By: Calaour, Carrey Dasco , Danica Amor Dimatulac , Kevin Lim , Shiela Marie Pagulayan , Sheena May Pua,

Mar Kristine

What is shock?
It is the condition of insufficient supply of oxygen and

nutrients to the body

 It may develop rapidly or slowly, depending on the

underlying cause. During shock, the body struggles to survive, calling on all its homeostatic mechanisms to restore blood flow. Any insult to the body can create a cascade of events resulting in poor tissue perfusion. Therefore, almost any patient with any disease state may be at risk for developing shock.

Symptoms
A person in shock has extremely low blood pressure. Depending on

the specific cause and type of shock, symptoms will include one or more of the following: Anxiety or agitation/restlessness Bluish lips and fingernails Chest pain Confusion Dizziness, lightheadedness, or faintness Pale, cool, clammy skin Low or no urine output Profuse sweating, moist skin Rapid but weak pulse Shallow breathing Unconsciousness

Stages of Shock
Compensatory (stage 1)
Progressive (stage 2) Irreversible (stage 3)

Compensatory Stage (Stage 1)

In the compensatory stage of shock, the BP remains

within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac input which is caused by the stimulation of the sympathetic nervous system and subsequent release of catecholamines. Patients often display the often-described fight or flight response.

Compensatory Stage (Stage 1)

The body shunts blood from organs such as the skin,

kidneys and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, bowel sounds are hypoactive, and urine output decreases in response to the release of aldosterone and ADH

Medical management
Fluid replacement and medication therapy to

maintain an adequate BP and reestablish and maintain adequate tissue perfusion. Treatment is directed toward identifying the cause of the shock, correcting the underlying disorder so that shock does not progress, and supporting those physiologic processes that thus far have responded successfully to the threat.

Progressive Stage (Stage 2)

In the second stage of shock, the mechanism that

regulate BP can no longer compensate, and the MAP (Mean Arterial Pressure) falls below normal limits. Patients are clinically hyposensitive; this is defines as a systolic BP of less than 90mm Hg or a decrease in systolic BP of 40mm HG.

Effects of Progressive Stage

Lack of adequate blood supply leading to dysrythmias and

ischemia. Respirations are rapid and shallow. Blood flow to the brain becomes impaired and mental status deteriorates. Acute renal failure may develop. Glomerular filtration rate of the kidneys cannot be maintained and drastic changes in the renal function occur. Decreased blood flow to the liver impairing the ability of livers cells to perform metabolic and phagocytic functions.

Effects of Progressive Stage

Metabolic activities of the liver are impaired.

Heart rate is rapid, sometimes exceeding 150bpm

Presence of chest pain and myocardial infarction may

occur. Combination of hypotension, sluggish blood flow, metabolic acidosis, coagulation system imbalance and generalized hypoxemia may occur and interfere with normal hemostatic mechanism. May cause gastrointestinal bleeding due to gastrointestinal ischemia.

Medical Management
Management in the progressive stage of shock depends

on the type of shock and its underlying cause. It is also based on the degree of decompensation on the organ systems. Medical intervention most common to all types of shock include the use of appropriate IV fluids and medications to restore tissue perfusion.

Irreversible Stage (Stage 3)

Also called refractory stage.
Represents the point along the shock continuum at

which organ damage is so severe that the patient does not respond to treatment and cannot survive.

Irreversible Stage (Stage 3)

Despite treatment, BP remains low.
Renal & liver failure, compounded by the release of

necrotic tissue toxins, creates an overwhelming acidosis. Reserves of ATP are almost depleted, and mechanisms for storing new supplies of energy have been destroyed. Respiratory system failure also occurs preventing oxygenation and ventilation.

Irreversible Stage (Stage 3)

Cardiovascular system becomes ineffective.
Multiple organ dysfunction would progress to

complete organ failure then death will become imminent.

Medical Management
Management is usually the same as for the progressive

stage. Treatment may be experimental to reduce or reverse the severity of the shock.

Classification of Shock
Hypovolemic Shock
Cardiogenic Shock Circulatory Shock
Septic Shock Neurogenic Shock Anaphylactic Shock

Hypovolemic Shock
It is the most common type of shock.
It is characterized by a decreased intravascular volume. Occurs when there is a reduction in intravascular

volume by 15% to 25%, which represents a loss of 750 to 1300 mL of blood in a 70-kg (154-lb.) person.

Causes
External fluid loss, as in traumatic blood loss
Internal fluid shifts, as in severe dehydration, severe edema, or ascites.

Pathophysiology
Decreased blood volume
Decreased venous return Decreased stroke volume Decreased cardiac output Decreased tissue perfusion

Medical Management
Correction of the underlying cause
Fluid and blood replacement Redistribution of fluid Pharmacologic therapy

Cardiogenic Shock
Occurs when the hearts ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues.
Patients in cardiogenic shock may experience the pain of angina and develop dysrhythmias and hemodynamic instability.

Causes of Cardiogenic Shock

Coronary
Noncoronary

A. Coronary
More common than noncoronary cardiogenic shock and is seen most often in patients with myocardial infarction.
Occurs when a significant amount of the left ventricular myocardium has been damaged.

b. Noncoronary
A cause of cardiogenic shock related to conditions that stress the myocardium as well as conditions that result in ineffective myocardial function.

Pathophysiology
Decreased cardiac contractility Decreased stroke volume and cardiac output

Pulmonary congestion

Decreased systemic Decreased tissue perfusion coronary artery perfusion

Medical Management
Correction of the underlying cause
Initiation of First-Line Treatment Pharmacologic Therapy Use of Mechanical assistive devices

Circulatory Shock
Occurs when blood volume is abnormally displaced in the vasculature. The displacement of blood volume causes a relative hypovolemia because not enough blood returns to the heart, which leads to subsequent inadequate tissue perfusion.

Causes
By loss of sympathetic tone
By release of biochemical mediators from cells

Types of Circulatory Shock

Septic Shock
Neurogenic Shock Anaphylactic Shock

Pathophysiology
Precipitating event
Vasodilation Activation of inflammatory response Maldistribution of blood volume Decreased venous return Decreased cardiac output Decreased tissue perfusion

Septic Shock
Most common type of circulatory shock caused by widespread infection.

Causes
Gram-negative bacteria
Gram-positive bacteria Viruses Fungi

Medical Management
Identification and elimination of the cause of

infection.

Neurogenic Shock
Also called vasodilation.
Occurs as a result of a loss of balance between

parasympathetic and sympathetic stimulation.

Causes
Spinal cord injury
Spinal anesthesia Nervous system damage Lack of glucose Depressant action of medication

Medical Management
Restoring sympathetic tone, either through

stabilization of a spinal cord injury or spinal anesthesia by positioning the patient properly. Specific treatment depends on the cause of shock.

Anaphylactic Shock
Occurs rapidly and is life-threatening.
It usually happens when patients who have already

produce antibodies to a foreign substance(antigen) develop a systemic antigen-antibody reaction. Because anaphylactic shock occurs in patients already exposed to an antigen and who have developed antibodies to it, it can often be prevented.

Causes
Severe allergic reaction

Medical Management
Removal of the causative antigen, administering

medications that restore vascular tone such as Epinephrine & Diphenhydramine, and providing emergency support of basic life functions.

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