Shock: Is a clinical state of cardiovascular collapse
characterized by failure of cells
perfusion resulting in
Hypotension
Tissue/cellular hypoxia
Impaired cellular metabolism & death due to an acute reduction of effective circulating
• Shock is a life-threatening condition that occurs when the body is not getting enough
• Shock requires immediate medical treatment and can get worse very rapidly.
Aetiology
• Shock can be caused by any condition that reduces blood flow including
Low blood volume as with heavy bleeding or dehydration
Changes in blood vessels as with infection or severe allergic reactions
Heavy external or internal bleeding from a serious injury
Spinal injuries can also cause shock
• Septic shock syndrome is an example of a type of shock from an infection
• Cardiogenic shock (associated with heart problems)
• Is an acute circulatory failure with sudden fall in cardiac output without actual reduction
• Cardiogenic shock is a disease state where the heart is damaged enough that it is unable to
• Occurs whenever the heart is unable to pump enough blood for the required needs.
• Some related disorders include heart attack, heart failure, cardiomyopathy, rupture of the
Hypovolemic Shock
• Hypovolemic shock is an emergency condition in which severe blood and fluid loss
• Is the type of shock that can cause many organs to stop working.
Severe fluid loss: e.g. Severe burns, crush injury of a limb, persistent diarrhoea &/or
vomiting.
Blood loss can be due to bleeding from cuts or other injury or internal bleeding such
as gastrointestinal tract bleeding.
The amount of blood in the body may drop when one loses too many other body
fluids which can happen with diarrhoea, vomiting, burns, and other conditions.
• The greater and more rapid the blood loss the more severe the shock symptoms
• Anaphylaxis is a severe whole-body allergic reaction
• On a subsequent exposure an allergic reaction occurs
Confusion, slurred speech, fainting, light-headedness, dizziness
Rapid or weak pulse, hypotension
Cyanosis
Hives and generalized itching
Anxiety
Sensation of feeling the heart beat (palpitations)
Nausea, vomiting and diarrhoea
Abdominal pain or cramping
Nasal congestion and cough
Septic Shock
• Septic shock is a serious condition that occurs when an overwhelming
• The brain, heart, kidneys, and liver may not work properly or may fail
• Complications of Septic Shock include
DIC (disseminated intravascular coagulation)
Multiple organ dysfunction syndrome
Acute Respiratory Distress Syndrome (ARDS)
Clinical Features of Shock
• A person in shock has extremely low blood pressure
Anxiety or agitation
Confusion
Pale, cool, clammy skin
Low or no urine output
Bluish lips and fingernails
Dizziness, light-headedness, or faintness
Profuse sweating, moist skin
Rapid but weak pulse
Shallow breathing
Chest pain
Unconsciousness
Management of Shock
Perform Pre-referral Management
• Urgently perform initial resuscitation for priorities to Airway, Breathing and Circulation
Maintain a clear airway. Extend neck, support jaw and suction
Ensure normal breathing. Use mechanical ventilator as indicated
Stop external bleeding
Monitor vital signs
Initiate I/V line
Immediately refer the patient to higher center
Management of Shock
Investigations
• FBP
• As this is a medical emergency, patients should be referred urgently after initial
Priorities: Airway- breathing- circulation.
Airway - maintain a clear airway. Extend neck, support jaw and suction.
Administer O2 by nasal catheter or ETT depending on severity.
Breathing- ensure normal breathing. Use mechanical ventilator as indicated.
Circulation- stop external bleeding, specific surgery to stop internal bleeding.
Administer fluids to maintain preload.
Oxygen Therapy
• Administer O2 via face mask, nasal catheter
Restore Blood Volume
• Insert large bore IV lines(14-16 gauge) or cut down and administer
• Modify myocardial contractility, heart rate and rhythm
(be careful to not induce tachycardia as that will cause further damage to the heart
muscle)
For Life threatening arrhythmias perform cardio version
Rhythm disturbances (ECG monitor)
• Treat arrhythmias with specific drugs (depending on the type of rhythm) and or
• The agents listed below should NOT be used unless you have the patient on a cardiac
Inotropic Agents: Adult Dosing
Dopamine(renal dose) 2-4 mcg/kg/min IV
Dobutamine 2.5- 10 mcg/kg/min IV
Adrenaline (epinephrine) 0.1 mcg/kg/min
Vasodilators for cardiogenic shock e.g. nitroprusside, nitroglycerine, hydralazine.
Traumatic Shock
• Stabilize chest defects, dress sucking wounds
• Exclude tamponade, tension pneumothorax and pulmonary embolism
• Antibiotics
underlying host defenses, the potential sources of infection and the most likely
responsible organisms.
Antibiotics must be broad spectrum and cover gram-positive, gram-negative and
anaerobic bacteria because all classes of these organisms produce an identical clinical
picture.
Antibiotics must be given parenterally in adequate doses.
Ant staphylococcal coverage is recommended in patients with an indwelling
intravascular line or devices.
Coverage directed against anaerobes should be included in patients with intraabdominal
or perineal infections.
Antipseudomonal coverage is indicated in patients with neutropenia or burns.
Immunocompetent patients usually can be treated with a single drug with broadspectrum.
Coverage such as a third generation cephalosporin.
Immunocompromised patients usually require dual antibiotic coverage with broadspectrum
antibiotics with overlapping coverage.
Within these general guidelines no single combination of antibiotics is clearly
superior to others.
Patients with infected foci should be taken for surgery after initial resuscitation and
administration of antibiotics.
Little is gained by spending hours to make the patient more stable when an infected
focus persists.
Anaphylactic Shock
• Airway- Intubation may be required and administer O2
• Hydrocortisone 100-250 mg IV or Methlprednisolone 50-100mg IM.
• Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed. Oxford: McGraw Hill
• Davidson, S (2006). Principles and practice of medicine 20th Ed. Churchill: Livingstone.
Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.
• Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold
• Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford
• Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.
• Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF
• Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby
perfusion resulting in
Hypotension
Tissue/cellular hypoxia
Impaired cellular metabolism & death due to an acute reduction of effective circulating
• Shock is a life-threatening condition that occurs when the body is not getting enough
• Shock requires immediate medical treatment and can get worse very rapidly.
Aetiology
• Shock can be caused by any condition that reduces blood flow including
Low blood volume as with heavy bleeding or dehydration
Changes in blood vessels as with infection or severe allergic reactions
Heavy external or internal bleeding from a serious injury
Spinal injuries can also cause shock
• Septic shock syndrome is an example of a type of shock from an infection
• Cardiogenic shock (associated with heart problems)
• Is an acute circulatory failure with sudden fall in cardiac output without actual reduction
• Cardiogenic shock is a disease state where the heart is damaged enough that it is unable to
• Occurs whenever the heart is unable to pump enough blood for the required needs.
• Some related disorders include heart attack, heart failure, cardiomyopathy, rupture of the
Hypovolemic Shock
• Hypovolemic shock is an emergency condition in which severe blood and fluid loss
• Is the type of shock that can cause many organs to stop working.
Severe fluid loss: e.g. Severe burns, crush injury of a limb, persistent diarrhoea &/or
vomiting.
Blood loss can be due to bleeding from cuts or other injury or internal bleeding such
as gastrointestinal tract bleeding.
The amount of blood in the body may drop when one loses too many other body
fluids which can happen with diarrhoea, vomiting, burns, and other conditions.
• The greater and more rapid the blood loss the more severe the shock symptoms
• Anaphylaxis is a severe whole-body allergic reaction
• On a subsequent exposure an allergic reaction occurs
Confusion, slurred speech, fainting, light-headedness, dizziness
Rapid or weak pulse, hypotension
Cyanosis
Hives and generalized itching
Anxiety
Sensation of feeling the heart beat (palpitations)
Nausea, vomiting and diarrhoea
Abdominal pain or cramping
Nasal congestion and cough
Septic Shock
• Septic shock is a serious condition that occurs when an overwhelming
• The brain, heart, kidneys, and liver may not work properly or may fail
• Complications of Septic Shock include
DIC (disseminated intravascular coagulation)
Multiple organ dysfunction syndrome
Acute Respiratory Distress Syndrome (ARDS)
Clinical Features of Shock
• A person in shock has extremely low blood pressure
Anxiety or agitation
Confusion
Pale, cool, clammy skin
Low or no urine output
Bluish lips and fingernails
Dizziness, light-headedness, or faintness
Profuse sweating, moist skin
Rapid but weak pulse
Shallow breathing
Chest pain
Unconsciousness
Management of Shock
Perform Pre-referral Management
• Urgently perform initial resuscitation for priorities to Airway, Breathing and Circulation
Maintain a clear airway. Extend neck, support jaw and suction
Ensure normal breathing. Use mechanical ventilator as indicated
Stop external bleeding
Monitor vital signs
Initiate I/V line
Immediately refer the patient to higher center
Management of Shock
Investigations
• FBP
• As this is a medical emergency, patients should be referred urgently after initial
Priorities: Airway- breathing- circulation.
Airway - maintain a clear airway. Extend neck, support jaw and suction.
Administer O2 by nasal catheter or ETT depending on severity.
Breathing- ensure normal breathing. Use mechanical ventilator as indicated.
Circulation- stop external bleeding, specific surgery to stop internal bleeding.
Administer fluids to maintain preload.
Oxygen Therapy
• Administer O2 via face mask, nasal catheter
Restore Blood Volume
• Insert large bore IV lines(14-16 gauge) or cut down and administer
• Modify myocardial contractility, heart rate and rhythm
(be careful to not induce tachycardia as that will cause further damage to the heart
muscle)
For Life threatening arrhythmias perform cardio version
Rhythm disturbances (ECG monitor)
• Treat arrhythmias with specific drugs (depending on the type of rhythm) and or
• The agents listed below should NOT be used unless you have the patient on a cardiac
Inotropic Agents: Adult Dosing
Dopamine(renal dose) 2-4 mcg/kg/min IV
Dobutamine 2.5- 10 mcg/kg/min IV
Adrenaline (epinephrine) 0.1 mcg/kg/min
Vasodilators for cardiogenic shock e.g. nitroprusside, nitroglycerine, hydralazine.
Traumatic Shock
• Stabilize chest defects, dress sucking wounds
• Exclude tamponade, tension pneumothorax and pulmonary embolism
• Antibiotics
underlying host defenses, the potential sources of infection and the most likely
responsible organisms.
Antibiotics must be broad spectrum and cover gram-positive, gram-negative and
anaerobic bacteria because all classes of these organisms produce an identical clinical
picture.
Antibiotics must be given parenterally in adequate doses.
Ant staphylococcal coverage is recommended in patients with an indwelling
intravascular line or devices.
Coverage directed against anaerobes should be included in patients with intraabdominal
or perineal infections.
Antipseudomonal coverage is indicated in patients with neutropenia or burns.
Immunocompetent patients usually can be treated with a single drug with broadspectrum.
Coverage such as a third generation cephalosporin.
Immunocompromised patients usually require dual antibiotic coverage with broadspectrum
antibiotics with overlapping coverage.
Within these general guidelines no single combination of antibiotics is clearly
superior to others.
Patients with infected foci should be taken for surgery after initial resuscitation and
administration of antibiotics.
Little is gained by spending hours to make the patient more stable when an infected
focus persists.
Anaphylactic Shock
• Airway- Intubation may be required and administer O2
• Hydrocortisone 100-250 mg IV or Methlprednisolone 50-100mg IM.
• Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed. Oxford: McGraw Hill
• Davidson, S (2006). Principles and practice of medicine 20th Ed. Churchill: Livingstone.
Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.
• Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold
• Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford
• Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.
• Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF
• Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby
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