SHOCK

Definition
• Condition of insufficient
perfusion of cells and vital
organs, causing tissue
hypoxia; perfusion inadequate
to sustain life; result in cellular,
metabolic, and hemodynamic
derangements
Classification by Etiology
1. Hypovolemia 2. Cardiogenic

• caused by inadequate • caused by impaired ability of

intravascular volume the heart to pump blood
• Losses: blood and fluid effectively
• Decreased contractility
• Impaired filling
• Impaired emptying
3. Distributive or Vascular
Caused by massive vasodilation
and a resultant relative
hypovolemia
a. Septic, resulting from massive
vasodilation caused by
release of mediators of the
inflammatory proses in
response to overwhelming
infection; predisposing factor
including bacteremia
b. Anaphylactic, resulting from
massive vasodilation caused
by release of histamine in
response to a severe allergic
reaction
c. Neurogenic, resulting from
massive vasodilatation
caused by suppression of
sympathetic nervous system
The three essential patterns of circulatory
shock
Stage of Shock
1. Initial
• Subclinical hypoperfusion
caused by inadequate
delivery or inadequate
extraction of oxygen
• Initiation, decreased tissue
oxygenation
• Decreased CO
2. Compensatory
• Attempt by neuroendocrine system
to compensate and restore tissue
to vital organs perfusion
• Neural compensation:
• ↙BP →Baroreceptor reflex
→stimulate vasomotor center in the
medulla →activate the SNS→
epinephrine & norepinephrine
released from adrenal medulla→
↙GFR, ↙urine output, ↗sodium
retention
3. Progressive

• ↙delivery of oxygen tissue→

change from aerobic to
anaerobic metabolism
Adequate cellular oxygenation depends
on
Red cell oxygenation
Oxygen delivery to alveoli
Oxygen exchange with blood
Red cell delivery to tissues
Adequate perfusion
Blood volume
Cardiac output
Hb levels
Distance between capillaries and
cells
Aerobic Metabolism

6 CO2
6 O2

METABOLISM 6 H2
O
GLUCOSE
36 ATP

HEAT (417 kcal)

Anaerobic Metabolism
2 LACTIC ACID

2 ATP
GLUCOSE METABOLISM
HEAT (32 kcal)
CONSEQUENCE OF ANAEROBIC
METABOLISM
Inadequate
cellular Oxygen
delivery

Inadequate
energy Lactic acid
Anaerobic
production production
metabolism

Metabolic Metabolic
Cell Death
failure acidosis
Pathophysiology of Shock
Pathophysiology Hypovolemic
Shock
Hemorrhage/Dehydration

Decreased intravascular volume

Decreased venous return

Decreased ventricular filling

Decreased stroke volume

Decreased CO

Inadequate tissue perfusion!!!!

Pathophysiology Cardiogenic
Shock
Impaired pumping
ability of LV

Decreased SV Inadequate systolic

emptying
Decreased CO Increased LV filling pressure
Decreased BP (preload)
Increased LA pressure
Decreased tissue
perfusion !!!! Increased pulmonary
capillary pressure
Pulmonary interstitial &
intraalveolar oedema!!!!
Pathophysiology of Septic Shock
Pathophysiology of Anaphylactic Shock
Pathophysiology of Neurogenic Shock
Clinical Presentation
2. Compensatory Stage:
1. Initial Stage
SNS stimulation
• No symptom but cardiac A. Subjective
output will be decreased • Anxiety, fear, feeling of
impending doom
• Thirst
B. Objective
• Tachycardia
• Decreased pulse pressure
• SBP increase
• DBP increase
 3. Progressive Stage: hypoperfusion

• Hyperpnoea A. Subjective
• Anorexia, nausea
• Skin: cool, pale, clammy
• Chest pain
• GI: decreased bowel sounds • Dyspnea
• Renal: oliguria B. Objective
• CNS: irritability, confusion • Tachycardia
• Hypotension
• Hypothermia
• Tachypnea
• GI: vomiting
• Renal: anuria
Hemodynamic Parameters
Class I II III IV

Blood loss (%) <15% 15-30% 30-40% >40%

Blood loss (ml) <750 ml 750-1500 ml 1500-2000 ml >2000 ml

Heart rate/min <100 >100 >120 140 or >

Blood pressure N N Decreased Decreased

Capillary refill N Delayed Delayed Delayed or absent

Ventilator rate/min 14-20 20-30 30-40 35 or >

Urine output (ml/hr) 30 or > 20-30 <20 Negligible

Skin appearance Cool, pink Cool, pale Cold, moist, pale Cold, clammy, cyanotic

Neurologic status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic
Diagnostic
1. Serum 2. Urine

• Chemistry • Urine specific gravity: ↗

• Sodium: ↗
• Potassium: ↙
• Urine osmolality: ↗
• Glucose: ↗ • Urine sodium: ↙
• Creatinine: ↗
• Total protein, albumin: ↙
• Hematology:
• Hemoglobin & hematocrit: ↙
• WBC: ↗
• ABG: respiratory alkalosis, PaO₂:↙
Specific Assessment
Specific to hypovolemic shock Specific to cardiogenic shock
• Subjective
• Subjective • History of precipitating
• History of precipitating • Chest pain
• Dyspnea
• Objective: • Thirst
• Flat neck veins • Anxiety
• Evaluation of severity of • Objective
hemorrhagic shock • Tachycardia
• Tachypnea
• Diagnostic test: • Jugular venous distention
• Dehidration: ↗ • Peripheral edema
• Hepatosplenomegaly
• Blood loss: ↙
• Diagnostic:
• ECG
• Cardiac catheterization
Specific to anaphylactic shock

• Subjective: • Objective
• History of precipitating • May be localized redness,
• Dyspnea swelling
• • Tachycardia
Nausea
• Hypotension
• Urticaria
• Cough
• Abdominal pain
• Change in level of
• Headache consciousness
• Paresthesia • Urinary incontinence
• Dysphagia
Nursing Diagnoses
• Cardiac output, decreased related • Altered peripheral tissue
to inadequate volume, inadequate perfusion related to
cardiac contractility, dysrhythmias
hypovolemia, decreased
• Fluid volume deficit related to blood
or fluid loss blood flow
• Altered cerebral tissue perfusion • Altered nutrition: less than
related to hypoxia, cerebral body requirement related to
hypoperfusion hypermetabolism, paralytic
• Ineffective airway clearance related ileus, decreased absorption
to tracheobronchial obstruction
caused by laryngeal edema,
bronchospasm, increased secretion,
artificial airway
 Collaborative Management
1. Maximize oxygen delivery to the
tissue Fluid Resuscitation
• Noted, the three determinants of oxygen delivery: Crystalloids Colloids Blood &
SaO₂, Hb, CO Blood
• Maintain optimal Hb & vascular volume products
• Volume replacement for hypovolemic & vasogenic • Whole
Isotonic Large molecule
shock
• NS (0.9% saline) (protein % starch) blood
• Venous vasodilator &diuretic to decrease preload for • Lactate ringer • Albumin • Packed
cardiogenic shock Hypotonic • Dextran RBCs
• Fluid challenge on 250 -500 ml of NS or LR over • ½ NS (0.45% saline) • Hetastarch • Fresh
5 – 10 minutes Hypertonic frozen
• Continue to administer 200 ml @ 5 minutes till ↗BP • 3% saline plasma
• D10W
• Type & crossmatch immediately if patient is
hemorrhaging • TPN (total
parenteral nutrition)
• Take care for hypothermia, fluid need to warm
• Maintain optimal cardiac
contractility:
• Monitor ECG, MAP, neurologic
status
• Administer drugs as prescribe
(dobutamin, diuretic)
• Do not allow patient to sit or stand
• Avoid overheating
• Position horizontally with leg
slightly elevated
• Correct metabolic acidosis
• Maintain optimal oxygen
saturation
• Monitor SaO₂, arterial blood
gas
• Ensure airway
• Administer O₂ at 5-6 L/min
• Monitor closely for changes
SaO₂ as indicative of ARDS
2. Minimize oxygen consumption of
the tissues
• Maintain bed rest & provide
adequate rest periods
• Control body temperature
• Monitor work breathing, used
mechanical ventilator for
respiratory fatigue
• Threat pain & anxiety
3. Maintain nutritional status
• Provide enteral feeding
• Provide parenteral feeding
• Closely monitor serum potassium,
magnesium
(Noted: Potassium is mainly an
intracellular ion& potassium disorders are
related to cardiac arrhythmias;
Magnesium is an intracellular cation.
Magnesium is mainly involved in ATP
metabolism, contraction and relaxation of
muscles, proper neurological functioning,
and neurotransmitter release)
4. Maintain renal perfusion & GFR

• Insert Foley catheter to monitor

hourly urine
• Monitor creatinine
• Replace volume as indicate by
CVP
• Administer dopamine as
prescribe
• Monitor closely for change in
color of urine