Shock Its Types and Management

Afza.Malik GDA

Whats is Shock Is Types and Nursing Management 

Shock Its types and Management

Shock its types and engagement ,Sepsis And Septic Shock, Cardiogenic Shock, Hypovolemic, Neurogenic Shock, Shock,Obstructive Shock and Anaphylactic shock.

Sepsis And Septic Shock

    Septic shock is a systemic response to a serious infection. The septic shock can cause death or dysfunction of one or more organs. The mortality rate from septic shock remains high despite advances in treatment.


The criteria falls under Systemic Inflammatory Response Syndrome (SIRS) when:

Any  2 of the following:

 Tachypnea > 20/minute or 

PaCO3 < 32 mm Hg on arterial blood gas (ABG) 

White blood cell count (WCC) < 4,000 or > 12,000

Heart rate > 90 bpm Temperature >38 or <36.


    SIRS due to a suspected or proven infectious source, such as a positive blood culture, CXR, or other findings.

Severe Sepsis:

    Signs of end organ dysfunction such as kidney damage, liver dysfunction, mental changes, increased lactate, coagulation disorders, etc.

Septic Shock:

Refractory hypotension even after adequate fluid intake. 


    Patients will present with hypotension and target organ hypoperfusion. In addition to the systemic features mentioned above, organ damage is manifested by altered mental status, respiratory and cardiovascular instability, liver disorders, acute kidney injury, and impaired coagulation. Lactate levels are increased due to tissue perfusion problems and are used in targeted therapy. Initially warm peripheries due to vasodilation. 

    This will present initially with reduced peripheral resistance, increased cardiac index, tachycardia, and hypotension; but later it can be affected by heart failure. Sepsis and septic shock are a systemic response to a serious infection. This can lead to multiple organ dysfunction and death. The mortality rate from septic shock remains high despite advances in treatment.

Differential Diagnosis

Other types of shock such as hypovolemic, cardiogenic, obstructive and anaphylactic shock.


    Once severe sepsis or septic shock is identified, time is of the essence. Treatment should begin according to the guidelines for survivors of sepsis. Prompt evaluation and initiation of treatment is essential. Blood cultures should be collected along with cultures from suspected sources, and broad-spectrum antibiotics should be started based on local guidelines and suspected organisms. Fluids should be given to correct hypovolemia. 

    Urine output should be measured regularly and responsiveness to fluids should be measured. Lactate levels can be used for targeted therapy. Monitoring of central venous pressure for fluid requirements and initiation of vasoactive therapy may be necessary. If hypotension persists, norepinephrine is the drug of choice. If respiratory failure occurs, ventilatory support may be required. Vasopressin may be required in resistant cases and renal replacement therapy in renal failure and acidosis.

Surviving Sepsis Campaign Packs
Ready In 3 Hours:

1. Measure the lactate value

2. Collect blood cultures before administering antibiotics

3. Administer broad spectrum antibiotics

 4. Administer 30 mL/kg crystalloids for hypotension or 24 mmol/L lactate.

Ready in 6 hours:

5. Use of vasopressors (for hypotension unresponsive to initial fluid administration) to maintain a mean arterial pressure (MAP) of 265 mm Hg

 6. For persistent arterial hypotension despite volume replacement (septic shock) or initial lactate 24 mmol/L (36 mg/dL):

-Measure central venous pressure (CVP)* Measure central venous oxygen saturation (Scvo2)3

7. Measure lactate again if baseline lactate was elevated. The targets for quantitative resuscitation included in the guidelines are PVC of 28 mm Hg: Scvo2 of 270% and lactate normalization.

Cardiogenic Shock

    Cardiogenic shock is insufficient tissue perfusion resulting from a primary heart problem due to myocardial or valvular dysfunction. It presents with hypotension, cool peripheries, dilated jugular veins, oliguria, altered mental status, and respiratory failure due to pulmonary edema. The central venous pressure can be increased with high systemic vascular resistance and a reduced cardiac index.


Heart attack

left ventricular failure


heart valve abnormalities trauma.

This must be distinguished from other forms of shock.


    Identify and attempt to treat the cause if possible. For myocardial infarction, reperfusion therapy should be initiated as soon as possible. Depending on the volume status and in the case of a right ventricular infarction, patients may require fluids. The pulmonary artery flotation catheter can help guide fluid therapy. Dobutamine can be used for its indicator effect, as can phosphodiesterase inhibitors such as milrinone/enoximon and levosimendan. 

    Dopamine and norepinephrine can be used with caution in resistant hypotension. Vasodilators are preferred when blood pressure is more stable. Diuretics are used for pulmonary edema along with non-invasive ventilation to relieve strain on the heart. In refractory cases, intra-aortic balloon counterpulsation and rescue PCI/CABG are used. Patients with recoverable ventricular failure or patients awaiting transplantation may receive left or right ventricular assist devices (LVAD/RVAD) and extracorporeal membrane oxygenators (ECMO).

Hypovolemic Shock

    Hypovolemia is the result of decreased circulating blood volume leading to target organ dysfunction or damage. This is also associated with salt depletion, thus differing from dehydration, which is a predominant loss of free water. It presents with hypotension, cold periphery, collapsed veins, impaired capillary refill time, and organ dysfunction such as acute kidney injury with oliguria, tachycardia, tachypnea, and altered mental status.


trauma and bleeding diarrhea and vomiting

bad burns

Surgical blood loss.



This must be distinguished from other causes of shock.


    Prompt detection is essential for treatment of this condition. If fluid treatment is started early, any abnormalities can be corrected early. Assess airway and breathing, followed by fluid estimation and recovery. Blood and colloids are used judiciously based on blood loss and volume status. Vital signs are checked regularly for response and adequacy of resuscitation. Surgical advice should be obtained early to locate and control the source of bleeding.

Obstructive Shock

    Extracardiac obstruction of blood flow can lead to obstructive shock, in which effective circulatory flow is restricted. It can present as cardiogenic shock with hypotension, tachycardia, cold peripheries, dilated jugular veins, pulsus paradoxus, reduced heart sounds, kidney damage, and altered mentality. The ECG may show tachycardia and reduced amplitude. 


Impaired diastolic filling (reduced preload) Direct venous obstruction (vena cava obstruction) due to intrathoracic tumors

Increased intra-thoracic pressure  

    tension pneumothorax

    Positive pressure mechanical ventilation asthma

Decreased cardiac compliance

              cardiac tamponade constrictive pericarditis

               Impaired systolic contraction (increased afterload)

 Right ventricle

                pulmonary embolism,

                acute pulmonary hypertension

Left ventricle

                 saddle embolism

                 Aortic dissection (rare).

    Diagnosis begins with suspicion of the disease. CXR can diagnose pneumothorax and pulmonary embolism in some cases. The echocardiogram will diagnose tamponade and distention of the right heart in pulmonary embolism. The tamponade may be due to infection (tuberculosis), uremia, trauma, malignancy, or an idiopathic cause. This must be distinguished from constrictive pericarditis, restrictive cardiomyopathy, left ventricular failure, and right ventricular failure.


    Once the problem is diagnosed, appropriate treatment should be instituted. Liquids should be used with caution. Many of the conditions are life-threatening if not treated promptly. In the case of tension pneumothorax, a needle thoracotomy followed by insertion of an intercostal drain can immediately improve hemodynamics. PE can be treated with thrombolysis and cardiac tamponade as described above. In appropriate cases, surgical advice should be obtained as soon as possible. 

Neurogenic Shock

    Neurogenic shock is a type of distributive shock that causes hypotension along with bradycardia. This is due to a failure of the autonomic system as a result of a spinal cord injury. This leads to a reduction in sympathetic tone in the blood vessels with accumulation of blood in the periphery. If the injury is above T6, loss of thoracic sympathetic tone results in bradycardia with hypotension; whereas when lower, unimpeded sympathetic tone causes and increases contractility. The extremities are hot above the level of injury and cold below the level of injury. Hypotension is severe and occasionally treatment-resistant. This must be differentiated from other causes of shock.


Brain Damage

Injury to the cervical or upper thoracic spine.


    The site of the injury should be examined. Fluids are the initial treatment for such spinal shock. Fluid resuscitation may be followed in selected cases by vasopressor support with norepinephrine or dopamine. Vasopressin can also be used in resistant cases. If bradycardia persists, atropine can also be used. Ventilation support may be required if the injury is higher and spinal stabilization is required in such cases.

Anaphylactic shock

    An anaphylactic reaction is an IgE-mediated allergic reaction that can result in shock and death if not recognized and treated promptly. Symptoms commonly include a rash, swelling of the throat, wheezing, and hypotension. It appears between 5 and 30 minutes after exposure, although this can last for several hours. This leads to the sudden release of immune mediators from mast cells and basophils. 

    This causes a general condition of the system leading to skin rashes, angioedema, bronchospasm, tachycardia, hypotension, arrhythmia, convulsions, diarrhea, seizures and coma. This can be caused by foods such as peanuts and fish, medications, toxins, latex, aspirin, X-ray contrast media, and antibiotics, among others. If the following symptoms appear within minutes of exposure to an allergen, there is a high likelihood of anaphylaxis: Skin or mucosal surface involvement

Difficulty Breathing

Cardiovascular Collapse

Gastrointestinal Symptoms.

This must be differentiated from cardiogenic shock, sepsis, poisoning and epilepsy.


           Anaphylactic shock: Occurs within minutes of exposure to the allergen. 

      Delayed Anaphylaxis: Occurs up to days after initial exposure. It has the same mechanism and is treated in the same way?

    Anaphylactoid reactions: occur due to mast cell degranulation and do not involve the allergy pathway.


`Assess and manage airway and breathing. In severe cases, intubation and ventilation may be required. Intravenous fluids are required for volume expansion. In suspected cases, epinephrine should be given in doses of 0.3-0.5 mg IM as soon as possible. or 0.1 mg IV in repeated doses titrated for effect. Histamine antagonists are used in conjunction with them to block HI and H2 receptors (often chlorpheniramine and ranitidine). Steroids are also used for delayed reactions. The use of vasopressors may be necessary. Tryptase levels can be sent to diagnose mast cell degranulation. Detected early and treated properly, it has a very good prognosis.

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