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Shock ˈshäk

By Oren Traub, MD, PhD, Departments of Internal Medicine and Adult Hospital Medicine, Pacific Medical Centers

Shock is a life-threatening condition in which delivery of oxygen to the organs is low, causing organ damage and sometimes death. Blood pressure is usually low.

  • Shock has several causes: Low blood volume, inadequate pumping action of the heart, or excessive widening (dilation) of blood vessels.

  • When shock is caused by low blood volume or inadequate pumping of the heart, people may feel sluggish, sleepy, or confused, and their skin becomes cold and sweaty and often bluish and pale.

  • When shock results from excessive dilation of blood vessels, the skin may be warm and flushed, and the pulse may be strong and forceful (bounding) rather than weak.

  • People who are in shock should be kept warm and positioned so their legs are elevated.

  • Intravenous fluids, oxygen, and sometimes drugs are given to help restore the blood pressure.

In the United States, hospital emergency departments report more than 1 million cases of shock each year. People go into shock when their blood pressure becomes so low that the body’s cells do not receive enough blood and therefore do not receive enough oxygen. As a result, cells in numerous organs, including the brain, kidneys, liver, and heart, stop functioning normally. If blood flow (perfusion) to these cells is not quickly restored, they become irreversibly damaged and die. If enough cells are damaged or dead, the organ they are in may fail and the person may die.

The failure of two or more organs is called multiple organ dysfunction syndrome (MODS), and this diagnosis carries a significant chance of death. People in shock require immediate emergency treatment and are usually cared for in the hospital intensive care unit.

Although low blood pressure is generally the cause of shock, blood pressure may not be low in the early stages of shock. Also, blood pressure can be low in people who do not have shock.

The medical disorder of shock has nothing to do with the “shock” that people feel from a sudden emotional stress.

Causes of Shock

Shock has several causes:

  • Low blood volume (hypovolemic shock)

  • Inadequate pumping action of the heart (cardiogenic shock)

  • Excessive widening of blood vessels (distributive shock)

Did You Know...

  • In some people with shock, blood pressure is so low that it cannot be measured with a blood pressure cuff.

  • Shock has nothing to do with sudden emotional stress.

Hypovolemic shock

Low blood volume results in less-than-normal amounts of blood entering the heart with every heartbeat and therefore less-than-normal amounts of blood being pumped out to the body and its cells.

Blood volume may be low because of severe bleeding, an excessive loss of body fluids, or, less commonly, inadequate fluid intake. Blood may be rapidly lost because of

  • External bleeding, such as that caused by an accident

  • Internal bleeding, such as that caused by an ulcer in the stomach or intestine, a ruptured blood vessel, or a ruptured ectopic pregnancy (a pregnancy outside the uterus)

An excessive loss of body fluids other than blood can result from

  • Major burns

  • Inflammation of the pancreas (pancreatitis)

  • Perforation of the intestinal wall

  • Severe diarrhea or vomiting

  • Some kidney disorders

  • Excessive use of diuretics, which increase the output of urine

  • Untreated diabetes

Fluid intake may be inadequate because a physical disability (such as severe joint disease), or a mental disability (such as Alzheimer disease) may prevent people from obtaining enough fluids even though they feel thirsty.

Cardiogenic shock

Inadequate pumping action of the heart can also result in less-than-normal amounts of blood being pumped out with every heartbeat. The most common causes of inadequate pumping action are

  • Malfunction of a heart valve (particularly an artificial valve)

  • Other disorders affecting the structure of the heart (for example, rupture of a wall of the heart)

  • An abnormal heart rhythm (arrhythmia)

  • Inability of the heart to fill (cardiac tamponade)

Distributive shock

Excessive dilation of blood vessels (vasodilation) increases the capacity of blood vessels and decreases blood pressure. This can decrease blood flow and oxygen delivery to organs.

Blood vessels may be excessively dilated because of

  • A serious allergic reaction (anaphylaxis or anaphylactic shock)

  • A severe bacterial infection (shock caused by such an infection is called septic shock)

  • Overdose of drugs or poisons that dilate blood vessels

  • Injuries to the spinal cord and rarely the brain (neurogenic shock)

  • Certain endocrine disorders such as Addison disease

The mechanisms by which these conditions cause vasodilation vary. For example, a spinal cord injury interrupts the nerves from the brain to the blood vessels that normally cause blood vessel constriction; poisons or toxins released by bacteria can cause the blood vessels to dilate.

Symptoms of Shock

Symptoms of shock are similar when the cause is low blood volume or inadequate pumping action of the heart. The condition may begin with sluggishness, sleepiness, and confusion. The skin becomes cold and sweaty and often bluish and pale. If the skin is pressed, color returns much more slowly than normal. Blood vessels may become more visible as a bluish network of lines under the skin. The pulse is weak and rapid, unless a slow heartbeat is causing the shock. Usually, the person cannot sit up without feeling light-headed or passing out. Breathing is rapid, but breathing and the pulse may both slow down if death is imminent. Blood pressure drops so low that it often cannot be measured with a blood pressure cuff. Eventually, the person may die.

When shock results from excessive dilation of blood vessels, the symptoms are somewhat different. The skin may be warm and flushed, and the pulse may be strong and forceful (bounding) rather than weak, particularly at first. However, later on, shock due to excessive dilation of blood vessels also produces cold, clammy skin and lethargy.

In the earliest stages of shock, especially septic shock, many symptoms may be absent or may be undetected unless they are specifically looked for. In older people, the only symptom may be confusion. Urine flow may be reduced (because blood supply to the kidneys is reduced), and waste products may build up in the blood. The blood pressure may be low.

Diagnosis of Shock

  • A doctor's evaluation

  • Blood tests

The diagnosis of shock is based mainly on evidence of organ damage found on a doctor's evaluation. For example, people may have a reduced level of consciousness, may not be producing urine, and may have bluish fingers or toes. People may also show signs of trying to compensate for their low blood volume or their heart's inadequate pumping. For example, they may have a rapid heart rate, be breathing rapidly, or be perspiring profusely.

Blood tests can help the diagnosis, but no finding alone is diagnostic, and doctors evaluate each by its trend (ie, worsening or improving) and in light of the person's overall condition. One blood test (the level of lactate) measures the amount of waste products of cellular activity in the blood. An elevated blood lactate level suggests to the doctor that the organs are not receiving enough oxygen and blood and that the person may have shock. Blood tests that show a high or low white blood cell count or bacteria or other microorganisms in the blood may help determine that the person has an infection that could be causing septic shock.

Blood tests may also indicate damage to specific organs. For example, a high level of creatinine can indicate that the kidneys are damaged, and a high level of troponin can indicate that the heart is damaged.

Prognosis of Shock

If untreated, shock is usually fatal. If shock is treated, the outlook depends on the cause, the other disorders the person has, the presence and severity of any organ failure, the amount of time that passes before treatment begins, and the type of treatment given.

Multiple organ dysfunction syndrome carries a significant risk of death. The risk of death increases as the number of affected organs increases. Regardless of treatment, the likelihood of death due to shock after a massive heart attack or due to septic shock, especially in older people, is high.

Treatment of Shock

  • Calling for help and stopping any bleeding

  • Intravenous fluids and/or blood transfusions

  • Sometimes drugs to help increase blood pressure

  • Other measures depending on cause

Initial treatment

Most important is to call for help and stop any major bleeding. After doing that, the person can be laid down and kept warm, with the legs elevated.

When emergency medical personnel arrive, they may provide oxygen through a face mask or insert a breathing tube. Fluids may be given by vein (intravenously) at a fast rate and in large volumes to raise blood pressure.

On arrival at an emergency department, the person may be given a blood transfusion if shock is caused by bleeding. Usually, blood is cross-matched before transfusion, but in an emergency when there is no time for crossmatching, type O negative blood can be given to anyone.

For some types of shock, drugs may be given intravenously to increase blood pressure. However, doctors use such drugs for as brief a time as possible because they can reduce blood flow to other tissues in the body or cause heart rhythm problems. Drugs can increase blood pressure by

  • Constricting blood vessels, which happens, for example, when doctors give epinephrine (used for people with anaphylaxis) or norepinephrine (sometimes used for people with other forms of shock)

  • Increasing the ability of heart to pump blood, which happens, for example, when doctors give dobutamine or milrinone

Treatment of cause

Fluids given intravenously, blood transfusions, and drugs may not be enough to counteract shock if bleeding or fluid loss continues or if shock is caused by a heart attack, infection, or another problem unrelated to blood volume. Treating the cause of shock is vital.

When shock is caused by an inadequate pumping action of the heart, efforts are made to improve the heart’s performance. In addition to fluids and drugs, other treatments include percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting if the cause is a heart attack. Surgery may also be needed if the cause is a damaged heart valve or rupture of a wall of the heart. Excess fluid that compresses the heart, a condition called cardiac tamponade, can be removed with a needle or surgery.

When shock is caused by an infection (such as sepsis), treatment of the infection includes antibiotics and removal of the source of infection.When shock is caused by bleeding, surgery may be necessary to stop the bleeding. If shock is caused by an endocrine disorder (such as Addison disease) or anaphylaxis, a corticosteroid drug may need to be given.

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