SHOCK

Shock
• Dangerous condition
– Not enough oxygen-rich blood reaching vital
organs such as brain and heart
• Caused by anything that significantly reduces
blood flow
• Life-threatening emergency
• May develop quickly or gradually
• Always call help for victim in shock
 Definition
• Shock is not:
– an absolute blood pressure measurement
– an independent diagnosis

• Shock is:
– a physiologic state in which significant, systemic
reduction in tissue perfusion results in decreased
tissue oxygen delivery
 Shock
• Can lead to irreversible cell and tissue injury
ultimately resulting in:
– end-organ damage
– multi-system organ failure
– death
• Mortality from shock remains high:
– cardiogenic shock from AMI - 60-90%
– septic shock - 35-40%
– hypovolemic shock - varies depending on disease state
 Physiologic Determinants
P = CO * SVR
MAP – CVP = CO * SVR

P = change in pressure
MAP = mean arterial pressure
CVP = central venous pressure
CO = cardiac output
SVR = systemic vascular resistance
 Normal Tissue Oxygenation
Three general conditions must be present:
1. Heart must efficiently pump blood
2. Blood volume sufficient to fill blood vessels
3. Blood vessels intact and functioning normally
 Causes of Shock
• Severe bleeding • Dehydration
• Severe burns • Electrocution
• Heart failure • Serious infections
• Heart attack • Extreme emotional
• Head or spinal reactions
injuries (temporary/less
• Severe allergic dangerous)
reactions
 Common Types of Shock

• Hypovolemic occurs when blood volume

drops
• Cardiogenic occurs with diminished heart
function
• Neurogenic occurs with nervous system
problems
• Anaphylactic extreme allergic reaction
 Development of Shock
• Assume any victim with serious injury is at risk
for shock
• Often occurs in stages
• May progress gradually or quickly
• Victim ultimately becomes unresponsive
• Not all victims experience all signs and
symptoms of shock
Signs and Symptoms of Shock

In compensatory shock (first stage):

– Anxiety, restlessness, fear
– Increased breathing and heart rate
In decompensatory shock (second stage):
– Mental status continues to deteriorate
– Breathing becomes rapid and shallow, and
heartbeat rapid
– Skin becomes pale or ashen and cool
– Nausea and thirst occur
Signs and Symptoms of Shock
continued

In irreversible shock (third stage):

• Victim becomes unresponsive
• Respiratory and cardiac arrest
 Common Features of Shock
• Hypotension
• Cool, clammy skin
• Oliguria
• Altered mental status
• Metabolic acidosis
 Evaluation of the Patient in Shock
• Primary
– History
– Physical Examination
– Laboratory
– Radiographic
• Secondary
– pulmonary artery catheterization
– echocardiography
 Urgency of Shock Treatment
• Shock continues to develop unless medical
treatment begins
• Call for help immediately
 First Aid for Shock
1. Check for responsiveness, normal breathing
and severe bleeding, and care for life-
threatening injuries first.
2. Call for help.
 First Aid for Shock continued

3. Have victim lie on

back and raise legs
so that feet are 6-12
inches above the
ground.
Put breathing,
unresponsive victim
(if no suspected
spinal injury) in
recovery position
Loosen any tight
clothing.
 First Aid for Shock continued

4. Be alert for vomiting;

turn victim’s head to
drain mouth.
5. Maintain normal body
temperature.
 Shock in Children

• Blood loss in
infants/children may
quickly lead to shock
• Susceptible to shock
from dehydration
• Early shock may be
less obvious but
child’s condition
rapidly declines
• Treatment is same as
for adults
 Anaphylaxis

• Severe allergic reaction in some people

• Also called anaphylactic shock
• Life-threatening emergency because airway
may swell
• Always call for help
 Causes of Anaphylaxis

• Common allergens:
– Certain drugs
– Certain foods
– Insect stings and bites
Development of Anaphylaxis
• Signs and symptoms may
begin within seconds to
minutes
• The more quickly it occurs –
the more serious
• You cannot know how
severe the reaction will be
Signs of anaphylaxis
• Itching
• Redness
• Swelling
• Progressing to:
– Tightness in the chest
– Difficulty breathing
– Unconsciousness
 Prevention of Anaphylaxis:
Medication Allergies
• Maintain a history of
medication reactions
and share it with
health care providers
• Wear a medical alert
ID
• Read product labels
carefully
 Prevention of Anaphylaxis:
Insect Stings

• Stay away from insect nesting areas

• Check around home for insect nests
• Wear clothing that covers arms and legs
• Wear shoes
• Do not swat or wave insects away
 Emergency Epinephrine
Auto-Injector
• May be carried by
people with severe
allergies
• Medication stops
anaphylactic reaction
• Ask a victim about it
• Help victim open and
use auto-injector
 First Aid for Anaphylaxis
1. Call for help
2. Help victim use his or her epinephrine auto-injector
3. Monitor victim’s breathing and be ready to give CPR if
needed
4. Help victim sit up in position of easiest breathing - put
unresponsive victim who is breathing in recovery
position
 Management of the Patient in Shock
• Shock is an emergency state:
– initial focus is on ABC’s of resuscitation
• airway, breathing, circulation
• Adequate venous access
– central venous access not always required, but
often necessary
• Optimization of volume status
• Identification of cause of shock and directed
therapy
Management - Hypovolemic Shock
• Volume replacement key for all causes of
hypovolemic shock
– nonhemorrhagic: crystalloid fluid replacement
– hemorrhagic: crystalloid fluid replacement and
blood product replacement
• Directed therapy to correct the cause of
hypovolemic shock
 Management - Cardiogenic Shock
• General points for cardiogenic shock
– PA catheter commonly used
– vasopressor support (specific discussion later)
often needed
– may need intra-aortic balloon pump
– hypotension may or may not be present
– identification of type of cardiogenic shock critical
for optimal management
 Management - Cardiogenic Shock
• Myocardial infarction
– most common cause of cardiogenic shock
– directed therapy for MI
• aspirin, heparin, glycoprotein IIb/IIIa inhibitors,
revascularization
• Pulmonary embolism
– most common cause of obstructive shock
– avenues available to rapidly resolve clot burden
• thrombolysis, interventional radiology directed clot
extraction, surgical embolectomy
 Management - Distributive Shock
• Identification of cause and directed therapy
– e.g. Addisionian crisis - steroid replacement
• Septic shock
– most common form of distributive (vasodilatory)
shock
– early and aggressive fluid replacement is
important and often underutilized
– vasopressor support often required
 Management - Distributive Shock
• Septic shock (continued)
– identification of infectious site/source and guided
therapy (antibiotics and drainage)
– steroid replacement with concomitant relative
adrenal insufficiency
– optimal glucose control
– recombinant human activated protein C
(drotrecogin alfa activated)
– attention to support of each organ system
 Pharmacological Therapy of Shock
• Goals:
– Increase CO to restore normal hemodynamics
– Increase blood pressure and redistribute blood
flow to vital organs (brain).

• Pharmacological agents used depend on

clinical and physiological parameters of shock
and type of shock.
– Agents used are primarily adrenergic receptor agonists
 Physiological actions of adrenergic receptors
Receptor type Receptor action (relative to hemodynamics)

α1 Arterial vasoconstriction
Increased myocardial contractility (minor)
α2 Constriction of venous capacitance (major)
Feedback inhibition of norepinephrine release at sympathetic
fibers
β1 Increased myocardial contractility (inotropy)
Increased heart rate (chronotropy)
β2 Relaxation of vascular smooth muscle (skeletal muscle)
(Relaxation of bronchial smooth muscle)
D1 Relaxation of splanchnic vascular smooth muscle
Relaxation of renal vascular smooth muscle
D2 Inhibition of norephinephrine uptake at sympathetic fibers
 Summary
• Treat shock as an emergency

• Remember the physiology that governs shock

- your goal in treatment is to intervene
appropriately to help correct the variable that
is driving the shock state.