The signs and symptoms of shock include

• Hypotension (systolic blood pressure below 90 mmHg)
• Weak, rapid pulse
• Tachypnea (more than 20 breaths per minute) due to acidosis
• Flushing of skin due to vasodilation
• Tachycardia and palpitations (heart rate above 90 beats per minute)
• Low grade fever with rigor and chills
• Shortness of breath
• Confusion and light headedness
• Decreased urinary output
• Reduced platelet count
• Abdominal pain
• Multiple organ dysfunction syndrome (MODS): Dysfunction of two or more organs

• Fever

  Many view fever as the body's natural beneficial response to infection, whereas others contend that fever is harmful and should be controlled. [atsjournals.org]

  Antibiotic treatment was de-escalated after 21 days; 4 days later fever, leukocytosis, hypotension and acute renal failure relapsed. [ncbi.nlm.nih.gov]

  alcohol/drug withdrawal, delirium tremens, drug fever, fat emboli, deep venous thrombosis, postoperative fever (48 h), fever after transfusion An abdominal wall abscess is depicted on the CT scan below. [emedicine.medscape.com]

• Chills

  Soon after, he developed fever, chills and a rash around the tattoo, according to a report in the British Medical Journal (BMJ). [thesun.co.uk]

  It can impact any part of the body and some symptoms may include: High or very low temperatures Chills Rapid heart rate Shortness of breath Cool, pale extremities Restlessness, agitation, lethargy or confusion If you or someone you care for is experiencing [hospitals.jefferson.edu]

  At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness. As sepsis worsens, the heart beats rapidly, breathing becomes rapid, people become confused, and blood pressure drops. [merckmanuals.com]

  This begins with weakness, chills, and a rapid heart and breathing rate. Left untreated, toxins produced by bacteria can damage the small blood vessels, causing them to leak fluid into the surrounding tissues. [zana.com]

• Fatigue

  Many who do survive are left with life-changing effects, such as post-traumatic stress disorder (PTSD), chronic pain and fatigue, organ dysfunction (organs don’t work properly) and/or amputations. [sepsis.org]

  […] symptoms of shock vary depending on circumstances and may include: Cool, clammy skin Pale or ashen skin Bluish tinge to lips or fingernails (or gray in the case of dark complexions) Rapid pulse Rapid breathing Nausea or vomiting Enlarged pupils Weakness or fatigue [mayoclinic.org]

  With reno-ocular manifestations, TINU syndrome is accompanied by symptoms such as fever, fatigue, malaise, anorexia, vomiting, and arthralgia. TINU syndrome is reported mainly in children or adolescent girls, and it is rare in adults. [kci.go.kr]

  It took so long to have that confidence in my health again, especially when you're experiencing fatigue and migraines and these conditions that I hadn't had before," she said. [cbsnews.com]

• Acutely Ill Patient

  Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit Care Med. 2006 ;34(3): 589 – 597. Google Scholar | Crossref | Medline | ISI 5. Povoa, PR, Carneiro, AH, Ribeiro, OS. [doi.org]

  ill patient requiring medical intervention to maintain homeostasis 5/24/2014 INTRODUCTION 10.   EPIDEMIOLOGY  4.6 cases/1000 persons in a study in US  200,000 cases annually with 50% mortality  M>F(most studies M=52-66%)  Extreme of ages are more [slideshare.net]

  […] clinical trial evaluated 328 severely ill patients with acute renal dysfunction to evaluate the renal protective effects of low-dose dopamine. [scielo.br]

• Rigor

  All steroid drug classes possess biological plausibility to affect a beneficial clinical effect among children with septic shock, but none has undergone rigorous, prospective assessment in a large, high-quality pediatric interventional trial. [ncbi.nlm.nih.gov]

  "It has been almost two decades since a rigorous approach has been undertaken to better define sepsis and during that time a lot of new science has emerged examining the pathophysiology of sepsis, in particular how the body responds to it." [medpagetoday.com]

  Hypotension (systolic blood pressure below 90 mmHg) Weak, rapid pulse Tachypnea (more than 20 breaths per minute) due to acidosis Flushing of skin due to vasodilation Tachycardia and palpitations (heart rate above 90 beats per minute) Low grade fever with rigor [symptoma.com]

  Anaphylactic shock – Significant and sudden drop in BP – Tachycardia – Frequent cutaneous signs: rash, urticaria, angioedema – Respiratory signs: dyspnoea, bronchospasm Septic shock – High fever or hypothermia (< 36 °C), rigors, confusion – BP may be [medicalguidelines.msf.org]

• Tachypnea

  […] mentation [derived from Glasgow Coma Score <13]) while SIRS (including tachycardia >90 and tachypnea >20) criteria is deleted. [medintensiva.org]

  Organ dysfunction Tachypnea (PO2 and PCO2 decrease), restlessness, confusion, kidney and liver insufficiency, encephalopathy, respiratory insufficiency, myocardial insufficiency. [lecturio.com]

  […] volume Faster rate of volume loss → poor compensation → higher morbidity Patients with multiple comorbidities → poor compensation → higher morbidity Etiology Hemorrhagic fluid loss Non-hemorrhagic fluid loss Clinical features Weak pulse, tachycardia, tachypnea [amboss.com]

  […] oliguria; or acute alteration in mental status Shock caused by infection; frequently caused by gram negative bacteria, although some cases have been caused by other bacteria, viruses, fungi, and protozoa; characterized by fever, chills, tachycardia, tachypnea [icd9data.com]

  Components of SIRS include tachycardia, tachypnea, hyperthermia or hypothermia, and elevated white blood count. [medpagetoday.com]

• Hyperpnea

  Some clues to a septic event include: Fever or unexplained signs with malignancy or instrumentation Hypotension Oliguria or anuria Tachypnea or hyperpnea Hypothermia without obvious cause Bleeding Physical Examination A thorough physical exam is essential [atsu.edu]

• Hypotension

  (hyperlactatemia without refractory hypotension), and a typical group (both refractory hypotension and hyperlactatemia). [ncbi.nlm.nih.gov]

  Scheeren Abstract Author Information Authors Article Metrics Metrics Norepinephrine is the first-line agent recommended during resuscitation of septic shock to correct hypotension due to depressed vascular tone. [journals.lww.com]

  Endogenous vasopressin levels are significantly lower in adult patients with severe sepsis which is thought to contribute to the hypotension of shock. [openanesthesia.org]

  Septic shock in children is defined as sepsis and cardiovascular organ dysfunction, not necessarily with hypotension. [pediatrics.aappublications.org]

• Tachycardia

  A 74-year-old woman presenting with sepsis demonstrated AF tachycardia characterised by severe hypotension. [ncbi.nlm.nih.gov]

  Hypotension, oliguria, tachycardia, and altered mental status indicate that the patient is in shock! [amboss.com]

  Fall in blood pressure, prolonged capillary refill time, tachycardia and tachypnoea occurring jointly or in various combinations provide an early clue. [academic.oup.com]

  Hypotension was present in 34% ( n = 120); the most common findings were tachycardia ( n = 251 [73%]) and skin-color changes ( n = 269 [78%]). [pediatrics.aappublications.org]

• Weak Pulse

  Symptoms of shock include Confusion or lack of alertness Loss of consciousness Sudden and ongoing rapid heartbeat Sweating Pale skin A weak pulse Rapid breathing Decreased or no urine output Cool hands and feet Shock is a life-threatening medical emergency [medlineplus.gov]

  References:[4][5][6] Cardiogenic shock Definition: systolic BP < 90 mm Hg with urine output < 20 mL/hr and normal or elevated left ventricular filling pressure Pathophysiology: ↓ stroke volume Etiology Clinical features Weak pulse, tachycardia Cold, clammy [amboss.com]

  pulses and cold clammy extremities. [accessmedicine.mhmedical.com]

  Symptoms of all types of shock include: Rapid, shallow breathing Cold, clammy skin Rapid, weak pulse Dizziness or fainting Weakness Depending on the type of shock the following symptoms may also be observed: Eyes appear to stare Anxiety or agitation Seizures [medicinenet.com]

  They may also check for: low blood pressure weak pulse rapid heartbeat Once they’ve diagnosed shock, their first priority is to provide lifesaving treatment to get blood circulating through the body as quickly as possible. [healthline.com]

• Renal Injury

  CONCLUSION: This case offers a guideline for the clinical management towards survival of GITB in transplant patients, complicated by septic shock and multiple organ failure, including acute renal injury and ARDS. [ncbi.nlm.nih.gov]

  The mechanism is by systemic hypotension, direct renal vasoconstriction, release of cytokines (eg, TNF), and activations of neutrophils by endotoxins and other peptides, which contribute to renal injury. [csh.org.tw]

  Growing evidence indicates that balanced crystalloids (lactated Ringer solution, Plasma-Lyte) are associated with a lower incidence of renal injury, less need for renal replacement therapy, and lower mortality in critically ill patients. [ccjm.org]

• Uremia

  In order to avoid uremia, it is recommended that renal replacement therapy be instituted early in the course of oliguric acute kidney injury in patients with severe sepsis or septic shock. → Recommendation level E (evidence level V: expert opinion) Comment [oadoi.org]

• Altered Mental Status

  CASE REPORT Our case involves an elderly man presenting with altered mental status of unknown etiology, in addition to hemodynamic instability, presumably due to septic shock, without any overt signs of bleeding. [ncbi.nlm.nih.gov]

  Signs of septic shock include low blood pressure, a rapid heart rate, altered mental status, and the need for a ventilator. Septic shock is life-threatening and requires immediate attention. [verywellhealth.com]

  Hypotension, oliguria, tachycardia, and altered mental status indicate that the patient is in shock! [amboss.com]

  mental status Renal - decreased urine output Pulm - acute lung injury or ARDS Heme - DIC or thrombocytopenia (plts GI - elevated bilirubin (>4) - due to poor perfusion of liver and cytokines Septic Shock = Sepsis + Hypotension refractory to fluids 2) [errolozdalga.com]

• Dizziness

  You may have fever, fast breathing, dizziness, or a fast heart rate if your infection has spread in your body. Care Agreement You have the right to help plan your care. [drugs.com]

  In addition to the symptoms of sepsis and severe sepsis, symptoms of septic shock can include Rapid pulse Dizziness or light-headedness Lower than normal body temperature Rapid breathing You may have a higher risk of going into septic shock if you have [sepsis.org]

  […] diabetes, Cirrhosis or kidney failure people with lowered immune systems, such as those with HIV or AIDS or those receiving chemotherapy Symptoms of septic shock Symptoms of septic shock include: low blood pressure (hypotension) that makes you feel dizzy [zana.com]

  Symptoms in older children and adults: - High temperature - Chills and shivering - Fast heartbeat - Fast breathing - Feeling dizzy or faint - Confusion and disorientation - Diarrhoea - Nausea and vomiting - Slurred speech - Severe muscle pain -B reathlessness [thesun.co.uk]

  […] shock vary depending on circumstances and may include: Cool, clammy skin Pale or ashen skin Bluish tinge to lips or fingernails (or gray in the case of dark complexions) Rapid pulse Rapid breathing Nausea or vomiting Enlarged pupils Weakness or fatigue Dizziness [mayoclinic.org]

• Agitation

  It can impact any part of the body and some symptoms may include: High or very low temperatures Chills Rapid heart rate Shortness of breath Cool, pale extremities Restlessness, agitation, lethargy or confusion If you or someone you care for is experiencing [hospitals.jefferson.edu]

  […] skin Bluish tinge to lips or fingernails (or gray in the case of dark complexions) Rapid pulse Rapid breathing Nausea or vomiting Enlarged pupils Weakness or fatigue Dizziness or fainting Changes in mental status or behavior, such as anxiousness or agitation [mayoclinic.org]

  […] mottled, cool extremities (cold shock) Decreased urine output (caused by poor circulatory perfusion) (less than 1 ml/kg/hr is oliguria) narrowing pulse pressure (cold shock) Disability: mental status changes occur as shock progresses restlessness → agitation [acls-algorithms.com]

  Symptoms may include: Cool, pale arms and legs High or very low temperature, chills Lightheadedness Little or no urine Low blood pressure, especially when standing Palpitations Rapid heart rate Restlessness, agitation, lethargy, or confusion Shortness [medlineplus.gov]

• Stupor

  On ICU 10th day, however, he experienced septic shock, with tachycardia, fever and a stuporous mental state. His blood pressure decreased despite receiving vasopressor and inotropic agents. [doi.org]

Laboratory tests

• Blood pressure
  
  • pO2
  • pCO2
  • Electrolytes
  • Clotting factors
  • Lactic acid levels
  • Platelet count

• Pulse oxymetry
• Blood and sputum cultures for microbes
• Urinalysis
• Liver function tests (LFTs)
• Renal function tests (RFTs)

Imaging

• Radiography of the chest
• Computerized tomography (CT) scans
• Magnetic resonance imaging (MRI)
• Ultrasound

Others

• Electrocardiography

• Hypoglycemia

  In this paper a case report was presented on a 67-year-old man who died of septic shock with hypoglycemia (BG 13mg/dl). The pathological diagnosis was hepatic cirrhosis and acute bacterial pneumonia. [dspace.lib.niigata-u.ac.jp]

  The patient was tachycardic with a rate of 114 bpm and initial labs showed thrombocytopenia (platelets 56 x 103/uL [140-440 x 103/uL]), hypoglycemia (15mg/dl [70-105mg/dl]), an elevated creatinine (2.7mg/dL [0.7- 1.25mg/dL]), and aspartate aminotransferase [ncbi.nlm.nih.gov]

  Other issues caused by septic shock, such as metabolic problems, hypoglycemia, hypocalcemia and other electrolyte problems can either directly or indirectly affect the brain. [abclawcenters.com]

  Results -> no increase in mortality -> no difference in inotropes -> excess superinfection rate Conclusions – in septic shock patients treated with hydrocortisone there was: no benefit from intensive insulin therapy, it led to increased episodes of hypoglycemia [lifeinthefastlane.com]

  Furthermore, inaccuracies inherent in point-of-care glucose monitoring may underestimate the incidence of hypoglycemia. [clinicaladvisor.com]

• Hyperlactacidemia

  Additionally, although all patients met the criteria for the previous definition of septic shock [ 9 ], approximately one fourth ( n = 139) of the included patients had no hyperlactacidemia (i.e., serum lactate >2 mmol/L) upon ICU admission and would [ccforum.biomedcentral.com]

• Staphylococcus Aureus

  The image below depicts embolic lesions in patient with Staphylococcus aureus endocarditis. Embolic lesions in patient with Staphylococcus aureus endocarditis. [emedicine.medscape.com]

  In particular, 32.9% of Klebsiella pneumoniae isolates were resistant to carbapenem, 33.6% of Staphylococcus aureus to methicillin, and 28.7% and 43.9% of Escherichia coli isolates to third-generation cephalosporins and fluoroquinolones, respectively. [ncbi.nlm.nih.gov]

  Septic shock acute organ dysfunction, streptococcal Septic shock due to Hemophilus influenza septicemia with acute organ dysfunction Septic shock due to methicillin susceptible Staphylococcus aureus septicemia with acute organ dysfunction Septic shock [icd9data.com]

  In order to investigate the compliance to current Swedish guidelines for diagnosis and coding of severe sepsis and septic shock, we studied the medical records from 300 patients with Escherichia coli bacteremia and 300 patients with Staphylococcus aureus [portal.research.lu.se]

• Pseudomonas

  Furthermore, nosocomial infections such as invasive aspergillosis and Pseudomonas aeruginosa occurred during hospitalization. [ncbi.nlm.nih.gov]

  […] anaerobic Septic shock acute organ dysfunction, Escherichia coli Septic shock acute organ dysfunction, gram negative Septic shock acute organ dysfunction, meningococcal Septic shock acute organ dysfunction, MRSA Septic shock acute organ dysfunction, Pseudomonas [icd9data.com]

  Pseudomonas aeruginosa Escherichia coli Klebsiella sp. Staphylococcus sp. [atsu.edu]

The treatment of septic shock consists of the following:

• Immediate hospitalization
• Breathing should be stabilized by oxygen therapy.
• Endotracheal intubation should be done, if necessary.
• Intravenous fluids to maintain blood pressure (volume resuscitation). Continuous monitoring of blood pressure should be done.
• Vasopressor drugs (like dopamine or norepinephrine) for maintenance of blood pressure.
• Inotropic drugs (for example, dobutamine) to increase the heart rate [6].
• Antibiotics (wide spectrum) for treatment of concomitant infection.
• Empirical antimicrobial therapy [7]
• Unfractionated heparin or low-molecular-weight heparin (LMWH) for management of disseminated intravascular coagulation.
• Corticosteroids for reducing inflammation [8][9]
• Protein C [10]
• Insulin therapy for blood sugar level maintenance.
• Dialysis
• Excision and drainage surgery for collection of pus in case of infections.

Mortality rate due to septic shock is very high due to delay in management and treatment of septic shock. Almost 50% of the patients of septic shock die. The mortality rate is about 40% in adults and approximately 25% in children. With immediate medical care, about 95% of the patients can recover but most die due to difficulty in recognizing the symptoms of shock and establishing a diagnosis.

The causes of septic shock include the following [1] [2]:

• Microbial infections causing septicemia (bacteremia or viremia)
  
  • Bacterial (gram positive bacterial infections are more common than gram negative ones, MRSA being the most common one)
  • Viral
  • Fungal
  • Super antigens (for example, toxic shock syndrome)

The risk factors for the development of sepsis include:

• Immunocompromised states (diabetes mellitus, AIDS, leukemia, organ transplant, etc.)
• Urinary tract infections (UTIs)
• Respiratory infections
• Gastrointestinal infections
• Long term catheterization
• Long term use of antibiotics and steroids
• Recent surgery
• Burn injuries
• Pregnancy
• Chronic illnesses (for example, cirrhosis, renal disease, etc.)
• Obesity
• Open wounds and fractures

More than 20 million cases of septic shock are registered per year. Elderly, children and immunocompromised patients are more susceptible due to weak immune systems as compared to healthy adults who are better equipped to fight systemic infections.

Men have been shown to be more susceptible to the complications of sepsis as compared to women. Higher incidence of sepsis and thereby, septic shock has been found among the Black populations.

Hemodynamic changes are the basic mechanism involved in pathogenesis of the disease. The endotoxins and microbial products activate multiple pathways that include the following [3][4] [5]:

• Activation of complement system product C3a which leads to endothelial activation. Endothelial activation causes the activation of procoagulant factors (tissue factor), nitric oxide (NO), reactive oxygen species and various cytokines (IL-6, IL-8, platelet activating factor (PAF)). All these factors lead to vasodilation and increased capillary permeability. Inadequate organ perfusion results leading to multiorgan failure.
• Activation of procoagulant factor XII and antifibrinolytic factors (plasminogen activator inhibitor, PAI-1) cause widespread disseminated intravascular coagulation (DIC) that causes thrombosis. As a result, inadequate tissue perfusion and tissue ischemia ensue.
• Activation of monocyte-neutrophil system causing the release of tumor necrosis factor (TNF) and various cytokines like interleukin-1 (IL-1) and high mobility group box 1 protein (HMGB1). These cytokines cause release of IL-10 and secondary inflammatory mediators that lead to apoptosis and ultimately cause immunosuppression. These cytokines also result in systemic manifestations like fever, metabolic abnormalities and decreased myocardial contractility.

The disease occurs in 3 stages:

• Non-progressive phase: Compensatory mechanisms are activated during this stage. The perfusion of vital organs is, however, maintained.
• Progressive stage: Circulatory and metabolic imbalances occur. Tissue hypo perfusion worsens during this stage.
• Irreversible stage: Irreversible tissue injury occurs and death is inevitable.

• Immediate treatment of bacterial and viral infections can help prevent sepsis and thereby, the septic shock.
• Long-term catheterization should be avoided to prevent nosocomial infections.
• Prophylactic therapy after surgeries can help prevent secondary infections.
• Surgeries should be avoided if they can be.
• Strict septic protocol should be followed during the surgical procedures.
• Vaccination against streptococcal and pneumococcal strains can help prevent septic shock that develops secondary to these infections.
• Open wounds should be properly washed and cleansed with antiseptic.

Septic shock is a condition in which body-wide infection occurs leading to involvement and failure of more than one organ. Marked hypotension can even lead to death if prompt treatment is not given. Sepsis or septic shock is most common in patients who are immunocompromised, have bacterial or viral infections or in children and elderly due to weakened immune mechanisms.

Septic shock is a condition in which an infection can trigger wide spread immune response in the body, as a result of which vital organs shut down.

Early signs and symptoms of the disease include lowering of blood pressure, increased respiratory and heart rate, confusion and agitation. Fever is a common symptom. The patient also feels difficulty in breathing and abdominal pain.

Diagnosis of this condition is difficult. Such patients should be immediately treated and hospitalized. Blood pressure, breathing and heart rate should be stabilized. With care, patient can recover but delay in the treatment can lead to death of the patient.

1. Hardaway RM. The etiology and treatment of traumatic and septic shock. Comprehensive therapy. Jun-Jul 1999;25(6-7):330-334.
2. Robin M, Le Gall JR. [Septic shock. Symptoms, etiology and treatment]. La Revue du praticien. Feb 21 1975;25(11):841-848.
3. Glauser MP, Heumann D, Baumgartner JD, Cohen J. Pathogenesis and potential strategies for prevention and treatment of septic shock: an update. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Feb 1994;18 Suppl 2:S205-216.
4. Lansing AM. The Pathogenesis and Treatment of Septic Shock. The Journal of the Kentucky Medical Association. Aug 1964;62:590-595.
5. Calandra T. Pathogenesis of septic shock: implications for prevention and treatment. Journal of chemotherapy. Nov 2001;13 Spec No 1(1):173-180.
6. Dupeyron JP, Pottecher T, Haberer JP, Gauthier-Lafaye JP. [Use of dobutamine in the treatment of septic shock]. Anesthesie, analgesie, reanimation. Sep-Oct 1977;34(5):917-927.
7. Zlotorowicz M. [Treatment of severe sepsis and septic shock--are antibiotics the only remedy to treat infections?]. Przeglad epidemiologiczny. 2001;55 Suppl 3:81-84.
8. Nguyen HB, Corbett SW, Menes K, et al. Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Jan 2006;13(1):109-113.
9. Cicarelli DD, Vieira JE, Bensenor FE. Early dexamethasone treatment for septic shock patients: a prospective randomized clinical trial. Sao Paulo medical journal = Revista paulista de medicina. Jul 5 2007;125(4):237-241.
10. Hasin T, Leibowitz D, Rot D, Weiss Y, Chajek-Shaul T, Nir-Paz R. Early treatment with activated protein C for meningococcal septic shock: case report and literature review. Intensive care medicine. Jul 2005;31(7):1002-1003.