Pathophysiology of Shock Definition State of circulatory shock Generalized, severe in blood supply to body tissue Even with all

l CVS compensatory mechanism activated, arterial pressure Hypotension state (resulting in tissue hypoxia) Types of Shock Hypovolaemic shock Distributive shock Neurogenic shock Anaphylactic shock Septic shock Obstructive shock Cardiogenic shock Stages of Shock Compensatory Employ physiological mechanisms to counter condition Progressive (Decompensation) Failure to compensate Progressive worsening injury Refractory Organ shock occurs Irreversible Additional Compensatory Mechanisms Breathing rapid, shallow Promotes venous return to heart Respiratory pump action Release of renin from kidney Result of sympathetic stimulation Angiotensin II (potent vasoconstrictor) TPR Adrenalin From adrenal medulla (result of sympathetic stimulation) Vasoconstrictor ( TPR) Release of ADH From post pituitary gland Water retention Arteriolar vasoconstriction Capillary hydrostatic pressure Net shift of fluid from interstitial into vascular space Liver glycogenolysis Induced by adrenalin, noradrenalin Results in release of glucose ( Blood glucose levels) Blood osmolarity (up to 20 mOsm) Induce shift of fluid from intracellular extracellular space (including intravascular) Movement of Fluid

Primary Disturbances (Precipitated by either) Grossly inadequate cardiac filling Depressed myocardial function ( central venous volume) Hypovolemic shock Cardiogenic shock Distributive shock Severe arrhythmias Obstructive shock Valvular dysfunction Coronary occlusions Myocardial infarction (Extreme heart failure) Primary Disturbance (Uncompensated)

Decompensatory Mechanism

Compensatory Responses

Shock Hypovolaemic Shock Acute loss of 15-20% of circulating blood volume Causes External loss of whole blood (haemorrhage) External loss of plasma (severe burns) External loss of extracellular fluids (GIT loss in vomiting, diarrhoea) Distributive Shock (Normovolaemic Shock) Neurogenic Anaphylactic Loss of blood vessel tone Enlargement of vascular compartment Displacement of vascular volume away from heart & central circulation Causes of loss of blood vessel tone Sympathetic control of vasomotor tone Presence of vasodilator substances in blood Venous return CO (but not total blood volume) Sympathetic control of blood vessel tone Massive vasodilatation Due to defect in Pooling of blood in peripheral blood vessels Capillary permeability Vasomotor center (VMC) in Brain stem Sympathetic outflow to blood vessels Part of manifestations of systemic Causes anaphylaxis, caused by immune-mediated Brain injury reaction (eg. histamine released in blood, Depressant action of drugs, general vasodilatation substances) anesthesia, hypoxoa, lack of glucose Emotional cause (transient form) Causes (common) reaction to Spinal anesthesia, spinal cord injury Drugs (penicillin) (above midthoracic region) (interrupt Food (nuts, shellfish) transmission of outflow from VMC) Insect venoms (bees, wasps, fire ants) Onset of anaphylaxis depends on Sensitivity of the person Rate of antigen exposure Quantity of antigen exposure Clinical Manifestations Depend on shock stage Related to Peripheral blood flow Excessive sympathetic stimulation Thirst Pallor Heart rate Cool, clammy skin BP Urine output Changes in sensorium Complications of Shock Acute respiratory distress syndrome (ARDS) Acute renal failure (ARF) Gastrointestinal complications Disseminated intravascular coagulation (DIC) Multiple organ dysfunction syndrome Additional Clinical Manifestations Cardiogenic Shock Signs of severe heart failure Septic Obstructive Shock Mechanical obstruction of flow of blood (through central circulation) Great veins Heart Lungs Causes Pulmonary embolism Cardiac temponade Pneumothorax Results in (signs of right-sided heart failure) Right heart pressure Impaired venous return

Most common type of distributive shock Associated with Severe infection (gram ve bacteria most frequently) Systemic response to infection Complications Acute respiratory distress syndrome Disseminated intravascular coagulation Multiple organ dysfunction syndrome Inflammatory mediators contributing to septic shock Interleukins TNF Platelet-activating factor Myocardial depressant factor

Anaphylactic Shock Signs of profound vasodilatation Warm peripheries BP Urticaria Bronchospasm Edema of face, pharynx, larynx Hypovolaemia

Septic Shock Fever & rigors Early signs Warm peripheries Bounding pulse Late signs Hypovolaemic shock Myocardial depression

Obstructive Shock Signs of right heart failure