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Shock

Acute Peripheral Circulatory Failure

Shock is defined as a life-threatening state of inadequate perfusion of tissues from various causes.


Presentation

Hypovolemic shock

The patients of hypovolemic shock present with a history of burns, trauma, bleeding, vomiting or diarrhea. Upon examination, the skin and mucosa are dry. There is orthostatic hypotension and the neck veins are collapsed.

Cardiogenic shock

In cardiogenic shock, the presenting symptoms may be chest pain, dyspnea, palpitations and dizziness. Upon physical examination, cyanosis may be seen. The pulses may also be faint and pulsus paradoxus can be present. Occasionally, a systolic murmur may be heard. Jugular venous distension may also be observed.

Distributive shock  

In septic shock, the patient may have a history of fever associated with chills and rigors. There may also be dysuria or shortness of breath depending upon the etiology. There may be a history of spinal trauma in case of neurogenic shock. Other findings suggestive of neurogenic shock include normal capillary refill time, areflexia and weakness below the level of the lesion and occasionally absent bulbocavernosus reflex.

Hypothermia
  • As part of the defence system, HSPs guarantee cell tolerance against a variety of stressors, including exercise, oxidative stress, hyper and hypothermia, hyper and hypoxia and improper diets.[ncbi.nlm.nih.gov]
  • : A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction Rapid and shallow breathing due to sympathetic nervous system stimulation and acidosis Hypothermia[en.wikipedia.org]
Pallor
  • Paleness of the face (pallor) 2. Cold, clammy skin 3. Fast, shallow breathing 4. Fast, weak pulse 5. Yawning or sighing 6. Confusion 7.[sja.org.uk]
Malaise
  • He was immediately hospitalized after developing fever, abdominal pain, malaise, and shock 16 hours after the commencement of the treatment. Abrupt acute brain swelling was noted 24 hours after hospitalization.[ncbi.nlm.nih.gov]
Dyspnea
  • But after the delivery of the placenta, the patient developed an episode of coughing and dyspnea followed by unconsciousness and bradycardia. She was given adrenaline and intubated, appearing ventricular fibrillation on a EKG.[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A 26-year-old Chinese man presented with dizziness, pruritus, dyspnea, hypotension, and tachycardia after eating cooked salted jellyfish. The patient had been stung twice by jellyfish half a year ago.[ncbi.nlm.nih.gov]
  • Treatment with TLV increased the urine volume and improved the dyspnea.[ncbi.nlm.nih.gov]
  • Cardiogenic shock In cardiogenic shock, the presenting symptoms may be chest pain, dyspnea, palpitations and dizziness. Upon physical examination, cyanosis may be seen. The pulses may also be faint and pulsus paradoxus can be present.[symptoma.com]
Hypotension
  • Persistent bleeding and uncontrollable hypotension are considered to be absolute indications for immediate surgical operation.[ncbi.nlm.nih.gov]
  • She was hypotension (90/60â ‰mm Hg), bradycardic (45 bpm) and was peripherally shut down.[ncbi.nlm.nih.gov]
  • OUTCOMES: Four days after initiating steroid administration, hypotension and bradycardia were improved and stable.[ncbi.nlm.nih.gov]
  • RESULTS: We established that hypotension was rare in children with severe febrile illness complicating only 29/3170 trial participants (0.9%).[ncbi.nlm.nih.gov]
  • We describe a previously healthy adolescent boy who presented with respiratory distress, hypotensive shock, and a diffuse erythematous rash. The final diagnosis was diabetic ketoacidosis.[ncbi.nlm.nih.gov]
Tachycardia
  • PATIENT CONCERNS: A 26-year-old Chinese man presented with dizziness, pruritus, dyspnea, hypotension, and tachycardia after eating cooked salted jellyfish. The patient had been stung twice by jellyfish half a year ago.[ncbi.nlm.nih.gov]
  • Acute anterioseptal myocardial infarction (Killip Class IV) with cardiogenic shock and arrhythmia including ventricular tachycardia and idionodal rhythm, and coronary artery dissection.[ncbi.nlm.nih.gov]
  • Low blood pressure and rapid heart rate (tachycardia) are the key signs of shock.[medicinenet.com]
  • However, there may be a slight rise in the heart rate (tachycardia tachy or fast cardia or heart). For example, donating blood.[emedicinehealth.com]
Cyanosis
  • Upon physical examination, cyanosis may be seen. The pulses may also be faint and pulsus paradoxus can be present. Occasionally, a systolic murmur may be heard. Jugular venous distension may also be observed.[symptoma.com]
Cold, Clammy Skin
  • Signs and symptoms of shock Signs of shock can include: weak, rapid pulse cold, clammy skin faintness/dizziness nausea. Immediately after an injury, people may show little evidence of experiencing shock.[healthywa.wa.gov.au]
  • Cold, clammy skin 3. Fast, shallow breathing 4. Fast, weak pulse 5. Yawning or sighing 6. Confusion 7.[sja.org.uk]
  • 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]
Confusion
  • Shock (not to be confused with emotional shock) is a life-threatening condition which happens when the body isn’t getting enough flow of blood.[sja.org.uk]
  • Synonyms for shock awe bump collapse confusion consternation disturbance earthquake excitement impact injury jolt scare trauma bombshell breakdown clash collision concussion crash distress encounter hysteria jarring percussion prostration ram start stroke[thesaurus.com]
  • […] signs and symptoms of shock include low blood pressure (hypotension); overbreathing (hyperventilation); a weak, rapid pulse; cold, clammy, grayish-bluish (cyanotic) skin; decreased urine flow (oliguria); and a sense of great anxiety and foreboding, confusion[medicinenet.com]
  • Shock Other names Circulatory shock Specialty Critical care medicine Symptoms Initial : Weakness, fast heart rate, fast breathing, sweating, anxiety, increased thirst [1] Later : Confusion, unconsciousness, cardiac arrest [1] Types Low volume, cardiogenic[en.wikipedia.org]
  • When you lose between 30% and 40% of your blood volume -- around a half-gallon -- your blood pressure will drop, you'll breathe fast, and you may get confused or flustered.[webmd.com]
Dizziness
  • Early dumping syndrome characterized by palpitation, dizziness, cold sweat, feebleness, and abdominal symptoms, occurs within 30 minutes after meals in patients who have undergone gastrectomy.[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A 26-year-old Chinese man presented with dizziness, pruritus, dyspnea, hypotension, and tachycardia after eating cooked salted jellyfish. The patient had been stung twice by jellyfish half a year ago.[ncbi.nlm.nih.gov]
  • After the last session of P-ESWL, he complained of dizziness. Physical examination revealed a large mass in the right abdomen.[ncbi.nlm.nih.gov]
  • Signs and symptoms of shock Signs of shock can include: weak, rapid pulse cold, clammy skin faintness/dizziness nausea. Immediately after an injury, people may show little evidence of experiencing shock.[healthywa.wa.gov.au]

Workup

In hypovolemic shock, the investigations that are helpful in evaluating a hemorrhagic etiology include complete blood count, prothrombin time, liver function tests, blood typing, disseminated intravascular coagulation panel. Upper and lower gastrointestinal tract endoscopy may be performed to look for hemorrhage. Abdominal imaging can also be used to visualize aortic aneurysm and other pathologies. The tests for non-hemorrhagic etiology include serum creatinine and electrolytes, serum lipase and liver function tests.

The investigations that are useful for detecting the etiology of cardiogenic shock include electrocardiography (ECG), cardiac enzymes, arterial blood gases, tox screen, lactic acid and blood urea nitrogen. The important tests for establishing the diagnosis of septic shock include complete blood count with differential, prothrombin time, lactic acid, arterial blood gases, C-reactive proteins, urinalysis and all cultures with gram stain. Abdominal imaging should be performed to look for liver abscess, peritoneal abscess, pancreatitis and intestinal obstruction.

Pneumoperitoneum
  • Tension pneumoperitoneum is a relatively rare occurrence in the pediatric population. However, tension pneumoperitoneum is associated with significant morbidity and mortality if it is not promptly diagnosed and treated.[ncbi.nlm.nih.gov]
Streptococcus Pneumoniae
  • BACKGROUND AND CASE PRESENTATION: We report a case of septic shock syndrome caused by Streptococcus pneumoniae in a patient who had undergone splenectomy due to an autoimmune lymphoproliferative syndrome (ALPS), which is characterized as a dysfunction[ncbi.nlm.nih.gov]

Treatment

The treatment of shock depends upon the etiology.

Hypovolemic shock

If shock is due to hemorrhage, blood is transfused into the patient. In case of dehydration, the circulating volume is restored with crystalloids or colloid solutions [5][6]. Inotropic support can also be given if required.

Cardiogenic shock

In cardiogenic shock, heart function is improved by providing inotropic support by dopamine, dobutamine or noradrenaline [7][8]. Thrombolytic therapy is given if a thrombotic etiology is suspected in myocardial infarction or if there is pulmonary embolism. Early revascularization by angioplasty or bypass surgery may be required. If there is any arrhythmia, it must be corrected.

Distributive shock 

Early fluid resuscitation is essential for a better prognosis in the cases of septic shock [9]. Broad spectrum antimicrobial therapy should promptly be started when the diagnosis of septic shock is made. Later on when culture reports are available, a better antibiotic can be administered if needed according to the causal pathogen. Inotropic agents may be used [10]. Intravenous fluids are given to achieve hemodynamic stability. Inotropic support by dopamine should be provided. If the patient has severe bradycardia, atropine may also be used.

Prognosis

Poor prognosis of cardiogenic shock is implied in the patients with old age and prior history of myocardial infarction. The mortality of the patients suffering from septic shock is higher at extremes of age and in immunosuppressive states (such as neutropenia, diabetes, alcoholism, renal and respiratory failure and hypogammaglobinemia). Positive blood cultures for the etiologic agents implies severe morbidity. Certain strains of bacteria (such as Pseudomonas) have a particularly high mortality. Hypovolemic shock is usually associated with a favorable prognosis if blood transfusion and intravenous fluids are promptly given.

Etiology

The etiology of shock depends upon its type.

Hypovolemic shock

Hypovolemic shock is usually associated with blood loss. The etiology of the blood loss may vary. Trauma to the liver, spleen, lungs or bones (in fracture) is associated with excessive hemorrhage which may lead to hypovolemic shock [1]. 

Gastrointestinal bleeding from ulcers, polyps and tumors can also cause significant blood loss. Other causes of blood loss include the rupture of the aortic or ventricular aneurysms, ectopic pregnancy and hemorrhagic ovarian cysts. 

Hypovolemic shock can also result from non-hemorrhagic causes such as dehydration (vomiting and diarrhea) and severe burns.

Cardiogenic shock

The risk factors for the development of cardiogenic shock include the following.

Cardiogenic shock can be a feature of conditions such as acute myocardial infarction, dilated cardiomyopathies, arrhythmias, valve defects, pericardial tamponade, constrictive pericarditis and aortic dissection.

Distributive shock

Distributive shock is due to abnormal distribution of blood flow causing relative hypovolemia. Septic shock is the most common cause of distributive shock.

The risk factors for the development of septic shock include the following.

The most common cause of septic shock in the elderly is urinary tract infection [2]. Anaphylactic shock and neurogenic shock are also common forms of distributive shock. Neurogenic shock is caused by injury of the spinal cord by fracture or displacement of the vertebra or during the administration of spinal anesthesia.

Obstructive shock

Obstructive shock occurs when an acute obstruction of the pulmonary or systemic blood flow develops as a result of congenital or acquired conditions. Possible causes are:

Epidemiology

Not much epidemiological data is available regarding hypovolemic shock. The incidence of cardiogenic shock in the patients of acute myocardial infarction is 5 to 10%. Severe sepsis occurs in as many as 3 cases per 1000 population in the United States. A study of the developed regions revealed septic shock to be the most common type of shock with 57% patients [3].

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of shock depends upon the type.

Hypovolemic shock

Hypovolemic shock results from significantly reduced volume of blood due to which the perfusion of all the tissues can not be effectively maintained.

Cardiogenic shock

Cardiogenic shock results from the failure of the pumping function of the heart.

Distributive shock 

Septic shock results from severe sepsis and is associated with the sequestration of large volume of blood in capillaries and veins [4]. Neurogenic shock results from the vasodilation and the loss of sympathetic tone in the vessels. The blood becomes pooled in the peripheral tissues.

Obstructive shock

Obstructive shock occurs when an acute obstruction of the pulmonary or systemic blood flow develops as a result of congenital or acquired conditions.

Prevention

There is no practical way to prevent hypovolemic or neurogenic shock. Cardiogenic shock can be prevented by reducing the risk factors for myocardial infarction and arrhythmias (such as avoidance of smoking, preventing obesity and avoiding the overdose of drugs that cause arrhythmias). Septic shock can be prevented if early antimicrobial therapy is started in the early stage of sepsis.

Summary

Shock is defined as a state of inadequate perfusion of the tissues of the body resulting in hypoxia and organ failure. Upon the basis of etiology and pathophysiology, shock is divided into four main categories:

Patient Information

Shock refers to the failure of the circulation of sufficient blood to all the tissues of the body. Shock may result from decreased volume of blood, abnormalities of the heart and nerves, and severe infection. It is an emergency condition and must be treated quickly. The treatment depends upon the cause and type of shock.

References

Article

  1. Clark DR. Circulatory shock: etiology and pathophysiology. Journal of the American Veterinary Medical Association. Jul 1 1979;175(1):78-81.
  2. Krcmery V. [Etiology and pathogenesis of septic shock]. Vnitrni lekarstvi. Jul 1996;42(7):467-469.
  3. Fisher JD, Nelson DG, Beyersdorf H, Satkowiak LJ. Clinical spectrum of shock in the pediatric emergency department. Pediatric emergency care. Sep 2010;26(9):622-625.
  4. Ackerman AD, Singhi S. Pediatric infectious diseases: 2009 update for the Rogers' Textbook of Pediatric Intensive Care. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Jan 2010;11(1):117-123.
  5. Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA : the journal of the American Medical Association. Nov 6 2013;310(17):1809-1817.
  6. Kobayashi L, Costantini TW, Coimbra R. Hypovolemic shock resuscitation. The Surgical clinics of North America. Dec 2012;92(6):1403-1423.
  7. Bourdarias JP, Dubourg O, Gueret P, Ferrier A, Bardet J. Inotropic agents in the treatment of cardiogenic shock. Pharmacology & therapeutics. 1983;22(1):53-79.
  8. Mueller HS. Inotropic agents in the treatment of cardiogenic shock. World journal of surgery. Feb 1985;9(1):3-10.
  9. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA : the journal of the American Medical Association. Sep 4 1991;266(9):1242-1245.
  10. Oba Y, Lone NA. Mortality benefit of vasopressor and inotropic agents in septic shock: A Bayesian network meta-analysis of randomized controlled trials. Journal of critical care. Apr 26 2014.

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Last updated: 2017-08-09 18:23