Shock

Dr Christiaan Vosloo
Definition

 Shock has many definitions…. in summary

 A mismatch in the cellular oxygen demand and the oxygen supply provided by the
cardiovascular system due to compromised tissue perfusion pressures resulting in
anaerobic metabolism and organ dysfunction
 A mean arterial perfusion pressure () of >65 mmHg is required to maintain tissue perfusion
 BP= Cardiac Output x Total Peripheral Resistance; thus, when the BP decreases, the heart
rate increases.
 Rule of thumb... When the HR > decreased Syst. BP, patient is in shock!
 Classification

• Obstructive
• Blockage in the circulation; an immediate life-saving procedure to alleviate blockage is Shock
1 required

• Distributive Obstructive Distributive Cardiogenic Hypovolaemic

• Relative hypovolaemia due to vasodilatation of the peripheral blood vessels;
2 combination of vasoconstrictors and fluid replacement is used

Pulmonary Cardiac
Anaphylactic Acute blood loss
• Cardiogenic embolism arrythmias
• Primarily cardiac dysfunction; requires inotropic support, surgery or other measures,
3 depending on the cause
Cardiac Severe
Septic Valvular
tamponade dehydration
• Hypovolaemic
• Intravascular volume loss; requires fluid replacement with isotonic crystalloids
4 Neurogenic Heart failure
Goals of treatment in
shock
 1. Find and treat the underlying cause
 2. Achieve and maintain MAP >65mmHg
 3. Achieve and maintain urine output of
>0.5ml/kg/hour
 4. Correct concurrent metabolic
abnormalities e.g. acidosis, electrolyte
imbalances, etc.
 Distributive Shock - Septic
SOFA
score
qSOFA screening
Distributive Shock -
Septic
 The presence of sepsis as defined by the SOFA score, with
a lactate of 2 mmol/L and persistent hypotension requiring
the administration of vasopressors to maintain a MAP of
>65 mmHG.
 Clinically: patient is toxically ill, pyrexial, with flushed,
warm extremities, and evidence of organ dysfunction
 Treatment:
 1. Definitive is intravenous empiric broad-spectrum
antibiotics
 2. Supportive treatment includes fluid therapy and
infusion of vasopressors
 3. Monitoring patient’s vitals, GCS, ABG,
electrolytes and urinary output – manage accordingly
 4. Blood tests: Baseline bloods, inflammatory
markers, BLOOD CULTURES
Distributive shock -
Anaphylactic
 IgE- and histamine-mediated hypersensitivity
reaction in response to an allergen resulting in
systemic vasodilation and redistribution of
intravascular fluid to the extravascular space
due to increased vascular permeability
 Combination of relative and true hypovolaemia
 Diagnosis:
 1. High index of suspicion
 2. Two of the following four systems are
involved : Cardiovascular (shock, end-organ
dysfunction), Respiratory (wheezing, stridor,
cough, dyspnoea), Dermatological (urticaria,
itching, rash, angioedema), Abdominal
(vomiting, stomach cramps); after exposure to a
likely allergen
Distributive shock - Anaphylactic
 1. Remove patient from stimulus and call for help
 2. Immediately give Adrenaline - 1mg/ml (1:1000) - 0.01mg/kg IM (Max 0,5ml IM) anterolateral aspect of thigh,
every 5-15 minutes if no improvement
 <6yrs - 0,15ml IM; 6-12 yrs - 0,3ml IM; >12 yrs - 0,5ml IM
 3. Then do ABCs
 4. H1 antihistamine – Promethazine IM or slow IV
 2-6 yrs - 6,25mg; 6-12 yrs - 12,5mg; >12 yrs - 25mg (Avoid if <2 or low BP)
 5. Crystalloids - (e.g. Ringers/Balsol)
 Rapid infusion of 20ml/kg (max 1-2 litres). Repeat IV infusion as necessary
 Adrenaline infusion (0,1 - 1 ug/kg/min) ONLY if unresponsive to IM adrenaline & fluids
 6. Nebulised bronchodilators: Every 15-20 mins if severe bronchospasm Salbutamol 5mg WITH Ipratropium
0,5mg
 7. H2 receptor antagonist: Cimetidine IM or Slow IV
 5mg/kg (Max - 300mg) Diluted in 20ml over 2 min
 8. Corticosteroids - Hydrocortisone IM or Slow IV
 <1 yr - 25mg; 1-6 yrs - 50mg; 6-12 yrs - 100mg; >12 yrs - 200mg
 9. Glucagon - IM or slow IV
 20ug/kg (Max 1-2mg) every 5 mins if unresponsive to adrenaline (Look out for vomiting and hyperglycaemia)
Distributive Shock -
Neurogenic
 State of imbalance between the parasympathetic and
sympathetic regulation of cardiac action and vascular
smooth muscle due to high spinal cord injuries, with
SBP <100mmHg and heart rate <60/min.
 Diagnosis:
 High spinal cord injury with motor deficit and
sensory level
 Hypotension and bradycardia
 End-organ dysfunction
 Treatment:
 Fluid replacement
 Inotropic infusion
Hypovolaemic shock
 Classic picture of shock
 Pale, cold, clammy skin
 Rapid, feeble pulse
 Decreased level of consciousness
 Decreased urine output
 Signs of dehydration present
Acute blood loss Severe dehydration
Find source of bleeding Crystalloids fluid bolus
and control it and rehydration fluids
Requires urgent blood Important to take
transfusion electrolytes and cause
and crystalloids (N/S or into consideration to
MRL) chose correct fluids

Monitor patient’s response carefully

Cardiogenic shock
Myocardial Rhythmic Mechanical

 Cardiac dysfunction from a variety of

causes, notably myocardial, rhythmic or
mechanical abnormalities, resulting in a
SBP < 90mmHg or MAP <30mmHg.
 Diagnosis:
 1. Based on history and clinical
picture of patient
 2. End-organ dysfunction, agitation
 3. Pale, cold, clammy extremities
 Treatment depends on cause
Heart failure treatment
Treat precipitating factors eg
HPT, viral infection, vit B1
deficiency, etc
Treat accordingly for each type Treat underlying cause eg
of arrythmia Valvular lesions, clotted
valves, infective endocarditis,
cardiac tumours
Consider pharmacological Interventional radiology,
treatment or defibrillation or cardiology, cardiothoracic
cardiac pacing surgery involved
 Obstructive shock
 Obstruction of the great vessels or the heart itself

Decreased preload Increased Increased

to right heart afterload to right afterload to left
heart and heart
decreased preload
to left heart
Tension Pulmonary Aortic stenosis
pneumothorax embolism (severe)
Vena cava Mediastinal or Aortic dissection
compression intracardiac masses
syndrome
Pericardial Leriche syndrome
tamponade
High-PEEP
ventilation
 Obstructive shock
 Diagnosis:
 1. Led by history, clinical picture, suspicions
 2. Typical features of shock
 Treatments: Unique to cause
 1. Massive pulmonary embolism – thrombolysis, supportive
 2. Tension pneumothorax – needle decompression, then ICD
 3. Cardiac tamponade – needle pericariocentesis/ open thoracotomy
and pericardotomy
 4. High PEEP ventilation – decrease PEEP
 5. Aortic dissection – cardiothoracic/vascular surgery
 6. Aortic stenosis – cardiology/cardiothoracic surgery
 7. Leriche syndrome – surgical embolectomy
The Common Denominator-
Anaerobic Metabolism
The END
Bibliography

 Standl T;Annecke T;Cascorbi I;Heller AR;Sabashnikov A;Teske W; (no date) The

nomenclature, definition and distinction of types of shock, Deutsches Arzteblatt
international. Available at: https://pubmed.ncbi.nlm.nih.gov/30573009/ (Accessed: 16 May
2023).
 Algorithms (no date) Resus. Available at:
https://resus.co.za/subpages/RCSA_Information/Resources/Algorithms.html (Accessed: 16
May 2023).