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Cardiovascular Shock

 

Definition: Acute failure to perfuse adequately the organ and the tissues of the body .

A. Background:

1.

The diagram shows the cross section through the vascular system. At the beginning, in the aorta, its cross-section is very small. As one goes further and more towards the capillaries, then the vessels do become narrower, but the number of vessels increases much more. Therefore, the cross-sections of all these vessels (the "sum") increases a lot.

The cross section of all the capillaries together is a total of 5000 cm2, compared to only 2.5 cm2 for the aorta!

 

cross section of the vascular system

larger?

2.

Therefore, because there are so many more smaller vessels and capillaries in the body, this may cause a problem.

3.

If they were all wide open, their total cross section would be much more than the cross section of the aorta.

4.

Therefore, if all the blood vessels were open, then the blood volume (approx. 5 litres) would easily fit in the small vessels and the blood pressure would drop to zero!

5.

In order to avoid that, the arterial and venous vessels must always show some degree of vasoconstriction.

6.

Shock is the condition when the blood pressure is too low

7.

To be precise: this is called cardiovascular shock, to distinguish this from other types of shock such as psychological shock.

 

Types of Shock:

  1. Problems with the heart: cardiogenic shock
  2. Problems with the blood volume: hypovolaemic shock
  3. Problems with the vessel wall tension: anaphylactic shock or septic shock

 

Heart: Cardiogenic Shock

The heart can no longer pump properly due to:

  • myocardial infarction: a (large) part of the left ventricle is no longer working
  • myocarditis: inflammation/infection of the heart makes the muscle weaker
  • arrhythmias (disturbance in the rhythm): leaving not enough time in the diastole for filling the ventricles.
  • other cardiac causes (valvular, tamponade, etc)

Blood Volume: Hypovolaemic Shock

External Fluid Loss:

  • haemorrhage (bleeding)
  • diarrhoea (cholera)
  • vomiting (babies)
  • dehydration (sunstroke)
  • burns (> 20%)

Internal Fluid Loss:

  • crushing injuries
  • pancreatitis
  • internal bleeding (ruptured spleen)

Blood Vessel: Anaphylactic Shock and Septic Shock

Anaphylactic Shock:

Extreme vasodilation due to an intense allergic reaction (insect bite, allergic to medicine such as penicilline, etc).

Septic Shock :

Extreme vasodilation due to bacterial infections and the entry of bacteria and their toxic products (=endotoxins) inside the blood.

Compensated Phase: Immediate Response

Immediate Response:

Decrease in parasympathetic and increase in sympathetic activity.

Hormones:

Increases in Angiotensin II, adrenaline and vasopressin (=ADH)

Cardiac response:

  • increased chronotropy (tachycardia)
  • increased inotropy (contraction force)

Vascular Response:

Vasoconstriction in muscles, gut, skin and kidney -> increase in the Peripheral Resistance

BUT:

Reduced perfusion in these organs also leads to acidosis, weakness, oliguria (=decreased urine output) and pallor

Skin:

The skin becomes wet, cold and pale due to the increased sympathetic stimulation.

Compensated Phase: Intermediate Response

Vascular Fluid Shift:

Up to 500 ml can be transfused back into the vascular system.

BUT:

This will produce a temporary anaemia (= less oxygen transported) but also reduce viscosity (=less work for the heart)

Compensated Phase: Long Term Response

Kidney:

Reduction in renal excretion and increase in fluid intake (thirst)

Liver:

increase in liver glycolysis (induced by adrenal and sympathetic stimulation) -> more blood proteins -> increase in oncotic pressure

Bone Marrow :

Increased production in red blood cells.

Physical Signs of impending Shock:

  1. skin is pale, cold and sweaty
  2. pulse is rapid and weak
  3. breathing is rapid and shallow
  4. urine output is decreased or even stopped
  5. general muscle weakness
  6. reduced mental awareness or confusion
  7. mean arterial pressure may be normal or reduced (last sign to be affected)

Decompensated Phase (= irreversible)

If the blood loss is too high and /or fluid replacement is started too late:
  • then irreversible damage to:
  • myocardium
  • tubular necrosis (kidneys)
  • cardiac failure
  • multi-organ failure

Ultimately: death

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