MINISTRY OF PUBLIC HEALTH OF UKRAINE

O. BOGOMOLETS NATIONAL MEDICAL UNIVERSITY

“Approved”
by the Methodological Council of
The Department of Internal Medicine №3
Head of the department
______________________Professor O.B. Iaremenko

Protocol # _______ on the ____ of 2019.

GUIDELINE OF LESSON

(TRAINING MANUAL)

FOR STUDENTS SELF-STUDY TRAINING

Discipline Internal Medicine with infective diseases and phthisiology

Module №4 Emergency conditions in Internal Medicine
Topic of lesson №6 Management of a patient with shock
School-year 2019/2020
Faculty foreign
Language of teaching English

Worked out by Petelytska Liubov, MD, postgraduate student, and Fedkov

Dmytro, MD, PhD, associate of professor

Revised and approved: Protocol # ___ on the __ of 2020.

Protocol # ___ on the __ of 2021.

Protocol # ___ on the __ of 2022.

Kyiv 2019

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 1. The topic actuality and the goal of the lesson. Shock is a life-
threatening circulatory disorder that leads to tissue hypoxia and a
disturbance in microcirculation. There are many different causes of
shock, which are classified into cardiogenic shock (e.g., as a result of
acute heart failure or cardiac tamponade), hypovolemic shock (e.g.,
following massive blood or fluid loss), and shock due to a disturbance in
the fluid distribution in the body (septic, anaphylactic, and neurogenic
shock). The common clinical findings are hypotension and tachycardia,
accompanied by specific symptoms related to the cause of shock.
Hypoxia can result in organ damage and complex metabolic disorders
such as kidney failure, DIC (disseminated intravascular coagulation),
ARDS (acute respiratory distress syndrome), and circulatory collapse.
Management of shock involves circulatory support and the treatment of
the underlying cause. Shock is associated with a very high mortality rate.
2. Learning competencies (attributions)
1. To have an idea about different types of shock: hypovolemic, cardiogenic,
obstructive, distributive, including anaphylactic and septic shocks.
2. To know mechanisms leading to different types of shock: hypovolemic,
cardiogenic, obstructive, distributive, including anaphylactic and septic
shocks
3. To be able to diagnosis different types of shock.
4. To be able to management of patients presenting with shock.
3. The structure of the lesson

Steps and their content Time

Preparatory step
1. Initial test control 30 min
2. Individual interrogation of students 30 min
The main step
1. Clinical examination of the patient and taking of the 60 min
primary diagnosis
2. Demonstration of the technique of main instrumental 30 min
methods for diagnostics
3. Discuss with students about plan of additional 30 min
investigations
4. Discuss with students about methods of treatment of the 20 min
patient
The final step
1. Final test control by situational tasks 30 min
2. Estimation of student’s knowledge and practical skills. 20 min
Taking individual marks.
3. Taking of homework for the next topic of the lesson 5 min
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 4.1. Lesson content
Table 1. Categories of shock
Category Hemodynamics Causes
Hypovolemic - ↓preload Hemorrhage, GI losses,
- ↑ SVR third spacing, burns
- ↓ CO
Distributive - ↓preload Sepsis, anaphylaxis,
- ↓SVR neurogenic shock,
- ↓/↑CO pancreatitis
Cardiogenic - ↑preload Myocardial infarction,
- ↑ SVR symptomatic bradycar-
- ↓ CO dia, valvular disease,
heart blocks, end-stage
heart failure
Obstructive - ↓ preload Pulmonary embolism,
- ↑ SVR t ension pneumothorax,
- ↓ CO pericardial tamponade

Abbreviations: CO, cardiac output; GI, gastrointestinal; SVR, systemic vascular

resistance.

Stages of shock

1. Non-progressive phase (stage of compensation): activation of

compensatory neurohumoral reflexes in order to maintain vital organ
perfusion →
 Peripheral vasoconstriction → cold, clammy extremities and
increased capillary refill time
 Decreased capillary hydrostatic pressure → increases absorption
of interstitial fluids into intravascular space to help maintain blood
pressure
 Tachycardia
 Oliguria

2. Progressive phase
 Worsening hypotension
 Hypoperfusion of peripheral tissues → generalized
tissue hypoxia → anaerobic metabolism in the underperfused organs
→ lactic acidosis → worsening tachypnea
 Precapillary dilation and postcapillary constriction of the blood vessels
→ pooling and stasis of blood in the capillary bed → decreased cardiac
output and formation of microthrombi in the capillaries → DIC and
further hypoxic injury to tissues

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  Acidosis, cerebral hypoperfusion → altered mental status

3. Irreversible phase (stage of decompensation): irreversible tissue

damage sets in
 Cerebral hypoxia → autonomic dysfunction → worsening of shock
 Myocardial ischemia → acute coronary syndrome → decreased
cardiac output → worsening of shock
 Widespread cell necrosis →Release of lysosomal enzymes → further
tissue injury → worsening of shock
 Activation of the immune system → release of cytokines → DIC, further
tissue damage → worsening of shock
 Bowel ischemia → bacteremic sepsis → worsening of shock
 The end result of these vicious cycles is a downward spiral from which
there is no recovery (multiple organ failure)

Table 2. Etiologies of cardiogenic shock

Decreased Stroke Volume Abnormal Heart Rates

Acute Myocardial Infarction Bradyarrhythmias
l Right-sided infarct l
Large left-sided infarct Sick sinus syndrome
l Infarct in setting of existing disease Junctional bradycardia
l Mechanical complications of infarction Complete heart block

1. Acute mitral regurgitation due papillary Tachyarrhythmias

muscle rupture l
l 2. Ventricular septal defect Atrial fibrillation/futter
l 3. Free wall rupture l Reentrant atrial tachycardia
l Ventricular tachycardia
Valvular Heart Disease l Ventricular fibrillation
l
Mitral stenosis or regurgitation
l Aortic stenosis or regurgitation

Dilated Cardiomyopathy
l Ischemic
l Viral/bacterial
l Toxin-induced
l Rheumatologic
l Thyroid disease
l Pheochromocytoma
l Congenital
l Peripartum
l Sarcoidosis
Hypertrophic cardiomyopathy
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 Restrictive cardiomyopathy
Myocarditis
Takotsubo Cardiomyopathy
Atrial Myxoma
Orthotopic Transplant Rejection
Cardiac Trauma
lAtrial Myxoma
Orthotopic Transplant Rejection

Table 3. Classification of hemorrhagic shock

Class I II III IV
Blood loss < 15% 15–30% 30–40% > 40%
Heart rate < 100 100–120 120–140 > 140
Systolic blood Normal Normal ↓ ↓
pressure
Pulse pressure Normal or ↓ ↓ ↓
↑
Respiratory rate 14–20 20–30 30–40 > 35
Urine output > 30 mL/hr 20–30 mL/hr 5–15 mL/hr Absent
Mental status Anxious Mildly Anxious, Confused,
anxious confused lethargic

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 Figure 1. Clinical pathway for diagnosing and managing shock

 Assess for immediate life-threatening

circumstances: airway, breathing, circulation
 Place on cardiac monitor, pulse oximeter,
obtain appropriate IV access.
 Consider central access (Class II)
 Maintain vigilance for occult shock Yes

Develop differential diagnosis for etiology of shock,

considering 4 types of shock: hypovolemic,
distributive, cardiogenic, and obstructive

Conduct focused history and physical examination, to

evaluate for both the type of shock and underlying
etiology

Yes Type and etiology clear? No

• Evaluate volume status and preload (Class II) Continue resuscitation and
• Physical examination (Indeterminate) initiate appropriate targeted
• Ultrasound (Class II) therapies
• Passive leg raise (Class II) (Class II)
• Noninvasive cardiac output monitors (Class III)

No
Type and etiology clear?

• Further
Yes diagnostics
• Laboratory tests including CBC,
chemistries, liver function tests, troponin,
ABG/VBG, lactate (Class II), central venous
oxygen (Class II)
• Imaging with chest x-ray, CT scan No
No Type and etiology clear?

Yes
Continue resuscitation, reassess clinically

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Table 4. Quick sequential organ failure assessment (qSOFA) score in patient
potentially at risk of dying from sepsis
Criteria Points
Respiratory rate ≥22/min 1
Change in mental status 1
Systolic blood pressure ≤100 mmHg 1
A qSOFA score of ≥2 points indicates organ dysfunction.

Table 5. Early goal directed therapy of patient with sepsis

Within 3 hours of presentation:
► Measure lactate
► Obtain blood cultures
► Bolus 30mL/kg crystalloid
hypotension of lactate≥4mmol/L
Within 6 hours of presentation:
► If persistent hypotension (mean arterial
pressure≤65mm Hg) despite adequate
for volume resuscitation, consider addition of
vasopressors ► Frequently re-assess volume
status and tissue perfusion for those with
persistent hypotension and/or initial
lactate≥4mmol/L
► Normalization of lactate

Table 6. Differential diagnoses of shock

Type of shock Hypo- Cardiogenic Distributive shock

volemic shock
shock Septic Neuroge- Anaphylac-
shock nic shock tic shock

Cardiac output / Cardiac ↓ ↓ ↑ ↓ ↓

index
Heart rate ↑ ↑ ↑ ↓ ↑
Central venous pressure ↔︎ or ↓ ↔︎ or ↑ ↔︎ or ↓ ↔︎ or ↓ ↔︎ or ↓
Pulmonary capillary ↓ ↑ ↓ ↓ ↓
wedge pressure (PCWP)

Left ventricular end-

diastolic pressure
(LVEDP)

Peripheral vascular ↑ ↑ ↓ ↓ ↓
resistance
Mixed venous oxygen ↓ ↓ ↑ ↓ ↓
saturation (SvO2)

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Table 7. Clinical criteria for diagnosing anaphylaxis

Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled:
1. Acute onset of an illness (minutes to several hours) with involvement of the skin,
mucosal tissue, or both
(eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula)
AND AT LEAST ONE OF THE FOLLOWING
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF,
hypoxemia)
b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse],
syncope,
incontinence)
2. Two or more of the following that occur rapidly after exposure to a likely allergen for
that patient (minutes to
several hours):
a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-
tongue-uvula)
b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF,
hypoxemia)
c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)
d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
3. Reduced BP after exposure to known allergen for that patient (minutes to several hours):
a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in
systolic BP*
b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that
person’s baseline

PEF, Peak expiratory flow; BP, blood pressure.

*Low systolic blood pressure for children is defined as less than 70 mm Hg from
1 month to 1 year, less than (70 mm Hg 1 [2 3 age]) from 1 to 10 years, and less than 90
mm Hg from 11 to 17 years.

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 Figure 2. Protocol for initial management of anaphylaxis

EVALUATE Airway, Breathing and Circulation

F
i Cardio-respiratory arrest Upper airway, lower respiratory or Consider lower
r cardiovascular symptoms or signs threshold for adrenaline
s and anaphylaxis is likely if:
t Give I.M. ADRENALINE - previous severe
- reaction
l Treat as per protocol
i if possible, remove - exposure to
n allergen known/likely
e Call for help allergen
- co-existent asthma
I.M. adrenaline dose
0.01 ml/kg adrenaline
(1mg/ml) or Hypotension or Stridor Wheeze
- hight flow - hight flow
 7.5 to 25 kg: 0.15 collapse
- hight flow oxygen oxygen oxygen
mg adrenaline - sit up - sit up
- lie down, extremities
auto-injector elevated - nebulized - nebulized β-
 ≥25 kg: 0.3 mg - normal saline 20 adrenaline 2 agonist
adrenaline auto - ml/kg i.v. or
injector intraosseous
- call for ICU support

S Observation: If no response in 5-10 If respiratory If respiratory

e Patients with respiratory minutes distress or no distress or no
symptoms or signs - repeate I.M. response response
c adrenaline
o should be observed for at within 5-10 within 5-10
- repeate fluid bolus
n least 6 to 8 hours in - set up adrenaline
minutes minutes
d hospital prior to infusion
discharge. Those - I.M. adrenaline - I.M. adrenaline
- - I.V. access - I.V. access
l presenting with - call for ICU
i hypotension or collapse support
n require close monitoring
for 12-24 hours.
e
If no response If no response in Angioedema or
in 5-10 minutes 5-10 minutes urticaria ONLY
- repeate - repeate - repeate P.O.
Discharge check list: nebulized nebulized β-2 antihistamine
- assess risk of future adrenaline agonist - if known to have
anaphylaxis - consider - consider further asthma, give
- prescribe adrenaline auto- further I.M. I.M. adrenaline inhaled β-2 agonist
injector if risk of recurrence adrenaline - call for ICU - observe for 4 hours
- provide discharge advice sheet: support – as this maybe be
allergen avoidance (if possible), an early
instruction for when and how presentation of
to use adrenaline auto -injector anaphylaxis
- arrange specialist allergy With persistent
Third-line:
review and specialist dietitian
Consider I.V. or P.O. antihistamine to control vomiting and/or
review if food involvement
- provide contact information for
cutaneous symptoms abdominal pain –
Consider I.V. or P.O. glucocorticoids to CONCIDER
patient support groups
prevent late phase respiratory reactions I.M. adrenaline
- discharge letter for the family
doctor 9
 4.2. The list of main medical/clinical terms, parameters, features
about the topic with short explanations

Term Definition or Description

Shock It is a state of acute circulatory failure leading to decreased organ
perfusion, with inadequate delivery of oxygenated blood to tissues
and resultant end-organ dysfunction.
Hypovolemic It occurs due to inappropriately low intravascular volume leading to
shock decreased preload, decreased stroke volume, and decreased
cardiac output. Hypovolemic shock can be due to decreased
intravascular fuid or decreased blood volume. Decreased blood volume
is due to hem-
orrhage.
Distributive It is characterized by profound systemic vasodilation and is commonly
shock associated with relative intravascular volume depletion.
Cardiogenic It is due to the failure of the left ventricle to generate adequate arterial
shock fow to deliver oxygenated blood to peripheral tissues.
Obstructive It results from either a critical decrease in preload or an increase in left
shock ventricle outfow obstruction.
Septic shock It is seen in patients with sepsis who develop underlying circulatory and
metabolic abnormalities resulting in hypotension that require
vasopressors to maintain a mean arterial pressure of ≥ 65 mmHg and
having a serum lactate level of ≥ 2 mmol/L despite adequate volume
resuscitation, resulting in a higher risk of mortality.
Anaphylaxis Severe, life-threatening generalized or systemic hypersensitivity
reaction,
which is characterized by being rapid in onset with life-threatening
airway,
breathing or circulatory problems, and is usually associated with skin
and mucosal changes.

5. Theoretical questions for self-control:

1. How is the shock classified?
2. What are the etiologies of cardiogenic shock?
3. What is the definition of anaphylaxis and septic shock?
4. Describe the early goal directed therapy of patient with sepsis?
5. What interventions are used for the acute management of
anaphylaxis?

6. Recommended literature:
6.1. Basic (textbook or international Guideline):
1. Singer M., Deutschman C., Seymour C., et al. The Third
International Consensus Definitions for Sepsis and Septic Shock
(Sepsis-3). JAMA 2016;315:801–10.
2. Muraro A., Roberts G., Worm M. Anaphylaxis: guidelines from
the European Academy of Allergy and Clinical Immunology.
Allergy. 2014 Aug;69(8):1026-45. doi: 10.1111/all.12437. Epub
2014 Jun 9.
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6.2. Additional (articles or national Guidelines):
1. Dellinger R., Levy M., Rhodes A., et al. Surviving sepsis
campaign: international guidelines for management of severe
sepsis and septic shock: 2012. Crit Care Med 2013;41:580–637.

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