INTRODUCTION

Shock is a life-threatening condition of circulatory failure, causing inadequate

oxygen delivery to meet cellular metabolic needs and oxygen consumption
requirements, producing cellular and tissue hypoxia. The effects of shock are
initially reversible, but rapidly become irreversible, resulting in multiorgan failure
(MOF) and death. When a patient presents with undifferentiated shock, it is
important that the clinician immediately initiate therapy while rapidly identifying
the etiology so that definitive therapy can be administered to reverse shock and
prevent MOF and death. (David F et al, 2014)

Definition

Shock is defined as a state of cellular and tissue hypoxia due to either reduced
oxygen delivery, increased oxygen consumption, inadequate oxygen utilization, or
a combination of these processes. This most commonly occurs when there is
circulatory failure manifested as hypotension (ie, reduced tissue perfusion);
however, it is crucial to recognize that a patient in shock can present hypertensive,
normotensive, or hypotensive. Shock is initially reversible, but must be recognized
and treated immediately to prevent progression to irreversible organ dysfunction.
"Undifferentiated shock" refers to the situation where shock is recognized but the
cause is unclear.

Signs and Symptoms of shock

If you go into shock, you may experience one or more of the following:

1. rapid, weak, or absent pulse

2. irregular heartbeat
3. rapid, shallow breathing
4. cool, clammy skin
5. dilated pupils
6. lackluster eyes
7. chest pain
8. nausea
9. confusion
10.decrease in urine
11.thirst and dry mouth
12.loss of consciousness

CAUSES OF SHOCK

Anything that affects the flow of blood through your body can cause shock. Some
causes of shock include:

1. severe allergic reaction
2. significant blood loss
3. heart failure
4. blood infections
5. dehydration
6. poisoning
7. burns

TYPES OF SHOCK

There are four subtypes of shock with differing underlying causes and symptoms:
hypovolemic, cardiogenic, obstructive, and distributive.

Hypovolemic Shock
Hypovolemic shock, the most common type, is caused by insufficient circulating
volume, typically from hemorrhage although severe vomiting and diarrhea are also
potential causes.
Hypovolemic shock is graded on a four-point scale depending on the severity of
symptoms and level of blood loss. Typical symptoms include a rapid, weak pulse
due to decreased blood flow combined with tachycardia, cool, clammy skin, and
rapid and shallow breathing.

Cardiogenic Shock
Cardiogenic shock is caused by a failure of the heart to pump correctly, either due
to damage to the heart muscle through myocardial infarction or through cardiac
valve problems, congestive heart failure, or dysrhythmia.

Obstructive Shock
Obstructive shock is caused by an obstruction of blood flow outside of the heart.
This typically occurs due to a reduction in venous return, but may also be caused
by blockage of the aorta.

Distributive Shock
Distributive shock is caused by an abnormal distribution of blood to tissues and
organs and includes septic, anaphylactic, and neurogenic causes.

Distributive shock can be further divided into septic, anaphylaxis, and neurogenic
shock

Septic
Septic shock is the most common cause of distributive shock and is caused by an
overwhelming systemic infection that cannot be cleared by the immune system,
resulting in vasodilation and hypotension.

Anaphylactic
Anaphylactic shock is caused by a severe reaction to an allergen, leading to the
release of histamine that causes widespread vasodilation and hypotension.
Neurogenic
Neurogenic shock arises due to damage to the central nervous system, which
impairs cardiac function by reducing heart rate and loosening the blood vessel
tone, resulting in severe hypotension.

Circulatory shock, commonly known simply as shock, is a life-threatening medical

condition that occurs due to the provision of inadequate substrates for cellular
respiration.Typical symptoms of shock include elevated but weak heart rate, low
blood pressure, and poor organ function, typically observed as low urine output,
confusion, or loss of consciousness.

Nursing assessment

 History: the history is vital in determining to determine the possible causes

and in determining the workup
 Vital signs: the vital signs prior to arrival at the emergency department
 Trauma: in patients with trauma, determine the mechanism of injury and any
information that may heighten suspicion of certain injuries
Nursing goals and planning in the management of shock

 Prevent recurrence of cardiogenic shock.

 Monitor hemodynamic status.
 Administer medications and intravenous fluids.
 Maintain fluid volume at a functional level.
 Report understanding of the causative factors of fluid volume deficit.
 Maintain normal blood pressure, temperature, and pulse.
 Maintain elastic skin turgor, most tongue and mucous membranes, and
orientation to person, place, and time.
 Monitor peripheral perfusion status
 Monitor skin color, temperature
 Monitor core body temperature
 Administer vasopressors
  Administer IV fluids
 Oxygenation
 Monitor for airway protection
 Assess lung sounds
 Administer corticosteroids
 Administer bronchodilators

MANAGEMENT OF SHOCK
A) MEDICAL MANAGEMENT
a. Phenylephrine
Adults
Phenylephrine injection may be administered subcutaneously or
intramuscularly in a dosage of 2 to 5 mg with further doses of 1 to 10 mg if
necessary according to response, or in a dose of 100 to 500 micrograms by
slow intravenous injection as a 0.1% solution, repeated as necessary after
at least 15 minutes.
Alternatively, 10 mg in 500 ml of glucose 5% injection or sodium chloride
0.9% injection may be infused intravenously, initially at a rate of up to 180
micrograms per minute, reduced according to response to 30-60
micrograms per minute.
Children
100 micrograms/kg bodyweight subcutaneously or intramuscularly.

Elderly
There is no need for dosage reduction in the elderly. (Wockhardt, 2016)
b) Norepinephrine
Adults
Initial rate of infusion:
When diluted as recommended in section 6.6 (the concentration of the
prepared infusion is 40 mg/litre noradrenaline base (80 mg/litre
noradrenaline tartrate)) the initial rate of infusion, at a body weight of 70 kg,
should be between 10 ml/hour and 20 ml/hour (0.16 to 0.33 ml/min). This is
equivalent to 0.4 mg/hour to 0.8 mg/hour noradrenaline base (0.8 mg/hour
to 1.6 mg/hour noradrenaline tartrate). Some clinicians may wish to start at
a lower initial infusion rate of 5 ml/hour (0.08 ml/min), equivalent to 0.2
mg/hour noradrenaline base (0.4 mg/hour noradrenaline tartrate).
(Wockhardt, 2016)
c)Epinephrine
Anaphylaxis

Inject Adrenalin intramuscularly or subcutaneously into the

anterolateral aspect of the thigh, through clothing if necessary. When
administering to a child, to minimize the risk of injection related injury,
hold the leg firmly in place and limit movement prior to and during an
injection. The injection may be repeated every 5 to 10 minutes as
necessary. For intramuscular administration, use a needle long enough
(at least ½ inch) to ensure the injection is administered into the muscle.
Monitor the patient clinically for the severity of the allergic reaction and
potential cardiac effects of the drug, and repeat as needed. Do not
administer repeated injections at the same site, as the resulting
vasoconstriction may cause tissue necrosis.

Adults And Children 30 kg (66 lbs) Or More

0.3 to 0.5 mg (0.3 to 0.5 mL) of undiluted Adrenalin administered

intramuscularly or subcutaneously in the anterolateral aspect of the
thigh, up to a maximum of 0.5 mg (0.5 mL) per injection, repeated every
5 to 10 minutes as necessary. Monitor clinically for reaction severity
and cardiac effects.

Children Less Than 30 kg (66 lbs)

0.01 mg/kg (0.01 mL/kg) of undiluted Adrenalin administered

intramuscularly or subcutaneously in the anterolateral aspect of the
thigh, up to a maximum of 0.3 mg (0.3 mL) per injection, repeated every
5 to 10 minutes as necessary. Monitor clinically for reaction severity
and cardiac effects.

Hypotension Associated With Septic Shock

Dilute 1 mL (1 mg) of epinephrine from its vial to 1,000 mL of a 5

percent dextrose or 5 percent dextrose and sodium chloride solution to
produce a 1 mcg per mL dilution. Administration in saline solution
alone is not recommended. If indicated, administer whole blood or
plasma separately.

Whenever possible, give infusions of epinephrine into a large vein.

Avoid using a catheter tie-in technique, because the obstruction to
blood flow around the tubing may cause stasis and increased local
concentration of the drug. Avoid the veins of the leg in elderly patients
or in those suffering from occlusive vascular diseases.

To provide hemodynamic support in septic shock associated

hypotension in adult patients, the suggested dosing infusion rate of
intravenously administered epinephrine is 0.05 to 2 mcg/kg/min, and is
titrated to achieve a desired mean arterial pressure (MAP). The dosage
may be adjusted periodically, such as every 10 - 15 minutes, in
increments of 0.05 to 0.2 mcg/kg/min, to achieve the desired blood
pressure goal.

After hemodynamic stabilization, wean incrementally over time, such as

by decreasing doses of epinephrine every 10 minutes to determine if
the patient can tolerate gradual withdrawal. Adrenalin diluted in 5
percent dextrose solutions or 5 percent dextrose and sodium chloride
solutions are stable for 4 hours at room temperature or 24 hours under
refrigerated conditions. (Belcher pharmaceuticals, 2016)

d) Milrinone
For intravenous administration.
Adults: Milrinone Injection should be given as a loading dose of 50μg/kg
administered over a period of 10 minutes usually followed by a continuous
infusion at a dosage titrated between 0.375μg/kg/min and 0.75μg/kg/min
according to haemodynamic and clinical response, but should not exceed
1.13mg/kg/day total dose. For instructions on dilution of the product before
administration and a guide to maintenance infusion delivery rates
Paediatric population:
In published studies selected doses for infants and children were:
• Intravenous loading dose: 50 to 75 μg/kg administered over 30 to 60
minutes.
• Intravenous continuous infusion: To be initiated on the basis of
hemodynamic response and the possible onset of undesirable effects
between 0.25 to 0.75 μg/kg/min for a period up to 35 hours.
In clinical studies on low cardiac output syndrome in infants and children
under 6 years of age after corrective surgery for congenital heart disease
75 μg/kg loading dose over 60 minutes followed by a 0.75 μg/kg/min
infusion for 35 hours significantly reduced the risk of development of low
cardiac output syndrome (Wockhardt, 2016)

e) Dopamine

For adults

Dopamine is given by intravenous (IV) infusion.

 Low dose: 1 to 5 mcg/kg/minute IV to increase urine output and

kidney blood flow.
 Intermediate dose: 5 to 15 mcg/kg/minute IV to increase kidney blood
flow, cardiac output and contractility, and heart rate.

 High dose: 20 to 50 mcg/kg/minute IV to increase blood pressure and

stimulate vasoconstriction; may increase infusion by 1 to 4
mcg/kg/minute at 10 to 30 minute intervals until desired response (for
example, adequate blood pressure) is achieved.
Safe and effective use of dopamine is not established in children.

 This means dopamine may be capable of improving urine flow, blood

pressure, blood flow to vital organs, and improving heart function in
patients with shock syndrome. (Omudhome Ogbru, 1996)

Nursing Management of Shock

A- Hypovolemic shock :
The Trendelenburg position involves placing the patient head
down and elevating the feet. It is named after German surgeon
Friedrich Trendelenburg (1844-1924), who created the position to
improve surgical exposure of the pelvic organs during surgery.
 It is a position use to treat hypovolemic shock.It was promoted as
a way to increase venous return to the heart, increase cardiac
output and improve organ perfusion. (Kane Guthrie, 2020)
 In Trendelenburg position, the patient is supine on the table with
their head declined below their feet at an angle of roughly 16°.

B- Septic shock
Septic patients should be placed in a semi-recumbent position (head of
the bed raised to 30–45°). Semi-recumbent reduces the risk of tracheal
aspiration and hospital-acquired pneumonia, particularly when mental
state is impaired or enteral nutrition administered.
Currently, it is recommended that ventilated patients be positioned in
the bed so the head of bed is elevated at the 30° to 45° (i.e., “semi-
recumbent”). This position may be important for at least two reasons:
(1) decreased risk of aspiration and (2) decreased work of breathing.

c- Anaphylactic shock
After administration of epinephrine, patients with anaphylaxis
should be placed supine with their lower limbs elevated. They
should not be placed seated, standing, or in the upright position.
In cases of vomiting or dyspnoea, the patient should be placed in
a comfortable position with the lower limbs elevated.
Case study

A 47-year-old man who runs a yard service cuts his thumb while attaching an
accessory to one of his mowers. The next morning, his thumb is sore and the skin
surrounding the cut is red. The man has thirty very impatient customers scheduled
for lawn mowing that day so he heads out early and works until early evening. By
the time he gets back home, the thumb is swollen and throbbing, and yellowish-
white pus is oozing out of the injured area. He also notices two red streaks going
up the inside of his forearm. Just as he begins to think about getting some medical
attention for his thumb, the man experiences a shaking chill and becomes queasy.
His wife then drives him to the ER at the nearest hospital, which takes about 35
minutes because of heavy traffic. Upon their arrival at the ER, the man's
temperature has reached 39.7ºC. He is flushed and ill-appearing, with a pulse of
125 and a blood pressure of 100/60 mm Hg. (His normal BP is 145/85 mm Hg.)
There are no other remarkable findings on physical examination.

Question 1.1: What is your preliminary diagnosis?

The combination of fever, tachypnea, and tachycardia suggests systemic

inflammatory response syndrome (SIRS), which is usually defined as the presence
of two or more of the following: (1) fever (> 38ºC) or hypothermia (< 36ºC); (2)
tachypnea (R > 24/min); tachycardia (P > 90/min); and (4) leukocytosis (>
12,000/(microliter), leukopenia (< 4,000/microliter), or >10% bands. SIRS can
have an infectious or noninfectious etiology. In this case, there are obvious signs of
microbial infection (pus oozing from a recent skin wound, fever), so a diagnosis of
sepsis (i.e., SIRS with a proven or suspected microbial etiology) is justified. The
patient has obvious hypotension in addition to the standard SIRS/sepsis symptoms,
so he appears to have progressed to severe sepsis (defined as sepsis plus
hypotension or one or more signs of organ dysfunction (metabolic acidosis, acute
encephalopathy, oliguria, hypoxemia, or disseminated intravascular coagulation).

Question 1.2: What should you do right away?

This is a dangerous situation because the man could rapidly progress to septic
shock (defined as sepsis with hypotension and organ dysfunction), which is often
fatal. This patient's history and symptoms (e.g., pus formation) indicate that he
almost certainly has a bacterial infection that is community acquired (i.e., not
nosocomial in origin), so antibiotic therapy should be initiated as soon as possible.
You do not know the identity of the causative agent at this time, so the safest
course of action is to order an antibiotic regimen that can provide broad coverage
of both Gram-positive and Gram-negative bacteria. (Because this is not a
nosocomial infection, the causative agent is not overly likely to be highly resistant
to antibiotics, but you can't be certain of this unless you run sensitivity tests.)

Question 1.3: What is the differential?

Much of the differential can be eliminated based on the patient's recent history and
obvious evidence of microbial infection. If fever, tachypnea, tachycardia, and
(possibly) hypertension were the only symptoms (as might occur if the patient had
an internal infection that they were not yet aware of), the differential could include:
cardiogenic shock, acute pancreatitis, systemic vasculitis, pulmonary embolism,
toxic ingestion, exposure-induced hypothermia, fulminant liver failure, and
collagen-vascular diseases.

Question 1.4: What tests should you perform?

Blood cultures should be ordered in hopes of identifying the causative agent.

However, microbial invasion of the bloodstream (bacteremia) is not required for
development of sepsis because local or systemic spread of microbial signal
molecules or toxins can also provoke this response. Blood cultures yield bacteria or
fungi in 20-40% of cases of severe sepsis (i.e., this case) and in 40-70% of cases of
septic shock. If the lab manages to isolate and identify the causative agent, you will
also want its sensitivity pattern. (It might be necessary or advisable to change the
antibiotic treatment based on these lab findings.) You could also order a CBC with
differential, to look for a left shift.

Test Results:

The lab isolates a Gram-positive coccus from the blood cultures. It is catalase
positive and coagulase positive. The CBC shows WBC count of 14,575/microliter
with differential 69 segs, 9 bands, 16 lymphs, and 6 monos, Hgb 14.1 g/dL, Hct
42.2%, MCV 90 fL, and platelet count: 230,000 per (L.

Question 1.5: What is the causative agent?

Staphylococcus aureus is the most likely causative agent. The positive catalase test
eliminates Streptococcus and Enterococcus species, and the positive coagulase test
essentially eliminates other Staphylococcus species. The production of yellowish-
white pus also points to S. aureus.

Question 1.6: What are the most important causative agents overall?

Most cases of sepsis are caused by bacteria. Gram-negative bacteria (especially

Pseudomonas aeruginosa, Escherichia coli, Proteus, Klebsiella, and Neisseria
meningitidis) now account for about 40% of cases. Gram-positive bacteria
(primarily Streptococcus,
 Nursing care plan

Nursing diagnosis Goals Interventions Rationale Evaluation

Hyperthermia Within 4 hours of Offer a tepid To facilitate After 4hours of the
related to sepsis nursing sponge bath body cooling nursing
as evidence by intervention, the and to provide intervention, the
temperature of patient will have a comfort patient has gained
39.5 degrees stabilized a stabilized
Celsius temperature within temperature within
the normal range of the normal range
36.1oC to 37.2oC

Risk of septic The patient should Administer IV To facilitate The patient

shock establish normal fluids therapy effective tissue expresses normal
vital signs, and perfusion and vitals, balanced
balanced input and vasopressors maintain input and output
output and inotropic circulatory
agents blood volume
(medications and also
that change the maintain blood
force of heart pressure level
contractions) and help
as prescribed improve organ
perfusion
Risk for impaired The patient should Maintain client Elevating the The patient start
gas exchange display respiratory airway by head bed will displaying
rate within the placing the enhances lung respiratory rate
normal range, with client in a expansion and within the normal
breath sound clear position of reduce range without
and chest x-ray comfort with respiratory breath sound and
clear the head bed effort has a chest x-ray
elevated 30o to clear
45o

MCQs questions
1. Failure of the heart to pump effectively causes the following type of shock

A. Anaphylactic
B. Cardiogenic
C. Hypovolemic
D. Septic
E. All of the above

------------------------------------

Answer: Cardiogenic

2. Overwhelming infection and resulting vasodilation can lead to the following

type of shock

A. Anaphylactic
B. Cardiogenic
C. Hypovolemic
D. Septic
E. A and B are correct

-----------------------------------

Answer: Septic

3. Trauma to the spinal cord and resultant loss of autonomic and motor reflexes
below the injury level can lead to the following type of shock

A. Cardiogenic
B. Hypovolemic
C. Neurogenic
D. Obstructive
E. None of the above

--------------------------------

Answer: Neurogenic

4. Cardiac tamponade can result in the following type of shock

 A. Cardiogenic
B. Hypovolemic
C. Neurogenic
D. Obstructive
E. B only is correct

-----------------------------------

Answer: Obstructive

5. The skin is warm and dry in the following type of shock

A. Cardiogenic
B. Hypovolemic
C. Septic
D. Obstructive
E. Neurogenic

--------------------------------

Answer: Neurogenic

6. What should be the position given to a patient in shock?

A. Head low
B. Fowler’s
C. Semi fowler’s
D. Supine
E. Recumbent

----------------------------------

Answer: Head low

7. The acid base balance which commonly accompanies shock is

 A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
E. Metabolic/Respiratory alkalosis

-----------------------------------------------

Answer: Metabolic Acidosis

8. Which stage of shock is associated with development of metabolic acidosis?

A. Initial
B. Compensatory
C. Progressive
D. Refractory
E. A and D only are correct

-----------------------------------

Answer: Progressive

9. Which stage of shock initiates the compensatory mechanisms to maintain the

BP and blood flow to the vital organs?

A. None
B. Compensatory 
C. Progressive 
D. Refractory 
E. Initial

-------------------------------------

Answer: Initial

10. Patients with large partial-thickness or full thickness burns can develop
 A. Anaphylactic shock
B. Cardiogenic Shock
C. Hypovolemic shock
D. Septic Shock
E. Distributive shock

----------------------------------------

Answer: Hypovolemic shock

11. Vasodilation and resulting hypotension and increased capillary permeability

is characteristic of 

A. Anaphylactic shock
B. Cardiogenic Shock
C. Hypovolemic shock
D. Anaphylactic and cardiogenic shock
E. Septic shock

--------------------------------------------

Answer: Septic shock

12.True or False: Hypovolemic shock occurs when there is low fluid in the
intestinal compartiment.

o True
o False

Answer: False

13. A patient is 1 hour post op from abdominal surgery and had loss 20% of their
blood volume during surgery. The patient is experiencing signs and
symptoms of hypovolemic shock. What position is best for this client?

A. Modified Trendelenburg
B. Trendelenburg
C. High fowler
D. Supine
E. Prone
 Answer: Trendelenburg

14. Which of the following clinical signs is not typical for a classical
representation of shock

A. Cool extremities
B. Weak pulses
C. Systemic hypertension
D. Tachypnea
E. B and C only

Answer: Systemic hypertension

15. Which of the following is not a major mechanism of lack of oxygen delivery to
tissues?

A. Inadequate blood volume

B. Inadequate cardiac performance
C. Inadequate vascular tone
D. Inadequate coronary perfusion
E. A and C are correct

REFERENCE

 Belcher Pharmaceuticals, LLC, revised Febuary 2016

 David F Gaieski, MD, 2014
 Mark E Mikkelsen, MD, MSCE, 2018
 Medically reviewed by Deborah Weatherspoon, Ph.D., R.N.,
CRNA — Written by April Kahn — Updated on July 16, 2019c
 Wockhardt UK Ltd, revised 14 June 2019