1

2
3
• Medical shock should not be confused with the
emotional state of shock
• Medical shock is a life-threatening
medical emergency and one
of the most common causes
of death for critically-ill people
 Stages of shock
Initial
 During this stage, the hypoperfusional state causes
hypoxia, leading to the mitochondria being unable to
produce adenosin triphosphate (ATP).
 the cell membranes become damaged
 cells perform anaerobic respiration
 a build-up of lactic and pyruvic acid which results in
systemic metabolic acidosis.
 Stages of shock
Compensatory (Compensating)
 This stage is characterised by the body employing
physiological mechanisms
 the person will begin to hyperventilate in order to rid
the body of carbon dioxide (CO2).
 The baroreceptors in the arteries detect the resulting
hypotension, and cause the release of adrenaline
and noradrenaline
 Stages of shock
 Noradrenaline causes predominately
vasoconstriction with a mild increase in heart rate,
 adrenaline predominately causes an increase in
heart rate with a small effect on the vascular tone
 the combined effect results in an increase in blood
pressure.
 Stages of shock
 Renin-angiotensin axis is activated and arginine
vasopressin is released to conserve fluid via the
kidneys
 cause the vasoconstriction of the kidneys,
gastrointestinal tract, and other organs to divert
blood to the heart, lungs and brain.
 The lack of blood to the renal system causes the
characteristic low urine production.
 Stages of shock
Progressive (Decompensating)
 the compensatory mechanisms begin to fail.
 sodium ions build up within while potassium ions
leak out.
 As anaerobic metabolism continues, increasing the
body's metabolic acidosis,
 As this fluid is lost, the blood concentration and
viscosity increase, causing sludging of the micro-
circulation.
 Stages of shock
Refractory
 At this stage, the vital organs have failed and the
shock can no longer be reversed.
 Brain damage and cell death have occurred.
 Death will occur imminently.
 Types of shock
Four types of shock:
– Hypovolaemic,
– Cardiogenic,
– Distributive,
– obstructive shock
 Hypovolemic shock
• This is the most common type of shock and based on
insufficient circulating volume.
• Its primary cause is loss of fluid from the circulation
from either an internal or external source.
• extensive bleeding, high output fistulae or severe
burns
 Distributive shock
• As in hypovolaemic shock there is an insufficient
intravascular volume of blood
• This form of "relative" hypovolaemia is the result of
dilation of blood vessels which diminishes systemic
vascular resistance
– Septic shock
– Anaphylactic shock *
– Neurogenic shock
 Cardiogenic shock
• This type of shock is caused by the failure of the
heart to pump effectively
• This can be due to damage to the heart muscle, most
often from a large myocardial infarction
• arrhythmias, cardiomyopathy, congestive heart
failure (CHF), contusio cordis or cardiac valve
problems.
 Obstructive shock
• In this situation the flow of blood is obstructed
which impedes circulation and can result in
circulatory arrest.
– Cardiac tamponade
– Tension pneumothorax
– Massive pulmonary embolism
– Aortic stenosis
 Endocrine shock
 Hypothyroidism
 Thyrotoxicosis
 Acute adrenal insufficiency
 Relative adrenal insufficiency in critically ill
 Signs and symptoms
• Hypovolemic shock
 Anxiety, restlessness, altered mental state due to
decreased cerebral perfusion and subsequent
hypoxia.
 Hypotension due to decrease in circulatory volume.
 A rapid, weak, thready pulse due to decreased blood
flow combined with tachycardia.
 Cool, clammy skin due to vasoconstriction and
stimulation of vasoconstriction.
 Signs and symptoms
 Rapid and shallow respirations
 Hypothermia due to decreased perfusion and
evaporation of sweat.
 Thirst and dry mouth, due to fluid depletion.
 Fatigue due to inadequate oxygenation.
 Cold and mottled skin (cutis marmorata), especially
extremities, due to insufficient perfusion of the skin.
 Distracted look in the eyes or staring into space,
often with pupils dilated.
 Signs and symptoms
• Kesadaran  gelisah sampai coma
• Kulit telapak tangan dingin, pucat, basah
• Nafas cepat
• Nadi cepat > 100 dan lemah
• Tekanan darah < 90-100 mmHg
• Capillary Refill Time > 2 detik
• Pulse pressure menyempit
• JVP rendah (vena jugularis eksterna)
• Produksi urine < 0.5 ml/kg/jam
 Signs and symptoms
Jika nadi teraba di:
- radialis > 80 mmHg *)
- femoralis > 70 mmHg
- carotis > 60 mmHg
25
Signs and symptoms
Signs and symptoms
 Signs and symptoms
• Septic shock
similar to hypovolaemic shock except in the first stages:
– Pyrexia and fever, or hyperthermia, due to
overwhelming bacterial infection.
– Vasodilation and increased cardiac output due to
sepsis.
• Neurogenic shock
similar to hypovolaemic shock except in the skin's
characteristics. In neurogenic shock, the skin is warm
and dry.
 Signs and symptoms
• Cardiogenic shock
similar to hypovolaemic shock but in addition:
– Distended jugular veins due to increased jugular
venous pressure.
– Absent pulse due to tachyarrhythmia.
• Obstructive shock,
similar to hypovolaemic shock but in addition:
– Distended jugular veins due to increased jugular
venous pressure.
– Pulsus paradoxus in case of tamponade
 Treatment
In the early stages, shock requires
immediate intervention to preserve life

The early recognition and treatment

depends on the transfer to a hospital.
 Treatment
RECOGNISE THE PROBLEM
GET HELP

ABC
 Treatment

The management of shock requires

immediate intervention, even before a
diagnosis is made.
Treatment
 Airway
• Head Tilt
• Chin lift
• Jaw Thrust
– No longer recommended for untrained
personnel.
– Used to be preserved for pts with suspected
spinal injury
• Advanced airway (ETT, LMA,
Combitube) only for trained personnel
Airway
 Breathing
• Assessment : Look, Feel, Listen
• Gasping > treat as not breathing
• Rescue Breaths :
– 2 x cont w. 30:2
– Over 1 sec inspiratory time
– Visible chest rise ~ 500-600 ml
• Advanced airway --> 8-10 x minutes w.o
synch
Breathing
 Circulation
• Assesment : Check Pulse
– Not more than 10 sec, only trained
personnel
• Push hard and push fast
• 100 x/minutes > 30:2 ratio
• 1.5-2 inch (4-5 cm)
• Allow recoil
• Minimize interruption
Circulation
 Hypovolaemic shock
• Immediately control the bleeding !!!
• Start giving infusions!!
• Blood transfusions
• Hypovolaemia due to burns, diarrhoea, vomiting,
etc. is treated with infusions of electrolyte solutions
 Hypovolaemic shock

Inotropic and vasoconstrictive drugs should

be avoided, as they may interfere in
knowing blood volume has returned to
normal
 Hypovolaemic shock
The most common type of fluid used in shock. :
 Crystalloids - Such as sodium chloride (0.9%), or
Hartmann's solution (Ringer's lactate).
 Colloids - For example, synthetic albumin
(Dextran™), polygeline (Haemaccel™), succunylated
gelatin (Gelofusine™) and hetastarch (Hepsan™).
 Combination
 Blood - Essential in severe haemorrhagic shock,
often pre-warmed and rapidly infused.
Pasang Infus di Vena Besar
Distributive shock
 Distributive shock
Immediate Management
• Stop any likely trigger agents
• Call for help
• Maintain airway and give 100% oxygen
• Lie patient flat with legs elevated
• Give adrenaline 50-100 ug IV ( 0.5-1mL of 1:10.000 )
if hypotensive, repeat as necessary. IM dose (0.5-
1mL of 1:1000 )
• Start rapid IV infussion
 Distributive shock
Subsequent management
• Give antihistamines ( chlorpheniramine 10-20 mg
slowly IV )
• Give corticosteroids (200mg hydrocortisone IV )
• Bronchodilators ( salbutamol 250ugIV or 2.5-5mg by
nebulizer, aminophylline 250mg up to 5mg/kg by
slow IV)
• Refer to ICU
Cardiogenic shock
 Obstructive shock

The only therapy consists of removing the

obstruction.
 Endocrine shock

In endocrine shock the hormone

disturbances are corrected.