Circulatory Shock: Santosh Dev

CIRCULATORY
SHOCK
Santosh Dev
Topic of discussion will be on:
• What is shock?
• Types of shock
• Stages of shock
• Treatment of shock
Basic Physiology
• Unit of life = cell
• Cells get energy (ATP) from cellular respiration:
O2 + Glucose ATP + water + CO2
No O2 = no energy
No energy = no life
Damage to Damage to Damage to

cell Tissues Organ
Damage to Damage to
Death System
Body
Role of cardiovascular system
• Transports oxygen (fuel) to cells
• Removes carbon dioxide and other waste products

from body
• Cardiovascular system must be able to maintain

sufficient flow through capillary beds to meet cell’s
oxygen and fuel needs.
Role of cardiovascular system
Flow = Perfusion
Adequate flow = Inadequate Flow =

Adequate Perfusion Inadequate Perfusion
= Hypo perfusion
SHOCK
What is shock ?
Shock or cardiovascular failure is characterized by
• hypo perfusion of tissue
• due to reduction in blood volume or cardiac output or
redistribution of blood,
• resulting in an inadequate effective circulatory volume.
Hypo perfusion of tissue results in:

• Insufficient delivery of oxygen and nutrients to the cells and
tissues.
• Inadequate clearance of metabolites.
What is shock ?
If prolonged:
• these state of affairs is not compatible with life and requires

immediate treatment.
• Failing to treatment causes progressive deterioration.
• Finally the condition becomes irreversible and ends in death.

Physiological causes of shock
There are 2 causes:

I. Due to decreased cardiac output:
 Cardiac abnormality that decreases ability to pump
blood
 Factors that decrease venous return.
II. Without decreased cardiac output:

 Excessive metabolic rate
 Abnormal tissue perfusion patterns.
Types of shock
On the basis of causes of shock, it is of 4 types:

I. Hypovolemic shock
II. Cardiogenic shock
III. Obstructive shock
IV. Distributive shock
a. Neurogenic shock
b. Anaphylactic shock
c. Septic shock
Hypovolemic shock
• Cardiac output is inadequate because the amount of
fluid in vascular system is inadequate to fill heart.
• Common causes are:
a. Loss of blood i.e. external or internal injury
b. Loss of plasma i.e. burns and exudative lesions
c. Loss of fluid i.e. dehydration due to excessive vomiting,
diarrhea, sweating.
d. Traumatic shock
Cardiogenic shock
• Shock caused by inadequate pumping action of
heart resulting decreased cardiac output.

a. Myocardial infraction
b. Arrhythmias
c. Valvular disorders
Obstructive shock
• Occurs due to obstruction to the diastolic feeling of
the heart, resulting in decrease in cardiac output.

a. Pulmonary embolism
b. Cardiac tamponade
Neurogenic shock
• Occurs due to marked reduction in sympathetic
vasomotor tone which results in vasodilatation and
pooling of blood in veins.
a. Deep general anesthesia
b. Spinal anesthesia affecting thoracolumbar sympathetic
outflow
c. Spinal injury
Anaphylactic shock
• A rapidly developing severe allergic reaction that
occurs when an individual who has previously been
sensitized to an antigen is re-exposed to it.
• The resultant antigen- antibody reaction releases

large quantity of histamine, causing vasodilatation
and increased capillary permeability.
Septic shock
• occurs due to disseminated bacterial toxin (endotoxin)
to many areas of body causing extensive damage.
• Bacterial toxin causes
– vasodilatation,
– depresses myocardium
– and increases capillary permeability so that plasma
leaks into the tissues and blood volume falls.
• Hence, septic shock is cardiogenic, hypovolemic as well
as distributive.
Stages of shock
On the basis of different degrees of severity,
shock is of 3 types:
a. Non progressive / compensatory stage
b. Progressive / reversible stage
c. Irreversible / refractory shock

Shock caused by hypovolemia-
Hemorrhagic shock
Relationship of Bleeding Volume to Cardiac Output and
Arterial Pressure
• About 10 % of total blood volume can be removed with

almost no effect on either arterial B.P or cardiac output.
• But 40-45 % of total blood volume loss diminishes the cardiac
output first and later the arterial pressure to Zero
Value of sympathetic nervous reflex:
• In the absence of sympathetic reflexes, only 15 to 20

% of the blood volume can be removed over a period
of 30 minutes before a person dies.
• But when the reflexes are intact, even at 30 to 40

percent loss of blood volume persons can sustain.
Progressive and Nonprogressive Hemorrhagic Shock
Compensatory responses of hypotension
in Non progressive stage
Sequence of events leading to
progressive stage
Irreversible stage
• After shock has progressed to certain stage, transfusion or any
type of therapy becomes incapable of saving the persons life.
Then the person is said to be in irreversible stage of shock.
• Even in this stage, therapy on

rare conditions, return arterial
pressure and cardiac output to
normal but still the circulatory
system continues to deteriorate,
and death ensures in another
few minutes to hour.
Irreversible stage
• The high energy phosphate reserves in the tissues of
the body, especially in liver and heart are greatly
diminished.
• Nearly all the ATP gets degraded to ADP, AMP and
eventually to Adenosine.
• The adenosine diffuses out of the cells into the
circulatory blood and is converted into uric acid.
• New adenosine is synthesized slowly so that once
depleted, the high energy phosphate stores of the
cells are difficult to replenish.
Treatment of shock
• Patients in shock are kept in cold room so that there
in no further hypovolemia from sweating.
1. Replacement therapy:
 Depending on the cause of hypovolemia (loss of blood,
plasma or fluids), the patient is transfused respectively
with blood, plasma(or plasma expanders like dextran
solution), or isotonic saline solutions.
Treatment of shock
Sympathomimetic drugs:
• drugs that mimics sympathetic stimulation.
• These drugs include norepinephrine and epinephrine
that have same effect as norepinephrine and
epinephrine .
Treatment with Glucocorticoids:
Oxygen therapy:
Trendelenberg position ( Head-Down Position)

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CIRCULATORY

Damage to Damage to Damage to

• Transports oxygen (fuel) to cells

• Removes carbon dioxide and other waste products

• Cardiovascular system must be able to maintain

Adequate flow = Inadequate Flow =

Hypo perfusion of tissue results in:

• these state of affairs is not compatible with life and requires

• Failing to treatment causes progressive deterioration.

• Finally the condition becomes irreversible and ends in death.

There are 2 causes:

II. Without decreased cardiac output:

On the basis of causes of shock, it is of 4 types:

• Common causes are:

• Common causes are:

• The resultant antigen- antibody reaction releases

b. Progressive / reversible stage

c. Irreversible / refractory shock

• About 10 % of total blood volume can be removed with

• In the absence of sympathetic reflexes, only 15 to 20

• But when the reflexes are intact, even at 30 to 40

• Even in this stage, therapy on

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