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Shock

Daniel T. Johnston, MD, MPH


MAJ, US Army MC
Department of Military and
Emergency Medicine

2004 Johnston, MD
Shock
1. Describe the basic underlying pathology that
exists in all forms of shock.
2. List the different types of shock.
3. List the stages of shock.
4. Describe the pathologic changes that occur in
patients who are in hemorrhagic shock
5. Describe the general appearance and behavior
of a patient in hemorrhagic shock.
2004 Johnston, MD
What Shock is not
2004 Johnston, MD
What is Shock?
A medical condition, not a diagnosis
Types:
Hypovolemic (eg. Hemorragic)
Cardiogenic
Distributive (eg. Septic, neurogenic)
Obstructive (eg. Cardiac tamponade, Tension
Pneumothorax)

TYPES OF SHOCK
More than 100 TYPES OF SHOCK have
been described
Often classified by the cause of the syndrome
Two or more types are often combined
Hypovolemia may occur with septic shock
Elements of cardiogenic shock may occur in
other types of shock
The three
essential
patterns
of circulatory
shock
I II III
TYPES OF SHOCK

Regardless of the classification,
the underlying defect is always
inadequate tissue perfusion!!!!
Shock
Tissue injury from trauma may exacerbate
shock by causing microemboli and further
activating the inflammatory and
coagulation systems
BLOOD AND ITS
COMPONENTS
Blood volume:
Average adult male has a blood
volume of 7% of total body weight
(approx. 5 Kg or 5 L of blood)
Average adult female has a blood
volume of 6.5% of body weight
BLOOD AND ITS
COMPONENTS
Red blood cells (erythrocytes) (RBCs):
Transport 99% of blood oxygen
Remaining 1% is carried dissolved in plasma
(0.3 ml O
2
/100 ml of blood)
Make up approximately 45% of the
blood (Hct) and are the most
abundant cells in the body
BLOOD AND ITS
COMPONENTS
Red blood cells (erythrocytes) (RBCs):
Provide oxygen to tissues and remove
carbon dioxide
Each RBC contains approximately 270
million hemoglobin molecules
Allow RBCs to pick up oxygen in the lungs and
release it to body tissues
FLUIDS AND
ELECTROLYTES
Water is the main component
of body mass:
Accounting for 50%-60% of
body weight in adults
Tissue Cells
Interstitial
Fluid in the
Interstitial
Space
Fluid
Spaces
Basic Physiology of
Hypovolemic Shock
2004 Johnston, MD
Causes
Anything that causes rapid fluid loss
Most commonly rapid blood loss: penetrating
trauma, GI, acute internal blood loss
Also be caused by fluid loss: can you name 2?
We will focus on blood loss


2004 Johnston, MD
Pathophysiology
Acute hemorrhage results in a physiologic
response from 4 systems:
Hematologic: Coagulation and Constriction
Cardiovascular: Inc. HR, SVR, Contractility;
blood shunted to heart, brain, kidneys and
away from skin, muscle, GI tract
Renal: Increase Renin production
Neuroendocrine: ADH release

STAGES OF SHOCK
THREE DISTINCT
STAGES
COMPENSATED SHOCK
DECOMPENSATED SHOCK
IRREVERSIBLE SHOCK
With small volume and pressure declines, compensations can
restore pressure. If losses are large, no recovery may be possible
Time
Outcomes of same vol. lost over diff. periods of time. Slow losses (III, IV)
allow compensations to take effect. Rapid loss (I, II) of same vol. is fatal
STAGES OF SHOCK
Compensated Shock
Entails some decreased tissue perfusion, but
the body's compensatory responses are
sufficient to overcome the decrease in
available fluid
Cardiac output and a normal systolic blood
pressure are maintained by increasing
catecholamine production
STAGES OF SHOCK
Compensated Shock
Rate & Depth of Respirations Increase
The decrease in perfusion and the subsequent
increase in acidosis lead to a chemoreceptor
response that increases the rate and depth of
ventilation so as to -
decrease metabolic acidosis by decreasing PCO
2
STAGES OF SHOCK
Compensated Shock
Sympathetic stimulation:
Sympathetic constriction of veins decreases amount of blood
held in veins causing BP and Cardiac Output (CO) to be
maintained.
Increases heart rate and contractility (inc. cardiac output) -
BP and CO are maintained
Constriction of the arteries leading to increased peripheral
vascular resistance (BP is maintained) - and decreased
capillary flow (cool skin)
Creates bronchodilation (improved air exchange)
STAGES OF SHOCK
COMPENSATED SHOCK
If the underlying cause of shock is
untreated, the compensatory
mechanisms eventually collapse
Low Flow
Micro-
Circulatory
System
AV Shunt
Precapillary
Sphincter
Control of A-V Shunt by
Precapillary Sphincter
STAGES OF SHOCK
COMPENSATED SHOCK - Vasoconstriction:
Progression of shock in the microcirculation
produces a sequence of changes in capillary
perfusion
Vasoconstriction begins as minimal perfusion to
capillaries continues
Oxygen and substrate delivery to the cells supplied by
these capillaries decreases
STAGES OF SHOCK
COMPENSATED SHOCK
Vasoconstriction:
Due to a lack of oxygen - anaerobic
metabolism replaces aerobic metabolism
Production of lactate and hydrogen ions increases
(acid production)
STAGES OF SHOCK
COMPENSATED SHOCK
Vasoconstriction:
Capillaries start to become leaky and
protein-containing fluid leaks into the
interstitial spaces (leaky capillary syndrome)
STAGES IN SHOCK
COMPENSATED SHOCK
Vasoconstriction:
AV shunts open (sphincters constrict),
particularly in the skin, muscle, GI tract
Causing less flow to the arterioles and less flow
through the capillaries
Sympathetic stimulation produces pale, sweaty
skin; rapid thready pulse; and elevated blood
glucose levels
STAGES OF SHOCK
COMPENSATED SHOCK
Vasoconstriction:
The release of epinephrine dilates coronary,
and cerebral arterioles and constricts other
arterioles
Blood is shunted to the heart, brain, and
kidneys and capillary flow to skeletal muscle
and other abdominal viscera decreases
Sympathetically mediated vasoconstriction
STAGES OF SHOCK
BLOOD PRESSURE IS MAINTAINED BY
COMPENSATORY MECHANISMS
Blood stored in venous system is transferred into
arterial system by venous constriction
Increased cardiac contractions
Increased heart rate (variable)
STAGES OF SHOCK
COMPENSATED SHOCK:
If this stage of shock is not treated by prompt
restoration of circulatory volume, shock
progresses to the next stage
HEMORRHAGIC SHOCK
One great consequence of blood loss is the intense
vasoconstriction, the shrinkage of the capacity of the
vascular bed to accommodate the decreased blood
volume...adjustments for blood loss take place...the entry
of fluid into the blood vessels in a compensatory attempt.
The greatest extravascular store of readily available fluid in
the body is...in the extracellular space. Dehydration and
oligemia may make quite early demands not only on this
but also on the intracellular supply as well.
Beecher, Henry K, Simeone, Fiorindo, Mallory, Tracy B., et al: Recent Advances in Surgery I.
The Internal State of the Severely Wounded Man on Entry to the Most Forward Hospital.
Surgery 22:672-711 Oct 1947

STAGES OF SHOCK
DECOMPENSATED SHOCK
MARKED INCREASE IN HEART RATE
PROLONGED CAPILLARY REFILL
BLOOD FLOW TO CRITICAL ORGANS DROPS
Decreased urine output (decreased flow to kidneys)
Altered mental status (decreased flow to brain)
STAGES OF SHOCK
DECOMPENSATED SHOCK - Capillary
and Venule Opening
As the shock state continues, the precapillary
sphincters relax, with some expansion of the
vascular space
Postcapillary sphincters resist local effects and
remain closed, causing blood to pool or stagnate
in the capillary system, producing capillary
engorgement
Pre-Capillary Sphincters Relax Due to Shock Related Stimuli
STAGES OF SHOCK
(please correct yours)
DECOMPENSATED SHOCK (Capillary and
Venule Opening):
Arterial hypotension and closing of the AV shunts
results in more blood flow through capillary
networks
Contribute to stagnation of blood flow in the
capillaries
STAGES OF SHOCK
DECOMPENSATED SHOCK (Capillary and
Venule Opening):
As increasing hypoxemia and acidosis lead to opening
of additional venules and capillaries, the vascular
space expands greatly
Even a NORMAL blood volume may be inadequate to
fill the container (this has implications for fluid
resuscitation)
STAGES OF SHOCK
DECOMPENSATED SHOCK (Capillary
and Venule Opening):
The capillary and venule capacity may become
great enough to reduce the volume of available
blood for the great veins and vena cava
Resulting in decreased venous return and a fall
in cardiac output
STAGES OF SHOCK
DECOMPENSATED SHOCK (Capillary
and Venule Opening):
The viscera (lung, liver, kidneys, and GI
mucosa) may become congested due to
stagnant blood flow
STAGES OF SHOCK
DECOMPENSATED SHOCK (Capillary
and Venule Opening):
The respiratory system attempts to compensate
for the acidosis by increasing ventilation to
blow off carbon dioxide
Increased respiratory rate
Producing a partially compensated metabolic
acidosis
STAGES OF SHOCK
DECOMPENSATED SHOCK (Capillary
and Venule Opening):
Clotting mechanisms are also affected, leading
to hypercoagulability (DIC)
This stage of shock often progresses to
irreversible shock if fluid resuscitation is
inadequate or delayed, or if the shock state is
complicated by trauma or sepsis


STAGES OF SHOCK
IRREVERSIBLE
SHOCK
2004 Johnston, MD
Question: What type of Shock would you
expect in these victims?
STAGES OF SHOCK
Irreversible Shock
Occurs when the body is no longer able to
maintain systolic pressure
Both the systolic and diastolic pressure begin
to drop
Pulse pressure may be narrowed to such an
extent that it is not detectable with a blood
pressure cuff
STAGES OF SHOCK
Irreversible Shock
Signs and symptoms
Bradycardia
Serious dysrhythmias
Frank hypotension
Evidence of multiple organ failure
Pale, cold, and clammy skin
Noticeably delayed capillary refill
Cardiopulmonary collapse is usually imminent
Time (hr)
Irreversible Shock. The loss of arterial pressure causes damage from
which ultimate recovery is not possible despite temp. restoration of BP
STAGES OF SHOCK
Irreversible Shock
As compensatory mechanisms fail
Cerebral blood flow decreases
Marked alteration in mental status
PO
2
may drop
PCO
2
usually remains normal or low unless there is
associated head or chest injury that leads to
hypoventilation
STAGES OF SHOCK
Irreversible Shock
Myocardial strength may decrease from
ischemia secondary to:
A reduction of circulating RBCs
A lower oxygen saturation
Decreased coronary perfusion secondary to
hypotension (especially diastolic hypotension)
STAGES OF SHOCK
Irreversible Shock-myocardial strength
decrease:
Necrosis of myocardium from same causes
associated with ischemia
Essentially simulating myocardial infarction
Decreased preloading leading to decreased
contractility
Acidosis possibly leading to decreased
contractility
Circumferential
Subendocardial
Infarction due
to Shock
STAGES OF SHOCK
Irreversible Shock: Cardiac rhythm
disturbances secondary to hypoxia
(Impaired cardiac function)

STAGES OF SHOCK
Irreversible Shock
Manifested by the progression of
cellular ischemia and necrosis and by
subsequent organ death despite
restoration of oxygenation and perfusion
Complications
of Shock
STAGES OF SHOCK
IRREVERSIBLE SHOCK
Disseminated Intravascular Coagulation (DIC)
Pulmonary capillaries become permeable,
leading to pulmonary edema
Decreases the absorption of oxygen and results in
possible alterations in carbon dioxide elimination
May lead to acute respiratory failure or adult
respiratory distress syndrome (ARDS)
Shock
Lung
Congestive atelectasis and diffuse alveolar
damage due to shock (ARDS)
Acute passive congestion of the lung due to shock
Congested Lung Due to Shock
STAGES OF SHOCK
IRREVERSIBLE SHOCK
Multiple Organ Failure
The amount of cellular necrosis required to
produce organ failure varies with each organ
as well as the underlying condition of the
organ
STAGES OF SHOCK
IRREVERSIBLE SHOCK
Multiple Organ Failure:
In this stage, blood pressure falls dramatically
Cells can no longer use oxygen, and
metabolism stops
STAGES OF SHOCK
IRREVERSIBLE SHOCK
Multiple Organ Failure:
Usually hepatic failure occurs, followed by
renal failure, and then heart failure
If capillary occlusion persists for more than 1-2
hours, the cells nourished by that capillary
undergo changes that rapidly become
irreversible
Acute congestion of liver due to shock
Acute centrilobular hemorrhage due to Shock
Acute cortical necrosis of the kidney due to shock
Acute tubular necrosis of the kidney due to shock
STAGES OF SHOCK
IRREVERSIBLE SHOCK
Multiple Organ Failure:
GI bleeding and sepsis may result from GI
mucosal necrosis
Pancreatic necrosis may lead to further
clotting disorders and severe pancreatitis
Intestinal mucosal hemorrhages due to shock
Adrenal gland hemorrhage due to shock
STAGES OF SHOCK
Variations in Physiological Responses to
Shock
Age and relative health
General physical condition
Preexisting diseases
2004 Johnston, MD
A few of the patients [in shock] even presented
a raised systolic blood pressure, while of those
with a blood pressure of under 100 mm. Hg.,
some had rapid pulses, others only slightly
more rapid than normal. A few, and these
generally patients over fifty years, showed a
pulse rate under seventy. In younger people the
blood pressure was better maintained but the
pulse rate tended to be faster.

Surgery Chapter 3 Shock and Resuscitation by Sir Zachary Cope, Edited by
Sir Zachary Cope, London, Her Majestys Stationary Office, 1953, p. 78-88
HEMORRHAGIC SHOCK
STAGES OF SHOCK
Variations in Physiological Responses to
Shock
Ability to activate compensatory mechanisms
Older adults are less able to compensate (develop
hypotension early)
Children compensate longer and deteriorate
faster
Medications may interfere with compensatory
mechanisms
SHOCK IS A
MOMENTARY
PAUSE IN THE
ACT OF DYING

HEMORRHAGIC
SHOCK
When much blood is lost, the
pulse becomes feeble, the skin
extremely pale, the body
covered with a malodorous
sweat, the extremities frigid,
and death occurs speedily
Aulus Conelius Celsus,
First Century Roman Savant

HEMORRHAGIC SHOCK
...the greatest loss of hemoglobin occurs in
wounds that involve compound fractures of
the long bones or traumatic amputation..it is
the wounds that are associated with great
hemorrhage that cause the severe shock.
Beecher, Henry K, Simeone, Fiorindo, Mallory, Tracy B., et al: Recent Advances in
Surgery I. The Internal State of the Severely Wounded Man on Entry to the Most
Forward Hospital. Surgery 22:672-711 Oct 1947
2004 Johnston, MD
Shock and Trauma
HEMORRHAGIC SHOCK
A word on autoregulation
The body sacrifices less vital organ tissue to maintain
oxygen and nutrient flow to the brain and heart
Vital organs are also protected by local factors that
provide these organs with the ability to autoregulate
blood flow
In the brain and heart, blood flow and oxygen delivery
remain constant over a wide range of arterial pressures
2004 Johnston, MD
Clinical Classes of Shock
Class I hemorrhage (loss of 0-15%)
In the absence of complications, only
minimal tachycardia is seen.
Usually, no changes in BP, pulse
pressure, or respiratory rate occur.
A delay in capillary refill of longer than 3
seconds corresponds to a volume loss of
approximately 10%.

2004 Johnston, MD
Class II hemorrhage (loss of 15-30%)
Clinical symptoms include tachycardia (rate >100
beats per minute), tachypnea, decrease in pulse
pressure, cool clammy skin, delayed capillary
refill, and slight anxiety.
The decrease in pulse pressure is a result of
increased catecholamine levels, which causes an
increase in peripheral vascular resistance and a
subsequent increase in the diastolic BP.

2004 Johnston, MD
Class III hemorrhage (loss of 30-40%)
patients usually have marked tachypnea and
tachycardia, decreased systolic BP, oliguria, and
significant changes in mental status, such as
confusion or agitation.
In patients without other injuries or fluid losses,
30-40% is the smallest amount of blood loss that
consistently causes a decrease in systolic BP.
Most of these patients require blood transfusions,
but the decision to administer blood should be
based on the initial response to fluids.

2004 Johnston, MD
Class IV hemorrhage (loss of >40%)
Symptoms include the following: marked
tachycardia, decreased systolic BP, narrowed
pulse pressure (or immeasurable diastolic
pressure), markedly decreased (or no) urinary
output, depressed mental status (or loss of
consciousness), and cold and pale skin.
This amount of hemorrhage is immediately life
threatening.

2004 Johnston, MD
Clinical Classification of Shock
HEMORRHAGIC SHOCK
Possibly, too much attention has been given to the fact
that on many occasions [patients in shock may have a
normal blood pressure]. ...[T]his has led to a tendency
to dismiss the blood pressure as a helpful sign even
when it is low - a fatal error, on some occasions.
More helpful than the level of the blood pressure, is
the direction of its swing - a falling blood pressure, a
rising pulse rate, are in most cases an urgent indication
of the need for blood.
Beecher, LTC Henry K: Annals of Surgery Vol 121, No. 6, June 1945. p769-792

HEMORRHAGIC SHOCK
Reminder: Critical Signs / Symptoms of Shock
pulse is usually rapid and weak
appearance of the wound, extent of blood-soaked
clothing, a history of delay in hospital admission, of
exposure, of exhaustion - all important considerations
when in the field
HEMORRHAGIC SHOCK
Critical Signs / Symptoms of Shock (cont.)
Research into thirst
Most important of all is the trend of the pulse and the
trend of the blood pressure
A rising pulse rate and a falling blood pressure nearly always
forecast immediate trouble, especially if associated with a
cool skin
2004 Johnston, MD
Patient Evaluation
In a patient with possible shock secondary to
hypovolemia, the history is vital in
determining the possible causes and in
directing the workup.
Symptoms of shock, such as weakness,
lightheadedness, and confusion, should be
assessed in all patients.
In the patient with trauma, determine the
mechanism of injury and any information that
may heighten suspicion of certain injuries
2004 Johnston, MD
In patients with GI bleeding, inquire about
hematemesis, melena, drinking history,
excessive nonsteroidal anti-inflammatory
drug use, and coagulopathies
The chronology of vomiting and
hematemesis should be determined.
If a gynecologic cause is being considered,
gather information about the following: last
menstrual period, risk factors for ectopic
pregnancy, vaginal bleeding (including
amount and duration), vaginal passage of
products of conception, and pain.

2004 Johnston, MD
HEMORRHAGIC SHOCK
TESTS FOR SHOCK
BLOOD PRESSURE
PULSE PRESSURE
PULSE RATE
RESPIRATORY RATE
CAPILLARY REFILL
GEN. APPEARANCE & BEHAVIOR
2004 Johnston, MD
If conscious, the patient may be able to
indicate the location of pain.
Vital signs, prior to arrival in the ED, should
also be noted.
Chest, abdominal, or back pain may indicate
a vascular disorder.
The classic sign of a thoracic aneurysm is a
tearing pain radiating to the back. Abdominal
aortic aneurysms usually result in abdominal
or back pain.

HEMORRHAGIC SHOCK
The usual mental lethargy associated with shock
may be replaced by remarkable mental acuity and
activity which may easily deceive an observer
into thinking that shock is not present
The very nature of shock dictates how difficult or
impossible it is to find a pathognomonic
sign/symptom or finding which is invariably
associated with the presence of shock.
HEMORRHAGIC SHOCK
REMEMBER: Blood pressure and
heart rate are unreliable indicators of
rapid deterioration in young trauma
patients
HEMORRHAGIC SHOCK
RELATIVE (paradoxical) BRADYCARDIA
May be indicative of a profound blood loss
Penetrating abdominal injuries
Ectopic pregnancy
May also occur in extremity trauma
2004 Johnston, MD
Dont Forget!
In the patient with trauma, hemorrhage
usually is the presumed cause of shock.
However, it must be distinguished from other
causes of shock. These include:
cardiac tamponade (muffled heart tones,
distended neck veins), tension
pneumothorax (deviated trachea, unilaterally
decreased breath sounds), and spinal cord
injury (warm skin, lack of expected
tachycardia, neurological deficits).

2004 Johnston, MD
Remember, hemorrhage can occur through
internal losses: chest, abdomen, thighs.
The chest should be auscultated for
decreased breath sounds, because life-
threatening hemorrhage can occur from
myocardial, vessel, or lung laceration.
The abdomen should be examined for
tenderness or distension, which may indicate
intraabdominal injury.
The thighs should be checked for deformities or
enlargement (signs of femoral fracture and
bleeding into the thigh).

2004 Johnston, MD
The patient's entire body should then
be checked for other external bleeding.
In the patient without trauma, the
majority of the hemorrhage is in the
abdomen


2004 Johnston, MD
Pregnancy-related disorders include
ruptured ectopic pregnancy, placenta previa,
and abruption of the placenta. Hypovolemic
shock secondary to an ectopic pregnancy is
common.
Hypovolemic shock secondary to an ectopic
pregnancy in a patient with a negative urine
pregnancy test is rare but has been
reported.

2004 Johnston, MD
The upper limit of normal for adult women
should be changed to 2.9 seconds, and the
upper limit of normal for the elderly should
be changed to 4.5 seconds....The
temperature dependence of capillary refill
raises questions regarding its reliability in
the pre-hospital setting.

Schriger, DL and Baraff, L: Defining Normal Capillary Refill:
Variation with Age, Sex, and Temperature Annals of Emerg Med
17:932-35
CAPILLARY REFILL TEST
CAPILLARY REFILL TEST
Given current normal values and the variables of
environmental temperature, age, sex and questions
regarding the interpretation [which is affected by
such things as lighting], one is left with the
impression that at present capillary refill testing
may be unreliable.

Knopp, RK Capillary Refill: New Concerns About an Old Bedside Test, Editorial
Annals of Emerg Med 17:990-1

2004 Johnston, MD
Final Question
22 yr old Special Forces jumper has canopy
collapse 40 feet above drop zone and presents to
your BAS with open facial fractures with blood
and teeth in oropharynx. He is conscious, has
obvious bilateral ankle fractures and an open
angulated fracture of the left femur. The combat
medic tells you his last vitals 5 minutes before
arriving to the BAS were 110/80, pulse 130, and
respirations 36.
2004 Johnston, MD
What should you do first?
What should you do second?
Are you concerned about shock? Why?


Thanks for participating!

2004 Johnston, MD
And Remember, Keep your Compensatory
mechanisms always ready by escaping the sofa!

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