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Shock

In medicine, shock (hypoperfusion) is a life-threatening medical emergency characterized by inability of the circulatory system to supply enough oxygen to meet tissue requirements. Hypotension is usually, though not always, present. Without prompt medical treatment, shock usually causes death. more...

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Types of shock

  • Hypovolemic shock. The single most common cause of shock is blood volume loss, resulting from a serious wound or a severe burn leading to hypovolemic shock. This may also be referred to as haemmorhagic shock.
  • Cardiogenic 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, or cardiac valve problems.
  • Distributive shock. As in hypovolemic shock there is an insufficient volume of blood. This form of relative hypovolaemia is the result of dilation of bloodvessels. Examples of this form of shock are:
    • Septic shock is caused by overwhelming infection leading to vasodilation. It is treated by antibiotics, fluid replacement, and vasoconstrictors.
    • Acute adrenal insufficiency is not infrequently the result of discontinuing corticosteroid treatment without tapering the dosage.
    • Less commonly severe anaphylactic reactions may cause anaphylactic shock as allergens trigger widespread vasodilation and movement of fluid out of the blood into the tissues.
    • The rarest cause of shock is acute spinal cord injury leading to neurogenic shock. Neurogenic shock is caused by the sudden loss of the sympathetic nervous system signals to the smooth muscle in vessel walls. Without this constant stimulation the vessels relax resulting in a sudden decrease in peripheral vascular resistance and decreased blood pressure.
  • Obstructive shock. Hereby the flow of blood is obstructed. 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). Or constrictive pericarditis which has the same effect.
    • 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 bloodvessels of the lungs and hinders the return of blood to the heart.

Symptoms and signs

The external signs and symptoms of shock are:

  • feeling of thickness, weakness, thirst;
  • pallor, especially visible at the inner side of the lips when the casualty has a dark skin;
  • rapid pulse (tachycardia, more than 120 beats per minute), the radial pulse is difficult to feel;
  • when pressing a finger nail, it takes more than two seconds for the color to come back;
  • confusion or anxiety;

Other signs can be evaluated:

  • decreased urine production
  • low blood pressure.

Patients with hypovolaemic or cardiogenic shock will have cold and clammy hands and feet. Septic, anaphylactic and neurogenic shock may present with warm extremities.

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Accuracy of glucose measurement in critically ill patients in shock
From CHEST, 10/1/05 by Srinivas B. Chakravarthy

PURPOSE: Strict normalization of blood glucose level improves outcome in critically ill patients. Accurate glucose measurement is an essential aspect of intensive insulin therapy. The various methods of testing (glucometer, blood gas analyzer and conventional laboratory analyzer) have not been studied simultaneously in patients in shock. This study is designed to prospectively evaluate different methods of glucose monitoring in critically ill patients. The specific aim is to evaluate the accuracy of bedside glucometer and blood gas analyzer in comparison with the clinical laboratory colorimetric method (gold standard).

METHODS: ICU patients in shock, defined as a systolic blood pressure of <90 mm Hg despite adequate volume resuscitation or requiring vasopressor therapy, were considered for enrollment. Arterial, venous and capillary blood samples were obtained simultaneously. A total of 243 samples were obtained from 21 patients. Glucose determinations were made with the glucometer (ACCU-CHEK Comfort Curve, Roche) from each of the vascular compartments. Arterial and venous glucose levels were determined using a blood gas analyzer (Radiometer ABL 700). Arterial and venous blood samples were tested in the clinical laboratory using the colorimetric plasma glucose analyzer (VITRIOS).

RESULTS: Mean venous blood glucose level determined on the VITRIOS analyzer (gold standard) was 129.6 mg/dl with a range of 54 to 350 mg/dl. Capillary blood glucose tested on glucometer was higher than the gold standard by a mean of 20.95 mg/dl (16.99%). The difference changed minimally when arterial or venous samples tested on glucometer were compared to the gold standard. Blood gas analyzer on the other hand, was higher by a mean of 3.07 mg/dl (2.68%) when compared to the gold standard.

CONCLUSION: Blood glucose determination with a glucometer is associated with a risk of obtaining falsely elevated blood glucose level. Blood gas analyzer is significantly more accurate.

CLINICAL IMPLICATIONS: Using glucometers to monitor blood glucose levels in patients with shock is associated with the risk of obtaining falsely elevated results and thus placing the patient at risk for hypoglycemia.

DISCLOSURE: Srinivas Chakravarthy, Grant monies (from sources other than industry) This study was supported by an award from The CHEST Foundation of the American College of Chest Physicians and Ortho Biotech Products, LP.; Grant monies (from industry related sources) The glucometer, chemistry strips and the reagents were provided by Roche.

Srinivas B. Chakravarthy MBBS * Boaz A. Markewitz MD Chris Lehman MD James F. Orme MD University of Utah Health Sciences Center, Salt Lake City, UT

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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