Shock Types: A Quick Overview

About this course

Shock is a severe manifestation of circulatory failure that results in cellular and tissue hypoxia.1 All cases of shock require rapid and proper identification to restore oxygen delivery to vital organs, as improper identification and delay in treatment can lead to vital organs being irreversibly damaged, causing multiple organ failure and death. This course provides an overview of the different types of shock and their causes, signs and symptoms, and potential treatment options.

Learning objectives

• Define the three stages of shock
• Review the physiologic changes associated with hypoxia.
• Review fluid administration requirements in the setting of shock
• Recognize the four major subtypes of shock, their causes, and their symptoms
• Understand the pharmacologic treatment options for the various shock types

Course outline

36 sections · finish in any order across devices

1. 1

   Introduction

   Shock is a severe manifestation of circulatory failure that results in cellular and tissue hypoxia.1 Simply put, it is a life-threatening condition that affects the body’s ability to perfuse organs.2,3 This causes a decreased oxygen output which is inadequate to meet the cellular metabolic demands o

   4 min

2. 2

   Defining Shock

   Shock is a medical condition in which the patient suffers from cellular and tissue hypoxia.3 This commonly happens when an individual has extremely low blood pressure, and their oxygen delivery to multiple organs is disrupted or stopped.3 However, it is important to note that not all people with low

   4 min

3. 3

   Shock Types

   There are four broad categories of shock, namely, cardiogenic, hypovolemic, distributive, and obstructive. Each has its own mechanism, causes, common signs and symptoms, and treatment options.2 The etiologies mentioned above can result in any of these four types and are manifested by the final outco

   4 min

4. 4

   Distributive Shock

   Also known as vasodilatory shock, distributive shock causes inadequate tissue perfusion.7 It is the most frequent form of shock, and results from the pathological redistribution of the absolute intravascular volume.6 In this shock type, systemic vasodilation results in decreased blood flow to vital

   4 min

5. 5

   Septic Shock

   Septic shock is caused by the dysregulated host response to infection.2 It causes severe metabolic, cellular, and circulatory abnormalities resulting in hypoperfusion.2 Septic shock is the most common type of shock overall.8

   4 min

6. 6

   Sign and Symptoms

   Most signs and clinical findings are insidious and can manifest in the form of:9

   4 min

7. 7

   Diagnosis

   Sepsis commonly occurs in patients over 65 years of age and in those with underlying malignant diseases.6 For many years, sepsis was diagnosed by the presence of an infection and systemic inflammatory response syndrome (SIRS).10 But SIRS has inadequate sensitivity and specificity. Thus, a new and im

   4 min

8. 8

   Treatment Options

   The two most important measures of initial treatment of sepsis and septic shock are source control and antibiotic therapy.10 To prevent organ dysfunction progression, early and aggressive source control is recommended to halt progression of the infectious agent and to improve patient outcomes.

   4 min

9. 9

   Resuscitation

   According to the fourth revision of the Surviving Sepsis Campaign (SSC) guidelines, resuscitation is the initial intervention for the management of sepsis and shock.10 Immediate resuscitation or achieving the targeted endpoint of resuscitation in a sepsis or septic shock patient during the first 6 h

   4 min

10. 10

    Vasopressor Support

    Septic shock patients with hypotension often require vasopressor support. For septic shock, norepinephrine is considered the first vasoactive agent choice because it includes alpha-1 and beta-1 stimulation, which helps increase peripheral vasoconstriction without significantly compromising cardiac o

    4 min

11. 11

    Corticosteroids

    Corticosteroids are also effective as they use immune modulation and cardiovascular modulation mechanisms to increase tissue perfusion.11. Steroids are recommended for to patients in which adrenal suppression is suspected, and vasopressor support is required.10

    4 min

12. 12

    Other Management Options

    Nutrition - Caloric intake improves mortality in underweight and overweight populations. The preferred feeding option is via enteral access. The patient should receive enteral feeding within 48 hours, and feeding goals should be met ideally within 72 hours of admission to the hospital.10,11

    4 min

13. 13

    Anaphylactic Shock

    Also known as allergic shock or anaphylaxis, anaphylactic shock is believed to be caused by a hypersensitive reaction by immunoglobulin E (Ig-E), resulting in respiratory distress and cardiovascular collapse.2 The central role is played by the mast cells and basophilic granulocytes that release medi

    4 min

14. 14

    Signs and Symptoms

    The clinical presentation of anaphylactic shock varies from person to person and depends on the site of entry and amount of the antigen, exposure type, and the sensitization degree, but it usually manifests in the form of respiratory symptoms, abdominal symptoms, or skin rashes or hives.6

    4 min

15. 15

    Treatment Options

    Immediate management is critical to prevent cardiac arrest.13 The first step in initial management is airway assessment. If the airway is compromised and respiratory distress is noted, emergency intubation should be performed.13 In patients with upper airway edema, early intubation is recommended.13

    4 min

16. 16

    Epinephrine

    Anaphylaxis is an extremely variable condition, with symptoms varying from mild to severe within minutes. Because of this, after initial management, the administration of epinephrine is the first treatment option to prevent life-threatening symptoms.13 Epinephrine is effective and should be administ

    4 min

17. 17

    Adjunctive Agents

    These agents are given in combination with epinephrine to treat associating symptoms of anaphylaxis.13 They are not used as first-line treatment and do not affect the upper and lower respiratory tract obstruction or prevention of life-threatening symptoms.13 These adjunctive agents include:

    4 min

18. 18

    Diagnosis

    Diagnosis is difficult and requires extensive investigation.15 The recommended course of action involves ruling out hemorrhagic shock first and then considering neurogenic shock.15 Healthcare professionals should gather information about the mechanism of injury, the presence of midline spinal tender

    4 min

19. 19

    Treatment Options

    Hypotension should be treated to prevent secondary injury.

    4 min

20. 20

    Cardiogenic Shock

    Cardiogenic shock is a hemodynamically complex syndrome that results in decreased cardiac output, hypoxia, and end-organ hypoperfusion.17,18 It has poor clinical outcomes and a mortality rate of 40%.18 It is caused due to systolic or diastolic dysfunction, resulting in a reduced ejection fraction or

    4 min

21. 21

    Causes

    The main cause of cardiogenic shock is decreased cardiac output, which can lead to ischemia, systemic hypoperfusion, vasoconstriction, and volume overload, culminating in multiple organ failures and even death.18 The initial cardiac damage or insult can occur because of various underlying conditions

    4 min

22. 22

    Diagnosis

    Cardiogenic shock, also known as cardiac shock, is diagnosed through various tests and physical examination.19 First, a patient’s medical history is collected, such as a personal and family history of cardiac conditions, any symptoms of a heart attack before arriving to the hospital, and any medicat

    4 min

23. 23

    Signs and Symptoms

    The signs and symptoms of patients with cardiogenic shock can be differentiated into two categories, such as “cold and wet,” which reflects a reduced cardiac index (CI), increased systemic vascular resistance (SVR), and increased pulmonary capillary wedge pressure (PCWP).17 Or “dry and cold,” which

    4 min

24. 24

    Treatment Options

    The Society for Cardiovascular Angiography and Intervention (SCAI) classified cardiogenic shock into stages from A through E. This was developed by a multidisciplinary team from cardiology, emergency medicine, critical care, and cardiac nursing.

    4 min

25. 25

    Mechanical Circulatory Support (MSC) Devices

    Early use of mechanical circulatory support (MSC) devices significantly improves health outcomes and is associated with substantial cardiovascular support without increased risk of myocardial ischemia.17 Moreover, it might lower the myocardial oxygen demand.17 MSC devices are better than vasopressor

    4 min

26. 26

    Hypovolemic Shock

    Hypovolemic shock is a life-threatening condition that requires early diagnosis and management to prevent progressive symptoms.20 Hypovolemic shock is characterized by inadequate blood volume circulation and perfusion, causing rapid fluid or blood loss, and leading to multiple organic failures or de

    4 min

27. 27

    Causes

    Hemorrhagic shock is due to an acute reduction in intravascular volume from bleeding.20 The critical drop in circulating blood volume triggers the shock, and the loss of a large amount of red blood cells intensifies tissue hypoxia.6 The following are common causes of hemorrhagic shock:2,6,20

    4 min

28. 28

    Diagnosis

    Multiple laboratory tests are conducted to diagnose hypovolemic shock, including:20,21

    4 min

29. 29

    Hemorrhagic Shock

    To improve survival rate and blood products transfusion, early resuscitation is critical for prompt bleeding source control.20

    4 min

30. 30

    Non-Hemorrhagic Shock

    Volume resuscitation should be started immediately to compensate for fluid loss. Since the type of fluid loss is difficult to determine, physicians recommend starting with 30ml/kg body weight of warm isotonic crystalloid solution, infused rapidly to restore tissue perfusion quickly.20

    4 min

31. 31

    Obstructive Shock

    Obstructive shock is triggered by an inadequate blood supply to vital organs; it closely resembles cardiogenic shock, but differentiation is necessary to provide appropriate treatment options.22 The major difference between the two is that cardiogenic shock is caused by primary cardiac dysfunction,

    4 min

32. 32

    Rapid Ultrasound in Shock (RUSH)

    Perera et. al. developed the RUSH Protocol (Rapid Ultrasound in Shock) and offered a structured ultrasound approach for differentiating between different shock types.22

    4 min

33. 33

    Fluid Resuscitation

    Fluid resuscitation is a common and most important treatment option for septic shock. According to international guidelines, aggressive fluid resuscitation results in improved outcomes.24 This is based on the theory that septic shock is strongly associated with hypovolemic shock and is characterized

    4 min

34. 34

    Different Intravenous Fluid Types

    There are several types of intravenous fluids available, such as:26

    4 min

35. 35

    Massive Transfusion Protocol

    The following is the fluid resuscitation protocol in children:27

    4 min

36. 36

    Conclusion

    Shock is a life-threatening condition with several types, etiologies, and underlying conditions resulting in multiple organ failures and poor health outcomes. Thus, a multidisciplinary team containing physicians, nurses, and specialists should be established to provide an appropriate treatment cours

    4 min

This course satisfies

Requirement summaries come from our state requirement records. Always confirm details with your board before you renew.

References and resources

• Shock - Heart and Blood Vessel Disorders. MSD Manual Consumer Version. https://www.msdmanuals.com/home/heart-and-blood-vessel-disorders/low-blood-pressure-and-shock/shock
• Hayas Haseer Koya, Paul M. Shock. Nih.gov. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK531492/
• UpToDate. www.uptodate.com. Accessed March 17, 2023. https://www.uptodate.com/contents/definition-classification-etiology-and-pathophysiology-of-shock-in-adults#H183084763
• Shock; circulatory failure. Cancer Therapy Advisor. Published January 17, 2019. https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/critical-care-medicine/shock-circulatory-failure/
• Gitz Holler J, Jensen HK, Henriksen DP, et al. Etiology of Shock in the Emergency Department: A 12-Year Population-Based Cohort Study. Shock. 2019;51(1):60-67. doi:https://doi.org/10.1097/SHK.0000000000000816
• Standl T, Annecke T, Cascorbi I, Heller AR, Sabashnikov A, Teske W. The nomenclature, definition and distinction of types of shock. Deutsches Aerzteblatt Online. 2018;115(45). doi:https://doi.org/10.3238/arztebl.2018.0757
• Smith N, Lopez RA, Silberman M. Distributive Shock. PubMed. Published July 25, 2022. https://www.ncbi.nlm.nih.gov/books/NBK470316/
• Kislitsina ON, Rich JD, Wilcox JE, et al. Shock – Classification and Pathophysiological Principles of Therapeutics. Current Cardiology Reviews. 2019;15(2):102-113. doi:https://doi.org/10.2174/1573403x15666181212125024
• Polat G, Ugan RA, Cadirci E, Halici Z. Sepsis and Septic Shock: Current Treatment Strategies and New Approaches. The Eurasian Journal of Medicine. 2017;49(1):53-58. doi:https://doi.org/10.5152/eurasianjmed.2017.17062
• Armstrong BA, Betzold RD, May AK. Sepsis and Septic Shock Strategies. Surgical Clinics of North America. 2017;97(6):1339-1379. doi:https://doi.org/10.1016/j.suc.2017.07.003
• Thompson K, Venkatesh B, Finfer S. Sepsis and septic shock: current approaches to management. Internal Medicine Journal. 2019;49(2):160-170. doi:https://doi.org/10.1111/imj.14199
• Anaphylaxis. www.hopkinsmedicine.org. Published 2021. https://www.hopkinsmedicine.org/health/conditions-and-diseases/anaphylaxis
• UpToDate. Uptodate.com. Published 2020. https://www.uptodate.com/contents/anaphylaxis-emergency-treatment#H19
• Ring J, Beyer K, Biedermann T, et al. Guideline for acute therapy and management of anaphylaxis. Allergo Journal International. 2014;23(3):96-112. doi:https://doi.org/10.1007/s40629-014-0009-1
• Dave S, Cho JJ. Neurogenic Shock. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK459361/#:~:text=Neurogenic%20shock%20is%20a%20combination
• Cleveland Clinic. Neurogenic Shock: Causes, Symptoms and Treatment. Cleveland Clinic. Published November 30, 2021. https://my.clevelandclinic.org/health/diseases/22175-neurogenic-shock
• Vahdatpour C, Collins D, Goldberg S. Cardiogenic Shock. Journal of the American Heart Association. 2019;8(8). doi:https://doi.org/10.1161/jaha.119.011991
• Tehrani BN, Truesdell AG, Psotka MA, et al. A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock. JACC: Heart Failure. 2020;8(11):879-891. doi:https://doi.org/10.1016/j.jchf.2020.09.005
• Cardiogenic Shock - Diagnosis | NHLBI, NIH. www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/cardiogenic-shock/diagnosis
• Taghavi S, Askari R, Nassar A. Hypovolemic Shock. National Library of Medicine. Published October 4, 2022. https://www.ncbi.nlm.nih.gov/books/NBK513297/
• Shagana JA, Dharnaj M, Jain AshishR, Nirosa T. Hypovolemic shock - A review. Drug Invention Today. 2018;10(7).
• Zotzmann V, Rottmann FA, Bode C, Wengenmayer T, Staudacher DL, Müller-Pelzer K. Obstructive Shock, from Diagnosis to Treatment. IMR Press. 2022;23(7):248.
• Kim, K. S. Obstructive Shock. Essentials of Shock Management. 2018; 45–54. doi:10.1007/978-981-10-5406-8_4
• Marik PE, Byrne L, van Haren F. Fluid resuscitation in sepsis: the great 30 mL per kg hoax. Journal of Thoracic Disease. 2020;12(Suppl 1):S37-S47. doi:https://doi.org/10.21037/jtd.2019.12.84
• Gupta S, Sankar J. Advances in Shock Management and Fluid Resuscitation in Children. Indian Journal of Pediatrics. 2023;90(3):280-288. doi:https://doi.org/10.1007/s12098-022-04434-3
• Intravenous Fluid Resuscitation - Critical Care Medicine. MSD Manual Professional Edition. Accessed March 26, 2023. https://www.msdmanuals.com/professional/critical-care-medicine/shock-and-fluid-resuscitation/intravenous-fluid-resuscitation#:~:text=Both%200.9%25%20saline%20and%20Ringer
• Marjanović V, Budić I. Fluid Resuscitation and Massive Transfusion Protocol in Pediatric Trauma. Acta Facultatis Medicae Naissensis. 2016;33(2):91-99. doi:https://doi.org/10.1515/afmnai-2016-0010

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