8. Shock. Types, symptoms, differential diagnosis

Page created on February 9, 2022. Not updated since.


Shock is a hemodynamic disturbance caused by different diseases, which leads to inadequate oxygen supply in the organs. The ensuing tissue hypoxia causes metabolic disorder in the tissues leading to temporary or permanent functional disorder, and in severe cases to cell death.

General features of shock:

  • The 5 P’s
    • Perfusion of skin – pale, cool skin
    • Pulse – weak peripheral pulse
    • Periphery – capillary refill time > 3 s
    • Pressure – systolic BP < 90 mmHg
    • Pee – oliguria (< 1 mL/kg/hour) or anuria (< 0,5 mL/kg/hour)
  • Tachycardia
  • Tachypnoea, dyspnoea
  • Altered mental status

Initial management is by ABCDE and assessing fluid responsiveness by fluid challenge or passive leg raise, and if fluid responsive, providing fluids. Afterward, management is directed at determining the underlying cause and type of shock and treating it specifically.

Hypovolaemic shock


  • Gastroenteritis
  • Burns
  • Sepsis
  • Diabetic ketoacidosis
  • Haemorrhage

Special clinical features include features of severe dehydration, like markedly decreased turgor, sunken eyes, sunken anterior fontanelle, and very dry buccal mucosa.

Management is by fluid resuscitation (see topic B28 in paeds 1).

Distributive shock


  • Sepsis
  • Anaphylaxis
  • Neurogenic shock (acute injury to CNS or spinal cord)

Special clinical features include high cardiac output (warm shock) causing pounding pulse, rapid capillary refill, warm and dry extremities, and wide pulse pressure. Later, cold shock can develop.

Management is by treating the underlying cause. Antibiotics for sepsis, epinephrine for anaphylaxis.

Cardiogenic shock


  • Congenital heart disease
  • Cardiomyopathy
  • Arrhythmia
  • Kawasaki disease
  • Myocarditis

Special clinical features include hepatomegaly, heart murmurs, and jugular venous distension.

Management is by using inotropes (norepinephrine, dobutamine, etc.) and assist devices like intra-aortic balloon pump and ventricular assist device. Large amounts of fluids should be avoided.

Obstructive shock


  • Cardiac tamponade
  • Tension pneumothorax
  • Ductal dependent congenital heart defect if the ductus arteriosus closes
  • Massive pulmonary embolism

Special clinical features include hepatomegaly, narrow pulse pressure, and jugular venous distension.

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