Study online at

4 ways to arrive at cellular hypoxia

—hypovolemia, cardiac dysfunction, vascular failure,
or obstructive processes that impair cardiac filling.


big overview of shock (key point, Dx,

A state of organ hypoperfusion with resultant cellular dysfunction and
● Mechanisms may involve decreased circulating volume, decreased cardiac
output, and vasodilation, sometimes with shunting of blood to bypass
capillary exchange beds.
● Symptoms include altered mental status, tachycardia, hypotension, and
● Diagnosis is clinical, including BP measurement and sometimes markers
of tissue hypoperfusion (eg, blood lactate, base deficit).
● Treatment is with fluid resuscitation, including blood products if
necessary, correction of the underlying disorder, and sometimes


pro tip: it's important to recognize
when shock is coming!



Shock- Pathophysiology

● Reduced perfusion -> hypoxia -> anaerobic metabolism
○ Lactic acidosis -> cell damage -> cell death
● Inflammatory and clotting cascades triggered
○ cytokines, leukotrienes, tumor necrosis factor, Nitric oxide ("cytokine storm" in influenza A,
● Vasodilation -> hypotension -> hypoperfusion
● Leukocyte and platelet adhesion to endothelium
○ clotting system activation with fibrin deposition
● Endothelial cell dysfunction -> inc microvascular permeability (causes microvascular
permiability, leads to third space, leads to hyptension)
○ third space, translocation of enteric bacteria (gives peritonitits)
● Neutrophil apoptosis inhibited -> increases inflammatory mediators
(shock is overwhelming display of force)
PRO TIP -- so not only do we need to think about fluids, but a ton of other things.


pathophysiology cont.

● inc oxygen extraction
● adrenergic and sympathetic mediated
vasoconstriction and tachycardia
○ inc cardiac output
● release of corticosteroids, renin, glucose


Graphic Organizer


multiple organ dysfunction

Most common in septic shock
10% of pts with severe traumatic injury
inc membrane permeability
alveoli dysfunction and inflammation
hypoxia, acute lung injury, ARDS
● Kidneys
○ acute tubular necrosis -> ARI
● Heart
○ dec. contractility and compliance
○ dec. cardiac output
● GI tract
○ ileus, submucosal hemorrhage, hepatocellular
necrosis, dec. production of clotting factors

CARDIOGENIC SHOCK Reduction in Cardiac Output primary cardiac disorder Improved blood pressure Improving level of consciousness Improving peripheral perfusion Decreasing tachycardia Decreasing lactate Normalizing pH . cool. and often cyanosis ○ earlobes. * Hemorrhage ● Increased losses body fluids ● Inadequate fluid intake 12. and nail beds. ○ capillary filling time is prolonged ● Diaphoresis ● Peripheral pulses are weak and rapid (Kuhn likes to feel radial pulse). shock sxs ● Lethargy. 5.. 3. confusion. SIRS Infectious and Noninfectious ● Sepsis ● Trauma.4°F) ● Heart rate >90 beats per minute ● Tachypnea > 20 breaths per minute ● White blood cell count <4000 cells/mm³ or >12. burns.0. 9.most use normal saline except in someone hypovolemic due to renal failure?!?!) no advantage to colloids (eg. pancreatitis. clammy. and hemorrhage ● Complications of surgery ● Adrenal insufficiency ● Pulmonary embolism ● Complicated aortic aneurysm ● Cardiac tamponade ● Anaphylaxis ● Drug overdose 11. ● Pale.8°F) or >38°C (100.Treatment Stop bleeding or fluid loss Crystalloid infusion 20cc/kg IV bolus which is a good couple liters (lactated ringers. 13. Signs of Successful Resuscitation 1. 6. used to clue us into shock) Shock Index hypovolemic shock HR / SBP (HR divided by systolic BP) 0. decreased preload > reduced stroke volume. blood is a colloid) Reassessment Massive transfusion protocols PRBCs : FFP : Platelet : cryoprecipitate (I think he said that now they do a 1:1:1:1 kinda thing) 14.. HYPOVOLEMIC SHOCK Decrease in intravascular volume. ischemia. albumin. Hypovolemic Shock.000 cells/mm³ or the presence of greater than 10% immature neutrophils (band forms) 2 OR MORE CRITERIA PRESENT (should lead to evaluation to make sure) 10. ● Tachypnea and hyperventilation ● BP low (< 90 mm Hg systolic) or unobtainable ● Urine output is low. shock index (used in trauma.7 normal SIRS (also used) (systemic inflammatory response syndrome) ● Temperature <36°C(96.8. 2. 4. nose. and somnolence are common.5 . ○ only femoral or carotid pulses are palpable.

.15.legs and or arms can't move) Loss of vascular tone from high spinal lesion loss of feedback loop from autonomic ganglia Warm skin.revascularization Supportive: ASA.agonist aerosol (albuterol is most common) H1 and H2 blockers (H1.... positive ionotropic and chronotropic effects within the myocardium smooth muscle relaxation in the bronchial tree and elsewhere Dopamine receptors smooth muscle of renal. Dopamine 16..benadryl. splanchnic.classic orally... Dopamine 18... NEUROGENIC SHOCK (high thoracic or cervical injury.pacing STEMI.....Treatment Tachydysrhythmias. 17. Dobutamine... Viagra 21. drugs affecting which receptors (i think he said norepinephrine is the go to in ED) 20...cardioversion Bradydysrhythmias. coronary..H2 ranitidine) Steroids (prednisone.. opioids.tachycardia Fluids and vasopressors with alpha activity .. Pro Tip: 3 most common 'pressors >> Norepinephrine... O2. Dobutamine.. Vasoactive receptors Alpha-1 adrenergic receptors sympathetic nerve endings on smooth muscle cells and on myocardial cells Alpha-2 adrenergic receptors systemic vasculature leads to vasoconstriction and increased systemic blood pressure β1 and β2-adrenergic receptors both located within the myocardium β2 receptors also being located vascular and bronchial smooth muscle.. ANAPHYLACTIC SHOCK (remember this is on a spectrum) Airway: angioedema and bronchospasm EpiPen Beta..dexamethasone for kids.TREAT AGGRESSIVELY .sodium hydrol IV?!) 22. Heparin Vasopressors (for hypovolemic shock): Norepinephrine. DISTRIBUTIVE SHOCK Distributive Shock Dec. pro tip: when you see multiple organ failure.. and ' cerebrovascular beds vasodilation within these vascular beds 19.. hypotension. +/. intravascular volume caused by arterial or venous vasodilation Anaphylaxis Endotoxin induced sepsis Spinal cord injury Drugs: nitrates. Cardiogenic Shock Tx: Cardiogenic Shock...

and vasodilation. SEPTIC SHOCK (Key points) SIRS ● Temperature <36°C(96. Elevated serum lactate levels (> 4) evidence of tissue hypoperfusion. and sometimes vasopressors. including blood products if necessary. sometimes with shunting of blood to bypass capillary exchange beds. ● Diagnosis is clinical.early antibiotic. base deficit). Tx: pericardial tamponade Pericardial tamponade hypotension. septic shock (points) SIRS associated with decreased SVR -> hyperdynamic compensation -> impaired contractility from myocardial depressants and hypoxemia.. and oliguria. summary points A state of organ hypoperfusion with resultant cellular dysfunction and death. 3 liters of fluid for the little old lady exampe.that is. muffled heart sounds Beck's triad Pericardiocentesis (Best way to Dx is ultrasound) * Not that common 28.. hypotension JVD. tension pneumo.. .000 cells/mm³ or the presence of greater than 10% immature neutrophils (band forms) 2 or more criteria present SIRS + infection = sepsis Sepsis + organ dysfunction = severe sepsis Sepsis + cellular hypoxemia = septic shock 24. correction of the underlying disorder.8°F) or >38°C(100. JVD... tracheal deviation respiratory distress and shock needle decompression 27. even if it's the wrong one just do it and kinda hope you get lucky Steroids (maybe.4°F) ● Heart rate >90 beats per minute ● Tachypnea > 20 breaths per minute ● White blood cell count <4000 cells/mm³ or >12.. hypotension. cava compression. "very common" 29. cardiac tamponade. decreased cardiac output. RV strain on EKG (and seen on echo) Surgical embolectomy Thrombolytics TPA works great for pt with large PE (not small or moderate PEs though) Also given to Pt in shock.. broad spectrum. atrial tumor or clot (mechanical interference with ventricular filling) Interference with ventricular emptying (PE) 26. ● Treatment is with fluid resuscitation. blood lactate. IV. Tx: Massive PE Chest pain. Gram-negative rods (classic. Tension Pneumo Tension pneumothorax dec breath sounds. tachycardia... OBSTRUCTIVE SHOCK Mechanical factors that interfere filling or emptying of the heart or great vessels. some do and some don't) Early goal directed therapy 25.. ● Mechanisms may involve decreased circulating volume.Pseudomonas) Fluids!!! (eg. tachypnea.E Coli.. ● Symptoms include altered mental status. Kuhn says he's seen TPA work in about 30 ER it's common to get 3 or 4 liters for sepsis mgmnt. obstructive shock (Tx).23. Much more than you'd think is normal) Antibiotics --. syncope. including BP measurement and sometimes markers of tissue hypoperfusion (eg.