SHOCK

• This is failure of circulatory system to

maintain adequate cellular perfusion.
• Shock can occur with normal BP and
hypotension can occur without
shock.Inadequate sytemic oxygen delivery
activates autonomic responses to maintain
sytemic oxygen delivery.
• SNS- NE,E, Dopamine and Cortisol
released causing vasoconstriction,
increased HR and increase in cardiac
contractility( Cardiac Output)
• Renin Angiotensin axis- Water and Sodium
conservation and vasocontriction hence
increase in blood volume and BP.
• Cellular response to decrease in systemic
oxygen delivery include:
• ATP depletion -Ion pump dysfunction
hence cellular edema
• Hydolysis of cellular membrane and
cellular death.
 Classification of Shock
• 1)Hypovolemic shock
• 2) Cardiogenic shock
• 3)Distributive shock
 Hypovolemic shock
• This is caused by decreased blood
volume.
• Decrease in blood volume results in
decrease in preload which leads to
inadequate LV filling, reflected as left and
right ventricular end diastolic volume and
pressure.
• Causes: Hemorrhage, Diarrhoea ,
Vomiting , Burns ,Trauma, Severe
dehydration,excessive sweating, use of
• diuretics.
• Loss of 25% or more of the blood volume
results in significant hypovolemia
 Cardiogenic Shock
• Results from severe depressionof cardiac
performance. Primarily it may results from
pulmonary or myocardial failure.
• Usually pulmonary edema coexists.
• Causes :Myopathic, mechanical
• Myopathic-Acute myocadial
infarction,myocarditis, dilated
cardiomyopathy, myocardial depression in
• septic shock
• Mechanical-a)Intracardiac (LV outflow
obstruction eg Aotic stenosis, reduction in
forward cardiac output eg aortic or mitral
regurgitation, arrhythmia) b)
Extracardiac/Obstructive shock
( Pericardial tamponade, Tension
pneumothorax, Severe pulmonary
hypertension)
 Distributive Shock
• Caused by profound perioheral
vasodilation
• Causes:
• 1) Septic Shock-Caused by systemic
microbial infection most commonly by
gram negative infection but can occur with
gram positive or fungal infections. It can
also be defined as sepsis with
hypotension, organ dysfunction or
unresponsiveness to fluid administration.
• 2) Neurogenic shock- Occurs with
cephalocaudal migration of anaethetic
agent or spinal cord injury owing to lose of
vascular tone and peripheral pooling of
blood.
• 3)Anaphylactic shock- Initiated by
generalized hypersensitivity response,
assosciated with systemic vasodilation
and increased vascular permeability.
Haemorrhagic shock is one of the
commonest form of hypovolemic
shock
 Classification of
haemorrhage
WHO classification
• Grade 0-no bleeding
• Grade 1-petechial bleeding
• Grade 2-mild blood loss (clinically
significant)
• Grade 3-gross blood loss, requires
transfusion
• Grade 4-debilitating blood loss, retinal or
cerebral associated with fatality
 Stages of Shock
• 1)Initial nonprogressive phase
• 2)Progressive stage/ established shock
• 3)Irreversible stage
 Initial non-progressive phase
Compensatory mechanism to
maintain the homeostasis so that
blood supply to vital organs is
maintained
By neuro humoral mechanism which
maintains blood pressure and
cardiac output
Widespread vasoconstriction of
vessels except coronary and
 Progressive phase
As the stage advances there is failure of
compensatory mechanism, dilatation of
arterioles, veinules and capillary bed
Because of this fluid leaks out of
capillaries into interstitium and there is
sludging of blood
This reduces the tissue perfusion leading
to hypoxia
Initially body tissue except brain and heart
suffers from hypoxia
 IRREVERSIBLE PHASE (DECOMPENSATED STAGE)
Cellular injury and tissue injury is so severe that
condition does not revert back to normal even after
correcting hemodynamic defects
Hypoxic and ischemic cell injury – causes leakage of
lysosomal enzymes which further aggravates condition
Myocardial infarction and synthesis of NO further
worsens condition
Intestinal ischemia causes microbes from intestinal flora
to enter the circulation which produces superimposed
bacteremic shock
Acute tubular necrosis occurs in kidney
 Signs and symptoms of hemorrhagic shock
Signs and symptoms of shock are life threatening and
should be treated as a medical emergency.
They include:
blue lips and fingernails
low or no urine output
excessive sweating
shallow breathing
dizziness or loss of consciousness
confusion
chest pain
low blood pressure
rapid heart rate
External hemorrhaging (bleeding) will be
visible. Internal hemorrhaging, however,
may be hard to recognize until symptoms
of shock appear.
Signs and symptoms of internal
hemorrhaging include:
abdominal pain
abdominal swelling
blood in the stool
blood in the urine
vaginal bleeding, which is heavy and
usually occurs outside of normal
menstruation
 Management of
haemorrhagic shock
Aim: To treat the underlying cause and replace fluid
Identify the underlying cause and treat
Intravenous fluids (plasma expanders) for
hypovolaemic shock
Nutrition support- High carloric food due to increased
metabolic requirements during shock
Oxygen therapy
Drugs:
Vasoconstrictors- to contract muscle fibres of arterial
vessel walls and to stimulate the vasomotor centre in
the medulla to raise blood pressure (for neurogenic
shock) Examples include norepinephrine, vasopressin