradrenaline causes predominately vasoconstriction
with a mild increase in heart rate,
adrenaline predominately causes an increase in heart
rate with a small effect on the vascular tone
the combined effect results in an increase in blood
pressure.
Stages of shock
Renin-angiotensin axis is activated and arginine
vasopressin is released to conserve fluid via the
kidneys
cause the vasoconstriction of the kidneys,
gastrointestinal tract, and other organs to divert
blood to the heart, lungs and brain.
The lack of blood to the renal system causes the
characteristic low urine production.
Stages of shock
Progressive (Decompensating)
the compensatory mechanisms begin to fail.
sodium ions build up within while potassium ions
leak out.
As anaerobic metabolism continues, increasing the
body's metabolic acidosis,
As this fluid is lost, the blood concentration and
viscosity increase, causing sludging of the micro-
circulation.
Stages of shock
Refractory
At this stage, the vital organs have failed and the
shock can no longer be reversed.
Brain damage and cell death have occurred.
Death will occur imminently.
Types of shock
Four types of shock:
Hypovolaemic,
Cardiogenic,
Distributive,
obstructive 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
from either an internal or external source.
extensive bleeding, high output fistulae or severe
burns
Distributive shock
As in hypovolaemic shock there is an insufficient
intravascular volume of blood
This form of "relative" hypovolaemia is the result of
dilation of blood vessels which diminishes systemic
vascular resistance
Septic shock
Anaphylactic shock *
Neurogenic shock
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
arrhythmias, cardiomyopathy, congestive heart
failure (CHF), contusio cordis or cardiac valve
problems.
Obstructive shock
In this situation the flow of blood is obstructed which
impedes circulation and can result in circulatory
arrest.
Cardiac tamponade
Tension pneumothorax
Massive pulmonary embolism
Aortic stenosis
Endocrine shock
Hypothyroidism
Thyrotoxicosis
Acute adrenal insufficiency
Relative adrenal insufficiency in critically ill
Signs and symptoms
Hypovolemic shock
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.
Signs and symptoms
Rapid and shallow respirations
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.
Signs and symptoms
Kesadaran gelisah sampai coma
Kulit telapak tangan dingin, pucat, basah
Nafas cepat
Nadi cepat > 100 dan lemah
Tekanan darah < 90-100 mmHg
Capillary Refill Time > 2 detik
Pulse pressure menyempit
JVP rendah (vena jugularis eksterna)
Produksi urine < 0.5 ml/kg/jam
Signs and symptoms
Jika nadi teraba di:
- radialis > 80 mmHg *)
- femoralis > 70 mmHg
- carotis > 60 mmHg
Signs and symptoms
Signs and symptoms
Signs and symptoms
Signs and symptoms
Septic shock
similar to hypovolaemic shock except in the first stages:
Pyrexia and fever, or hyperthermia, due to
overwhelming bacterial infection.
Vasodilation and increased cardiac output due to
sepsis.
Neurogenic shock
similar to hypovolaemic shock except in the skin's
characteristics. In neurogenic shock, the skin is warm
and dry.
Signs and symptoms
Cardiogenic shock
similar to hypovolaemic shock but in addition:
Distended jugular veins due to increased jugular
venous pressure.
Absent pulse due to tachyarrhythmia.
Obstructive shock,
similar to hypovolaemic shock but in addition:
Distended jugular veins due to increased jugular
venous pressure.
Pulsus paradoxus in case of tamponade
Treatment
In the early stages, shock requires
immediate intervention to preserve life

The early recognition and treatment


depends on the transfer to a hospital.
Treatment
RECOGNISE THE PROBLEM
GET HELP

ABC
Treatment

The management of shock requires


immediate intervention, even before a
diagnosis is made.
Treatment
Airway
Head Tilt
Chin lift
Jaw Thrust
No longer recommended for untrained
personnel.
Used to be preserved for pts with suspected
spinal injury
Advanced airway (ETT, LMA,
Combitube) only for trained personnel
Airway
Breathing
Assessment : Look, Feel, Listen
Gasping > treat as not breathing
Rescue Breaths :
2 x cont w. 30:2
Over 1 sec inspiratory time
Visible chest rise ~ 500-600 ml
Advanced airway --> 8-10 x minutes w.o
synch
Breathing
Circulation
Assesment : Check Pulse
Not more than 10 sec, only trained
personnel
Push hard and push fast
100 x/minutes > 30:2 ratio
1.5-2 inch (4-5 cm)
Allow recoil
Minimize interruption
Circulation
Hypovolaemic shock
Immediately control the bleeding !!!
Start giving infusions!!
Blood transfusions
Hypovolaemia due to burns, diarrhoea, vomiting, etc.
is treated with infusions of electrolyte solutions
Hypovolaemic shock

Inotropic and vasoconstrictive drugs should


be avoided, as they may interfere in
knowing blood volume has returned to
normal
Hypovolaemic shock
The most common type of fluid used in shock. :
Crystalloids - Such as sodium chloride (0.9%), or
Hartmann's solution (Ringer's lactate).
Colloids - For example, synthetic albumin
(Dextran), polygeline (Haemaccel), succunylated
gelatin (Gelofusine) and hetastarch (Hepsan).
Combination
Blood - Essential in severe haemorrhagic shock,
often pre-warmed and rapidly infused.
Pasang Infus di Vena Besar
Distributive shock
Distributive shock
Immediate Management
Stop any likely trigger agents
Call for help
Maintain airway and give 100% oxygen
Lie patient flat with legs elevated
Give adrenaline 50-100 ug IV ( 0.5-1mL of 1:10.000 )
if hypotensive, repeat as necessary. IM dose (0.5-1mL
of 1:1000 )
Start rapid IV infussion
Distributive shock
Subsequent management
Give antihistamines ( chlorpheniramine 10-20 mg
slowly IV )
Give corticosteroids (200mg hydrocortisone IV )
Bronchodilators ( salbutamol 250ugIV or 2.5-5mg by
nebulizer, aminophylline 250mg up to 5mg/kg by
slow IV)
Refer to ICU
Cardiogenic shock
Obstructive shock

The only therapy consists of removing the


obstruction.
Endocrine shock

In endocrine shock the hormone


disturbances are corrected.