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ShockShock is a serious, often life-threatening medical condition where insufficient blood flow reaches the body tissues. As blood is the body's carrier of oxygen and nutrients, this leads to a deficiency of these essential inputs to life. The process affected, where blood enters the tissues, is called perfusion and this process not occurring properly causes a hypoperfusional (hypo = below) state. Medical shock must not be confused with the emotional state, and the two are not related. Medical shock is a life-threatening medical emergency and one of the leading causes of death for critically ill people. This primary cause may lead to many other medical emergencies, such as hypoxia (a lack of oxygen in the body tissues) or cardiac arrest (the heart stopping). Shock can have a number of effects, all with similar outcomes, but all relate to a problem with the body's circulatory system. In 1972 Hinshaw and Cox suggested the following classification which is still used today. It uses four types of shock: hypovolaemic, cardiogenic, distributive and obstructive shock: Hypovolaemic shock - This is the most common type of shock and based on insufficient circulating volume. Its primary cause is loss of fluid from the circulation from either an internal or external source. An internal source may be haemorrhage. External causes may include extensive bleeding, high output fistulae or severe burns. Cardiogenic shock - This type of shock is caused by the failure of the heart to pump effectively. This can be due to damage to the heart muscle, most often from a large myocardial infarction. Other causes of cardiogenic shock include arrhythmias, cardiomyopathy, congestive heart failure (CHF), contusio cordis or cardiac valve problems. Distributive shock - As in hypovolaemic shock there is an insufficient intravascular volume of blood. This form of "relative" hypovolaemia is the result of dilation of blood vessels which diminishes systemic vascular resistance. Examples of this form of shock are: Septic shock - This is caused by an overwhelming infection leading to vasodilation, such as by Gram negative bacteria i.e. Escherichia coli, Proteus species, Klebsiella pneumoniae which release an endotoxin which produces adverse biochemical, immunological and occasionally neurological effects which are harmful to the body. Gram-positive cocci, such as pneumococci and streptococci, and certain fungi as well as Gram-positive bacterial toxins produce a similar syndrome. Anaphylactic shock - Caused by a severe anaphylactic reaction to an allergen, antigen, drug or foreign protein causing the release of histamine which causes widespread vasodilation, leading to hypotension and increased capillary permeability. Neurogenic shock - Neurogenic shock is the rarest form of shock. It is caused by trauma to the spinal cord resulting in the sudden loss of autonomic and motor reflexes below the injury level. Without stimulation by sympathetic nervous system the vessel walls relax uncontrolled, resulting in a sudden decrease in peripheral vascular resistance, leading to vasodilation and hypotension. Obstructive shock - In this situation the flow of blood is obstructed which impedes circulation and can result in circulatory arrest. Several conditions result in this form of shock. Cardiac tamponade in which blood in the pericardium prevents inflow of blood into the heart (venous return). Constrictive pericarditis, in which the pericardium shrinks and hardens, is similar in presentation. Tension pneumothorax. Through increased intrathoracic pressure, bloodflow to the heart is prevented (venous return). Massive pulmonary embolism is the result of a thromboembolic incident in the bloodvessels of the lungs and hinders the return of blood to the heart. Aortic stenosis hinders circulation by obstructing the ventricular outflow tract Recently a fifth form of shock has been introduced:[1] Endocrine shock based on endocrine disturbances. Hypothyroidism, in critically ill patients, reduces cardiac output and can lead to hypotension and respiratory insufficiency. Thyrotoxycosis may induce a reversible cardiomyopathy. Acute adrenal insufficiency is frequently the result of discontinuing corticosteroid treatment without tapering the dosage. However, surgery and intercurrent disease in patients on corticosteroid therapy without adjusting the dosage to accommodate for increased requirements may also result in this condition. Relative adrenal insufficiency in critically ill patients where present hormone levels are insufficient to meet the higher demands Treatment In the early stages, shock requires immediate intervention to preserve life. Therefore, the early recognition and treatment depends on the transfer to a hospital. The management of shock requires immediate intervention, even before a diagnosis is made. Re-establishing perfusion to the organs is the primary goal through restoring and maintaining the blood circulating volume ensuring oxygenation and blood pressure are adequate, achieving and maintaining effective cardiac function, and preventing complications. Patients attending with the symptoms of shock will have, regardless of the type of shock, their airway managed and oxygen therapy initiated. In case of respiratory insufficiency (i.e. diminished levels of consciousness, hyperventilation due to acid-base disturbances or pneumonia) intubation and mechanical ventilation may be necessary. A paramedic may intubate in emergencies outside the hospital, whereas a patient with respiratory insufficiency in-hospital will be intubated usually by a physician. The aim of these acts is to ensure survival during the transportation to the hospital; they do not cure the cause of the shock. Specific treatment depends on the cause. A compromise must be found between: raising the blood pressure to be able to transport "safely" (when the blood pressure is too low, any motion can lower the heart and brain perfusion, and thus cause death); respecting the golden hour. If surgery is required, it should be performed within the first hour to maximise the patient's chance of survival. Hypovolaemic shock In hypovolaemic shock, caused by bleeding, it is necessary to immediately control the bleeding and restore the victim's blood volume by giving infusions of balanced salt solutions. Blood transfusions are necessary for loss of large amounts of blood (e.g. greater than 20% of blood volume), but can be avoided in smaller and slower losses. Hypovolaemia due to burns, diarrhoea, vomiting, etc. is treated with infusions of electrolyte solutions that balance the nature of the fluid lost. Sodium is essential to keep the fluid infused in the extracellular and intravascular space whilst preventing water intoxication and brain swelling. Metabolic acidosis (mainly due to lactic acid) accumulates as a result of poor delivery of oxygen to the tissues, and mirrors the severity of the shock. It is best treated by rapidly restoring intravascular volume and perfusion as above. Inotropic and vasoconstrictive drugs should be avoided, as they may interfere in knowing blood volume has returned to normal. Regardless of the cause, the restoration of the circulating volume is priority. As soon as the airway is maintained and oxygen administered the next step is to commence replacement of fluids via the intravenous route. Opinion varies on the type of fluid used in shock. The most common are: Crystalloids - Such as sodium chloride (0.9%), or Hartmann's solution (Ringer's lactate). Dextrose solutions which contain free water are less effective at re-establishing circulating volume, and promote hyperglycaemia. Colloids - For example, synthetic albumin (Dextran™), polygeline (Haemaccel™), succunylated gelatin (Gelofusine™) and hetastarch (Hepsan™). Colloids are, in general, much more expensive than crystalloid solutions and have not conclusively been shown to be of any benefit in the initial treatment of shock. Combination - Some clinicians argue that individually, colloids and crystalloids can further exacerbate the problem and suggest the combination of crystalloid and colloid solutions. Blood - Essential in severe haemorrhagic shock, often pre-warmed and rapidly infused. Vasoconstrictor agents have no role in the initial treatment of hemorrhagic shock, due to their relative inefficacy in the setting of acidosis, and due to the fact that the body, in the setting of hemorrhagic shock, is in an endogenously catecholaminergic state. Definitive care and control of the haemorrhage is absolutely necessary, and should not be delayed. Cardiogenic shock In cardiogenic shock: depending on the type of myocardal infarction one can infuse fluids or in shock refractory to infusing fluids, inotropic agents. Inotropic agents, which enhance the heart's pumping capabilities, are used to improve the contractility and correct the hypotension. Should that not suffice an intra-aortic balloon pump -which reduces workload for the heart, and improves perfusion of the coronary arteries- can be considered or a left ventricular assist device -which augments the pump-function of the heart. The main goals of the treatment of cardiogenic shock are the re-establishment of circulation to the myocardium, minimising heart muscle damage and improving the heart's effectiveness as a pump. This is most often performed by percutaneous coronary intervention and insertion of a stent in the culprit coronary lesion or sometimes by cardiac bypass. Although this is a protection reaction, the shock itself will induce problems; the circulatory system being less efficient, the body gets "exhausted" and finally, the blood circulation and the breathing slow down and finally stop (cardiac arrest). The main way to avoid this deadly consequence is to make the blood pressure rise again with fluid replacement with intravenous infusions; use of vasopressing drugs (e.g. to induce vasoconstriction); use of anti-shock trousers that compress the legs and concentrate the blood in the vital organs (lungs, heart, brain). use of blankets to keep the patient warm - metallic PET film emergency blankets are used to reflect the patient's body heat back to the patient. [edit] Distributive shock In distributive shock caused by sepsis the infection is treated with antibiotics and supportive care is given (i.e. inotropica, mechanical ventilation, renal function replacement). Anaphylaxis is treated with adrenaline to stimulate cardiac performance and corticosteroids to reduce the inflammatory response. In neurogenic shock because of vasodilation in the legs, one of the most suggested treatments is placing the patient in the Trendelenburg position, thereby elevating the legs and shunting blood back from the periphery to the body's core. However, since bloodvessels are highly compliant, and expand as result of the increased volume locally, this technique does not work. More suitable would be the use of vasopressors. [edit] Obstructive shock In obstructive shock, the only therapy consists of removing the obstruction. Pneumothorax or haemothorax is treated by inserting a chest tube, pulmonary embolism requires thrombolysis (to reduce the size of the clot), or embolectomy (removal of the thrombus), tamponade is treated by draining fluid from the pericardial space through pericardiocentesis. [edit] Endocrine shock In endocrine shock the hormone disturbances are corrected. Hypothyroidism requires supplementation by means of levothyroxine, in hyperthyroidism the production of hormone by the thyroid is inhibited through thyreostatica, i.e. methimazole (Tapazole®) or PTU (propylthiouracil). Adrenal insufficiency is treated by supplementing corticosteroids. Self treatment for shock can be very effective if the shock is not too severe. Peppermint essential oils or Neroli essential oil inhaled directly from the bottle can be very effective. Dr Bach’s rescue remedy is excellent ... just put 4 drops on the tongue if possible. |
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