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Shock Management

Shock is the cause of death in most patients. Early interventions and proper management can safe lives. In this article the author who is a Registered Nurse and Lecturer in Health Sciences discusses the common types of shocks, how they may be diagnosed and treated. The prognosis and methods of preventing shock are also discussed.

Shock is defined as a state of circulatory dysfunction in which tissue O2 delivery is less than required. If untreated, multi-organ failure and death will result. Shock is the final common pathway of numerous disease states. Shock is a life-threatening medical emergency and is one of the leading causes of death. The primary cause may lead to many other medical emergencies like hypoxia and cardiac arrest. Hypoxia is defined as lack of oxygen to the tissues. Cardiac arrest is the cessation of cardiac contractions.

Patho physiology: There are many general classifications however the following are most widely recognised:

  1. Hypovolemic Shock:

    Most common type of shock, due to insufficient circulating volume. Main cause is loss of fluid from the circulatory system e.g. bleeding, burns.

  2. Cardiogenic Shock:

    Due to failure of the myocardium to pump effectively. Often due to damage of the heart muscle as a result of Myocardial Infarction. Other causes include arrhythmias, cardiomyopathy, Congestive Heart Failure and cardiac valve problems.

  3. Distributive Shock:

    Some authors include septic shock, Anaphylactic and Neurogenic shock under this classification. Other authors classify them separately. As the name implies, in this type of shock, there is no blood loss but the shock is due to dilation of blood vessels.

Septic Shock:

Due to sepsis caused by an overwhelming infection leading vasodilatation e.g. infection by bacteria of the Proteus species. These release toxins which produce adverse biochemical, immunological and occasionally neurological effects. Patients usually have a history of fever, pyrexia and hyperthermia.

Anaphylactic Shock:

Caused by severe reaction to an allergen, antigen, drug or foreign protein. Release of histamine caused widespread vasodilatation.

C. Neurogenic Shock:

This is a very uncommon type of shock. It is most often seen in patients who have had extensive spinal cord injuries. The loss of autonomic and motor reflexes below the level of injury results in loss of sympathetic control. This leads to relaxation of vessel walls and peripheral dilation and hypotension.

  1. Endocrine Shock:

    Mainly due to hormone disturbances e.g. Hypothyroidism and adrenal insufficiency. Hypothyroidism is corrected with levothyroxin and adrenal insufficiency is corrected with corticosteroids.

  2. Obstructive Shock:

    Obstruction of blood flow results in cardiac arrest. Examples which lead to this type of shock are Cardiac tamponade, Tension pneumothorax, Pulmonary embolism and aortic stenosis.

Signs and Symptoms:

Clinical signs are for the most part non-specific. Any one or a combination of any of the following may be present. The stage and severity of the shock will influence the signs and symptoms.

  1. Tachycardia: Heart rate of greater than 100 b/min in an adult patient. Some authors may describe this as a “galloping heart”.
  2. Hypotension – Low blood pressure, particularly decreased diastolic BP
  3. Oliguria: Urinary output of less than 0.5ml per kg of body weight in an adult patient.
  4. Changed level of Consciousness, usually a decrease in LOC
  5. Underlying infection / blood loss, spinal cord injury

Stages of Shock

There are three stages of shock are commonly identified. Stage I, sometimes called the compensated or non progressive stage because the symptoms may be mild or non-existent. Stage II is often called the decompensated or progressive stage. Stage III may be referred to as the irreversible stage.

Stage I. Early, Reversible and Compensatory Shock

This stage is characterized by low BP. It results in decreased perfusion, particularly to the peripheral tissues. Initial signs of shock include sinus tachycardia, peripheral vasoconstriction (blood vessels throughout the body become slightly smaller in diameter) and the renal system (kidneys) works to retain fluid in the cardiovascular system. These processes are activated to maintain and restore tissue perfusion. The end result is that blood flow to key vital organs is maintained. The key vital organs are the kidneys, brain, and heart. As a result of this compensatory mechanism the body is maintained. Consequently, the patient in this stage of shock displays very few symptoms. Proper treatment at this stage can halt progression of shock.

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  1. I actually like this article even though it uses quite a bit of techinical words (whose meanings are not explained enough for the lay person such as myself). It’s good to know about these things and what they mean.

  2. Good Day Anne,

    Thank You for reading my article and above all thank you for your very honest feedback. As you will appreciate, these are my (simplified) notes from one of my lectures to my undergraduate class of Nursing Students.

    I will work on making these postings more simpler so that people with less medical knowledge can understand. From my perspective, these postings are for public consumption.

    If you identify the difficult words, I will explain then. Thank You, once again.

    Shergill

  3. Can you “fill in” with more details. I found the article useful. I am a Medical student and could do with more details.

    Jenny.

  4. Good Day Jenny,

    It is a great pleasure to know that my articles are being read widely. I will try to increase the width and depth of this article. However, as a University Lecturer who specializes in teaching undergraduate nurses I do not feel that I have the expertise and/or knowledge to teach medical students.

    Bye for now.

    Shergill.

  5. Hi,

    Thanks for this very good article…i wish that you will publish more nursing articles in the near future as this is very helpful to us especially to a new grad RN like me and loves to read more about nursing articles.

  6. Good Day Margie,

    Great to hear your comments. Read my other articles and you will learn a lot about nursing. I have been in the field for many years. I have travelled the world, cared for people and made a reasonably good living. Good luck with your career.

    Shergill

  7. Great article, easy to follow, it really helped me prepare for an exam. Thanks for sharing.

  8. hi good day,
    thank you so much for viewing this article. I hope theres so many people that know how to manage there self in case of this tragedy.I have learn more, but please make sure that you can give atleast easy details for instance that the person know it easily.I hope it can make our guide to help in other people.More powers and goodluck to your job.

  9. Good Day Raquel,

    Key thing to health management is early intervention. Early interventions in sepsis actually prevents it. So it saves money for the patinet and prevents complications and costly treatments.

    Shergill

  10. Nicely written article. I am a nursing student studying for my Rn and your article was just right! Thank you SO much!

  11. Hello Diane,

    Sorry for this late response.

    It is nice to hear from a diligent student nurse like yourself. I know the feeling. I also know the feeling of being able to help. It is addictive. Nursing is addictive. I hope you enjoy your career. Right now, I am sure you are learning alot.

    Nursing is a rewarding career. Thank You for reading and commenting on my article.

    Shergill

  12. I am doing an assignment for my nursing class and have to develop a plan of care for a patient in shock. I have chosen hypovolemic shock because I have yet another assignment for hypovolemia, so I thought this would be a good way to prepare for that. My question is, what is going to take priority, decreased cardiac output OR inneffective tissue perfusion? I have an article that says in the initial stage, tissue perfusion is decreased but still effective and that cardiac output is what is decreased initially. Signs and symptoms are typically changing very slowly so you must be comparing to baseline often to note the trends. I am just stuck on this part. I really liked your article and wanted to pick your brain. Thanks!

    Amanda in Kansas City

  13. Amanda, It would seem to me that cardiac output would be the priority. Once that is increased tissue perfusion shouls follow the trend. I am not absolute on this but, that would be the way I would go with it.

  14. Thank you for your synopsis on shock.

    A topic as vast as this can be quite difficult to encapsulate briefly and adequately.

  15. Hi Barb,

    Thank You for reading and commenting on my article.

    Maintaining Cardiac output is a priority. Without cardiac output or with decreased cardiac tssue perfusion will not be achieved. The aims of most interventions are to improve cardiac output.

    Some medications decrease life expectancy in the long run but they are used in the intensive care units to prevent immediate death.

    I have driven through Ohio many times.

  16. Hi Crit Care Nurse in WA,

    We all learn from one another. My educators helped me learn. I an helping my students learn. I write these articles for the benefit of student nurses because text books are too lenghty and sometimes miss the main point.

    I have been to Perth in WA. I have many students in WA.

  17. its a really nice article! hope you will publish more article to help nursing student like me…

  18. Hi Grace,

    I am an Educator and A Registered Nurse.

    I will write on anything for which will help students. Make a few suggestions, please.

  19. Great article: to the point, well paced, excellent refresher on a condition that I do not see often in my area. Thanks

  20. Hi Kate,

    Thank you for your nice comments. Much appreciated.

  21. Do you have an educational video on the different types of shock. I teach at a nursing college and would like to present such a video

  22. thanks for this science, its very good articles, ask permission to distribute to the other

  23. It’s the best time to make some plans for the longer term and it’s time to be happy.
    I have read this post and if I may just I desire
    to suggest you some interesting issues or advice. Maybe you could write next articles relating to this article.

    I desire to learn even more things about it!

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