Shock

Aka: Shock, Undifferentiated Shock, Targets of Adequate Perfusion In Fluid Replacement, Fluid Responsiveness Markers, Hypovolemic Shock, Hypovolemia, Dehydration, Distributive Shock

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II. Definitions

  1. Shock
    1. Impaired tissue oxygenation and perfusion
    2. Imbalance in delivery and consumption of oxygen and metabolic substrates
    3. Numerous causes and mechanisms, but 4 general types: Hypovolemic, Distributive, Cardiogenic, Obstructive

III. Pathophysiology: Shock

  1. Circulatory insufficiency resulting in inadequate oxygen supply for given demand
  2. Triggers a cascading metabolic spiral culminating in cell injury and cell death
    1. Intracellular Calcium overload
      1. Free radical oxidative damage
      2. Impaired mitochondrial ATP synthesis
      3. Impaired Muscle relaxation and myocardial contractility
    2. Metabolic Acidosis
      1. Results from anaerobic metabolism, Lactic Acidosis, and Renal Failure
      2. Increases Calcium overload
      3. Decreases myocardial and other Muscle contractility
      4. Decreased Catecholamine response
      5. Increased Interstitial Edema
    3. Pro-inflammatory Cytokines (e.g. Interleukins, Tumor Necrosis Factor)
      1. Limited to specific shock types (e.g. Septic Shock, Anaphylaxis)
      2. Systemic vasodilation secondary to endothelial cell activation and nitric oxide release
  3. Compensatory mechanisms (Blood Pressure may be normal when compensation is adequate)
    1. Cardiac Output increase
      1. Responds to Catecholamine and Cortisol release
    2. Arterial Vasoconstriction
      1. Selective shunting of Blood Flow from the skin, skeletal Muscle, Kidney and Gastrointestinal Tract
    3. Venous constriction
      1. Increases Preload and return of blood to heart and brain
    4. Increased Sodium and water reabsorption
      1. Antidiuretic Hormone
      2. Renin-Angiotensin System
  4. Failed compensation
    1. Metabolic Acidosis
    2. Coagulopathy (including Disseminated Intravascular Coagulation)
    3. Inflammatory mediator release
    4. Multiorgan dysfunction and death
    5. Hypotension

IV. Types

  1. Precautions: Undifferentiated Shock
    1. Many shock presentations are combinations of more than one shock type
    2. Septic Shock is primarily Distributive Shock, but also associated with third spacing and Hypovolemic Shock
    3. A massive tension pneumo-Hemothorax may cause both obstructive shock and Hypovolemic Shock
  2. Hypovolemic Shock
    1. Defined as intravascular fluid volume that is insufficient for adequate end-organ perfusion
    2. Hemorrhagic Shock (acute blood loss)
      1. Examples: Trauma (most common), Ruptured Abdominal Aortic Aneurysm, GI Bleed
    3. Dehydration
      1. Examples: Acute Gastroenteritis with Vomiting, Diarrhea, Diabetic Ketoacidosis
    4. Third-Spacing
      1. Examples: Burn Injury, Pancreatitis
  3. Distributive Shock
    1. Defined as systemic vasodilation that renders an otherwise sufficient circulating volume to be inadequate
      1. Hemodynamic parameters are paradoxically opposite other forms of shock
      2. SVR decreases (primary) and Cardiac Output, Pulse Pressure, SvO2 and ScvO2 increases
    2. Adrenal crisis
      1. Fever may be present (as in Septic Shock)
    3. Septic Shock
      1. Systemic inflammatory response with diffuse, peripheral vasodilation and decreased Cardiac Output
    4. Neurogenic Shock (esp. cervical and upper thoracic Spinal Cord Injury above T6)
      1. Loss of sympathetic nervous function
      2. Results in decreased vascular tone, Hypotension with paradoxical Bradycardia
      3. Neurogenic Shock does not cause a narrowed Pulse Pressure (sympathetic reflex)
      4. Contrast with Spinal Shock (below T6 Level), which results in Flaccid Paralysis below the lesion
    5. Anaphylaxis
      1. Mast Cell degranulation
      2. Cytokine-induced vasodilation
  4. Cardiogenic Shock
    1. Defined as cardiac pump failure (decreased Cardiac Index <1.8, increased left heart filling pressures)
    2. Congestive Heart Failure
    3. Cardiomyopathy (e.g. Viral Myocarditis, cardiotoxic agents)
    4. Trauma (e.g. Cardiac Contusion)
    5. Supraventricular Tachycardia or other Arrhythmias
    6. Structural heart defects (e.g. valvular rupture, left to right shunt)
  5. Obstructive Shock
    1. Defined as heart or Great Vessel obstruction to flow with decreased Preload or increased Afterload
    2. Tension Pneumothorax
    3. Pericardial Tamponade
    4. Massive Pulmonary Embolism (increased RV Afterload, RV bowing limits LV filling)

V. Causes (Mnemonic: SHRIMP CAN)

  1. Septic Shock
  2. Hypovolemic Shock (e.g. Hemorrhagic Shock, severe Dehydration)
  3. Respiratory Compromise (e.g. Tension Pneumothorax, massive Pulmonary Embolism)
  4. Ingestion (toxin, Overdose)
  5. Metabolic (e.g. DKA, Adrenal Insufficiency, Hypothyroidism)
  6. Psychiatric (Water Intoxication)
  7. Cardiogenic Shock (MI, CHF, Cardiac Tamponade)
  8. Anaphylactic shock
  9. Neurogenic Shock (e.g. Spinal Shock)
  10. (2016) CALS Manual

VI. History

  1. Medications and toxins
    1. Antiarrhythmics
    2. Anticoagulants
    3. Antihypertensives
    4. Diuretics
    5. Drugs of Abuse
    6. Poisons (Pesticides, Toxic Alcohols, Cyanide exposure)
  2. Hypovolemia sources
    1. Ectopic Pregnancy
    2. Gastrointestinal losses
      1. Severe Diarrhea
      2. Vomiting
      3. Decreased oral intake
    3. Gastrointestinal Bleeding
      1. Melana
      2. Hematochezia
      3. Hematemesis
  3. Distributive causes (especially Septic Shock)
    1. Fever, chills, sweats or myalgias
    2. Infectious sources
      1. Cough or other respiratory symptoms
      2. Headache, neck stiffness or acute neurologic changes
      3. Focal Abdominal Pain (e.g. Acute Cholecystitis, Appendicitis, Diverticulitis)
      4. Urinary symptoms (e.g. Dysuria, urgency, frequency, Flank Pain)
      5. New rashes (e.g. Cellulitis)
    3. Predisposing factors
      1. Indwelling Urinary Catheter
      2. Indwelling lines (e.g. PICC Line)
      3. Retained Foreign Body (e.g. retained tampon)
      4. Recent procedures or surgeries
      5. Immunocompromised state
  4. Cardiogenic causes
    1. Chest Pain
    2. Shortness of Breath on exertion (e.g. decreased walk distance)
    3. Orthopnea or paroxysmal nocturnal Dyspnea
    4. Volume overload (recent increased weight)
  5. Obstructive causes
    1. Venous Thromboembolism Risks
    2. Recent Trauma

VII. Symptoms

  1. Light Headedness
  2. Weakness
  3. Palpitations
  4. Fatigue
  5. Syncope
  6. Decreased Urine Output

VIII. Signs

  1. Altered Mental Status (lethargy, coma)
  2. Dry mucous membranes
  3. Decreased skin turgur
  4. Pallor
  5. Delayed Capillary Refill

IX. Signs: General

  1. See Primary Survey
  2. See Secondary Survey
  3. General Findings
    1. Diaphoresis
    2. Pallor
    3. Fever
  4. Head and neck findings
    1. Conjunctival pallor (Anemia)
    2. Dry mucous membranes
    3. Flat nondistended Jugular Veins
      1. Exception: Distented jugular neck veins in obstructive shock (e.g. Tension Pneumothorax)
  5. Respiratory findings
    1. Tachypnea
      1. Respiratory compensation for Metabolic Acidosis (e.g. Lactic Acidosis, Ketoacidosis) or
      2. Primary respiratory etiology (e.g. Pneumonia, Pneumothorax, Pulmonary Embolism)
    2. Kussmaul Respirations (deep sighing respirations)
      1. Examples: DKA, Hemorrhage, peritonitis, Uremia
    3. Asymmetric lung sounds
      1. Examples: Pneumothorax, Pneumonia
  6. Cardiovascular findings
    1. New cardiac murmur
    2. Pulsus Paradoxus
    3. Peripheral Edema (unilateral or bilateral)
    4. Decreased Capillary Refill
    5. Peripheral pulses (symmetry)
    6. Cold clammy extremities (peripheral vasconstriction)
      1. Exception: Warm extremities with vasodilation in Distributive Shock
  7. Abdominal findings
    1. Peritoneal signs
    2. Pregnancy
    3. Ascites
    4. Ecchymosis
      1. Seat Belt Sign
      2. Flank or periumbilical Ecchymosis (intra-abdominal Hemorrhage)
  8. Neurologic findings
    1. See Glasgow Coma Scale
    2. Altered Mental Status
    3. From Disorientation to coma
    4. Extremity weakness

X. Signs: Vital Signs

  1. See Toxin Induced Vital Sign Changes
  2. Heart Rate
    1. Compensatory Sinus Tachycardia
      1. Expected response to shock but inconsistently present
    2. Paradoxical absolute or Relative Bradycardia
      1. May be seen in severe shock with decreased Cardiac Output
    3. Arrhythmias
      1. Primary Tachycardia or profound Bradycardia with secondary Cardiogenic Shock
  3. Blood Pressure
    1. Hypotension is a late response to shock
      1. In young children, Hypotension is even more ominous, with little warning to cardiovascular collapse
      2. Not uniformly present (do not rely on Blood Pressure alone to diagnose shock)
  4. Pulse Oximetry (Oxygen Saturation)
    1. Hypoxemia
    2. Hypoventilation
  5. Temperature
    1. Hypothermia or Hyperthermia
    2. Abnormal Temperature (high or low) may suggest SIRS Response
    3. Heat Illness or Accidental Hypothermia may also cause Hypotension or shock state
  6. Fingerstick Glucose (bedside Glucose)
    1. Severe Hyperglycemia
      1. Diabetic Ketoacidosis
      2. Hyperosmolar Hyperglycemic State
    2. Hypoglycemia
      1. May suggest overwhelming infection or Adrenal Insufficiency
  7. Other bedside evaluation of shock
    1. Passive Leg Raise Maneuver (predicts response to 300 ml fluid bolus)
      1. Indicative of fluid-responsiveness if Blood Pressure increases or Heart Rate decreases with leg raise
    2. Shock Index
      1. Shock Index = (Heart Rate) / (Systolic Blood Pressure)
      2. Mild Shock: 0.6 to 1
      3. Moderate Shock: 1 to 1.4
      4. Severe Shock: >1.4

XI. Labs (as indicated, as markers of hypoperfusion and differential diagnosis)

  1. Bedside
    1. Fingerstick Glucose (bedside Glucose)
  2. Miscellaneous initial labs
    1. Complete Blood Count
    2. Comprehensive metabolic panel
    3. Coagulation tests (INR, PTT)
    4. Venous Blood Gas
    5. Blood Type and Cross Match
  3. Urine tests
    1. Urinalysis and Urine Culture
    2. Urine Pregnancy Test
    3. Urine toxicology
  4. Cardiac Markers
    1. Serum Troponin
    2. Brain Natriuretic Peptide (BNP)
  5. Infection suspected
    1. Serum Lactic Acid (associated with Metabolic Acidosis with Anion Gap)
    2. Blood Cultures
  6. Endocrine labs
    1. Thyroid Stimulating Hormone (TSH)
    2. Serum Cortisol

XII. Diagnostics

  1. Electrocardiogram
    1. See EKG in Myocardial Ischemia
    2. See EKG in Pulmonary Embolism
    3. See EKG monitoring in Trauma
    4. See QRS Widening
    5. See Prolonged QT
  2. Noninvasive monitoring (optional, but no proven protocols as of 2015)
    1. End-Tidal CO2 Monitoring
    2. Infrared spectroscopy
  3. Invasive monitoring (central catheter)
    1. Central oxygen
      1. Has been part of surviving Sepsis guidelines
        1. However as of 2015, Lactic Acid may be equivalent and without invasive monitoring
      2. Greater tissue Oxygen Consumption indicated with SvO2 < 65% or ScvO2 <68%
        1. Normal SvO2 or ScvO2 does not exclude hypoperfusion
        2. Mixed venous Oxygen Saturation (SvO2) goal >65%
        3. Central Venous Oxygen Saturation (ScvO2) goal >68%
    2. Central Venous Pressure
      1. Falling out of favor as of 2012
      2. Serial Inferior Vena Cava Ultrasound for Volume Status may be as effective without invasive testing

XIII. Imaging

  1. Chest XRay
    1. Pneumothorax
    2. Hemothorax
    3. Pneumonia
    4. Pulmonary Edema
    5. Wide Mediastinum (>8 cm)
  2. Bedside Ultrasound
    1. See eFAST Exam
    2. See Rapid Ultrasound in Shock
    3. See Inferior Vena Cava Ultrasound for Volume Status
    4. See Bedside Lung Ultrasound in Emergency (Blue Protocol)
    5. HIMAP Mnemonic
      1. Heart
      2. Inferior Vena Cava
      3. Morison's Pouch
      4. Aorta
      5. Pneumothorax

XIV. Precautions

  1. Initial shock findings may be subtle (e.g. mild confusion and Sinus Tachycardia)
    1. Initial systolic Blood Pressure may be normal (in compensated shock)

XV. Management: Approach

  1. See ABC Management
  2. Treatment per specific causes as above
    1. See Trauma Evaluation
    2. See Hemorrhagic Shock
    3. See Septic Shock
    4. See Cardiogenic Shock
  3. Two large bore IVs (18 gauge or larger)
    1. Intraosseous Access if IV Access is unavailable
  4. Fluid Replacement
    1. Crystalloid (LR or NS)
    2. Packed Red Blood Cell Transfusion as indicated (replace blood loss with blood)
  5. Fluid Responsiveness Markers
    1. See targets of adequate perfusion as listed below
    2. Assess Stroke Volume, cardiac ouput or surrogates before and after fluid challenge
      1. Administer 250-500 cc IV crystalloid challenge (over 10 minutes)
      2. Expect increased Stroke Volume >10-15% after fluid challenge
        1. See Stroke Volume Estimation by Bedside Ultrasound (Velocity-Time Integral)
      3. Consider Vasopressors if poor response after the first liter (2L in Septic Shock)
    3. IVC Ultrasound for Volume Status
      1. Serial measurements may serve as guide to adequate fluid Resuscitation
    4. Other Bedside Ultrasound Markers
      1. Hyperdynamic left heart and empty left ventricle also indicates additional fluids
      2. Continually reassess for excessive fluid Resuscitation (B Line Artifacts, engorged IVC)
    5. Passive Leg Raise Maneuver
      1. Elevation of both legs above the heart
      2. Provides a transient autologous fluid bolus of 300-400 cc
  6. Vasopressors (refractory severe Hypotension)
    1. Step 1: Norepinephrine
    2. Step 2: Vasopressin
    3. Step 3: Consider Epinephrine for inotropic or chronotropic support
    4. Step 4: Consider Angiotensin II
      1. Weingart (2018) EM:Rap 18(6): 3
      2. Khanna (2017) N Engl J Med 377(5):419-30 [PubMed]
  7. Respiratory support as needed
    1. See Noninvasive Ventilation
    2. See Advanced Airway
    3. See Rapid Sequence Intubation
      1. Ketamine may be a preferred induction agent in Hypotension
    4. Time intubation based on expectation of improvement with initial Resuscitation
      1. May resuscitate first and reassess if expect initial improvement in first 15 minutes
      2. Intubate if response to Resuscitation is expected to be delayed
    5. Choose short-acting post-intubation Sedatives and Analgesics
      1. Avoid Benzodiazepines
      2. Preferred Sedative: Dexmetetomidine
      3. Preferred Analgesic: Fentanyl
  8. Empiric Therapy
    1. See Septic Shock
      1. Empiric Antibiotic selection based on suspected source
    2. Treat Hemorrhagic Shock
      1. Blood Products and emergent surgical intervention
      2. Even a 2 gram decrease in Hemoglobin From 9 to 7, decreases Oxygen Delivery by 30%
        1. Contrast with the minimal effect of oxygenation above PaO2 60-70 mmHg
    3. Consider empiric Adrenal Insufficiency management
      1. See Stress Dose Steroid
      2. See Adrenal Insufficiency
      3. Hydrocortisone or Dexamethasone
    4. Consider cardiopulmonary causes with emergent interventions as indicated
      1. Acute Coronary Syndrome
      2. Massive Pulmonary Embolism
      3. Aortic Dissection (or other vascular catastrophe)
      4. Cardiac Tamponade
      5. Cardiogenic Shock

XVI. Management: Targets of Adequate Perfusion

  1. Exam markers
    1. Improved mentation
    2. Improved Capillary Refill (and decreased skin mottling)
    3. No findings of Fluid Overload (increased JVD, lung rales, Hypoxia)
  2. Lab, diagnostics and Vital Sign markers
    1. Mean arterial pressure (MAP): >65 mmHg (>50 mmHg may be preferred in Trauma)
    2. Urine Output: >0.5 ml/kg/h (>1 ml/kg/h in children, >2 ml/kg/h in infants)
      1. Unreliable in Acute Kidney Injury
      2. Delayed response from time of fluid delivery to Urine Output response (risk of Fluid Overload)
      3. Consider monitoring with indwelling Urinary Catheter
    3. Serum Lactate Clearance (10% serum lactate reduction over 2 hours)
      1. Correlates with Central Venous Oxygen Saturation (ScvO2)
    4. IVC Ultrasound for Volume Status
      1. IVC collapses >50% on inspiration and is 1.5 to 2.5 cm in diameter
  3. Invasive markers
    1. Central Venous Pressure (CVP): 8-12 mmHg
      1. Falling out of favor, although still a part of 2012 surviving Sepsis guideline
      2. High CVP target is associated with Fluid Overload risk
    2. Central Venous Oxygen Saturation (ScvO2)
      1. Falling out of favor, although still a part of 2012 surviving Sepsis guideline
      2. No survival benefit in ProCESS, ARISE and ProMISE trials as target in Sepsis

XVII. Precautions: Positive Fluid Balance

  1. Avoid over-compensating in Fluid Replacement (Positive Fluid Balance, hypervolemia, Fluid Overload)
  2. Adverse effects of Positive Fluid Balance
    1. Delirium
    2. Diastolic Dysfunction
    3. Cardiac conduction abnormalities
    4. Increased respiratory effort
    5. Decreased GFR
    6. Sodium retention
    7. Malabsorption
    8. Ileus
    9. Decreased Wound Healing
    10. Pressure Ulcers
  3. References
    1. Avila (2014) J Brasil Nefrol 36(3): 379-88 [PubMed]

XVIII. References

  1. DeBlieux in Herbert (2016) EM:Rap 16(5):8-9
  2. Loflin (2015) Crit Dec Emerg Med 29(9): 11-18
  3. Goldberg (2015) Crit Dec Emerg Med 29(3): 9-19

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Related Studies

Ontology: Dehydration (C0011175)

Definition (MEDLINEPLUS)

When you're dehydrated, your body doesn't have enough fluid to work properly. An average person on an average day needs about 3 quarts of water. But if you're out in the hot sun, you'll need a lot more than that. Most healthy bodies are very good at regulating water. Elderly people, young children and some special cases - like people taking certain medications - need to be a little more careful.

Signs of dehydration in adults include

  • Being thirsty
  • Urinating less often than usual
  • Dark-colored urine
  • Dry skin
  • Feeling tired
  • Dizziness and fainting

Signs of dehydration in babies and young children include a dry mouth and tongue, crying without tears, no wet diapers for 3 hours or more, a high fever and being unusually sleepy or drowsy.

If you think you're dehydrated, drink small amounts of water over a period of time. Taking too much all at once can overload your stomach and make you throw up. For people exercising in the heat and losing a lot of minerals in sweat, sports drinks can be helpful. Avoid any drinks that have caffeine.

Definition (NCI_CTCAE) A disorder characterized by excessive loss of water from the body. It is usually caused by severe diarrhea, vomiting or diaphoresis.
Definition (NCI) A condition resulting from the excessive loss of water from the body. It is usually caused by severe diarrhea, vomiting or diaphoresis.
Definition (NCI_NCI-GLOSS) A condition caused by the loss of too much water from the body. Severe diarrhea or vomiting can cause dehydration.
Definition (NAN) Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.
Definition (MSH) The condition that results from excessive loss of water from a living organism.
Definition (PSY) State of excessively reduced body water or water deficit.
Definition (CSP) condition that results from excessive loss of water from a living organism.
Concepts Disease or Syndrome (T047)
MSH D003681
ICD9 276.51
ICD10 E86.0
SnomedCT 154759001, 37472003, 34095006
LNC MTHU020843
French DESHYDRATATION, Exsiccose, Déshydratation
English body water dehydration, DEHYDRATION, Dehydrated, Dehydration, Dehydration [Disease/Finding], exsiccosis, loss of body water, deficient fluid volume, Deficient fluid volume, Exsiccosis, DEHYDRATED, dehydration, Pure water depletion syndrome, Dehydration (disorder), DEFICIENT FLUID VOLUME
Portuguese DESIDRATACAO, Exsicose, Stress Hídrico, Desidratação
Spanish DESHIDRATACION, Exsicosis, Stress Hídrico, deshidratación (trastorno), deshidratación, síndrome de depleción de agua libre, Deshidratación
German DEHYDRATATION, Exsikkose, Dehydratisierung, Dehydratation
Dutch excissosis, dehydratie, Dehydratie, Uitdroging
Japanese 脱水, ﾀﾞｯｽｲ
Swedish Uttorkning
Czech dehydratace, Dehydratace, Exsikóza
Finnish Dehydraatio
Russian OBEZVOZHIVANIE, DEGIDRATATSIIA, ДЕГИДРАТАЦИЯ, ОБЕЗВОЖИВАНИЕ
Croatian DEHIDRACIJA
Polish Odwodnienie
Hungarian Dehydratio, Exsiccosis
Norwegian Dehydrering, Uttørking, Uttørring
Italian Disidratazione
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hypovolemic Shock (C0020683)

Definition (NCI) Shock resulting from insufficient blood volume for the maintenance of adequate cardiac output, blood pressure and tissue perfusion.
Definition (NCI_FDA) Shock resulting from insufficient blood volume for the maintenance of adequate cardiac output, blood pressure and tissue perfusion.
Concepts Pathologic Function (T046)
MSH D012769
ICD10 R57.1
SnomedCT 207030009, 158358001, 39419009
English Shock, Hypovolemic, [D]Hypovolaemic shock, [D]Hypovolemic shock, Hematogenic Shock, Oligemic Shock, [D]Hypovolemic shock (context-dependent category), hypovolaemic shock, hypovolemic shock (diagnosis), hypovolemic shock, shock hypovolemic, [D]Hypovolaemic shock (situation), [D]Hypovolemic shock (situation), HYPOVOLEMIC SHOCK, SHOCK, HYPOVOLEMIC, Hypovolemic shock, Hypovolaemic shock, Low volume shock, Hypovolemic shock (disorder), hypovolemic; shock, shock; hypovolemic, Hypovolemic Shock
Japanese 血液量減少性ショック, ｹﾂｴｷﾘｮｳｹﾞﾝｼｮｳｾｲｼｮｯｸ
Spanish [D]choque hipovolémico (categoría dependiente del contexto), Choque Hipovolémico, [D]shock hipovolémico, [D]choque hipovolémico, [D]choque hipovolémico (situación), choque hipovolémico (trastorno), choque hipovolémico, shock hipovolémico, Shock hipovolémico
Portuguese Choque Hipovolêmico, Choque hipovolémico
French Choc hypovolémique
German Hypovolämischer Schock, Hypovolaemischer Schock, hypovolaemischer Schock, Volumenmangelschock
Italian Shock ipovolemico
Czech Hypovolemický šok
Korean 순환혈액량 감소성 쇼크
Hungarian Hypovolaemiás shokk, Hypovolaemiás shock
Norwegian Hypovolemisk sjokk
Dutch hypovolemisch; shock, shock; hypovolemisch, hypovolemische shock, Hypovolemische shock
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Shock (C0036974)

Definition (MSH) A pathological condition manifested by failure to perfuse or oxygenate vital organs.
Definition (MEDLINEPLUS)

Shock happens when your blood pressure is too low and not enough blood and oxygen can get to your organs and tissues. Causes of shock include internal or external bleeding, dehydration, burns, or severe vomiting and/or diarrhea. All of these involve the loss of large amounts of body fluids. Shock often accompanies injury.

Specific types of shock include

  • Hypovolemic shock, caused by internal or external bleeding
  • Septic shock, caused by infections in the bloodstream
  • Anaphylactic shock, caused by a severe allergic reaction
  • Cardiogenic shock, caused by the inability of the heart to pump blood effectively
  • Neurogenic shock, caused by damage to the nervous system

Symptoms of shock include cold and sweaty skin, weak but rapid pulse, irregular breathing, dry mouth, dilated pupils and reduced urine flow. Shock is life threatening and it is important to get help right away. Treatment of shock depends on the cause.

National Institute of General Medical Sciences
Definition (NCI) A life-threatening condition that requires immediate medical intervention. It is characterized by reduced blood flow that may result in damage of multiple organs. Types of shock include cardiogenic, hemorrhagic, septic, anaphylactic, and traumatic shock.
Definition (CSP) a profound hemodynamic and metabolic disturbance characterized by the failure of the circulatory system to maintain adequate perfusion of vital organs; causes inadequate delivery of nutrients and insufficient removal of cellular waste products to and from the tissues.
Concepts Pathologic Function (T046)
MSH D012769
ICD9 785.50
ICD10 R57.9
SnomedCT 207026006, 267302008, 274729009, 158354004, 27942005
LNC LA7473-7
English Shock, CARDIOVASCULAR COLLAPSE, CIRCULATORY FAILURE, COLLAPSE CIRCULATORY, SHOCK CIRCULATORY, Shock, unspecified, Circulatory Collapse, Collapse, Circulatory, Failure/peripheral circul., Periph.circulatory failure, [D]Failure of peripheral circulation (context-dependent category), [D]Failure of peripheral circulation, [D]Failure/peripheral circul., [D]Periph.circulatory failure, [D]Peripheral circulatory failure, circulatory shock, shock, shock (diagnosis), Cardiovascular collapse, Collapse cardiovascular, Collapse circulatory, Collapse circulatory peripheral, Collapse peripheral circulatory, Failure peripheral circulatory, Shock circulatory, Collapse peripheral vascular, Collapse vascular, Vascular collapse, Shock vascular, Shock NOS, Failure circulatory, Failure of peripheral circulation NOS, Shock [Disease/Finding], Failure, Circulatory, Circulatory Failure, shock disorder, shocks, vascular collapse, shock syndrome, circulatory collapse, disorders shock, physiological shock, shocked, vascular shock, acute circulatory failure, circulatory failure, shocking, collapse, shock, physiological, cardiovascular collapse, Shock, unspecified (disorder), [D]Failure of peripheral circulation (situation), Circulatory shock, Circulatory failure, SHOCK, Circulatory collapse, Shock - physiological, Acute circulatory failure, Peripheral circulatory failure, Peripheral vascular failure, Peripheral vascular shutdown, Shock (disorder), cardiovascular; collapse, circulatory; collapse, collapse; cardiovascular, collapse; circulatory, collapse; vascular, shock; syndrome, syndrome; shock, vascular; collapse, Shock, NOS, Failure of peripheral circulation
French CHOC, Collapsus de la circulation périphérique, Défaillance de la circulation périphérique, Choc circulatoire, Choc, non précisé, Collapsus vasculaire périphérique, Choc d'origine vasculaire, CHOC CIRCULATOIRE, COLLAPSUS CARDIO-VASCULAIRE, COLLAPSUS CIRCULATOIRE, DEFAILLANCE CIRCULATOIRE, Défaillance circulatoire, Insuffisance circulatoire aiguë, Collapsus circulatoire, Défaillance circulatoire périphérique, Choc, État de choc, Collapsus cardio-vasculaire, Collapsus cardiovasculaire, Collapsus vasculaire, Collapsus
Portuguese CHOQUE, Choque circulatório, Colapso cardiovascular, Colapso circulatório, Colapso circulatório periférico, Colapso vascular periférico, Choque vascular, Choque NE, CHOQUE CIRCULATORIO, COLAPSO CARDIOVASCULAR, COLAPSO CIRCULATORIO, INSUFICIENCIA CIRCULATORIA, Insuficiência circulatória, Insuficiência circulatória aguda, Insuficiência Circulatória, Choque Circulatorio, Colapso da Circulação Periférica, Choque Hemodinâmico, Colapso vascular, Insuficiência circulatória periférica, Choque, Colapso Circulatório
German SCHOCK, kardiovaskulaerer Kollaps, Schock Kreislauf, Schock vaskulaer, Schock, unspezifisch, Kollaps, Kreislauf, Versagen des peripheren Kreislaufs, Kollaps, kardiovaskulaer, Versagen der peripheren Gefaesse, vaskulaerer Kollaps, Kollaps vaskulaer, KOLLAPS KARDIOVASKULAER, KREISLAUFKOLLAPS, KREISLAUFSCHOCK, KREISLAUFVERSAGEN, Schock, nicht naeher bezeichnet, Kreislaufversagen, akutes Kreislaufversagen, Versagen des Kreislaufs, peripheres Kreislaufversagen, Kreislaufkollaps, Schock
Spanish SHOCK, Colapso circulatorio periférico, Colapso vascular, Shock no especificado, Colapso cardiovascular, Shock vascular, Colapso vascular periférico, Insuficiencia de la circulación periférica, Shock circulatorio, [D]insuficiencia circulatoria periférica (categoría dependiente del contexto), COLAPSO CARDIOVASCULAR, COLAPSO CIRCULATORIO, INSUFICIENCIA CIRCULATORIA, SHOCK CIRCULATORIO, Fallo circulatorio, Fallo circulatorio agudo, Insuficiencia Circulatoria, Choque, shock, no especificado, choque, no especificado, [D]insuficiencia circulatoria periférica, choque, no especificado (trastorno), [D]insuficiencia circulatoria periférica (situación), Choque Circulatorio, Choque Hemodinámico, Shock, Shock Hemodinámico, Shock Hipovolémico, choque (trastorno), choque, insuficiencia circulatoria aguda, insuficiencia circulatoria periférica, insuficiencia vascular aguda, insuficiencia vascular periférica, shock, Colapso circulatorio, Insuficiencia circulatoria periférica, Colapso Circulatorio
Italian Insufficienza circolatoria periferica, Shock non specificato, Collasso vascolare periferico, Collasso vascolare, Collasso cardiovascolare, Collasso circolatorio periferico, Shock vascolare, Shock circolatorio, Collasso circolatorio, Insufficienza circolatoria acuta, Insufficienza circolatoria, Shock
Dutch collaps perifere circulatie, perifere circulatoire collaps, vasculaire collaps, collaps cardiovasculair, perifere vaatcollaps, cardiovasculaire collaps, vasculaire shock, collaps circulatoir, falen perifere circulatie, circulatoire shock, niet-gespecificeerde shock, collaps vasculair, circulatoir falen, acuut circulatoir falen, falen circulatoir, cardiovasculair; collaps, circulatoir; collaps, collaps; cardiovasculair, collaps; circulatoir, collaps; vasculair, shock; syndroom, syndroom; shock, vasculair; collaps, Shock, niet gespecificeerd, circulatoire collaps, perifeer circulatoir falen, shock, Cardiovasculaire shock, Circulatiestoring, Shock
Japanese 循環性ショック, 血管性ショック, 循環虚脱, 心血管虚脱, 末梢性循環虚脱, 末梢循環性虚脱, 血管虚脱, ショック、詳細不明, 末梢循環不全, 末梢血管虚脱, ﾏｯｼｮｳｹｯｶﾝｷｮﾀﾞﾂ, ｹｯｶﾝｾｲｼｮｯｸ, ｹｯｶﾝｷｮﾀﾞﾂ, ﾏｯｼｮｳｼﾞｭﾝｶﾝｾｲｷｮﾀﾞﾂ, ﾏｯｼｮｳｼﾞｭﾝｶﾝﾌｾﾞﾝ, ｼﾞｭﾝｶﾝｾｲｼｮｯｸ, ﾏｯｼｮｳｾｲｼﾞｭﾝｶﾝｷｮﾀﾞﾂ, ｼｮｯｸ, ｼﾝｹｯｶﾝｷｮﾀﾞﾂ, ｼｮｯｸｼｮｳｻｲﾌﾒｲ, ｼﾞｭﾝｶﾝｷｮﾀﾞﾂ, ショック症状, 急性循環不全, 循環不全, ｷｭｳｾｲｼﾞｭﾝｶﾝﾌｾﾞﾝ, ｼﾞｭﾝｶﾝﾌｾﾞﾝ, ショック, 急性循環不全状態
Swedish Chock
Czech šok, Kolaps oběhový, Periferní oběhový kolaps, Šok cévní, Periferní cévní kolaps, Selhání periferní cirkulace, Cévní kolaps, Kolaps kardiovaskulární, Periferní oběhové selhání, Šok, Šok, blíže neurčený, Oběhový šok, Kardiovaskulární kolaps, Oběhový kolaps, Oběhové selhání, Akutní oběhové selhání, Selhání cirkulace
Finnish Sokki
Russian SHOK, GIPOVOLEMICHESKII SHOK, ГИПОВОЛЕМИЧЕСКИЙ ШОК, ШОК
Korean 상세불명의 쇼크
Croatian ŠOK
Polish Wstrząs, Wstrząs oligowolemiczny, Ostra niewydolność krążenia
Hungarian A keringés összeomlása, Peripheriás keringési összeomlás, Keringésösszeomlás, A peripheriás keringés összeomlása, Keringési shock, Peripheriás keringési elégtelenség, Shock, Elégtelenség, peripheriás keringés, Peripheriás vascularis collapsus, Szív-érrendszer eredetű collapsus, Keringési elégtelenség, Cardiovascularis collapsus, Vascularis collapsus, Vascularis shock, Shock, nem meghatározott, Heveny keringési elégtelenség
Norwegian Sjokk, Sirkulasjonssvikt, Sirkulasjonskollaps
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hypovolemia (C0546884)

Definition (CCC) Dehydration or fluid loss
Definition (NCI_FDA) Abnormally decreased volume of circulating fluid (plasma) in body.
Definition (NCI) Abnormally decreased volume of circulating fluid (plasma) in body.
Definition (MSH) An abnormally low volume of blood circulating through the body. It may result in hypovolemic shock (see SHOCK).
Definition (CSP) abnormally decreased volume of circulating fluid (plasma) in the body.
Concepts Finding (T033)
MSH D020896
ICD9 276.50, 276.52, 276.5
ICD10 E86 , E86.1, E86.9
SnomedCT 28560003, 154763008, 37472003, 190897005, 190895002
LNC MTHU013362
English HYPOVOLAEMIA, Oligemia, Deficient Fluid Volume, volume depletion (diagnosis), volume depletion, Hypovolemias, Volume depletion NOS, Fluid volume deficit, Volume depletion, unspecified, Hypovolemia [Disease/Finding], rndx fluid volume deficit (diagnosis), rndx fluid volume deficit, depletion volume, hypovolaemia, fluid volume deficit, volume depletion disorder, hypovolemia, oligemia, deficit fluid volume, Hypovolaemia (disorder), Volume depletion NOS (disorder), Fluid volume deficit (finding), HYPOVOLEMIA, Fluid Volume Deficit, Volume depletion, Fluid volume depletion, Fluid depletion, Hypovolaemia, Sodium and water depletion, Depletion of volume of plasma AND/OR extracellular fluid, Hypovolemia (disorder), deficit; fluid, deficit; volume (plasma) (extracellular fluid), fluid; deficit, Depletion of volume of plasma or extracellular fluid, Hypovolemia
Dutch oligemie, volumedepletie, tekort; vocht, tekort; volume (plasma) (extracellulaire vloeistof), vocht; tekort, Volumedepletie, hypovolemie, Hypovolemie
French Déplétion volémique, HYPOVOLEMIE, Hypovolémie
German Oligaemie, Depletion des Volumens, HYPOVOLAEMIE, Volumenmangel, Hypovolaemie, Hypovolämie
Italian Oligoemia, Deplezione di volumi, Ipovolemia
Portuguese Oligoemia, Depleção do volume, HIPOVOLEMIA, Hipovolemia
Spanish Depleción de volumen, Oligemia, HIPOVOLEMIA, déficit de volumen, disminución del líquido extracelular, déficit de volumen (hallazgo), depleción de volumen, SAI (trastorno), depleción de volumen, SAI, depleción de sodio y agua, depleción de volumen, depleción del volumen de líquidos, depleción del volumen de plasma Y/O de líquido extracelular, hipovolemia (trastorno), hipovolemia, depleción del L.E.C., disminución del L.E.C., Hipovolemia
Swedish Hypovolemi
Japanese ｹﾂｴｷﾘｮｳｹﾞﾝｼｮｳｼｮｳ, 循環血液量減少, 血液量減少(疾患), 循環血液量不足, 循環血液量不足症, 血液量不足(疾患), 血液量不足症, 血量減少症, 循環血液量減少症, 血液量減少症, 血量減少(疾患)
Czech hypovolémie, Hypovolemie, Oligemie, Deplece objemu
Finnish Hypovolemia
Russian GIPOVOLEMIIA, ГИПОВОЛЕМИЯ
Korean 용적체액상실
Polish Hipowolemia
Hungarian Volumen depletio, Hypovolaemia, Oligaemia
Norwegian Hypovolemi
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Distributive shock (C2938913)

Concepts Disease or Syndrome (T047)
English Distributive shock
Dutch distributieve shock
Spanish Shock distributivo
Portuguese Choque distributivo
Italian Shock distributivo
German Distributionsschock
French Choc distributif
Japanese ｹﾂｴｷﾌﾞﾝﾌﾟｲｼﾞｮｳｾｲｼｮｯｸ, 血液分布異常性ショック
Czech Distribuční šok
Hungarian Distributiv sokk
Derived from the NIH UMLS (Unified Medical Language System)

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