Pathophyfisiology of

Shock

Emmy Pranggono

Internal Medicine
Padjadjaran University
Hasan Sadikin Hospital
Bandung
 Delivery O2
Requirement O2

hipoperfusion

cellular dysfuntion

production and release mediator

microvaculature changed
PATHOGENESIS AND ORGAN
RESPONSE
- Microcirculation
- Cellular responses
- Neuroendocrine responses
- Cardiovascular responses
- Pulmonary responses
- Renal responses
- Metabolic derangement
- Inflammatory Responses
Classification of shock
CVP COP SVR
Hypovolemic

Traumatic
Cardiogenic

Septic
Hyperdynamic

Hypodynamic
Neurogenic
PHATOGENESIS and ORGAN RESPONSE

AUTOREGULATION
COP SVR to maintain
MAP

sustaining brain and coronary

perfusion
(high metabolic rates high, low
stores of energy)

expense of other tissue : skin,

SYSTEMIC VASCULAR RESISTANCE (SVR)
- Determined by luminal DIAMETER of
arterioles
- Arteriole smooth muscle
. adrenergic receptor ~
vasoconstriction
. adrenergic receptor ~
vasodilatation

MOST FUNDAMENTAL RESPONSE

Reduce Blood Pressure

efferent symphatetic nerve ~ release

Other vasoconstrictor substance
- angiotensin II
- vasopressin
- endothelin-1
- thromboxan A
Circulating vasodilators during shock
- prostacyclin (PGI)
- nitric oxide (NO)
- adenosine (metabolic product)

Perfusion
Vasoconstrictor
Transport to the cell
Microsirculary flow
capillary permeability
diffusion of O, CO,
nutrients,products of
metabolism
exchanges of the
product across cell
membrane
Central of pathophysiologic
response of shock
Mild and Moderate Hypovolumia

Restitution intravascular volume

by:
1. Arteriol vasoconstriction ~
hydrostatic
pressure
2. Changes in cellular metabolic
function hyperglicemia
glycolysis
Extracellular osmolarity
lypolisis
CELLULAR RESPONSES
Impaired transport of interstitial
nutrient

Mitochondrial
transmembrane
dysfunction potential

ATP intracell
Na and
water anaerobic metabolites
( lactate) ~ vasodilator Cell
NEUROENDOCRINE RESPONSES
HYPOVOLEMIA, HYPOTENSION, HYPOXIA
Chemoreceptor
Baroreceptor

epinephrine-adr. medula inhibit

vasomotor

vagal activity
adrenergic
Heart Rate
vasoconstriction
NEUROENDOCRINE RESPONSES

SEVERE PAIN/SEVERE STRESS

Hypothalamus
Pancreatic

ACTH ~ Cortisol Glucagon

peripheral glucosa ,
gluconeogenesis
aminoacid uptake
lipolysis, gluconeogenesis

Blood glucose
CARDIOLOYGY RESPONSES

Mean Arterial Pressure (MAP) =

Diastol + 1/3 ( Sistole-Diastol)

MAP = SVR x COP

COP = SV x HR

SVR = Systemic Vascular Resistance

COP = Cardiac Out Put
SV = Stroke Volume
HR = Heart Rate
PULMONARY RESPONSES

SHOCK

PVR Tachypnea Pain

. TV RFC
. Vd, Vt
Atelectasis
. Resp alkalosis

Under/non ventilated alveoli,

interst/alveoli edema
RENAL RESPONSES

SHOCK and HYPOPERFUSION

Acute Tubular Necrosis

renal blood flow GFR
arteriolar resistance
ADH,
Aldosteron
Conserve salt and
water
METABOLIC DERANGEMENT

Hypoxia ~ SHOK

* Hepatic gluconeogenesis
* Lactate production
* Hepatic lypolisis
* Protein catabolism ~
. negative protein
balance
. severe muscle
wasting
INFLAMMATORY RESPONSES
- Proinflammatory mediator C3a,
C5a, C5-9
- Activation of coagulation
cascade
microvascular
thrombosis
microvascular injury
- Thromboxane A2 ~ potent
vasoconstrictor
- Platelet-activating Factor
Pulmonary vasoconstrition,
NEUROENDOCRINE RESPONSES

Adrenergic discharge
Renin angiotensi I
angiotensi II
(potent
vasoconstrictor)
adrenal cortex posterior
pituitary

aldosterone
vasopressin
Hipovolumic shock

Mild Moderate
Severe
(<20% Blood vol) (20-40%) >40%

Cool extremities Same,plus Same,plus:

Capillary refill time Tachycardia
Hemodynamic
Tachypneu instability
Diaphoresis Oliguria
Marked tachyc
Collaps vein Postural changes
Mental status