:BY

EMAN M.
IBRAHEM
:Agenda

 Definition
 Types
 Stages
 Diagnosis
 Management
:Definition

 Shock is the state of not enough blood flow to the tissues of

the body as a result of problems with the circulatory
system.
 Many organs can be damaged as a result. Shock requires
immediate treatment and can get worse very rapidly. As many 1
in 5 people in shock will die from it.
:Types of shock

 Hypovolemic (caused by too little blood volume)

 Cardiogenic (due to heart problems)
 Septic (due to infections)
 Anaphylactic (caused by allergic reaction)
 Neurogenic (caused by damage to the nervous system)
 Obstructive (pulmonary embolism, tamponade, tension
pneumothorax)
:Types and causes of shock
:Compensatory stage

 This stage is characterised by the body employing physiological mechanisms, including

neural, hormonal and bio-chemical mechanisms, in an attempt to reverse the condition.
 The baroreceptors in the arteries detect the hypotension resulting from large amounts of
blood being redirected to distant tissues, and cause the release of epinephrine and
norepinephrine. Norepinephrine causes
predominately vasoconstriction with a mild increase in heart rate.
 The lack of blood to the renal system causes the characteristic
low urine production.
:Progressive/decompensated stage

 In the absence of successful treatment of the underlying cause, shock will

proceed to the progressive stage. During this stage, compensatory
mechanisms begin to fail.
 The prolonged vasoconstriction will also cause the vital organs to be
compromised due to reduced perfusion. If the bowel becomes sufficiently
ischemic, bacteria may enter the blood stream, resulting in the increased
complication of endotoxic shock.
:Refractory stage

 At this stage, the vital organs have failed and the shock can no
longer be reversed. Brain damage and cell death are occurring.
 :Diagnosis

 The diagnosis of shock is commonly based on a combination of

symptoms, physical examination, and laboratory tests.
 A high degree of suspicion is necessary for the proper diagnosis of shock.
While many laboratory tests are typically performed, there is no test that
either makes or excludes the diagnosis.
:Investigations

 CBC and coagulation studies, electrolytes

 BUN/creatinine and urinalysis; hepatic function panel
 Chest x-ray, ECG
 Lactate (to gauge the degree of hypoperfusion)
 Urine pregnancy test
 Arterial blood gas for O2/pH
 If a particular type of shock is suspected, further studies may be
directed accordingly:
 Infectious etiology (sepsis) – blood, sputum, urine, pelvic, or wound
cultures; head CT and lumbar puncture; targeted imaging(US/CT)
 Cardiogenic – cardiac enzymes and echocardiogram obstructive
– CT or V/Q scan (PE), echo (tamponade)
:Management

• Shock is a true emergency and should be treated quickly

A and aggressively in the ED to decrease morbidity.

• Do not wait until labs and/or studies return to begin

B resuscitation

• Remember the ABCs

C
 :Management

Management may include:

 Securing the airway via intubation if necessary to decrease the work of
breathing and for guarding against respiratory arrest.
 Oxygen supplementation: Arterial oxygen saturation should be
maximized, and central venous oxygenation levels targeted above 70%.
 It is important to keep the person warm to avoid hypothermia as well as
adequately manage pain and anxiety as these can increase oxygen
consumption.
 Circulatory support is crucial
 obtain IV access through large bore peripheral lines or a central venous catheter (which can help
for rapid fluid and medication delivery, as well as provide invasive monitoring).
 In most kinds of shock, crystalloid fluids (normal saline or Ringer’s lactate) should be given as
boluses. Be careful with rapid fluid administration to the patient in cardiogenic shock with
pulmonary edema.
 Blood products may be necessary in certain types of hemorrhagic shock.
 If volume resuscitation does not improve the patient’s hemodynamic status, vasoactive
medications such as epinephrine, norepinephrine, dopamine, and vasopressin may be used.
 Careful monitoring of fluid status is encouraged, using a urinary catheter,
intraarterial blood pressure measurements, and central venous pressure monitoring.
 Aggressive treatment of the underlying cause of shock is warranted:
- Hypovolemia due to hemorrhage may warrant surgical or interventional
control.
-Sepsis syndromes should be treated with early goal-directed therapy and aggressive
antibiotic treatment .
- Cardiogenic shock may necessitate emergent angiography or surgical
procedures (bypass, valve repair, IABP).
- Obstructive shock due to PE often requires anticoagulation or
thrombolysis, whereas when due to cardiac tamponade emergent drainage
of the pericardial fluid may be necessary.
 Despite proper treatment, the mortality rates from shock can
exceed 50 percent.