Shock Overview

The word shock is used differently by the medical community and the general public.
The connotation by the public is an intense emotional reaction to a stressful situation or
piece of news. Its medical meaning is much different.

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

How the body works

Cells need two things to function: oxygen and glucose. This allows the cells to generate
energy and do their specific jobs.

Oxygen in the air enters the body through the lungs; where oxygen molecules cross into
the smallest blood vessels, the capillaries, and are picked up by red blood cells and
attached to hemoglobin molecules. The red blood cells are pushed through the body by
the actions of the pumping heart and deliver the oxygen to cells in all the tissues of the
body. The hemoglobin then picks up carbon dioxide, the waste product of metabolism,
where it is then taken back to the lungs and breathed back into the air, whereby the whole
cycle starts again.

Glucose is generated in the body from the foods we eat. It travels in the blood stream as
well, and using an insulin molecule that "opens the door," it enters the cell to provide
energy for cellular metabolism.

Shock Causes

When things go wrong

If cells are deprived of oxygen, instead of aerobic (with oxygen) metabolism, the cells
use the anaerobic (without oxygen) pathway to produce energy. Unfortunately, lactic acid
is formed as the by product of anaerobic metabolism. This acid changes the acid-base
balance in the blood and leads to a downward spiral where cells start to leak toxic
chemicals into the bloodstream, cause blood vessel walls to become damaged, and this
process ultimately leads to the death of the cell. If enough cells die, then organs start to
fail, and the body dies.

Think of the cardiovascular system of the body as similar to the oil pump in your car. For
efficient functioning, the electrical pump needs to work to pump the oil, there needs to be
enough oil, and the oil lines need to be intact. If any of these components fail, oil pressure
falls and the engine may be damaged. In the body, if the heart, blood vessels, or
bloodstream (circulation) fail, then the body fails.

Where things go wrong

The oxygen delivery system to the body's cells can fail in a variety of ways.

• The amount of oxygen in the air that is inhaled can be decreased.

• Examples include breathing at high altitude or carbon monoxide poisoning.

The lung may be injured and not be able to transfer oxygen to the blood stream. Causes
of this may include, among others:

• pneumonia (an infection of the lung),

• congestive heart failure where the lung fills with fluid, or

• trauma with collapse or bruising of the lung.

The heart may not be able to adequately pump the blood to the tissues of the body. Cases
of this may include, among others:

• In the case of a heart attack, where muscle tissue is lost, or by a rhythm

disturbance of the heart, when the heart can't beat in a coordinated way.

• It may also occur because of heart inflammation due to infection or other causes,
again where the effective beating capabilities of the heart are lost.

There may not be enough red blood cells in the blood. If there aren't enough red blood
cells (anemia), then not enough oxygen can be delivered to the tissues with each heart
beat. Causes may include:

• acute or chronic bleeding,

• inability of the bone marrow to make red blood cells, or

• the increased destruction of red blood cells by the body (an example includes
sickle cell disease).

There may not be enough other fluids in the blood vessels. The blood stream contains
the blood cells (red, white, and platelets), plasma (which is more than 90% water), and
many important proteins and chemicals. Loss of body water or dehydration can cause
shock.

The blood vessels may not be able to maintain enough pressure within their walls to
allow blood to be pumped to the rest of the body. Normally, blood vessel walls have
tension on them to allow blood to be pumped against gravity to areas above the level of
the heart. This tension is under the control of the unconscious central nervous system,
balanced between the action of two chemicals, adrenaline (epinephrine) and
acetylcholine. If the adrenaline system fails, then the blood vessel walls dilate and blood
pools in the parts of the body closest to the ground and may have a difficult time
returning to heart to be pumped around the body.

Since one of the steps in the cascade of events causing shock is damage to blood vessel
walls, this loss of integrity can cause blood vessels to leak fluid, leading to dehydration
which initiates a vicious circle of worsening shock.

Hypovolemic Shock

There needs to be enough red blood cells and water in the blood for the heart to push the
fluids around within the blood vessels. When the body gets dehydrated, there may be
enough red blood cells, but the total volume of fluid is decreased, and pressure within the
system falls. Cardiac output is the amount of blood that the heart can pump out in one
minute. It is calculated as the stroke volume (how much blood each heart beat can push
out) multiplied by the heart rate (how fast the heart beats each minute). If there is less
blood in the system to be pumped, the heart speeds up to try to keep its output steady.

Water makes up 90% of blood. If the body becomes dehydrated because water is lost or
fluid intake is inadequate, the body tries to maintain cardiac output by making the heart
beat faster. But as the fluid losses mount, the body's compensation mechanisms fail, and
shock will occur.

Hypovolemic (hypo=low + volemic=volume) shock due to water loss can be the endpoint
of many illnesses, but the common element is the lack of fluid within the body.

Gastroenteritis can cause significant water loss from vomiting and diarrhea, and is a
common cause of death in third world countries. Heat exhaustion and heat stroke is
caused by excessive water loss through sweating as the body tries to cool itself. Patients
with infections can lose significant amounts of water from sweating. People in diabetic
ketoacidosis lose significant water because of because of elevated blood sugars.

Ultimately in hypovolemic shock, the patient cannot replace the amount of fluid that was
lost by taking in enough water, and the body is unable to maintain blood pressure and
cardiac output. In all shock states, when cells start to malfunction waste products build
up, a downward spiral of cell death begins, increased acidosis occurs, and a worsening
body environment leads to further cell death - and ultimately organ failure.

Hemorrhagic Shock

A subset of hypovolemic shock occurs when there is significant bleeding that occurs
relatively quickly. Trauma is the most common example of bleeding or hemorrhage, but
bleeding can occur from medical conditions as well including:

• Bleeding from the gastrointestinal tract is common; examples include stomach or

duodenal ulcers, colon cancers or diverticulitis.
 • In women, excessive bleeding can occur from the uterus.

• People with cancers or leukemia have the potential to bleed spontaneously from a
variety of sources if their bone marrow does not make enough clotting factors.

• Patients who are taking blood thinners (anticoagulant medications) can bleed
excessively as well.

Blood loss has two effects on the body. First, there is a loss of volume within blood
vessels to be pumped (see hypovolemic shock) and second, a reduced oxygen carrying
capacity occurs because of the loss of red blood cells. Otherwise healthy people can lose
up to 10% of their blood volume (about the amount that a person donates at a blood
drive) without becoming symptomatic with weakness, lightheadedness, or shortness of
breath.

The treatment of hemorrhagic shock depends on the cause. Finding and controlling the
source of bleeding is of paramount importance. Intravenous fluids are used to help with
resuscitation to increase the fluid volume within the blood vessel space, but blood
transfusion is not always mandatory. If the bleeding is controlled and the patient becomes
more stable, the bone marrow may be allowed to replenish the red blood cells lost.

If the red blood cell count in the blood decreases gradually over time, either because of
bleeding or the inability of the body to make enough new red cells, the body can adjust to
the lower levels to maintain adequate cell perfusion but the individual's exercise tolerance
may decrease. This means that they may do well in normal daily activities but find that
routine exercise or household activities bring on weakness or shortness of breath. The
treatment depends on the underlying diagnosis, since it isn't a total fluid problem like in
hypovolemic shock.

Cardiogenic Shock

When the heart loses its ability to pump blood to the rest of the body, blood pressure
falls. Although there may be enough red blood cells and oxygen, they can't get to the
cells that need them.

The heart is a muscle itself and needs blood supply to work. When a heart attack occurs,
the blood supply to part of the heart is lost, and that can stun and irritate the heart muscle
so that it isn't able to beat with an appropriate squeeze to push blood to the rest of the
body. This decreases stroke volume, and cardiac output falls.

Treatment includes trying to restore blood supply and the use of medications to support
blood pressure. In more dire circumstances, machines can be used to assist the heart to
support blood pressure.

Neurogenic shock
There are involuntary muscles within blood vessel walls that maintain the squeeze so that
the volume within the vessels stays constant even if the body changes position against
gravity. Think of when you get up out of bed in the morning. If your blood vessels didn't
squeeze a little tighter, gravity would make the blood flow to your feet, the lowest part of
your body, away from your brain, and you might pass out. The squeeze is maintained by
signals from nerves in the sympathetic trunk, a long bundle of fibers running from the
skull to the tailbone alongside the vertebral column.

In brain or spinal injury, the sympathetic trunk stops working and blood vessels dilate
and result in blood pooling away from the heart. Since there isn't enough blood returning
to the heart, the heart has a hard time pumping blood around the body.

This situation looks like hypovolemic shock, since effectively there isn't enough fluid to
fill the blood vessels, but because there isn't enough sympathetic tone or adrenaline
release, the heart rate does not show a compensatory increase to increase cardiac output.

Treatment includes fluids and medications to increase the tone in the blood vessel walls.

Hypoglycemic Shock and Hyperglycemia

High or low blood sugars are almost associated with diabetes. In people with diabetes, the
body does not make enough insulin to permit glucose to enter the cells for aerobic
metabolism. As treatment, insulin needs to be injected, or medication needs to be taken to
boost the body's lower insulin production. There must be a balance between how much
medication is taken and how much food is eaten.

If not enough food is ingested, then the blood sugar drops (hypoglycemia) and no
glucose is available to enter the cells, even if there is enough insulin to permit glucose to
enter the cells. The brain is very susceptible to low blood sugars, and coma has a very
quick onset. Treatment is providing sugar. If the person is awake enough to swallow, a
sugar solution by mouth is used, otherwise, intravenous fluids containing glucose are
provided. If the lack of sugar was of short duration, the person will awaken almost
immediately after treatment. If blood sugars remain low for prolonged periods of time,
the brain's ability to recover is potentially lost.

When blood sugar levels spiral high out of control, there is risk of significant dehydration
(see below) and shock. If there is not enough insulin in the blood stream, cells cannot use
the glucose that is present and instead turn to an alternative anaerobic metabolism to
generate energy. Since glucose can't enter cells to be used, hyperglycemia (hyper= high
+ gly=sugar = emia) occurs as the glucose level build in the blood stream. The kidneys
try to excrete excess sugar, but because of chemical concentration gradients between
blood and urine, significant amounts of water are lost as well. The body quickly becomes
dehydrated and blood pressure drops, decreasing blood flow to cells. Cells which are now
lacking glucose inside them are now starved of oxygen and turn to anaerobic metabolism,
causing acid waste product build up. Excess acid in the body changes the metabolism for
all organs, making it more difficult for oxygen to be used. This downward spiral will
continue until insulin and significant fluids are given.

Shock Symptoms

Shock is defined as abnormal metabolism at the cellular level. Since it is not easy to
directly measure cellular problems, the symptoms of shock are indirect measurements of
cellular function. Shock is the end stage of all diseases, and symptoms will often be
dependant on the underlying cause.

Vital signs

As the patient goes through the various stages of shock, vital signs change. In the early
stages, the body tries to compensate by moving fluids around from within cells to the
blood stream with an attempt to maintain blood pressure in a normal range. However,
there may be a slight rise in the heart rate (tachycardia = tachy or fast + cardia or heart).
Think of donating blood. A unit of blood (or about 10% of your blood volume) is
removed, yet the body compensates well, except for a little lightheadedness, which is
often resolved by drinking fluids. Another example is exercising and forgetting to drink
enough fluids and feeling a little tired at the end of the day.

As the body loses the ability to compensate, the breathing rate gets faster and the
tachycardia increases as the body tries to pack as much oxygen onto the remaining red
blood cells as possible and deliver them to the cells. Unfortunately, blood pressure starts
to fall (hypotension=hypo or low + tension= pressure) as compensation mechanisms fail.

Body function

Cells don't get enough oxygen and the organs that they comprise start to fail. All organs
may be affected.

• As the brain is affected, the patient may become confused or lose consciousness
(coma).

• There may be chest pain as the heart itself doesn't get an adequate oxygen supply.

• Diarrhea often occurs as the large intestine becomes irritated due to hypotension.

• Kidneys may fail and the body may stop making urine.

• The skin becomes clammy and pale.

Exams and Tests

The approach to the patient in shock requires that treatment occur at the same time as the
diagnosis occurs. The source of the underlying disease needs to be found. Sometimes it is
obvious, for example, a trauma victim bleeding from a wound. Other times, the diagnosis
is elusive. The type of tests will depend upon the underlying condition.

That said, the diagnosis is most often found through the medical history. A thorough
physical examination will be undertaken and the patients vital signs monitored.

• Patient vital signs monitored might include continual blood pressure, heart rate,
and oxygen measurement. Special catheters may be inserted into the large veins in
the neck, chest, arm, or groin and threaded near the heart or into the pulmonary
artery, to measure central pressures, which may be a better indicator of the body's
fluid status. Other catheters may be inserted into arteries (arterial lines) to
measure blood pressures more directly. Tubes may be placed in the bladder
(Foley catheter) to measure urine output.

• Blood laboratory tests will be performed (the type dependent on the underlying
disease or condition).

• Radiologic tests may be performed, again dependent on the underlying illness.

Self-Care at Home

If you come upon a person in shock, the initial response should be to call 911 and
activate the emergency response system.

Lay the person down in a safe place and try to keep them warm and comfortable.

Medical Treatment

• EMS personnel are well trained in the initial assessment of the patient in shock.
The first course of action is to make certain that the ABCs have been assessed.
The so-called ABCs are:

• Airway: assessment of whether the patient is awake enough to try

to take their own breaths and/or if there is there anything blocking the
mouth or nose.

• Breathing: assessment of the adequacy of breathing and whether it

may need to be assisted with mouth-to-mouth resuscitation or more
aggressive interventions like a bag and mask or intubation with an
endotracheal tube.

• Circulation: assessment of the adequacy of the blood pressure

adequate and determination of whether intravenous lines are needed for
delivery of fluid or medications to support the blood pressure.

• If there is bleeding that is obvious, attempts to control it with direct pressure will
be attempted.
 • A fingerstick blood sugar will be checked to make certain that hypoglycemia (low
blood sugar) does not exist. Many people can appear to be on death's door, but
wake up and remain normal when given sugar.

• In the Emergency Department, diagnosis and treatment will happen at the same
time.

• Patients will be treated with oxygen supplementation through nasal cannulae, a

face mask, or endotracheal intubation. The method and amount of oxygen will be
titrated to make certain enough oxygen is available for the body to use. Again, the
goal will be to pack each hemoglobin molecule with oxygen.

• Blood may be transfused if bleeding (hemorrhage) is the cause of the shock state.
If bleeding is not the case, intravenous fluids will be given to bolster the volume
of fluids within the blood vessels.

• Intravenous drugs can be used to try to bolster blood pressure (vasopressors).

They work by stimulating the heart to beat stronger and by squeezing blood
vessels to increase the flow within them.

Next Steps

Follow-up

Patients in shock are critically and will be admitted to an intensive care unit. Depending
on the underlying condition, a variety of specialists will be involved with their care.
Nurses with advanced training, respiratory therapists, and pharmacists will be added to
the team of doctors assigned to one patient.

When the body is in a stressed state, it becomes more susceptible to infection. As well,
having tubes in one's body for prolonged periods lead to higher infection risk. While in
the hospital, the staff will be vigilant in trying to prevent nosocomial (hospital-borne)
infections.

Extended nursing care is often needed if one survives shock. Rehabilitation may take a
prolonged period of time as different organs recover their function. The amount of time
the body was in a shock state often determines the extent of organ damage, and full
recovery may never be complete. Brain injury can lead to stroke and thought impairment.
Heart and lung damage can lead to significant disabilities that may include reduced
exercise tolerance. Kidney damage can lead to the need for dialysis.

Outlook

Shock is a culmination of multiple organ systems in the body that have failed or are in the
process of failing. Even with the best of care, there is a significant risk of death.