SHOCK

WHAT IS SHOCK?
A physiological state characterized by a significant, systemic reduction in tissue perfusion, resulting in decreased tissue oxygen delivery and insufficient removal of cellular metabolic products, resulting in tissue injury.

Approach to the Patient in Shock

History Recent illness Fever Chest pain, SOB Abdominal pain Comorbidities Medications Toxins/Ingestions Recent hospitalization or surgery Baseline mental status

Physical examination Vital Signs CNS mental status Skin color, temp, rashes, sores CV JVD, heart sounds Resp lung sounds, RR, oxygen sat, ABG GI abd pain, rigidity, guarding, rebound Renal urine output

HYPOVOLEMIC SHOCK
The most common type of shock Characterized by decreased intravascular volume Occurs when there is a reduction in intravascular volume by 15% to 30%

CAUSES
bleeding: trauma, GI bleeding, ruptured aneurysms, hemorrhagic pancreatitis protracted vomiting or diarrhea adrenal insufficiency; diabetes insipidus

dehydration
third spacing: intestinal obstruction, pancreatitis, cirrhosis

Burns

PATHOPHYSIOLOGY
Decreased intravascular volume

Decreased venous return

Decreased ventricular filling

Decreased stroke volume

Decreased cardiac output

Inadequate tissue perfusion

CARDIOGENIC SHOCK
Occurs when the hearts ability to contract and to pump blood is impaired and the supply of oxyge is inadequate for the heart and tissues
SBP < 90 mmHg PCWP > 18 mmHg

CAUSES
Systolic dysfunction Diastolic dysfunction Valvular dysfunction Cardiac arrhythmias Coronary artery disease Mechanical complications

PATHOPHYSIOLOGY
Impaired pumping ability of the left ventricle

Decreased SV

Inadequate systolic emptying

Elevated left ventricular filling pressure Decreased CO Increased LAP Decreased BP

Increased pulmonary venous pressure

Decreased tissue perfusion

Increased pulmonary capillary pressure

Pulmonary interstitial edema; intra-alveolar edema

NEUROGENIC SHOCK
Vasodilation occurs as a result of a loss of balance between sympathetic and parasympathetic stimulation Occurs after acute spinal cord injury Sympathetic outflow is disrupted leaving unopposed vagal tone Results in hypotension and bradycardia

 Spinal shock- temporary loss of spinal reflex activity below a total or near total spinal cord injury (not the same as neurogenic shock, the terms are not interchangeable) Loss of sympathetic tone results in warm and dry skin Shock usually lasts from 1 to 3 weeks Any injury above T1 can disrupt the entire sympathetic system Higher injuries = worse paralysis

CAUSES
Spinal cord injury Spinal anesthesia Depressant action of drugs Insulin reaction

PATHOPHYSIOLOGY
Loss of sympathetic tone Massive vasodilation Venous dilation Decreased venous return Decreased stroke volume Decreased CO Decreased tissue perfusion Decreased peripheral vascular resistance

Arteriolar dilation

ANAPHYLACTIC SHOCK
Is caused by a severe allergic reaction when patients who have already produced antibodies to a foreign substance (antigen) develops a systemic antigen-antibody reaction

CAUSES
Antibiotics Insects Foods Blood products Contrast agents latex

PATHOPHYSIOLOGY
Exposure to antigen Activation of sensitized antibodies Antigen-antibody reaction Release of vasoactive mediators

Massive vasodilation Venous and arterial dilation

Increased capillary permeability Interstitial edema Relative hypovolemia

SEPTIC SHOCK
Is a serious condition that occurs when an overwhelming infection leads to lifethreatening low blood pressure. Severe sepsis with refractory hypotension: MAP >60 mm Hg after fluid resuscitation (30-50 cc/kg of crystalloids)

CAUSES
Extended hospitalization Advanced age Debilitating illness Immunodeficiency disorder Ventilator > 48 h Disseminated malignancy Hyperalimentation Biliary tract surgery Genital tract surgery

PATHOPHYSIOLOGY