SHOCK

LECTURE PRESENTATION

BY

PROF T.K LAMBART

TO
MB ChB = LUSAKA APEX MEDICAL UNIVERSITY
 Shock
Definition:
Is circulatory dysfunction resulting with inadequate oxygen delivery
to the tissues (hypo perfusion).
It is life threatening medical emergency.
Shock
If untreated it will cause multiple organ dysfunction, multiple organ
failure and death.
Types of shock include = (1 to 8).
1) Hypovolaemic shock
The most common type
Follows fluid loss:
 Haemorrhage = external and/ or internal
 Diarrhea/vomiting
 Burns
2)Cardiogenic shock
Myocardial pump failure:
Congestive Cardiac Failure ( C C F )
Myocardial infarction ( M I )
Cardiac arrhythmias
Cardiomyopathy
Defective cardiac valves
3) Anaphylactic shock

Associated with wide spread vessel dilatation.

Follows allergic reaction to antigen, drug, and other
allergens
There is histamine release that causes widespread
vasodilatation , hypotension, hypoperfusion and
reduced oxygen delivery to tissues.
 4) Neurogenic shock
Associated with spinal cord injury.
Loss of autonomic and motor reflexes below the level of
injury results in loss of sympathetic control.
Relaxation of vessel walls causes peripheral vessel
dilatation,hypotension and hypoperfusion reducing
oxygen delivery to tissues.
 5) Septic shock
Severe septicaemia caused by bacterial infection like proteus
species releasing toxins which produce adverse biochemical,
immunological and neurological effects.
The toxins cause widespread vasodilatation, hypotention and
hypoperfusion.
 6) Endocrine shock
Is due to hormonal disturbances.
Examples are:
1) Hypothyroidism causing hypotension and
hypo perfusion.
2) Adrenal insufficiency causing hypotension and
hypo perfusion.
 7) Distributive shock

There is no blood loss and no fluid loss

There is widespread vasodilatation causing
hypotension and hypo perfusion
This is as occurs in septic, anaphylactic and
neurogenic shock.
 8) Obstructive shock

This is due to blood flow obstruction causing

insufficient oxygen delivery to tissues.
This may be caused by:
1) Cardiac tamponade
2) Aortic stenosis
3) Pulmonary embolism
4) Tension pneumothorax
 Stages of shock
Stage 1
Reversible shock
Compensatory mechanism is effective
Patient may still be asymptomatic.
Early signs include:
Sinus tachycardia (more than 100/min in adult)
Peripheral vasoconstriction = reduced perfusion to
tissues (cold extremities)
Compensatory mechanisms ensure adequate blood
supply to vital organs (Brain. Heart and kidneys).
 Classification of hypovolaemic
shock (most common).

Reversible shock
Class 1:
Blood loss:750mls =15% of blood volume.
Pulse rate: slight tachycardia =80 bpm (only change).
Blood pressure=systolic/diastolic unchanged.
Respiratory rate remains normal(16/min= adult patient.
Urine output (mls/hr) 30mls or more (normal).
Extremities look normal
Capillary refill: is quick, within 1sec.
 Class 11 shock
Blood loss = 15oo mls
Pulse rate = 1oo beats per min.(bpm)
Blood pressure=Systolic(normal).Diastolic(raised)
Respiratory rate=tachypnea (more than 16/min in adult)
Urine output = is reduced to 20mls/hr
Extremities look pale
Capillary refill is slow, it takes about 2seconds
Mental state: patient looks anxious
 Class 111 shock

Blood loss = 2000mls

Pulse rate =120 bpm and its thready
Blood pressure:
Systolic = reduced. Diastolic =reduced
Respiratory rate = 20/min (tachypnoea)
Urine output = is reduced to 10mls/hr
Extremities look pale and feel cold.
Capillary refill is slow lasting more than 2seconds.
Mental state: patient is aggressive and confused
 Class 1V shock
Blood loss = more than 2000 mls
Pulse rate =more than 120bpm and very thready
Blood pressure:
Systolic = very low. Diastolic =unrecordable
Respiratory rate = more than 20/min
Urine output is less than 10mls/hr
Extremities= are very cold and clammy.
Capillary refill is undetectable
Mental state patient is drowsy or unconscious.
 Septic shock

This follows bacterial infection invading bloodstream causing

septicaemia.
If not treated quickly and effectively it becomes severe and
irreversible.
It is commonly associated with hospital acquired infection because
bacteria involved is usually resistant to common antibiotics.
Septicaemia causes inflammatory response throughout the
circulation leading to septic shock.(SIRS).
 Septic shock contd
The circulatory dysfunction that follows
adversely affects blood flow and oxygen delivery
to the brain, the heart the liver and to the
kidneys. It may also complicate by causing
uncontrollable blood clotting in the circulation ( D
I C).
If not treated septic shock causes multiple organ
failure and death.
Shock effects on vital organs
Brain:
The most vital organ of the body.
Normal cerebral blood flow:
50 to 60 mls/100gm of brain/min.
Normal oxygen delivery and utilization
4.5mls/100gm of brain/min
Gray matter receives more than white matter.
Reducing CBF:20mls/100gm/min:
Brain compensates by increasing extraction of
both oxygen and glucose
Shock effects on vital organs (brain)
contd
When CBF is reduced to 15mls/100gm/min:
There is marked fall in somatosensory evoked
potentials but if CBF is corrected brain recovery occurs
without structural damage.
When CBF is reduced 12mls /100gm/min.
There is damage to ionic pump causing irreversible
brain damage
 Management of shock

History of blood or fluid loss should be thorough;

state time of onset, amount lost and duration.
This may be done together with resuscitation.
Insert 2 wide-bore cannulae(14 or 16 gauge)
collect blood samples and start fluid resuscitation.
Examination
First physical examination is aimed at diagnosing the cause and
checking for signs that will help to classify shock at the time of
admission.
Aggressive treatment is aimed at dealing with the cause (stop the
haemorrhage) and reverse the shock by giving appropriate fluids.
 Fluid management
Haemorrhagic shock:
Aim to stop the haemorrhage:
 External haemorrhage: control by direct pressure and arrange
for surgical repair.
Internal haemorrhage: emergency surgery to stop the
haemorrhage
Emergency grouping and x-marching
 Christalloids
Normal saline
Dextrose saline
Hartman solution
Ringers lactate
First litre to run fast to improve vital signs
(5% dextrose may increase cerebral oedema in
patient with brain injury=don’t give in head injury
patient)
 Colloids
Volume expanding effect
Blood
Blood products:
Frozen fresh plasma
Platelets
Irreversible shock
Stage 11
Is irreversible
Multiple organ failure has occurred
Fluid administration at this stage does not
benefit the patient.
‘Patient is in terminal stage’.
Questions and answer session = 10 minutes feel free to do so.