Management of Shock

Shock is a serious medical condition where the tissue perfusion is insufficient to meet
demand for oxygen and nutrients because the body is not getting enough blood flow.
This can damage multiple organs and can get worse very rapidly. This hypoperfusional
state is a life-threatening medical emergency and one of the leading causes of death for
critically ill people.

Major classes of shock:

1. Hypovolemic Shock (caused by inadequate blood volume)

Hypovolemic shock is an emergency condition in which severe blood and fluid loss
makes the heart unable to pump enough blood to the body. This type of shock can
cause many organs to stop working.

Blood loss can be due to bleeding from cuts or other injury or internal bleeding such as
gastrointestinal tract bleeding. The amount of blood in your body may drop when you
lose too many other body fluids, which can happen with diarrhea, vomiting, burns, and
other conditions.

Management of Shock

Symptoms:

 Anxiety, restlessness, altered mental state due to decreased cerebral perfusion

and subsequent hypoxia.
 Hypotension due to decrease in circulatory volume.
 A rapid, weak, thready pulse due to decreased blood flow combined with
tachycardia.
 Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction.
 Rapid and deep respirations due to sympathetic nervous system stimulation and
acidosis.
 Hypothermia due to decreased perfusion and evaporation of sweat.
 Thirst and dry mouth, due to fluid depletion.
  Fatigue due to inadequate oxygenation.

Cold and mottled skin (cutis marmorata), especially extremities, due to insufficient
perfusion of the skin.

Therapy:

 Maintain or increase intravascular volume, In hypovolaemic shock, caused by

bleeding, it is necessary to immediately control the bleeding and restore the
victim's blood volume by giving infusions of balanced salt solutions. Blood
transfusions are necessary for loss of large amounts of blood (e.g. greater than
20% of blood volume), but can be avoided in smaller and slower losses.
Hypovolaemia due to burns, diarrhoea, vomiting, etc. is treated with infusions of
electrolyte solutions that balance the nature of the fluid lost.
 Decrease any future fluid loss via I.V fluid regimen
 Give supplementary O2 therapy to commence replacement of fluids via the
intravenous route.

2. Cardiogenic shock (associated with heart problems)

Cardiogenic shock is a disease state where the heart is damaged enough that it is
unable to supply sufficient blood to the body. Most common causes are :
a). acute myocardial infarction
b). dilated cardiomyopathy, This is a serious disease in which the heart muscle
becomes inflamed (enlarged and stretched) and doesn't work as well as it should.
c). acute myocarditis
d). arrhythmias

Symptoms:
similar to hypovolaemic shock but in addition:

 Distended jugular veins due to increased jugular venous pressure.

 Absent pulse due to tachyarrhythmia.

Therapy :
The main goals of the treatment of cardiogenic shock are the re-establishment of
circulation to the myocardium, minimising heart muscle damage and improving the
heart's effectiveness as a pump.

 Oxygen (O2) therapy to reduces the workload of the heart by reducing tissue
demands for blood flow.
 Administration of cardiac drugs
 Increase heart’s pumping action through medication such as Dopamine,
dobutamine, epinephrine, norepinephrine, amrinone
3. Septic shock (associated with infections)
Septic shock is a serious condition that occurs when an overwhelming infection leads to
low blood pressure and low blood flow. The brain, heart, kidneys, and liver may not
work properly or may fail.

Most common of this case may it’s happened to the patients with Meningococcemia,
Waterhouse-Friderichsen syndrome, DIC (disseminated intravascular coagulation),
Multiple organ dysfunction syndrome (MODS), Acute Respiratory Distress Syndrome
(ARDS).

Symptoms:
similar to hypovolaemic shock except in the first stages:

 Pyrexia and fever, or hyperthermia, due to overwhelming bacterial infection.

 Vasodilation and increased cardiac output due to sepsis.

Therapy:

 Restore intravascular volume via I.V fluid

 Give supplemental O2 therapy
 Identify and control source of infection
 Administer antibiotic
 Remove risk factor for infection

4. Neurogenic shock (caused by damage to the nervous system)

Neurogenic shock is shock caused by the sudden loss of the sympathetic nervous
system signals to the smooth muscle in vessel walls. This can result from severe central
nervous system (brain and spinal cord) damage. With the sudden loss of background
sympathetic stimulation, the vessels suddenly relax resulting in a sudden decrease in
peripheral vascular resistance and decreased blood pressure.

Signs and symptoms:

similar to hypovolaemic shock except in the skin's characteristics. In neurogenic shock,
the skin is warm and dry.

Therapy:

 Large volumes of fluid may be needed to restore normal hemodynamics

 Vasopressors (Norepinephrine)
 Atropine (speeds up heart rate and Cardiac Output)
5. Anaphylactic Shock (caused by allergic reaction)
Anaphylaxis is an severe, whole-body allergic reaction. After an initial exposure to a
substance like bee sting toxin, the person's immune system becomes sensitized to that
allergen. On a subsequent exposure, an allergic reaction occurs. This reaction is
sudden, severe, and involves the whole body.

Common causes include insect bites/stings, horse serum (used in some vaccines), food
allergies, and drug allergies.

Symptoms of anaphylaxis are related to the action of Immunoglobulin E and other

anaphylatoxins, which act to release histamine and other mediator substances from
mast cells (degranulation). In addition to other effects, histamine induces vasodilation of
arterioles and constriction of bronchioles in the lungs, also known as bronchospasm
(constriction of the airways).

Symptoms can include the following :

Polyuria, respiratory distress, hypotension (low blood pressure), encephalitis, fainting,
unconsciousness, urticaria (hives), flushed appearance, angioedema (swelling of the
lips, face, neck and throat), tears (due to angioedema and stress), vomiting, itching,
diarrhea, abdominal pain, anxiety, impending sense of doom.

Therapy :

 Identify and remove causative antigen

 Administer counter-mediators such as anti-histamine