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

Etiology
1. Cardiogenic

Cardiology

2. Hypovolumic

Bleeding, Vomits,
diarrhea, polyuria

3. Distributive

Septic, anaphylactic,
adrenal crisis,
neurogenic

4. Obstructive

cardiac temponade

Sign
Pump failure

Turgor

sign and symptom of

Infection

Pulsus paradoxus
(systolic > 10
tension pneumothorax mmHg in inspiration),
dyspneu, tachycardia
Massive pulmonary
embolism

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,
muscle, GIT

MALDISTRIBUTION OF BLOOD FLOW

Hypotension
Hypoperfusion
~ MAP < 60 mmHg
Organ
disfungsi organ
or
~ Systolic > 40 mmHg
~
awareness
~ oliguria
~
lactic acidosis

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
derangement of cellular metabolism

Mild and Moderate Hypovolumia

Restitution intravascular volume by:
1. Arteriol vasoconstriction ~
hydrostatic
pressure
2. Changes in cellular metabolic
function
hyperglicemia
glycolysis

Extracellular osmolarity
lypolisis
proteolysis
volume interstitiel

CELLULAR RESPONSES

Impaired transport of interstitial

nutrient
Mitochondrial
transmembrane
dysfunction

ATP

potential

intracell Na and
water
anaerobic

metabolites
( lactate) ~ vasodilator
swelling

Cell

NEUROENDOCRINE RESPONSES
HYPOVOLEMIA, HYPOTENSION, HYPOXIA

Chemoreceptor
Baroreceptor
epinephrine-adr. medula
vasomotor
vagal activity
adrenergic
Heart Rate
vasoconstriction

inhibit

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
. TV
. Vd, Vt
Atelectasis
. Resp alkalosis

Pain
RFC

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
Impairment of renal function

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,
bronchoconstriction
systemic vasodilation

NEUROENDOCRINE RESPONSES

Adrenergic discharge
Renin
angiotensi I

angiotensi II
(potent vasoconstrictor)
adrenal cortex
posterior
pituitary
aldosterone

vasopressin

tubular reabsorption Na
vasoconstriction
water reabsorption

Hipovolumic shock
Mild

Moderate

(<20% Blood vol)

(20-40%)

Severe
>40%

Cool extremities
Same,plus
Same,plus:
Capillary refill time
Tachycardia
Hemodynamic
Tachypneu
instability
Diaphoresis
Oliguria
Marked
tachyc
Collaps vein
Postural changes
Mental
status
tederioration
Anxiety

Terima kasih