classification of shock

1. MANAGEMENT OF SHOCK

2. DEFINITION OF SHOCK
 Shock is a systemic state of low tissue
perfusion, which is inadequate for normal
cellular respiration.
 Shock is not synonymous to hypotension.

3. PATHOPHYSIOLOGY OF SHOCK
 Cellular
 Micro vascular
 Systemic
-Cardiovascular
-Respiratory
-Renal
-Endocrine

5. Stages of Shock
A progressive process: Intervene early
 Compensated Shock (nonprogressive stage)
Cardiac output
(HR x SV) and systemic vascular resistance
(peripheral vasoconstriction) work to keep BP
within normal by reflex compensatory
mechanism.
 On exam: Tachycardia; decreased pulses & cool
extremities in cold shock; flushing and
bounding pulses in warm shock; oliguria; labs
may show mild lactic acidosis

6. Stages of shock . . .
• Progressive(Uncompensated)stage :
• Compensatory mechanisms are overwhelmed.
• Widespread hypoxia.
• Hypotensive shock.
• On exam: As above, plus hypotension, altered mental
status; decreased urine output, labs may show increased
lactic acidosis
• Generally quick progression to cardiac arrest.

7. Stages of shock . . .
Irreversible stage :
Widespread cellular injury.
Release of lysosomal enzymes, worsened cardiac
contractility.
Irreversible organ damage, death.

8. CLASSIFICATION OF SHOCK
 A- Classification of Shock by Causes
(1) Hypovolemic shock  Loss of fluid
(2) Cardiogenic shock  Pump failure
(3)Distributive shock
- Neurogenic shock
-Anaphylactic shock  IgE mediated
- Septic shock  Sepsis

9.  B. Classification of Shock according to
hemodynamic changes:
⑴Hypodynamic Shock: Cardiac Output ,
Vascular Resistace,
Cold Skin;
⑵ Hyperdynamic Shock: Cardiac Output ,
Vascular Resistace ,
Warm Skin;

11. HYPOVOLEMIC SHOCK

12. • Non-hemorrhagic
• Vomiting
• Diarrhea
• Bowel obstruction, pancreatitis
• Burns
• Neglect, environmental (dehydration)
• Hemorrhagic
• GI bleed
• Trauma
• Massive hemoptysis
• AAA rupture
• Ectopic pregnancy, post-partum bleeding
Hypovolemic Shock

13. Signs & Symptoms:
Hypotension,
Tachycardia, ,
Oliguria,
Diminished Pulses.
Markers: monitor urine output (UOP), central venous
pressure (CVP), blood pressure(BP), heart rate(HR),
hematocrit(Hct), mental state(MS), cardiac output(CO),
lactic acid and pulmonary capillary wedge pressure(PCWP)

14. Classes of acute hemorrhage
Class I Class II Class III Class IV
Blood
loss
< 750 cc 0-
15%
750-1500
15-30%
1500-2000
30-40%
>2000cc
>40%
HR Normal
PP Normal
BP Normal Normal
UOP Normal Normal Decreased Negligible
Mental Normal Anxious Confused Lethargic
Fluid Crystalloid Crystalloid Crys+blood Crys+blood
*ATLS; 2004. 70kg male

15. CARDIOGENIC SHOCK
• Causes:
1.Cardiomyopathies: myocardial ischemia,
myocardial infarction, cardiomyopathy,
myocardiditis, myocardial contusion
2.Mechanical: cardiac valvular insufficiency,
papillary muscle rupture, septal defects, aortic
stenosis

16.  3- Arrythmias:
bradyarrythmias (heart block),
tachyarrythmias (atrial fibrillation, atrial flutter,
ventricular fibrillation)
 4- Obstructive disorders:
pulmonary embolism PE,
tension peneumothorax,
pericardial tamponade,
constrictive pericaditis,
severe pulmonary hypertension

17. Signs and symptoms :
 Dyspnea,
 gallop,
 low BP,
 oliguria
Monitor/findings:
 CXR
 pulmonary venous congestion,
 elevated CVP,
 Low CO.

18. SEPTIC SHOCK
This type of shock is due to infection/sepsis.
• Any focus of infection can cause infection.
-Gastrointestinal
-Genitourinary
-oral
-skin.

19. Pathogenesis of Sepsis

20. Systemic Inflammatory Response
Syndrome (SIRS)
• Systemic inflammatory response to a variety of
severe clinical insults manifested by 2 or more of
the following conditions
• Temperature >38.5ºC or <35ºC
• Heart rate >90 beats/min
• Respiratory rate >20 breaths/min or PaCO2,
<32 torr (<4.3 kPa)
• White blood count >12,000 cells/mm3,
<4000 cells/mm3, or
>10% immature (band) cells

21. Multiple Organ Dysfunction
Syndrome (MODS)
• Progressive distant organ failure
(initially
uninvolved) following severe infectious
or
noninfectious insults (severe burn,
multiple trauma, shock, acute
pancreatitis)

22. STAGES OF SEPTIC SHOCK
• WARM SHOCK
• Inflammatory triad
fever
tachycardia
flushed skin
• Hyperperfusion
altered sensorium
urine output
>wide pulse
pressure
 COLD SHOCK
Hypotension
Cold clammy skin
Mottling
Tachycardia
Cyanosis
Narrow pulse pressure
acidosis

23. Signs:
 Early– warm with vasodilation (hyper dynamic
circulation), often adequate urine output,
fever and tachypnea.
 Late-- vasoconstriction, (hypodynamic circulation).
hypotension,
oliguria,
altered mental status

25. LABORATORY FINDINGS
 Early : hyperglycemia, respiratory alkalosis,
hemoconcentration, WBC typically normal or low.
 Late : Leukocytosis, lactic acidosis
 VeryLate :Disseminated Intravascular Coagulation
& Multi-Organ System Failure

26. Anaphylactic Shock
• Anaphylaxis – a severe systemic
hypersensitivity reaction characterized by
multisystem involvement
• IgE mediated
• Anaphylactoid reaction – clinically
indistinguishable from anaphylaxis, do not
require a sensitizing exposure
• Not IgE mediated

27. ANAPHYLACTIC SHOCK
 This type occurs due to binding of a foreign antigen to
immunoglobin E (IGE) on the mast cells and basophils ,
releasing large amounts of histamine and SRS-A ( slow-
release substance-anaphylaxis) which will produce
bronchospasm , laryngeal edema and respiratory distress
with hypoxia , massive vasodilatation hypotension and
shock.
 This type occurs on exposure to penicillin , anesthetic
drugs , serum injections and stings .

28. Organ systemic dysfunction
 ORGAN SYSTEM
 CNS
 HEART
 PULMONARY
 MANIFESTATION
 Encephalopathy
(ischemic or septic)
cortical necrosis
 Tachycardia/
bradycardia SVT, MI,
Ventricular ectopy
 Acute respiratory failure,
acute respiratory distress
syndrome

29. Organ systemic dysfunction. . .
 Gastro intestinal
 Kidney
 Erosive gastritis,
pancreatitis, acalculus
cholecystitis, colonic
submucosal hemorrhage
 Pre renal failure, acute
tubular necrosis

30. SEVERITY OF SHOCK
Compensated Mild shock Moderate Severe shock
Lactic acidosis + ++ ++ +++
Urine output N N reduced anuric
Level of
consciousness
N N drowsy comatose
Respiratory
rate
N increased increased laboured
Pulse rate Mild increase increased increased increased
BP N N Mild
hypotension
Severe
hypotension

31. Summary
Type PAOP C.O. SVR
HYPOVOLEMIC   
CARDIOGENIC   
DISTRIBUTIVE  or N varies 
OBSTRUCTIVE   

32. Goals of Shock
Resuscitation
Restore blood pressure
Normalize systemic perfusion
Preserve organ function

33. % Blood
Volume loss
< 15% 15 – 30% 30 – 40% >40%
HR <100 >100 >120 >140
SBP N N, DBP,
postural drop
Pulse
Pressure
N or
Cap Refill < 3 sec > 3 sec >3 sec or
absent
absent
Resp 14 - 20 20 - 30 30 - 40 >35
CNS anxious v. anxious confused lethargic
Treatment 1 – 2 L
crystalloid, +
maintenance
2 L
crystalloid, re-
evaluate
2 L crystalloid, re-evaluate,
replace blood loss 1:3
crystalloid, 1:1 colloid or blood
products. Urine output >0.5
mL/kg/hr