SHOCK
Susanna Hilda Hutajulu, MD, PhD
Div Hematology and Medical Oncology
Department of Internal Medicine
Universitas Gadjah Mada Yogyakarta
Outline
• Definition
• Epidemiology
• Physiology
• Classes of Shock
• Clinical Presentation
• Management
Definition
• A physiologic state characterized by
• Inadequate tissue perfusion
• Clinically manifested by
• Hemodynamic disturbances
• Organ dysfunction
Epidemiology
• Mortality
• Septic shock – 35-40% (1 month mortality)
• Cardiogenic shock – 60-90%
• Hypovolemic shock – variable/mechanism
Pathophysiology
• Imbalance in oxygen supply and demand
• Conversion from aerobic to anaerobic metabolism
• Appropriate and inappropriate metabolic and physiologic responses
Pathophysiology
• Cellular physiology
• Cell membrane ion pump dysfunction
• Leakage of intracellular contents into the extracellular space
• Intracellular pH dysregulation
• Resultant systemic physiology
• Cell death and end organ dysfunction
• MSOF and death
Pathophysiology
Physiology
• Characterized by three stages
• Preshock (warm shock, compensated shock)
• Shock
• End organ dysfunction
Physiology
• Compensated shock
• Low preload shock – tachycardia, vasoconstriction, mildly
decreased BP
• Low afterload (distributive) shock – peripheral
vasodilation, hyperdynamic state
Pathophysiology
• Shock
• Initial signs of end organ dysfunction
• Tachycardia
• Tachypnea
• Metabolic acidosis
• Oliguria
• Cool and clammy skin
Pathophysiology
• End Organ Dysfunction
• Progressive irreversible dysfunction
• Oliguria or anuria
• Progressive acidosis and decreased cardiac output
• Agitation, obtundation, and coma
• Patient death
Classification
Hypovolemic Shock
• Results from decreased preload
• Etiologic classes
Hypovolemic Shock
• Hemorrhagic Shock
Parameter I II III IV
Blood loss (ml) <750 750–1500 1500–2000 >2000
Blood loss (%) <15% 15–30% 30–40% >40%
Pulse rate (beats/min) <100 >100 >120 >140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate (bpm) 14–20 20–30 30–40 >35
Urine output (ml/hour) >30 20–30 5–15 Negligible
CNS symptoms Normal Anxious Confused Lethargic
Cardiogenic Shock
• Results from pump failure
• Decreased systolic function
• Resultant decreased cardiac output
• Etiologic categories
• Acute myocard infarct
• Arrhythmic
• Congestive heart failure
• Extracardiac (obstructive)
Distributive Shock
• Results from a severe decrease in SVR
• Vasodilation reduces afterload
• May be associated with increased CO
• Etiologic categories
• Sepsis (vasogenic)
• Neurogenic / spinal � loss of sympathetic tone
• Other
Distributive Shock
• Other causes
• Systemic inflammation – pancreatitis, burns
• Toxic shock syndrome
• Anaphylaxis and anaphylactoid reactions
• Toxin reactions – drugs, transfusions
Distributive Shock
• Septic Shock
SIRS 2 or more of the following: Temp >38 or <36 HR > 90 RR > 20 WBC > 20K >10% bands
Sepsis SIRS in the presence of suspected or documented infection
Severe Sepsis Sepsis with hypotension, hypoperfusion, or organ dysfunction
Septic Shock Sepsis with hyotension unresponsive to volume resuscitation, and evidence of hypoperfusion or organ dysfunction
MODS Dysfunction of more than one organ
Clinical Presentation
• Clinical presentation varies with type and cause, but there
are features in common
• Hypotension (SBP<90 or Delta>40)
• Cool, clammy skin (exceptions – early distributive, terminal
shock)
• Oliguria
• Change in mental status
• Metabolic acidosis
Evaluation
• Done in parallel with treatment
• Full laboratory evaluation (cardiac enzymes, blood gas
analysis)
• Basic studies – Rontgen, ECG
• Basic monitoring – VS, urine output, CVP
• Imaging if appropriate (CT-scan)
• Echocardiography
Treatment
• Manage the emergency
• Determine the underlying cause
• Definitive management or support
Manage the Emergency
• Control airway and breathing
• Maximize oxygen delivery
• Place lines, tubes, and monitors
Determine the Cause
• Often obvious based on history
• Trauma most often hypovolemic (hemorrhagic)
• Postoperative most often hypovolemic (hemorrhagic or third
spacing)
• Debilitated hospitalized patients most often septic
• Must evaluate all patients for risk factors for MI and consider
cardiogenic
• Consider distributive (spinal) shock in trauma
Definitive Management
• Hypovolemic
• Fluid resuscitate (blood or crystalloid)
• Control ongoing loss
• Cardiogenic
• Restore blood pressure (chemical and mechanical)
• Prevent ongoing cardiac death
• Distributive
• Fluid resuscitate
• Pressors for maintenance
• immediate antibiotics control for infection
• Steroids for adrenocortical insufficiency
Resuscitation Fluids
• Blood
• Lactated Ringers
• Normal Saline
• Colloids
• Blood Substitutes