Diagnosis &

Management of Shock
Suriyadi

DEFINITIONS
Shock: Inadequate perfusion
resulting in O2 debt at cellular
level

Types of Shock
Distributive Shock
Neurogenic shock
Septic shock
Anaphylactic shock
Hypovolemic Shock
Cardiogenic Shock

Etiologic Classification
of Shock

Hemorrhagic/Hypovolemic
Cardiogenic
Distributive (SIRS, septic,
high output failure, spinal
cord injury, anaphylactic)

Stages of Shock
Initial Stage
Compensatory
Stage
Progressive Stage
Irreversible Stage

Initial Stage
Initially, the body compensates with the
onset of shock.
No changes are noted clinically.
Changes are beginning to occur on the
cellular level.

Compensatory Stage
Fluid shift from insterstital to
intravascular space.
Activation of SNS - activation of
epinephrine and norepinephrine.
Kidneys release renin into blood
formation of angiotension & release of
aldosterone, ADH

Decreased CO
SNS stimulation
Epinephrine &
norepinephrine
released
Vasoconstriction
Increased SVR

Renin secreted by
kidney

hydrostatic pressure

Angiotension
Aldosterone
ADH
Increase blood volume

Blood Pressure Maintained

fluid pulled into

capillary

Progressive Stage
Vicious circle of compensation
eventually leads to decompensation.
Blood pressure starts to fall - SBP
below 80 is considered danger signal.
Tachycardia; tachypnea; decreased
urine output; decreased body
temperature; cold, pale clammy skin.

Irreversible Stage
Body attempts at compensation have
failed - death is imminent.
Pooling and sludging of blood;
thrombosis of small vessels occurs.
Tissue hypoxia and anoxia occur lactic acid accumulation contributes to
cell death.

Parameters of Adequate
Resuscitation
Urine output (0.5 - 1.0 ml/kg/hr)
acceptable renal perfusion
Reversal of lactic acidosis (nl. pH)
improved perfusion
Normal mental status
adequate cerebral perfusion

Management of Shock
* Oxygenation
In all types of shock, supplemental oxygen is
administered to protect against hypoxemia.

Management of Shock
* Positioning
the recommended position for the patient in
shock is supine with legs elevated 45
degrees.

Management of Shock
* Replacing Fluid Volume
The primary goal of shock therapy is to
increase the circulating blood volume.
crystalloids
colloids

Fluid replacement should be based on central

venous pressures or pulmonary artery
pressures and cardiac output.

Management of Shock
*

Pharmacologic Agents
Vasoconstrictors
Dopamine
Norepinephrine

Vasodilators
Nitroprusside
Nitroglycerin

Sympathomimetics
Epinephrine

Corticosteriods
Decadron
Solumedrol

Appropriate
antidotes or
antibiotics

Complications of Shock

Metabolic Acidosis
Acute Tubular Necrosis
DIC
ARDS
SIRS & MOSF