shock - Specific Types

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.

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.

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.

First Aid – Symptoms of Shock

Treatment of Hypovolemic, Cardiogenic and Neurogenic
Hypoperfusion

To healthcare professionals, medical shock is different from the emotional and psychological
stress caused by a sudden and personal cataclysmic event. Medical shock is a measurable
emergency with unique signs and symptoms that if left untreated, will lead to death.

There are three main types of shock; hypovolemic shock, cardiogenic shock and neurogenic
shock. Each presents with different symptoms requiring a variety of treatment responses.
Essentially, however, the definition of shock is basically the same for all types; the body, due
to trauma or damage, is simply unable to supply cells with adequate amounts of oxygen and
nutrients.

Hypovolemic Shock

This type of shock is caused by sudden blood loss. Without the required volume of blood, the
heart cannot pump enough blood to make up for the blood loss and organs begin to fail.

Causes of hypovolemic shock can be:

• severe cuts or traumatic injuries

• traumatic amputation
• internal bleeding
• loss of fluids caused by burns, diarrhea or vomiting for example, that in
turn, can cause blood levels to drop

Symptoms of hypovolemic shock vary with severity but generally include:

• agitation or anxiety
• pale, cool, clammy skin
• sweating
• feeling weak
• decreased urine output
• rapid breathing and increased heart rate
• confusion followed by unconsciousness in later stages

Cardiogenic Shock

Cardiogenic shock occurs when the heart becomes damaged, from a heart attack for example.
In a weakened state the heart is unable to pump the blood effectively and supply to the body’s
tissues is depleted.

Causes of cardiogenic shock can be:

Read on

• First Aid – Anaphylactic Shock

• First Aid for Venomous Snake Bites
• Diabetes – Insulin Shock

• heart attack (myocardial infarction)

• infectious cardiac diseases
• myocarditis or endocarditis (inflammation or infection of the heart)
• certain drugs and medication (cocaine or antidepressants, for example)
• trauma to the heart area
• cardiac arrhythmias (abnormal heart rhythms)

Symptoms of cardiogenic shock generally include:

• severe shortness of breath

 • rapid breathing
• fast heart rate (tachycardia)
• confusion or unconsciousness
• pale, cool, clammy skin
• decrease in urination
• sweating
• weak pulse

Neurogenic Shock

Neurogenic shock also known as vasogenic shock, occurs when blood vessel constriction is
disrupted. Usually the autonomic nervous system keeps the blood vessels partially constricted
via signals from nerves. When blood and fluid loss happens, or there is damage to the central
nervous system, the autonomic nervous system along with the impaired nerve signals are
overridden, and the vessels begin to dilate.

When all the blood vessels dilate at one time, there is insufficient blood to go around. Instead
the blood pools away from the heart and neurogenic shock ensues.

Causes of neurogenic shock include:

• spinal cord injury (above T6)

• spinal anesthesia
• pain
• drugs
• emotional or psychological stress
• central nervous system dysfunction

Symptoms of neurogenic shock generally include:

• low heart rate

• low blood pressure
• slow heart rate
• ability to sweat depleted leading to warm, dry skin
• hypothermia

Treatment for Shock

As a layperson, there are some things that can be done to aid a shock victim until emergency
medical responders arrive:

• Call 911 immediately if it hasn't already been done and alert them that
shock is suspected
• Keep the patient warm due to an added risk of hypothermia
• If the patient does not have a back or neck injury, have the person lie flat
and elevate the legs about 12 inches. (Known as the Trendelenburg
position, it helps to improve circulation)
• Do not give the patient anything to eat or drink
The key to treating all types of shock is to replace the fluid loss causing it. Emergency
professionals will administer IV fluids, medications and transport to the hospital for blood
replacement in severe cases.

In cardiogenic shock, the cardiac issues that caused the shock will be diagnosed and dealt
with. Neurogenic shock usually requires the use of medications known as vasoconstrictors.
Epinephrine is one such vasoconstrictor and constricts blood vessels.

While there are three major types of shock, there are several more classifications of shock,
such as anaphylaxis that are acknowledged by healthcare professionals. Learn about the
different classifications and the levels of shock severity.