Shock DR Sadia Hussain: Assistant Professor Pediatric Medicine King Edward Medical University Lahore

SHOCK
Dr Sadia Hussain
MBBS, FCPS
Assistant Professor Pediatric Medicine
King Edward Medical University Lahore
DEFINITION
• “A life threatening condition that leads to global
tissue hypoperfusion and impaired cellular
metabolism, manifested in turn by serious
pathophysiological abnormalities”.
• “ A state in which profound widespread

reduction of effective tissue perfusion leads first
to reversible, and then if prolonged, to
irreversible cellular injury”
PATHOPHYSIOLOGY
• Circulatory insufficiency creating imbalance
between oxygen delivery and demand of
tissues, resulting in end organ dysfunction.
• At cellular level mitochondria are affected
first.
• Anaerobic metabolism starts due to oxygen
absence leading to lactic acid production and
metabolic acidosis.
STAGES OF SHOCK
• PRE-SHOCK: compensated phase with normal
B.P.
• SHOCK: compensatory mechanism of body
overwhelmed
• END-ORGAN FAILURE: irreversible organ
damage and death
HOW TO RECOGNIZE SHOCK
• Tachypnea, Tachycardia and cutaneous
vasoconstriction may be early signs of shock.
• Hypotension develops late and ABSENCE OF
HYPOTENSION DOES NOT EXCLUDE SHOCK.
• Serum lactic acid and base deficit are good
parameters for detecting presence and extent
of shock.
CAUSE OF SHOCK
• To be determined by;
• A thorough detailed history
• Detailed physical examination
• Urgent investigations like blood gases,
imaging,bedside USG.
CLASSIFICATION OF SHOCK
• A) HEMORRHAGIC SHOCK( HYPOVOLEMIC)
• B) NON-HEMORRHAGIC SHOCK INCLUDING

1) Septic shock
2) Cardiogenic shock
3) Obstructive shock ( tension pneumothorax,
pericardial tamponade)
4) Neurogenic shock
5) Anaphylactic shock
HEMORRHAGIC SHOCK / HYPOVOLEMIA
• Loss of intravascular volume leads to dec

preload and cardiac output
• In early phase volume loss leads to
baroreceptor activation causing peripheral
vaso-constriction, inc cardiac contractility and
inc in HR and diastolic pressure leading to
narrow pulse pressue.
• As loss progresses COP fall leading to fall in BP.
MANAGEMENT
• Secure airway and optimize breathing.
• Stop bleeding.
• Restore blood volume by fluids and/or blood.
• Initial fluid volume is 20ml/kg in bolus and
may be repeated 3times.
• Target goal of fluid resuscitation is to maintain
urine output 0.5-1ml/kg/hr.
SEPTIC SHOCK
• Most common form of distributive shock
• Combination of hypovolemia, CVS depression,
capillary leak and systemic infection are to be
considered.
• Common causative org are step.pneumonie,
staph.aureus, klebsiella, pseudomonas etc.
SYSTEMIC INFLAM ATORY SYNDROM
labelled if 2 or more of followings present,

• Temp <97F or >101F
• HR >2SD or<10th centile
• RR >2SD or on vent
• TLC > or < than normal or 10% bands
SEPSIS
• SIRS+ suspected/confirmed infection.
SEVERE SEPSIS
• Sepsis + CVS dysfunction or ARDS or >1 organ
system dysfunction.
SEPTIC SHOCK
• Sepsis + CVS dysunction persisting after atleast
40ml/kg fluid in 1hr
OR
Requirement of vasoactive agents
MAY BE COLD/WARM SHOCK.

INVESTIGATIONS
• CBC to see dec in plt, inc/dec in TLC or inc
bands
• Coagulation profile and FDPs
• Blood and urine cultures
• Blood sugar, electrolytes, alumin, ABGs,
lactate
• CRP, PROCALITONIN
MANAGEMENT
• Early recognition & prompt intervention
• Airway & breathing support
• Initial fluid resuscitation
• Antibiotic therapy
• Ionotrops and vasopressors if needed
• GOALS OF THERAPY are CRT<2sec, normal BP for
age, warm extremities with good periph. Pulses,
UOP>1ml/kg/hr and normal mental statu
CARDIOGENIC SHOCK
• Happens when> 40% myocardium becomes non
functional due to ischemia, inflammation or toxins.
• Dec in cardiac output due to pump failure, valve
insufficiency or arrythmias.
• Present as ill, drowsy, sweaty, pale with
tachycardia, feeble pulses and hypotension
• UOP will be dec and serum lactate ll be raised.
• For diag cardiac markers,ECG nd echo may be
needed.
MANAGEMENT
• Airway breathing stabilization
• Start ionotropes
• Treat arrythmias if any
• Correct electrolyte imbalance if any
• Treatment of cause like steroids in Rheumatic
fever or SLE carditis, thrombolysis/ angioplasty
more in adults
OBSTRUCTIVE SHOCK
• Due to extra cardiac problems leading to Rt
heart failure.
• PULMONARY: embolism/ sev pulm HTN.
• MECHANICAL: dec in VR to Rt heart like in
tamponade, tension pneumothorax,
constrictive pericarditis.
• Treat underlying cause.
NEUROGENIC SHOCK
• Due to severe brainstem or spinal injury
resulting in autonomic system disruption.
• Treated with good fluid and vasopressor
resuscitation.
ANAPHYLACTIC SHOCK
• IgE mediated response due to insect stings,
food or medicines.
• Cardinally circulatory collapse associated with
bronchospasm, inc airway resistance, skin
manifestations as urticaria, GIT inv.
MANAGEMENT
• Airway breathing stabilization
• Epinephrine s/c, i/m
• Steroids
• Antihistamines
• Fluids
• bronchodilators

Shock DR Sadia Hussain: Assistant Professor Pediatric Medicine King Edward Medical University Lahore

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SHOCK

• “ A state in which profound widespread

• B) NON-HEMORRHAGIC SHOCK INCLUDING

• Loss of intravascular volume leads to dec

labelled if 2 or more of followings present,

MAY BE COLD/WARM SHOCK.

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