Case:

 A 27 year old male is involved in a RTA.

He sustains a burst fracture of T2 with
complete neurological deficit below this
level. Fours hours following admission
his SpO2 is 85%, his blood pressure is
80/40 and his heart rate is 45.
 How would you classify this patients'
haemodynamic status?
 How would you manage this patient?
 Case:
A 72 year old female is admitted complaining of
weakness, sweating and dysuria. Her temperature is
39C, pulse 130, BP 76/44, warm peripherally, lung fields:
reduced air entry bilaterally, oliguria, Hb 16 g/dl, WCC
27, PO2 8.2, Urine gram -ve bacilli, >105 organisms.
What is your diagnosis?
How would you classify this patients haemodynamic
status?
How would you manage this patient?
Shock
Shock
“A rude unhinging of the machinery of life”

“A brief pause in the act

of dying”
Fick Principle

Air’s gotta go in and out.

Blood’s gotta go round and round.
Any variation of the above is not a
good thing!
Shock

Inadequate oxygenation or
perfusion causes:
Inadequate cellular
oxygenation
Shift from aerobic to anaerobic
metabolism
AEROBIC METABOLISM
6 CO2

6 O2
6 H2O
METABOLISM

GLUCOSE 36 ATP

HEAT (417 kcal)

ANAEROBIC METABOLISM

2 LACTIC ACID

GLUCOSE METABOLISM 2 ATP

HEAT (32 kcal)

Ultimate
Effects of
Inadequate
Anaerobic Cellular
Metabolism Oxygen
Delivery

Lactic
Inadequate
Energy Anaerobic Acid
Production Metabolism Production

Metabolic Metabolic
Failure CELL Acidosis
DEATH
 Maintaining perfusion
requires:
 Volume
 Pump
 Vessels
Failure of one or more of these causes
shock
Definition:

 A physiological state characterized by a

significant, systemic reduction in tissue
perfusion, resulting in decreased tissue
oxygen delivery and insufficient removal
of cellular metabolic products, resulting
in tissue injury.
TERMINOLOGY
 Hypovolaemic shock  Hypotension
 Haemorrhagic shock  Hypovolaemia
 Haematogenic shock  Oliguria & Anuria
 Septic shock  Hypoxaemia
 Anaphylactic shock  Systemic inflammatory
 Spinal shock response
 Neurogenic shock syndrome(SIRS)
 Vasovagal shock  Multiple organs
dysfunction
 Cardiogenic shock syndrome(MODS)
TYPES OF SHOCK
Pathophysiology

 Shock occurs when a diminished amount

of blood is available to the circulatory
system
 The vascular system fails to hold the fluid
portion of the blood
 Vasodilation of the blood vessels occurs
and disrupts the osmotic fluid balance in
the body
Pathophysiology

 Plasma leave the blood and enter the

interstitial spaces
 The formed elements remain in the blood
 Blood viscosity increases
 The rate of blood flow decreases
 Insufficient amounts of O2 are being
transported in the blood
Renal responses to shock

 In an effort to
sustain falling
blood pressure the
kidneys will help to
conserve body
fluids by reducing
the rate of urine
production.
 Hormonal response to
shock
 The neuro-endocrine
system responds to
shock by increasing
the secretion of anti-
diuretic hormone
(ADH), ADH causes
vasoconstriction and
an increased
reabsorption of water
in the nephrons - and
a decrease in urine
production
Predisposing Factors

 Extreme fatigue
 Extreme exposure to heat or cold
 Extreme dehydration
 Illness
 Severe injury
Shock
 Hypovolemic Shock = Low Volume

–Trauma –Vomiting
–Non-traumatic –Diuresis
blood loss –Sweating
Vaginal –Third space losses
GI Pancreatitis
GU Peritonitis
–Burns Bowel obstruction
–Diarrhea
Shock
 Cardiogenic Shock = Pump Failure

–Acute M I –Mechanical
–CHF obstruction
–Bradyarrhythmias (“distributive shock”)
Cardiac tamponade
–Tachyarrhythmias Tension pneumothorax
Pulmonary embolism
Shock

 Vasogenic Shock = Low Resistance

 Spinal cord trauma

 neurogenic shock
 Depressant drug toxicity
 Simple fainting
Shock
 Mixed Shock
 Septic Shock
 Overwhelming infection
 Inflammatory response occurs
 Blood vessels
 Dilate (loss of resistance)
 Leak (loss of volume)
Shock
 Mixed Shock
 Septic Shock
 Fever
 Increased O2 demand
 Increased anaerobic metabolism
 Bacterial toxins
 Impaired tissue metabolism
Shock
 Mixed Shock
 Anaphylactic Shock
 Severe allergic reaction
 Histamine is released
 Blood vessels
 Dilate (loss of resistance)
 Leak (loss of volume)
Signs and Symptoms

 Low Blood Pressure

 Systolic BP is usually below 90 mmHg
 Pulse is rapid and weak
 Respiration is rapid and shallow
 Skin is pale, cool, and clammy
 Drowsiness
Classification of
Shock
•Hypovolemic
•Septic/Inflammatory
•Cardiogenic (Intrinsic, compressive &
Obstructive)
•Neurogenic
•Anaphylactic
Types of Shock

Hypovolemic Shock
 Results from trauma in which there is
blood loss
 Decreased blood volume causes a
decrease in blood pressure
 Insufficient amounts of O2 is being
transported to body tissues and organs
Types of Shock

Respiratory Shock
 Results when the lungs are unable to
supply enough O2 the circulating blood
 Trauma that may produce respiratory
shock include:
 Pneumothorax
 Injury to the respiratory control center
Types of Shock

Neurogenic Shock
 Results due to the overall dilation of the
blood vessels within the cardiovascular
system
 Decreased blood pressure
 Insufficient amounts of O2 is being
transported to body tissues and organs
Types of Shock

Psychogenic Shock
 Commonly known as “fainting” (syncope)
 Results due to a temporary dilation of the
blood vessels in the body causing a
decrease in the blood flow to the brain
Types of Shock

Cardiogenic Shock
 Results due to the inability of the heart to
pump enough blood to the body
 Decreased cardiac output
 Decreased blood pressure
 Insufficient amounts of O2 is being
transported to body tissues and organs
Types of Shock

Septic Shock
 Results due to a severe infection
 Usually a bacterial infection
 Toxins released by the bacteria cause dilation
of the blood vessels within the cardiovascular
system
 Decreased blood pressure
 Insufficient amounts of O2 is being transported
to body tissues and organs
Types of Shock

Anaphylactic Shock
 Results due to a severe allergic reaction
 Allergic reaction may be caused by:
 Foods
 Insect bites
 Drugs
 Inhaling dusts, pollens, etc…
Types of Shock

Metabolic Shock
 Results due to a severe illness that goes
untreated
 For example, untreated diabetes
 Results due to an extreme loss of bodily fluid
 For example, excessive urination, diarrhea, or
vomiting
Psychological Impact

 Shock can be compounded, or produced

by the psychological reaction to an injury
or a situation
 Fear is the commonest
 Provide reassurance and comfort
Immediate Management
Immediate Management

 Maintain normal body temperature

 In most cases, elevate the feet and legs above
the level of the heart
 Exceptions include:
 Neck injury – immobilize in the position found
 Head injury – elevate the head and shoulders
 Leg fracture – splint and elevate
Secondary Management
Secondary Management

Vital Signs
 Pulse  Pupils
 Respiration  Level of
 Blood pressure consciousness
 Temperature  Movement
 Skin color  Abnormal nerve
response
Pulse

 A direct extension of
the functioning of the
heart
 Normal pulse rate for
adults
 60 – 80 bpm
 Normal pulse rate in
children
 80 – 100 bpm
Abnormal Pulse

 Rapid and weak  Slow and strong

 Shock  Skull fracture
 Bleeding  Stroke
 Diabetic coma  No pulse
 Heat exhaustion  Cardiac arrest
 Rapid and strong  Death
 Heatstroke
 Severe fright
Respiration

 Normal respiration rate for adults

 ~ 12 breaths per minute
 Normal respiration rate for children
 ~ 20 breaths per minute
 Rapid and shallow respiration is
indicative of shock
Blood Pressure

 Normal systolic blood

pressure in adults
 Males: 115 – 120 mm Hg
 Females: 105 – 110 mm Hg
 Normal diastolic blood
pressure in adults
 Males: 75 – 80 mm Hg
 Females: 65 – 70 mm Hg
Blood Pressure

 High Blood Pressure

 Systolic BP > 140 mm Hg
 Diastolic BP > 90 mm Hg
 Low Blood Pressure
 Systolic BP < 100 mm Hg
 Diastolic BP < 60 mm Hg
Temperature

 Normal body temperature

 ~ 98.6°F (~ 37°C)
 Core temperature is most accurately
measured at the tympanic membrane of the
ear
 Changes in body temperature are reflected in
the skin
Skin: Temperature
 Cool, clammy skin
 Shock
 Trauma
 Heat exhaustion
 Cool, dry skin
 Overexposure to cold
 Hot, dry skin
 Disease
 Infection
 Overexposure to environmental heat
Skin: Color

 Three skin colors are  Red skin color

commonly identified  Heatstroke
in medical  High blood pressure
emergencies:  Elevated body
 Red temperature
 White
 Blue
Skin: Color

 White skin color  Blue skin color

 Shock  Airway obstruction
 Insufficient circulation  Respiratory
 Fright insufficiency
 Hemorrhage
 Heat exhaustion
 Insulin shock
Pupils
 Pupils are extremely sensitive to changes in
the nervous system
 If one or both pupils are dilated…
 Shock
 Head injury
 Heatstroke
 Hemorrhage
 CNS stimulant drug
 One constricted pupil…
 CNS depressant drug
Level of Consciousness

 In normal conditions, the we are:

 Alert
 Aware of the surrounding environment
 Responds quickly to vocal stimulation
 Abnormal levels of consciousness may result
due to…
 Shock
 Head injury
 Heatstroke
Summary

 May not be able to determine the type of

shock
 Immediate management of shock is
universal
 Provide reassurance and comfort
 Maintain normal body temperature
 In most cases, elevate the feet and legs
above the level of the heart
 Case:
A 72 year old female is admitted complaining of
weakness, sweating and dysuria. Her temperature is
39C, pulse 130, BP 76/44, warm peripherally, lung fields:
reduced air entry bilaterally, oliguria, Hb 16 g/dl, WCC
27, PO2 8.2, Urine gram -ve bacilli, >105 organisms.
What is your diagnosis?
How would you classify this patients haemodynamic
status?
How would you manage this patient?
 What is your diagnosis?
 Gram negative septicaemia/septic shock
 How would you classify this patients
haemodynamic status?
 High output, low Volume, septic shock
 How would you manage this patient?
 1. Oxygen therapy / mechanical ventilation if
necessary
 2. Fluid loading with colloid.
 3. Adrenaline or noradrenaline infusion.
Case:

 A 27 year old male is involved in a RTA.

He sustains a burst fracture of T2 with
complete neurological deficit below this
level. Fours hours following admission
his SpO2 is 85%, his blood pressure is
80/40 and his heart rate is 45.
 How would you classify this patients'
haemodynamic status?
 How would you manage this patient?
How would you classify this patients'
haemodynamic status?
Spinal shock, low heart rate, loss of sympathetic tone.
How would you manage this patient?
1. Ensure patent airway and adequate ventilation.
2. Oxygen therapy.
3. Adrenaine @ 1-10m /min