1. SHOCK
Part II
Bethelhem Berhanu

2. Classification of Shock
Shock
Hypovolaemic
Septic
Cardiogenic
Distributive
Anaphylactic
Neurogenic

3. Hypovolemic Shock
• most common
• reduced circulating volume
Hemorrhagic shock
External or Internal
Non Hemorragic hypovolemic shock
Vomiting Diuresis
Diarrhoea Burns

4. Pathophysiology of Hypovolemic shock
Hypovolemia
Multiorgan failure
↓Venous
Return
↓Preload
CO = SV x HR
↓Cardiac output
BP = CO x TPR
Hypotension
Perfusion failure &
Tissue hypoxia
Organ dysfunction

5. Bodily responses
Physiologic responsessympathetic activity – tachycardia and SVR
Hyperventilation
collapse of venous capacitance vessels
stress hormones
Attempt to replace intravascular volume loss
The body will prioritize – Brain and heart
Severity ~ magnitude and the rate of fluid loss

6. “TENNIS STAGING”
15,15-30,30-40,40
American College of Surgeons,
1989
Postural
Drop

7. Clinical Manifestations
•
•
•
•
•
•
•
•
Anxiety - lethargy
Tachypnea
Tachycardia – weak, thready pulse
Normal → Orthostatic drop → Hypotension
Delayed Capillary refill
Cool clammy skin
Oliguria
Thirst

8. Mild (<20% Blood
Volume)
Moderate (20–40%
Blood Volume)
Severe (>40% Blood
Volume)
Cool extremities
Same, plus:
Same, plus:
Increased capillary refill
time
Tachycardia
Hemodynamic instability
Tachypnea
Marked tachycardia
Oliguria
Hypotension
Postural changes
Mental status deterioration
(coma)
Diaphoresis
Collapsed veins
Anxiety

9. Treatment principles:
Hypovolemic Shock
• control ongoing loss
• rapid reexpansion of the circulating
intravascular blood volume
• GOAL: restore blood volume and improve
tissue perfusion and oxygenation

10. Control bleeding
•
•
•
•
•
Direct pressure on the site of wound, Gauze
Elevation
Pressure points Tourniquets Surgical Methods
•
•
•
•
Artery forceps (Spencer Well’s forceps)
Ligation
Cauterisation
Splenectomy – splenic rupture, Hysterectomy for post
partum bleeding

11. Treatment contd.
• ABC …
– Supplemental Oxygen
– Endotracheal intubation
• Secure a large bore IV line for fluid
resuscitation
– Median cubital vein, saphenous vein and
sometimes the internal jugular and subclavian
veins
– In pediatric patient - intraosseus line

12. Re-expansion of Intravascular volume
Fluid Therapy
Crystalloid solutions –
0.9% saline
Ringer Lactate
Colloid solutions – 5% albumin, gelatins, hetastarch
 20 ml/kg in 5 – 15 minutes – repeat upto 60 ml/kg
 Blood transfusion – 1 unit of blood in 20 minutes
 >40% of blood loss (class IV)
 If the patient is anemic ( Hg < 8g/dl)
We may need to supplement fresh frozen plasma and platelates

13. Treatment contd.
• Improved perfusion :
 Warmth
 Strong pulses
 Better capillary refill
 improved mental status
 Lower HR
 BP – ideally 90+(agex2)

higher Urine output.

15. Septic Shock
Sepsis
• Septicemia - Presence of microbes or their toxins
Sepsis and organ
in blood
dysfunction, hypoperfusion,
Severe Sepsis
or hypotension
• Sepsis – Systemic inflammatory response
syndrome (SIRS) that has a proven or suspected
microbial etiology
Septic
Sepsis-induced
hypotension
• Severe sepsis – Hypoperfusion with signs of organ
shock
dysfunction – Lactic acidosis, oliguria etc.
• Septic shock - Sepsis + hypotension (ABP<90
mmHg systolic, or MODS
40 mmHg less than patient's
normal BP) for at least 1 hr despite adequate fluid
resuscitation;
Death

16. Septic, contd.
• Importance??
– The most common of the distributive types,
– The leading cause of Deaths in ICU in the US.
– Increasing in occurrence
• Increased life support for high risk patients
• Increase in invasive procedures
• Growing number of the immunocompromised
– HIV
– Chemotherapy

17. Septic, contd.
• PREDISPOSING FACTORS - examples
–Extended hospitalization
–Advanced age
–Debilitating illness
–Immunodeficiency disorder
–Disseminated malignancy

18. Septic, contd.
• Focus of infection
– Pneumonia, UTI, Meningitis, skin and soft tissue
infections, GI infections, etc.
• Gram –ve bacteria (70%) – LPS – Lipid A
• Peptidoglycan & lipoteichoic acid of gram +ves
• Polysaccharide surface of Candida

19. Septic, contd.
MONOCYTE,
MACROPHAGES
NEUTROPHILS
CD 14
Bacteria
LPS
LPS
TNF-A
IL-1
ENDOTHELIAL CELL
LBP LPS
soluble CD 14
LBP LPS
Cellular chemotaxis
Endotherlial injury
Activation of coagulation cascade

21. Septic, contd.
• The syndrome of septic shock
– Systemic vasodilation (hypotension)
– Diminished myocardial contractility
– Widespread endothelial injury and activation,
causing systemic leukocyte adhesion and
pulmonary alveolar capillary damage (ARDS)
– Activation of the coagulation system, culminating
in DIC

22. Septic Shock Hemodynamics
Warm (hyperdynamic) shock
hypotensive
tachycardia
tachypnea
bounding pulse
warm, well perfused
extremities
skin flushed, moist
Cold (hypodynamic) shock
hypotensive
tachycardia
tachypnea
narrow, thready pulse
cold, poorly perfused
extremities
skin pale, dry

23. Principles of treatment:
Septic shock
• Ventilatory support
• IV fluids – crystalloids or colloids - Fill the tank
• Vasoactive agents – Norepinephrine,
Dopamine etc.
• Draw blood for culture – before Antibiotics
• Remove septic focus – Resect a gangrenous
bowel, Drain an abscess
• Early empirical antibiotic therapy

24. Neurogenic Shock
• Cause – high spinal cord injury, spinal
anaesthesia
• Pathophysiology - Interruption of
sympathetic vasomotor input
• extremities are warm
• Rx – IV fluids
• norepinephrine or a pure -adrenergic agent
(phenylephrine)

26. Hypovolemic shock
• History –
• Trauma
• tearing type of chest pain
• hematemesis, melena, severe diarrhea
• P/E – Obvious bleeding
• Cool clammy skin
• sweating
• Narrow pulse pressure
• Delayed capillary refill
• Anxious, confused

27. Cardiogenic shock
• History - chest pain, shortness of breath,
diaphoresis, syncope etc.
• Symptoms of Hypoperfusion plus
• Raised JVP
• gallop
• Rales – Basal creptations
• Beck’s triad

28. Septic shock
• History – Sx of underlying infection
• P/E
– Evidences of Infection
– Warm extermities
– Bounding pulse
– Wide pulse pressure
– Brisk capillary refill
– Obtunded

31. References
• Harrison’s principles of internal medicine18th edition
• ACS surgery: principles & practice
• Mannipal manual of surgery
• Robbin’s basic pathology
• Shwartz principles of surgery
• Davidson’s principles and practice of medicine
• World Wide Web

32. QUESTION