Chapter 15

Shock and Multisystem Failure

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Shock

• A condition in which tissue perfusion is inadequate to

deliver oxygen and nutrients to support vital organs and
cellular function
• Affects all body systems

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Classifications of Shock

• Hypovolemic
• Cardiogenic
• Septic
• Neurogenic
• Anaphylactic

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Which of the following types of shock is caused by a

hypersensitivity reaction?
a. Hypovolemic
b. Anaphylactic
c. Neurogenic
d. Septic

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

b. Anaphylactic
Rationale: Anaphylactic shock is caused by a
hypersensitivity reaction. It is a circulatory shock state
resulting from a severe allergic reaction producing an
overwhelming systemic vasodilation and relative
hypovolemia.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cellular Effects of Shock

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Compensatory Mechanisms in Shock

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stages of Shock:

• Compensatory
• Progressive
• Irreversible

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Compensatory Stage of Shock
• SNS causes vasoconstriction, increased HR, and increased
heart contractility.
• This maintains BP and CO.
• Body shunts blood from skin, kidneys, and GI tract, which
results in cool, clammy skin, hypoactive bowel sounds,
and decreased urine output.
• Perfusion of tissues is inadequate.
• Acidosis occurs as a result of anaerobic metabolism.
• Respiratory rate increases due to acidosis and may cause
a compensatory respiratory alkalosis.
• Confusion may occur.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Progressive Stage of Shock

• Mechanisms that regulate BP can no longer compensate,

and BP and MAP decrease.
• All organs suffer from hypoperfusion.
• Vasoconstriction continues, further compromising cellular
perfusion.
• Mental status further deteriorates as a result of
decreased cerebral perfusion and hypoxia.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Progressive Stage of Shock
• Lungs begin to fail, decreased pulmonary blood flow
causes further hypoxemia, and carbon dioxide levels
increase; alveoli collapse and pulmonary edema occur.
• Inadequate perfusion of the heart leads to dysrhythmias
and ischemia.
• As MAP falls below 70, GFR cannot be maintained. Acute
renal failure may occur.
• Liver function, GI function, and hematologic function are
all affected.
• DIC (disseminated intravascular coagulation) may occur
as a cause or complication of shock.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Irreversible Stage of Shock

• At this point, organ damage is so severe that the patient

does not respond to treatment and cannot survive.
• BP remains low.
• Renal and liver functions fail.
• Anaerobic metabolism worsens acidosis.
• Multiple organ dysfunction progresses to complete organ
failure.
• The judgment that shock is irreversible is made only in
retrospect.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

For All Types of Shock

• Early identification and timely treatment

• Identify and treat the underlying cause
• The sequence of events for the different types of shock
will vary. Therefore, the management and care of the
patient will vary.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pathophysiology of Hypovolemic Shock

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Modified Trendelenburg

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pathophysiology of Cardiogenic Shock

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Circulatory Shock

• Septic shock
• Neurogenic shock
• Anaphylactic shock

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pathophysiology of Circulatory Shock

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Management of All Types of Shock

• Fluid replacement to restore intravascular volume

• Vasoactive medications to restore vasomotor tone and
improve cardiac function
• Nutritional support to address metabolic requirements

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Which of the following vasoactive agents are used for its

vasoconstrictive properties?
a. Nitroprusside (Nipride)
b. Dobutamine (Dobutrex)
c. Nitroglycerin (Tridil)
d. Norepinephrine (Levophed)

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

d. Norepinephrine (Levophed)
Rationale: Norepinephrine (Levophed) is a vasoconstrictor
used in the treatment of shock.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Replacement

• Crystalloids: 0.9% saline, lactated Ringer’s, hypertonic

solutions (3% saline)
• Colloids: albumin, dextran (dextran may interfere with
platelet aggregation)
• Blood components for hypovolemic shock
• Complications of fluid replacement include fluid overload
and pulmonary edema.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Vasoactive Medications

• Used when fluid therapy alone does not maintain MAP

• Support hemodynamic status; stimulate the SNS
• Do vital signs frequently; continuous monitoring of vital
signs every 15 minutes or more often.
• Give through central line if possible. Extravasation may
cause extensive tissue damage.
• Dosages are usually titrated to patient response.
• See Table 15-2.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutritional Therapy

• Nutritional support is needed to meet increased metabolic

and energy requirements and prevent further catabolism
due to depletion of glycogen.
• Support with parenteral or enteral nutrition.
• GI system should be used, if possible, to support its
integrity.
• Administration of glutamine
• Administration of H2 blockers or proton pump inhibitors

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Psychological Support of Patients and
Families

• Anxiety
• Support of coping
• Patient and family education
• Communication
• End-of-life issues
• Grief processes

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Multiple Organ Dysfunction Syndrome:
MODS

• A phase of the progression of shock

• Altered organ function that requires medical intervention
to support continued organ function
• Classified as primary or secondary
• High mortality rate; 75%
• Prevention is key.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

A patient has a blood pressure of 150/90. What is the

pulse pressure?
a. 30
b. 40
c. 60
d. 20

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

c. 60
Rationale: Pulse pressure = Systolic BP – Diastolic BP;
150 – 90 = 60

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins