Circulation
Amal Alabbadi
Sukainah Alalwi
Fatimha Almarhoon
Khadijah almubarak
Objective
[Link] understand the causes of shock
2. To recognize shock utilizing the physical examination
3. To review the management of different types of shock
What are the causes of shock?
Amal Alabbadi
2160002144
Definition of shock:
An abnormality of the circulatory system
causing inadequate tissue perfusion which,
if not corrected, will result in → cell death.
Causes of shock
Hypovolemic shock Cardiogenic Obstructive shock Distributive Dissociative shock
shock shock
Causes of shock
Hypovolemic shock Cardiogenic Obstructive shock Distributive Dissociative shock
shock shock
Hemorrhagic Non-hemorrhagic
shock hypovolemic
shock
Inadequate intake
Excessive output
Causes of shock
Hypovolemic shock Cardiogenic Obstructive shock Distributive Dissociative shock
shock shock
Primary cardiac disorder
Pump failure from myocardial injury or dysfunction: Myocarditis,
cardiomyopathy, ischemia, infarct.
Arrhythmias
Valvular disease
Ventricular septal defect
Causes of shock
Hypovolemic shock Cardiogenic Obstructive shock Distributive Dissociative shock
shock shock
Extra-cardiac obstruction
Cardiac tamponade
Pulmonary embolism
Tension pneumothorax
Causes of shock
Hypovolemic shock Cardiogenic Obstructive shock Distributive Dissociative shock
shock shock
Sepsis and Anaphylaxis Neurogenic shock
SIRS
Cascade of cytokines Inflammatory mediators: Acute spinal
& other immune and Histamine injury
inflammatory Leukotriene C4
modulators Prostaglandin D2
Causes of shock
Hypovolemic shock Cardiogenic Obstructive shock Distributive Dissociative shock
shock shock
CO poisoning
Cyanide poisoning
Physical examination of shock.
Sukainah Al-alawi
2160005104
Recognizing shock.
• General appearance.
• Vital Signs.
• Mental status.
• Skin changes.
• CV: JVP, heart sounds.
Physical examination:
Pulse: Respiratory Rate: Blood pressure:
Tachycardia Tachypnea Hypotension
Mental status: JVP: Heart Sounds:
Early: Agitation. Low: Hypovolemia, Muffled heart sounds
Late: Sepsis. may be noted in
High: LV Failure, Right cardiac tamponade.
Obtundation.
Heart Problems.
Orthostatic Vital Signs:
1. Change in pulse and blood
pressure as a patient is moved
from a supine to sitting or erect
position.
2. No general agreement to what
changes constitute a ‘positive
response’.
3. The test is insensitive and
nonspecific.
4. Never be performed in a
potentially unstable patient.
Continue…
Skin Capillary Blanch Test: The exception to this
rule is in vasogenic
1. Cool and pale early on.
1. Nail bed takes >2 shock.
2. Peripheral cyanosis
seconds to ‘pink up’.
may appear later.
2. If acute blood loss
excess 15% of total Why ?
blood volume.
Management of hemorrhagic shock
Fatimha Almarhoon
2160002959.
HEMORRHAGIC SHOCK
A 23 year old man got into a car
accident and he was thrown 22
feet away.
He was taken to the ED and was
unconscious and pale and fresh
blood was flowing from a
laceration in his right groin. His
vitals:
T 37.0
HR 150 bpm
BP 90/40
RR 24
O2 Sat 78
What is your next step in management?
General management
ABC
AIRWAY, BREATHING, O2
SAT, CARDIAC MONITOR
01 02 INTRAVENOUS ACCESS
CROSS MATCH IF
HEMORRHAGE SUSPECTED
CONTROL EXTERNAL BLEEDING
BY APPLYING PRESSURE
03 04 FOLEY CATETHER
MONITOR URINE OUTPUT
ONGOING ASSESSMENT
BP, PR, RR,SKIN, LOC
05 06 INVASIVE
MONITORING
ATRIAL LINE
Specific management
Volume resuscitation Blood products Hemorrhagic control
• NS or Ringer’s lactate • Blood products if no • Address or control source
boluses response to two fluid of bleeding
• 1–2 L in adults ■ 10– boluses, ongoing
20 cc/kg in neonates, hemorrhage, or if
infants, and young impending
children cardiovascular
collapse
• Two units PRBC in
adults ■ 10–15 mL/kg
PRBC in neonates,
infants
• Platelet
• O- blood
Specific management
1. Restore circulating blood volume
Treatment for hemorrhagic shock consisted of rapidly and aggressive infusing several
liters of isotonic crystalloid by using:
• At least two short, large bore catheters
• Pressure infusion devices
2. Access
• Peripheral access (preferred):
Sites: forearm, antecubital, saphenous vein cutdown
• Central access:
Sites: femoral vein, internal jugular vein, subclavian vein
3. Consultation
Management Of
Non-hemorrhagic
Shock
Khadijaa Ahmed Almubarak
2160003996
NON-HEMORRHAGIC SHOCK
A 45-year-old female is brought to
the ED after collapsing at home
shortly after sustaining a bee sting
to her left hand, the patient is
unresponsive & without palpable
pulse, but breathing.
Her vital signs: BP: 60/40, HR:
130s, RR: 20
Anaphylactic shock
Management:
Airway management
IM Epinephrine
Fluid management: crystalloid boluses via large-bore IVs
Histamine blockade: Diphenhydramine (H1) , Cimetidine (H2)
Corticosteroid to reduce inflammation
NON-HEMORRHAGIC SHOCK
A 22-year-old previously healthy
male presents to the ED
complaining of flulike symptoms
and progressive shortness of
breath
He appears ill with BP 80/50, HR
120, RR 30 and T 38.0ºC. He has
evidence of poor perfusion, and
jugular venous distention.
Cardiogenic Shock
Management:
Will depend on the underlying cause
The goal is to improve the myocardial contractility & pump function
Ensure adequate ventilation & oxygenation
Intropes for depressed LV function: Dobutamine
Other options include emergency angioplasty
NON-HEMORRHAGIC SHOCK
A 19-year-old male presents to the
ED Stabbed in his anterior chest,
looks gasping, intoxicated with
sever SOB
BP 88/42, HR 110, RR 30
Tension pneumothorax
Management:
Ensure adequate ventilation & oxygenation
Needle decompression: 14- or 16-gauge needle in the 2 nd or 3rd intercostal
midclavicular line
Chest tube: in the 4th intercostal space anterior axillary line (skin incision 1
ICS below)
Other Causes
Septic shock
Cardiac temponade intavenous crystalloid,
Intravenous crystaloid, definitive therapy (AB,
pericardiocentesis surgical drainage)
Massive PE
Arrhythmias
Intravenous crystalloid,
Specific anti-arrhythmic
inotropes, thrombolysis or
therapy
surgery
Non-Hemorrhagic Shock
Anaphylactic Cardiac
Arrhythmias
Shock Tamponade
Cardiogenic Tension
Septic Shock
Shock Pneumothorax
Massive PE
REFERENCES
1. Blok B, Cheung D, Platts-Mills T. First aid for the emergency medicine
boards.
2. Helman A, Pencinar R. The ABCs of emergency medicine. 7th ed. 2008.
Thank you
Any questions?
