Al-Azhar University

Faculty of Medicine
General Surgery
Department
Types of shock, hypovolemic
shock, anaphylactic shock
 ILOs
By the end of this topic, you have to;
Define shock
Enumerate types of shock
Recognize etiology of hypovolemic shock
Outline compensatory mechanisms of hypovolemia
Describe neural and endocrine factors compensate hypovolemia
Describe changes in vital signs & skin in case of hypovolemic shock
Describe changes in pulse & blood pressure in different stages of hemorrhagic shock
Describe how to monitor the patient with severe hypovolemic shock?
Manage a patient with hypovolemic shock
Outline replacement therapy in patient with hypovolemic shock
Define irreversible shock
Enumerate causes of irreversible shock
Define anaphylactic shock
Describe clinical presentation of anaphylactic shock & how to manage?
 Shock
Definition: is a pathophysiological condition that leads
to inadequate tissue perfusion through the micro-
circulation with impaired cellular metabolism
Classification of shock
Hypovolemic shock; diminished blood volume
Cardiogenic shock; inefficient myocardial function
Neurogenic shock; peripheral pooling of blood
Anaphylactic shock; antigen antibody reaction
Septic shock; severe infection
Endocrine shock; acute deficiency of corticosteroid
 Hypovolemic Shock

Etiology:
• Blood loss as in internal or external hemorrhage
• Plasma loss as in burns and peritonitis
• Fluid loss as in severe vomiting, diarrhea or
dehydration
 Hypovolemic Shock
Compensatory mechanisms of hypovolemia
The physiological response to hemorrhage has two aims:
1- Stopping the bleeding by immediate vasoconstriction & clot formation
2- Maintaining effective circulatory volume and perfusion of critical
tissues (brain & heart), this achieved by neural & endocrine factors
 Neural factors (rapid); stimulation of sympathetic system
 Stimulus; drop blood pressure, decreased venous return
 Receptors; arterial baroreceptors, atrial stretch receptors
 Response; stimulation of sympathetic system
 Effects;
• constriction of veins, that displacing blood from the capacitance side
of the circulation into the heart
• Constriction of arterioles raises the peripheral resistance
• Increased rate & strength of cardiac contraction
 Hypovolemic Shock
 Endocrine factors (delayed);
 Catecholamine; released from adrenal medulla & nerve
endings, they increase the heart rate & myocardial contraction,
and cause vasoconstriction at skin, kidney, viscera
 Metabolic hormones; ACTH, cortisol, growth hormone,
glucagon are increased; that leads to hyperglycemia, increase
extracellular fluid osmolality that lead to withdraws water from
the intracellular fluid
 Renin-angiotensin aldosterone system; renin secreted in
response to renal hypoperfusion that convert angiotensinogen
into angiotensin I which converted into angiotensin II in lung;
• Actions of angiotensin II; powerful vasoconstrictor, stimulates
sodium & water retention by relase of aldosterone
 Vasopressin (ADH); stimulate water retention from kidney
Hypovolemic Shock
Hypovolemic Shock
 Hypovolemic Shock
Clinical picture; the manifestations correlate with the amount of
hemorrhage on one hand and the cardiovascular reserve on the other
hand
Symptoms; weakness, fainting, the patient feels cold & thirsty
Signs; the patient looks anxious to drowsy
 Pulse & blood pressure;
• Mild blood loss (less than 500ml); remain normal
• Loss (500 – 1500ml) rapid weak pulse but stable blood pressure
• Loss (more than 1500ml) tachycardia & hypotension
 Pulse pressure; decreases (thready pulse)
 Respiratory rate; tachypnea and air hunger
 Temperature; hypothermia
 Skin; pale, cold, clammy (sweat secretion) & vasoconstriction
 Oliguria; diminished renal perfusion, release of ADH
 Hypovolemic Shock
Monitoring the severely shocked patient;
 Clinical parameters; pulse, Bl pressure, RR, temp, capillary refill
 A Foley’s catheter insertion; check urinary output (n; 1-2ml/kg/hr)
 Central venous pressure (CVP); roughly corresponds to blood
volume (high indicates overtransfusion, low indicate hypovolemia)
 Pulmonary artery wedge pressure (PAWP); measured by Swan-
Ganz catheter inserted into a small branch of pulmonary artery
 ECG
 Temperature; difference between the peripheral & core
temperature may assess cardiac output & peripheral perfusion
 Peripheral temp measured by sensor at big toe, while core temp by
probe placed in rectum or esophagus
 Blood gases; Po2 (n; 80-100mmHg), PCO2 (n; 35-45mmHg)
 Serial detection of hemotocrit in cases of bleeding
 Treatment of hypovolemic Shock
Anti-Shock measures & Treatment of the cause
Anti-Shock Measures
 Stop hemorrhage;
 Packing
 Pressure is applied manually
 Elevation of the leg above the level of the heart stop venous bleeding
& decrease arterial bleeding
 Supporting devices; pneumatic anti-shock garment which can
tamponade lower limb, pelvis, abdominal bleeding. Balloon
tamponade to compress bleeding esophagel V
 Maintain air way & oxygenation
 Analgesia; to relief pain & anxiety, to improve blood flow to brain
 Positioning of the patient; recumbent position with moderate
elevation of lower limbs
 Temperature; keep the patient comfortably warm
 Treatment of hypovolemic Shock
 Start intra-venous fluid resuscitation;
 2 large bore cannulas or do venous cut-down
 A blood sample is withdrawn for cross-matching
 Regimen; rapid infusion of lactated Ringer’s solution
started immediately. Then blood transfusion may indicate
Alternative to blood transfusion; human plasma, Dextran,
artificial blood substitutes
 Pharmacological support;
 Inotropic drugs; Dopamine in myocardial insufficiency
 Vasodilator drugs; given when blood volume & CVP has
been restored to normal; to reduce afterload, increase
cardiac output & decrease myocardial work
 Steroids
 Irreversible Shock
Def; hypovolemic shock becomes refractory to the ant-
shock therapy with severe central nervous system &
cardiac dysfunction
Causes;
 Inadequate volume replacement
 Multisystem trauma with occult injuries as cardiac
tamponade or hemopneumothorax
 Acute myocardial insufficiency either from direct
cardiac injury or secondary to prolonged coronary
hypoperfusion
 Anaphylactic Shock
Etiology; it follow administration of an antigens like;
antibiotics, anesthetics, sera, dextran
 The antigen unites with antibodies leading to release of
large amount of histamine resulting in capillary paralysis
with pooling of blood in the capillary bed
Clinical picture;
 Bronchospasm, laryngeal edema, respiratory distress
 Hypotension with massive vasodilatation
Treatment;
 Intravenous crystalloid infusion
 Antihistaminic
 Endotracheal intubation may be needed
 Quiz
Define shock
Enumerate types of shock
Recognize etiology of hypovolemic shock
Outline compensatory mechanisms of hypovolemia
Describe neural and endocrine factors compensate hypovolemia
Describe changes in vital signs & skin in case of hypovolemic shock
Why oliguria occur in hypovolemic shock?
Describe changes in pulse & blood pressure in different stages of hemorrhagic shock
How to monitor the patient with severe hypovolemic shock?
First aid management of patient with hypovolemic shock
Outline replacement therapy in patient with hypovolemic shock
Drug therapy in case of hypovolemia
Define irreversible shock
Enumerate causes of irreversible shock
Define anaphylactic shock
Describe clinical presentation of anaphylactic shock & how to manage?
THANK YOU