Shock is a hemodynamic state characterized by impaired tissue perfusion. Each type of shock comprises a wide variety of causes that require prompt assessment and management since shock represents an emergent situation.
There are common types of shock, including cardiogenic shock, hypovolemic shock, obstructive shock, and distributive shock (which can be further subdivided into anaphylactic shock, neurogenic shock, and septic shock). They present with different clinical manifestations and outcomes.
Acute management of the different types of shock involves the restoration of circulatory stability and appropriate organ perfusion, which includes addressing the underlying cause.
5 Common Types of Shock: Introduction
Shock is the state of acute circulatory failure that develops when there is an impairment in tissue perfusion and cellular oxygenation. To simplify it more, it is the state when the cells, tissues, and organs do not receive adequate oxygen and nutrients to perform their function properly. It is a life-threatening medical emergency that worsens quickly and requires immediate diagnosis and urgent resuscitation. This condition most commonly occurs when there is an acute drop in blood pressure and reduced blood flow to the organs and tissues. A person in shock can present with hypertension, hypotension, or normotension. At first, shock is reversible, but it can lead to irreversible organ dysfunction if not recognized and treated immediately. (1)
The evaluation of a patient presenting with shock involves a thorough assessment, including detailed medical history, physical examination of the patient, and monitoring vital signs. Shock is a medical emergency that demands immediate action, as it can lead to organ failure and even death. The first step in approaching a patient with suspicion of shock is to assess the vital signs. These include blood pressure, oxygen saturation, heart rate, and respiratory rate. A patient in shock may exhibit low blood pressure, increased heart rate, and shallow breathing. It is essential to monitor these vital signs frequently to track the patient’s response to treatment and adjust the management plan accordingly. (1, 2)
After measuring the vital signs, the clinician should obtain a thorough clinical history of the patient, including information about any underlying medical conditions, recent surgeries or medical procedures, medications, and allergies. The next step in evaluating shock is to perform a physical examination. The clinician should examine the patient’s cardiovascular, respiratory, and neurological systems, looking for signs of hypoperfusion or organ dysfunction. The skin should also be examined for temperature, moisture, and color changes, as this can provide valuable information about the severity of shock.
Once the evaluation is complete, the clinician should use the information gathered to develop a management plan tailored to the patient’s needs. The plan includes restoring blood volume, infusing vasoactive drugs, and keeping vital functions in support until full recovery.
There are different types of shock, and each type has its unique cause and set of symptoms. The most common types of shock include hypovolemic shock, cardiogenic shock, septic shock, anaphylactic shock, and neurogenic shock. Let’s have a brief overview of the types of shock to differentiate them accordingly.
1. Hypovolemic shock
Hypovolemic shock is a critical condition that results when there is a loss of effective intravascular volume leading to circulatory failure. This may be due to the loss of plasma from the circulatory system or due to the loss of other fluids from the body (Gastrointestinal losses, renal losses, skin losses, third space sequestration). This leads to tissue hypoperfusion and hypoxia. As a result, the body becomes deprived of oxygen and nutrients. This happens when a person has lost more than 25 to 30% of his blood volume (3). It could also be the result of severe dehydration, excessive sweating, vomiting, diarrhea, and hemorrhage. All of these conditions eventually lead to hypovolemic shock. If left untreated, the reduced blood flow can cause severe damage to organs, leading to subsequent organ failure (3, 4, 5).
When treating hypovolemic shock, it is important to find out the underlying cause of hypovolemia, which could be the result of hemorrhage or other fluid losses. Trauma is the main root cause of hypovolemic shock resulting from blood loss, but it can also occur without traumatic conditions. In most patients with hypovolemic shock, the first abnormal vital sign is tachycardia, which is an abnormally increased heart rate. Other symptoms include:
- Rapid breathing;
- Excessive sweating;
- Cold and clammy skin;
- Generalized weakness;
- Rapid pulse;
If hemorrhage is the cause of hypovolemic shock in the patient, the best way to treat this condition is by transfusion of whole blood. The source of bleeding should also be identified, and further loss should be prevented as it has good prognostic value if promptly treated. It can be done through surgical or endoscopic techniques. Interventional radiology techniques are also being used for this purpose nowadays. If the hypovolemic shock is caused by loss of plasma, the best therapy is the administration of plasma. When it is due to any other fluid loss, an appropriate electrolyte solution should be given to the patient to replace the lost fluid. Sometimes plasma is not available. In these cases, dextran solutions are available to correct the shock. Early recognition and prompt management are essential for improving outcomes and preventing life-threatening complications (3, 6).
2. Cardiogenic shock
Cardiogenic shock is a medical condition in which the heart fails to supply oxygen-rich blood to the body to meet its needs. It can be lethal because it usually initiates a vicious cycle of decreased oxygen that can ultimately lead to multiple organ failures. Cardiogenic shock is most commonly caused by an Acute Myocardial Infarction that damages a significant proportion of the myocardium. Other causes include Heart Valve Diseases, congenital heart defects, severe arrhythmias, and cardiomyopathy. It can also be caused by drug overdose, severe infection, or trauma. (7, 8)
The symptoms of cardiogenic shock may vary depending on the extreme severity of the condition. Common symptoms include:
- Shortness of breath
- Chest heaviness
- Chest pain
- Low blood pressure
- Patients may also experience nausea, vomiting, sweating, and fainting.
Chest pain is the distinctive feature of cardiogenic shock that is associated with Acute Coronary Syndrome. Cardiogenic shock is typically diagnosed based on a combination of clinical symptoms, physical examination, and diagnostic tests. These tests may include an electrocardiogram (ECG), chest X-ray, echocardiogram, blood tests (Troponin I and T), and angiography. (9)
Cardiogenic shock is a medical emergency and requires prompt treatment. Treatment of cardiogenic shock may include improvement in blood flow and oxygen supply to organs to avoid severe damage. This may involve medications, such as vasoactive agents and inotropic agents, to increase blood pressure and improve heart function, as well as oxygen therapy to improve oxygen supply to the body’s tissues. (10) In severe cases, mechanical ventilation or extracorporeal membrane oxygenation (ECMO) may be necessary to provide respiratory support and improve blood oxygenation. In some cases, surgery may be required to repair or replace damaged heart valves or to perform a coronary artery bypass graft. In fatal cases, even support devices are also used to help heart function. After the condition of shock has been managed, the next step is to monitor any other disease associated with it and then treat it accordingly. (9, 11)
3. Septic shock
Septic shock is a life-threatening condition that occurs when the body’s immune system overreacts to an infection, causing damage to multiple organs and tissues. It is a medical emergency that requires rapid diagnosis and treatment to prevent irreversible harm.
The term septic shock is used to describe a severe form of sepsis, which is a potentially life-threatening condition caused by the presence of harmful microorganisms, such as bacteria, viruses, or fungi, in the body. When the immune system detects the presence of these microorganisms, it releases a cascade of cytokines, which trigger a systemic inflammatory response in an attempt to eliminate the infection. (12)
In septic shock, the immune response becomes exaggerated, causing widespread inflammation and damage to organs and tissues. The most common cause of septic shock is bacterial infections. These include infections by Pseudomonas (20%), Staphylococcus aureus (20%), and Escherichia coli (16%) as a potential source for sepsis and development of septic shock. The most common sites of infection leading to sepsis are respiratory tract infections (42%), such as pneumonia, urinary and genital tract infections (10%), and infections of the bloodstream (21%). (13, 14)
The symptoms of septic shock are similar to those of sepsis but are more severe and may include the following:
- Low blood pressure (hypotension);
- Rapid heartbeat (tachycardia);
- Rapid breathing (tachypnea);
- Confusion or disorientation;
- Reduced urine output;
- Cool, clammy skin;
- Fever or hypothermia;
- Fatigue or weakness;
- Nausea and vomiting.
Treatment for septic shock usually involves aggressive supportive care, including:
- Oxygen therapy to support breathing;
- Intravenous fluids to maintain blood pressure;
- Vasopressor medications to increase blood pressure;
- Antibiotics to treat the underlying infection;
- Nutritional support to maintain metabolic functioning;
- Organ support, such as mechanical ventilation or dialysis, as needed.
The goal of treatment is to stabilize the patient’s condition and prevent further damage to organs and tissues. In every case, patients require admission to an intensive care unit for close monitoring and specialized care. Prevention of septic shock involves early recognition and treatment of infections. From the healthcare perspective, it is important to practice good hygiene, including handwashing and avoiding contact with people who are sick. Individuals with weakened immune systems, such as those with diabetes or HIV, may be at increased risk for septic shock and should take extra precautions to prevent infections. (12)
4. Anaphylactic shock
Anaphylactic shock is an acute allergic condition in which arterial pressure decreases significantly. It results primarily from an antigen-antibody reaction that rapidly occurs after exposure to an antigen to which the patient is sensitive. It causes the basophils and mast cells in the body to release histamine and other vasodilatory substances that stimulate a hypersensitivity reaction. Intravenous injection of large amounts of histamine causes “histamine shock,” which has characteristics identical to anaphylactic shock. If left untreated, anaphylactic shock can lead to respiratory and cardiac arrest, which can be fatal. (15)
The symptoms of anaphylactic shock can be sudden and severe, and they can affect multiple systems in the body. These symptoms may include:
- Skin reactions such as hives, itching, and flushing;
- Swelling of the face, lips, tongue, or throat;
- Difficulty breathing or shortness of breath;
- Rapid or weak pulse;
- Low blood pressure;
- Nausea, vomiting, or diarrhea;
- Dizziness or fainting.
Prevention of anaphylactic shock involves avoiding known allergens whenever possible. For individuals with known allergies, it is important to carry an epinephrine auto-injector at all times and to educate friends, family, and coworkers about how to recognize the signs of Anaphylaxis and how to administer the medication in an emergency. (16)
During Anaphylaxis, CPR may be required if the patient presents with manifestations of cardiac arrest. In addition to CPR, various medications may also be administered to manage the allergic reaction and its symptoms. These medications include:
- Epinephrine (adrenaline): Epinephrine is a vasopressor and inotropic drug that is thought to improve hemodynamic status by decreasing vasodilation and vascular permeability associated with anaphylactic shock. In this way, it reduces angioedema and also improves bronchodilation as a result of its Beta-2 agonist properties.
- Oxygen: Oxygen therapy and airway management are of paramount importance during an anaphylactic episode or an anaphylactic shock. Angioedema may produce glottic edema, impeding appropriate ventilation and oxygenation.
- Intravenous (IV) antihistamines and cortisone: Antihistamines and cortisone are indicated for histamine antagonism and inflammation reduction, respectively.
- Beta-agonist (such as albuterol): Beta-agonists are drugs used for bronchoconstriction during an anaphylactic attack. They exert their effects by Beta-2 receptor agonism and subsequent bronchial muscle relaxation. Albuterol is a commonly used beta-agonist drug. (16)
5. Neurogenic shock
Neurogenic shock is a distributive type of shock caused by the sudden loss of normal autonomic tone throughout the body resulting especially in massive vasodilatation. Neurogenic shock occurs in patients with spinal cord or brain injury and deep general anesthesia. It is often characterized by bradycardia, hypotension, and thermal dysregulation. Autonomic instability may develop consequently and persist several weeks after the spinal cord injury. Management should be prompt in the initial phase to avoid further ischemic damage to the cord. In neurogenic shock, there is a disruption in the normal balance between the sympathetic and parasympathetic nervous systems. This imbalance results in a decrease in heart rate, blood pressure, and vascular tone. As a result, there is a decrease in organ perfusion, leading to organ dysfunction and failure. (17, 18)
The treatment of neurogenic shock involves addressing the underlying cause of the condition and providing supportive care to maintain organ perfusion and prevent further complications. Here are some common treatments used for neurogenic shock:
- Fluid resuscitation: Neurogenic shock can cause a drop in blood pressure, so fluid resuscitation may be necessary to maintain organ perfusion. This involves administering intravenous fluids, such as saline or lactated Ringer’s solution, to increase blood volume and improve blood pressure. (17)
- Vasopressors: If fluid resuscitation is insufficient to maintain adequate blood pressure, vasopressors may be required. These medications work by constricting blood vessels and increasing vascular tone, which can help to raise blood pressure and maintain organ perfusion. (19)
- Oxygen therapy: Neurogenic shock can cause a decrease in oxygenation; therefore, supplemental oxygen may be necessary to improve oxygenation and prevent further organ damage.
- Stabilization of the spine: If neurogenic shock is caused by a spinal cord injury, it is important to stabilize the spine to prevent further damage. This can involve immobilization with a cervical collar and backboard or surgical intervention if indicated.
- Monitoring and support: Patients with neurogenic shock require close monitoring and support to ensure adequate organ function. This can include monitoring vital signs, electrolytes, and urine output, as well as providing nutrition and pain management as needed in the context of ICU management. (20, 21)
It is possible to recover from shock if it is promptly recognized and appropriately treated. The prognosis for recovery depends on the underlying cause of the shock, the severity of the shock, and how quickly it is treated. In some cases, shock can be life-threatening and can lead to serious complications, such as organ failure or death. However, with early and effective treatment, many patients with shock can recover and return to their normal activities. Recovery from shock may take time and may involve ongoing medical care and follow-up to prevent the recurrence of the condition. (1)
The author does not report any conflict of interest.
This information is for educational purposes and is not intended to treat disease or supplant professional medical judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.
Introducing Valvular Heart Disease
Heart Failure with Preserved Ejection Fraction
Dyspnea Due to Respiratory Causes
Diagnosis and Management of Anaphylaxis
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