Types and treatment of shock

1. In the name of Allah,In the name of Allah,
the most Beneficent,the most Beneficent,
the most Mercifulthe most Merciful

2. 2

3. ShockShock
 The word shock is used differently by theThe word shock is used differently by the
medicalmedical communitycommunity and the general public. byand the general public. by
the public is an intense emotional reaction to athe public is an intense emotional reaction to a
stressful situation or bad news.stressful situation or bad news.

4.  Medically, shock is defined as a condition whereMedically, shock is defined as a condition where
the tissues in the body don't receive enoughthe tissues in the body don't receive enough
oxygen and nutrients to allow the cells tooxygen and nutrients to allow the cells to
function. This ultimately leads to cellular death,function. This ultimately leads to cellular death,
progressing to organ failure, and finally, ifprogressing to organ failure, and finally, if
untreated, whole body failure and death.untreated, whole body failure and death.

5. TypesTypes
Hinshaw and Cox classificationHinshaw and Cox classification
It names four types of shock:It names four types of shock:
Hypovolemic,Hypovolemic,
Cardiogenic,Cardiogenic,
DistributiveDistributive
Obstructive shockObstructive shock
In many patients, shock is aIn many patients, shock is a
combination of two or more ofcombination of two or more of
these four types of shockthese four types of shock

6. Stages of ShockStages of Shock
 shock is divided into the following three major stages:shock is divided into the following three major stages:
 AA nonprogressive stagenonprogressive stage (sometimes called the(sometimes called the
compensated stagecompensated stage), in which the normal circulatory), in which the normal circulatory
compensatory mechanisms eventually cause fullcompensatory mechanisms eventually cause full
recovery without help from outside therapy.recovery without help from outside therapy.
 AA progressive stage,progressive stage, in which, without therapy, thein which, without therapy, the
shock becomes steadily worse until death.shock becomes steadily worse until death.
 AnAn irreversible stage,irreversible stage, in which the shock hasin which the shock has
progressed to such an extent that all forms of knownprogressed to such an extent that all forms of known
therapy are inadequate to save the person's life, eventherapy are inadequate to save the person's life, even
though, forthough, for

7. Circulatory ShockCirculatory Shock
 Circulatory shockCirculatory shock means generalizedmeans generalized
inadequate blood flow through theinadequate blood flow through the
body, to the extent that the bodybody, to the extent that the body
tissues are damaged because of tootissues are damaged because of too
little flow, especially because of toolittle flow, especially because of too
little oxygen and other nutrientslittle oxygen and other nutrients
delivered to the tissue cells.delivered to the tissue cells.

8. Hypovolemic shockHypovolemic shock
 HypovolemiaHypovolemia means diminished bloodmeans diminished blood
volume. This is the most commonvolume. This is the most common
type of shock and based ontype of shock and based on
insufficient circulatinginsufficient circulating volumevolume..
 Its primary cause is loss of fluid fromIts primary cause is loss of fluid from
thethe circulationcirculation (most often "(most often "
hemorrhagichemorrhagic shock"). Causes mayshock"). Causes may
include internal bleeding,include internal bleeding,
traumatic bleedingtraumatic bleeding, or severe, or severe burnsburns..

9. Other causesOther causes Hypovolemic shockHypovolemic shock
 GastroenteritisGastroenteritis can cause significant water loss fromcan cause significant water loss from
vomitingvomiting andand diarrheadiarrhea, and is a common cause of death, and is a common cause of death
in third world countries.in third world countries.
 Heat exhaustion and heat strokeHeat exhaustion and heat stroke is caused by excessiveis caused by excessive
water loss throughwater loss through sweatingsweating as the body tries to coolas the body tries to cool
itself.itself.
 Patients withPatients with infectionsinfections can lose significant amounts ofcan lose significant amounts of
water from sweating. People inwater from sweating. People in diabetic ketoacidosisdiabetic ketoacidosis
lose significant water because of because of elevatedlose significant water because of because of elevated
blood sugars.blood sugars.

10.  Intestinal obstructionIntestinal obstruction is often a cause ofis often a cause of
severely reduced plasma volume.severely reduced plasma volume.
Distention of the intestine in intestinalDistention of the intestine in intestinal
obstruction partly blocks venous bloodobstruction partly blocks venous blood
flow in the intestinal walls, which increasesflow in the intestinal walls, which increases
intestinal capillary pressure. This in turnintestinal capillary pressure. This in turn
causes fluid to leak from the capillaries intocauses fluid to leak from the capillaries into
the intestinal walls and also into thethe intestinal walls and also into the
intestinal lumen. Because the lost fluid hasintestinal lumen. Because the lost fluid has
a high protein content, the result is reduceda high protein content, the result is reduced
total blood plasma protein as well astotal blood plasma protein as well as
reduced plasma volume.reduced plasma volume.

11. In almost all patients who have severe burns or other
denuding conditions of the skin, so much plasma is
lost through the denuded skin areas that the plasma
volume becomes markedly reduced.
The hypovolemic shock that results from plasma loss
has almost the same characteristics as the shock
caused by hemorrhage, except for one additional
complicating factor: the blood viscosity increases
greatly as a result of increased red blood cell
concentration in the remaining blood, and this
exacerbates the sluggishness of blood flow.

12. Cardiogenic shockCardiogenic shock
 This type of shock is caused by the failure of the heartThis type of shock is caused by the failure of the heart
to pump effectively. This can be due to damage to theto pump effectively. This can be due to damage to the
heart muscle, most often from a largeheart muscle, most often from a large
myocardial infarctionmyocardial infarction..
 Other causes of cardiogenic shock includeOther causes of cardiogenic shock include arrhythmiasarrhythmias,,
cardiomyopathycardiomyopathy,, congestive heart failurecongestive heart failure (CHF), or(CHF), or
cardiac valvecardiac valve problems.problems.

13. YouTube - Atrial Fibrillation - What Is Atrial Fibrillation Video - Ab
ouTube - Cardiac Arrhythmia.flv

14. End Result of Circulatory ShockEnd Result of Circulatory Shock
 the shock itself breeds more shock.the shock itself breeds more shock. That is, the inadequateThat is, the inadequate
blood flow causes the body tissues to beginblood flow causes the body tissues to begin
deteriorating, including the heart and circulatory systemdeteriorating, including the heart and circulatory system
itself. This causes an even greater decrease in cardiacitself. This causes an even greater decrease in cardiac
output, and a vicious circle ensues, with progressivelyoutput, and a vicious circle ensues, with progressively
increasing circulatory shock, less adequate tissueincreasing circulatory shock, less adequate tissue
perfusion, more shock, and so forth until death. It isperfusion, more shock, and so forth until death. It is
with this late stage of circulatory shock that we arewith this late stage of circulatory shock that we are
especially concerned, because appropriate physiologicespecially concerned, because appropriate physiologic
treatment can often reverse the rapid slide to deathtreatment can often reverse the rapid slide to death

15. YouTube - Cardiac Arrhythmia.flv
YouTube - Myocardial Infarction_1.flv
YouTube - Cardiomyopathy_1.flv

17.  Sympathetic Reflex Compensations inSympathetic Reflex Compensations in
ShockShock
 Value of the Sympathetic Nervous Reflexes.Value of the Sympathetic Nervous Reflexes.
 15 to 20 per cent15 to 20 per cent
 30 to 40 per cent30 to 40 per cent
 Protection of Coronary and Cerebral BloodProtection of Coronary and Cerebral Blood
Flow by the Reflexes.Flow by the Reflexes.

18. Distributive shockDistributive shock
 As in hypovolaemic shock there is anAs in hypovolaemic shock there is an
insufficient intravascular volume of blood. Thisinsufficient intravascular volume of blood. This
form of "relative" hypovolaemia is the result ofform of "relative" hypovolaemia is the result of
dilation of blood vessels which diminishesdilation of blood vessels which diminishes
systemic vascular resistancesystemic vascular resistance..

19. Septic shockSeptic shock
 Caused by an overwhelming systemic infectionCaused by an overwhelming systemic infection
resulting inresulting in vasodilationvasodilation leading to hypotension.leading to hypotension.

20. Anaphylactic shockAnaphylactic shock
 Caused by a severeCaused by a severe
anaphylactic reactionanaphylactic reaction to anto an allergenallergen,,
antigenantigen,, drugdrug or foreign proteinor foreign protein
causing the release ofcausing the release of histaminehistamine whichwhich
causes widespread vasodilation, leadingcauses widespread vasodilation, leading
to hypotension and increased capillaryto hypotension and increased capillary
permeability.permeability.

21. Neurogenic shockNeurogenic shock
Neurogenic shock is the rarest form of shock.Neurogenic shock is the rarest form of shock.
It is caused byIt is caused by traumatrauma to the spinal cordto the spinal cord
resulting in the sudden loss of autonomic andresulting in the sudden loss of autonomic and
motor reflexes below the injury level.motor reflexes below the injury level.
Without stimulation by sympathetic nervousWithout stimulation by sympathetic nervous
system the vessel walls relax uncontrollably,system the vessel walls relax uncontrollably,
resulting in a sudden decrease in peripheralresulting in a sudden decrease in peripheral
vascular resistance, leading to vasodilation andvascular resistance, leading to vasodilation and
hypotension.hypotension.

22. Causes of Neurogenic Shock.Causes of Neurogenic Shock.
 Some neurogenic factors that can cause loss of vasomotor tone includeSome neurogenic factors that can cause loss of vasomotor tone include
the following:the following:
 Deep general anesthesiaDeep general anesthesia often depresses the vasomotor center enough tooften depresses the vasomotor center enough to
cause vasomotor paralysis, with resulting neurogenic shock.cause vasomotor paralysis, with resulting neurogenic shock.
 Spinal anesthesia,Spinal anesthesia, especially when this extends all the way up the spinalespecially when this extends all the way up the spinal
cord, blocks the sympathetic nervous outflow from the nervous systemcord, blocks the sympathetic nervous outflow from the nervous system
and can be a potent cause of neurogenic shock.and can be a potent cause of neurogenic shock.
 Brain damageBrain damage is often a cause of vasomotor paralysis. Many patients whois often a cause of vasomotor paralysis. Many patients who
have had brain concussion or contusion of the basal regions of the brainhave had brain concussion or contusion of the basal regions of the brain
develop profound neurogenic shock. Also, even though brain ischemiadevelop profound neurogenic shock. Also, even though brain ischemia
for a few minutes almost always causes extreme vasomotor stimulation,for a few minutes almost always causes extreme vasomotor stimulation,
prolonged ischemia (lasting longer than 5 to 10 minutes) can cause theprolonged ischemia (lasting longer than 5 to 10 minutes) can cause the
opposite effect-total inactivation of the vasomotor neurons in the brainopposite effect-total inactivation of the vasomotor neurons in the brain
stem, with consequent development of severe neurogenic shock.stem, with consequent development of severe neurogenic shock.

23. Obstructive shockObstructive shock
 In this situation the flow of blood is obstructedIn this situation the flow of blood is obstructed
which impedes circulation and can result inwhich impedes circulation and can result in
circulatory arrest. Several conditions result incirculatory arrest. Several conditions result in
this form of shock.this form of shock.

24. Cardiac tamponadeCardiac tamponade
in which fluid in the pericardium prevents inflow ofin which fluid in the pericardium prevents inflow of
blood into the heart (venous return). Constrictiveblood into the heart (venous return). Constrictive
pericarditis, in which the pericardium shrinks andpericarditis, in which the pericardium shrinks and
hardens, is similar in presentation.hardens, is similar in presentation.

25. ouTube - Cardiac tamponade English version.fl

26. ouTube - Atrial Fibrillation - What Is Atrial Fibrillation Video - Ab.f

27. Tension pneumothoraxTension pneumothorax
 Through increased intrathoracicThrough increased intrathoracic
pressure, bloodflow to the heart ispressure, bloodflow to the heart is
prevented (venous return).prevented (venous return).

28. Massive pulmonary embolismMassive pulmonary embolism
 is the result of a thromboembolic incident in theis the result of a thromboembolic incident in the
bloodvessels of the lungs and hinders the returnbloodvessels of the lungs and hinders the return
of blood to the heartof blood to the heart

29. ouTube - DVT _ Pulmonary Embolism.f

30. Aortic stenosisAortic stenosis
Hinders circulation by obstructingHinders circulation by obstructing
the ventricular outflow tractthe ventricular outflow tract

31.  Septic ShockSeptic Shock
 Septic shockSeptic shock refers to a dangerously low bloodrefers to a dangerously low blood
pressure (hypotension) that may result frompressure (hypotension) that may result from
sepsis, or infection. This can occur through thesepsis, or infection. This can occur through the
action of a bacterial lipopolysaccharide calledaction of a bacterial lipopolysaccharide called
endotoxin.endotoxin.
 The mortality associated with septic shock isThe mortality associated with septic shock is
presently very high, estimated at 50% to 70%.presently very high, estimated at 50% to 70%.

32. Physiology of Treatment in ShockPhysiology of Treatment in Shock

33.  Replacement TherapyReplacement Therapy
 Blood and Plasma Transfusion.Blood and Plasma Transfusion. If a person is in shockIf a person is in shock
caused by hemorrhage, the best possible therapy is usuallycaused by hemorrhage, the best possible therapy is usually
transfusion of whole blood.transfusion of whole blood.
 If the shock is caused by plasma loss, the best therapy isIf the shock is caused by plasma loss, the best therapy is
administration of plasma;administration of plasma;
 when dehydration is the cause, administration of anwhen dehydration is the cause, administration of an
appropriate electrolyte solution can correct the shock.appropriate electrolyte solution can correct the shock.
 Whole blood is not always available, such as underWhole blood is not always available, such as under
battlefield conditions. Plasma can usually substitutebattlefield conditions. Plasma can usually substitute
adequately for whole blood because it increases the bloodadequately for whole blood because it increases the blood
volume and restores normal hemodynamics.volume and restores normal hemodynamics.

34.  Plasma cannot restore a normal hematocrit, but the human bodyPlasma cannot restore a normal hematocrit, but the human body
can usually stand a decrease in hematocrit to about half ofcan usually stand a decrease in hematocrit to about half of
normal before serious consequences result, if cardiac output isnormal before serious consequences result, if cardiac output is
adequate.adequate.
 Sometimes plasma is unavailable. In these instances, variousSometimes plasma is unavailable. In these instances, various
plasma substitutesplasma substitutes have been developed that perform almost exactlyhave been developed that perform almost exactly
the same hemodynamic functions as plasma. One of these isthe same hemodynamic functions as plasma. One of these is
dextran solution.dextran solution.
 dextran,dextran, a large polysaccharide polymer of glucose . Certaina large polysaccharide polymer of glucose . Certain
bacteria secrete dextran as a by-product of their growth, andbacteria secrete dextran as a by-product of their growth, and
commercial dextran can be manufactured using a bacterialcommercial dextran can be manufactured using a bacterial
culture procedureculture procedure
 Dextrans of appropriate molecular size do not pass through theDextrans of appropriate molecular size do not pass through the
capillary pores and, therefore, can replace plasma proteins ascapillary pores and, therefore, can replace plasma proteins as
colloid osmotic agents.colloid osmotic agents.

35. Sympathomimetic DrugsSympathomimetic Drugs
 AA sympathomimetic drugsympathomimetic drug is a drug that mimics sympathetic stimulation. Theseis a drug that mimics sympathetic stimulation. These
drugs includedrugs include norepinephrinenorepinephrine,, epinephrineepinephrine , In two types of shock,, In two types of shock,
sympathomimetic drugs have proved to be especially beneficial.sympathomimetic drugs have proved to be especially beneficial.
 The first of these isThe first of these is neurogenic shock,neurogenic shock,
 Administering a sympathomimetic drug takes the place of the diminishedAdministering a sympathomimetic drug takes the place of the diminished
sympathetic actions and can often restore full circulatory function.sympathetic actions and can often restore full circulatory function.
 The second type of shock in which sympathomimetic drugs are valuable isThe second type of shock in which sympathomimetic drugs are valuable is
anaphylactic shock,anaphylactic shock, in which excess histamine plays a prominent role. Thein which excess histamine plays a prominent role. The
sympathomimetic drugs have a vasoconstrictor effect that opposes thesympathomimetic drugs have a vasoconstrictor effect that opposes the
vasodilating effect of histamine.vasodilating effect of histamine.
 Sympathomimetic drugs have not proved to be very valuable in hemorrhagicSympathomimetic drugs have not proved to be very valuable in hemorrhagic
shock. The reason is that in this type of shock, the sympathetic nervous systemshock. The reason is that in this type of shock, the sympathetic nervous system
is almost always maximally activated by the circulatory reflexes already; sois almost always maximally activated by the circulatory reflexes already; so
much norepinephrine and epinephrine are already circulating in the blood thatmuch norepinephrine and epinephrine are already circulating in the blood that
sympathomimetic drugs have essentially no additional beneficial effect.sympathomimetic drugs have essentially no additional beneficial effect.

36. Treatment by the Head-Down Position.Treatment by the Head-Down Position.
 When the pressure falls too low in most types of shock,When the pressure falls too low in most types of shock,
especially in hemorrhagic and neurogenic shock, placingespecially in hemorrhagic and neurogenic shock, placing
the patient with the head at least 12 inches lower thanthe patient with the head at least 12 inches lower than
the feet helps tremendously in promoting venousthe feet helps tremendously in promoting venous
return, thereby also increasing cardiac output. Thisreturn, thereby also increasing cardiac output. This
head-down position is the first essential step in thehead-down position is the first essential step in the
treatment of many types of shock.treatment of many types of shock.

37. Oxygen Therapy.Oxygen Therapy.
 major effect of shock is too little delivery of oxygen tomajor effect of shock is too little delivery of oxygen to
the tissues, giving the patient oxygen to breathe can bethe tissues, giving the patient oxygen to breathe can be
of benefit in many instances. However, this frequentlyof benefit in many instances. However, this frequently
is far less beneficial than one might expect, because theis far less beneficial than one might expect, because the
problem in most types of shock is not inadequateproblem in most types of shock is not inadequate
oxygenation of the blood by the lungs but inadequateoxygenation of the blood by the lungs but inadequate
transport of the blood after it is oxygenated.transport of the blood after it is oxygenated.

38.  Treatment with Glucocorticoids (Adrenal CortexTreatment with Glucocorticoids (Adrenal Cortex
Hormones That Control Glucose Metabolism).Hormones That Control Glucose Metabolism).
Glucocorticoids are frequently given to patients inGlucocorticoids are frequently given to patients in
severe shock for several reasons:severe shock for several reasons:
 (1) increase the strength of the heart in the late stages(1) increase the strength of the heart in the late stages
of shock;of shock;
 (2) glucocorticoids stabilize lysosomes in tissue cells(2) glucocorticoids stabilize lysosomes in tissue cells
and thereby prevent release of lysosomal enzymes intoand thereby prevent release of lysosomal enzymes into
the cytoplasm of the cells, thus preventing deteriorationthe cytoplasm of the cells, thus preventing deterioration
from this source; andfrom this source; and
 (3) glucocorticoids might aid in the metabolism of(3) glucocorticoids might aid in the metabolism of
glucose by the severely damaged cells.glucose by the severely damaged cells.

39. Circulatory ArrestCirculatory Arrest
 A condition closely allied to circulatory shock is circulatoryA condition closely allied to circulatory shock is circulatory
arrest, in which all blood flow stops.arrest, in which all blood flow stops.
 This occurs frequently on the surgical operating table as a resultThis occurs frequently on the surgical operating table as a result
ofof cardiac arrestcardiac arrest oror ventricular fibrillationventricular fibrillation. Ventricular fibrillation can. Ventricular fibrillation can
usually be stopped by strong electroshock of the heart,usually be stopped by strong electroshock of the heart,
 Cardiac arrest often results from too little oxygen in theCardiac arrest often results from too little oxygen in the
anesthetic gaseous mixture or from a depressant effect of theanesthetic gaseous mixture or from a depressant effect of the
anesthesia itself.anesthesia itself.
 A normal cardiac rhythm can usually be restored by removingA normal cardiac rhythm can usually be restored by removing
the anesthetic and immediately applying cardiopulmonarythe anesthetic and immediately applying cardiopulmonary
resuscitation procedures, while at the same time supplying theresuscitation procedures, while at the same time supplying the
patient's lungs with adequate quantities of ventilatory oxygen.patient's lungs with adequate quantities of ventilatory oxygen.