Lectures 4.
SHOCK. Intensive care of the shock. Extreme conditions. Cardio – pulmonary resuscitation.
Circulatory shock, commonly known as just shock, is a serious, life-threatening medical condition where insufficient blood flow reaches the body tissues. As the blood carries oxygen and nutrients around the body, reduced flow hinders the delivery of these components to the tissues, and can stop the tissues from functioning properly.The process of blood entering the tissues is called perfusion, so when perfusion is not occurring properly this is called a hypoperfusional (hypo = below) state.
Circulatory shock should not be confused with the emotional state of shock, as the two are not related. Medical shock is a life-threatening medical emergency and one of the most common causes of death for critically-ill people. Shock can have a variety of effects, all with similar outcomes, but all relate to a problem with the body’s circulatory system. For example, shock may lead to hypoxemia (a lack of oxygen in arterial blood) or cardiac arrest (the heart stopping).
StagesShockClassification and external resources
ICD-10 many incl. R57.
ICD-9 785
DiseasesDB 12013
MedlinePlus 000039
eMedicine emerg/531 med/285 emerg/533
MeSH D012769
There are four stages of shock. As it is a complex and continuous condition there is no sudden transition from one stage to the next.[9]
Initial
During this stage, the hypoperfusional state causes hypoxia, leading to the mitochondria being unable to produce adenosine triphosphate (ATP). Due to this lack of oxygen, the cell membranes become damaged, they become leaky to extra-cellular fluid, and the cells perform anaerobic respiration. This causes a build-up of lactic and pyruvic acid which results in systemic metabolic acidosis. The process of removing these compounds from the cells by the liver requires oxygen, which is absent.
Compensatory (Compensating)
This stage is characterised by the body employing physiological mechanisms, including neural, hormonal and bio-chemical mechanisms in an attempt to reverse the condition. As a result of the acidosis, the person will begin to hyperventilate in order to rid the body of carbon dioxide (CO2). CO2 indirectly acts to acidify the blood and by removing it the body is attempting to raise the pH of the blood. The baroreceptors in the arteries detect the resulting hypotension, and cause the release of adrenaline and noradrenaline.
Noradrenaline causes predominately vasoconstriction with a mild increase in heart rate, whereas adrenaline predominately causes an increase in heart rate with a small effect on the vascular tone; the combined effect results in an increase in blood pressure. Renin-angiotensin axis is activated and arginine vasopressin is released to conserve fluid via the kidneys.
Also, these hormones cause the vasoconstriction of the kidneys, gastrointestinal tract, and other organs to divert blood to the heart, lungs and brain. The lack of blood to the renal system causes the characteristic low urine production. However the effects of the Renin-angiotensin axis take time and are of little importance to the immediate homeostatic mediation of shock .
Progressive (Decompensating)
Should the cause of the crisis not be successfully treated, the shock will proceed to the progressive stage and the compensatory mechanisms begin to fail. Due to the decreased perfusion of the cells, sodium ions build up within while potassium ions leak out. As anaerobic metabolism continues, increasing the body’s metabolic acidosis, the arteriolar smooth muscle and precapillary sphincters relax such that blood remains in the capillaries[1]. Due to this, the hydrostatic pressure will increase and, combined with histamine release, this will lead to leakage of fluid and protein into the surrounding tissues. As this fluid is lost, the blood concentration and viscosity increase, causing sludging of the micro-circulation. The prolonged vasoconstriction will also cause the vital organs to be compromised due to reduced perfusion[. If the bowel becomes sufficiently ischemic, bacteria may enter the blood stream, resulting in the increased complication of endotoxic shock[.
Refractory (Irreversible)
At this stage, the vital organs have failed and the shock cao longer be reversed. Brain damage and cell death have occurred. Death will occur imminently.
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person’s life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the victim themselves. Dependent on the severity of the emergency, and the quality of any treatment given, it may require the involvement of multiple levels of care, from a first aider to an emergency physician through to specialist surgeons.
Any response to an emergency medical situation will depend strongly on the situation, the patient involved and availability of resources to help them. It will also vary depending on whether the emergency occurs whilst in hospital under medical care, or outside of medical care (for instance, in the street or alone at home).Contents [hide]
1 Response
2 Clinical response
3 Non-trauma emergencies
For emergencies starting outside of medical care, a key component of providing proper care is to summon the emergency medical services (usually an ambulance), by calling for help using the appropriate local emergency telephone number, such as 999, 911, 112 or 000 or 111. After determining that the incident is a medical emergency (as opposed to, for example, a police call), the emergency dispatchers will generally run through a questioning system such as AMPDS in order to assess the priority level of the call, along with the caller’s name and location.
Those trained to perform first aid can act within the bounds of the knowledge they have, whilst awaiting the next level of definitive care. Those who are not able to perform first aid can also assist by remaining calm and staying with the injured or ill person. A common complaint of emergency service personnel is the propensity of people to crowd around the scene of victim, as it is generally unhelpful, making the patient more stressed, and obstructing the smooth working of the emergency services. If possible, first responders should designate a specific person to ensure that the emergency services are called. Another bystander should be sent to wait for their arrival and direct them to the proper location. Additional bystanders can be helpful in ensuring that crowds are moved away from the ill or injured patient, allowing the responder adequate space to work.
Many states of the USA have “Good Samaritan Laws” which protect civilian responders who choose to assist in an emergency.[1] Responders acting within the scope of their knowledge and training as a “reasonable person” in the same situation would act are often immune to liability in emergency situations. Usually, once care has begun, a first responder or first aid provider may not leave the patient or terminate care until a responder of equal or higher training (e.g., fire department or emergency medical technicians) assumes care. This can constitute abandonment of the patient, and may subject the responder to legal liability. Care must be continued until the patient is transferred to a higher level of care, the situation becomes too unsafe to continue, or the responder is physically unable to continue due to exhaustion or hazards.
The principles of the chain of survival apply to medical emergencies where the patient has an absence of breathing and heartbeat. This involves the four stages of Early access, Early CPR, Early defibrillation and Early advanced life support
Unless the situation is particularly hazardous, and is likely to further endanger the patient, evacuating an injured victim requires special skills, and should be left to the professionals of the emergency medical and fire service.
Clinical response
Within hospital settings, an adequate staff is generally present to deal with the average emergency situation. Emergency medicine physicians have training to deal with most medical emergencies, and maintain CPR and ACLS certifications. In disasters or complex emergencies, most hospitals have protocols to summon on-site and off-site staff rapidly.
Both emergency room and inpatient medical emergencies follow the basic protocol of Advanced Cardiac Life Support. Irrespective of the nature of the emergency, adequate blood pressure and oxygenation are required before the cause of the emergency can be eliminated. Possible exceptions include the clamping of arteries in severe hemorrhage.
Non-trauma emergencies
While the golden hour (medicine) is a trauma treatment concept, two emergency medical conditions have well-documented time-critical treatment considerations: stroke and myocardial infarction (heart attack). In the case of stroke, there is a window of three hours within which the benefit of clot-busting drugs outweighs the risk of major bleeding. In the case of a heart attack, rapid stabilization of fatal arrhythmias can prevent sudden cardiac death. In addition, there is a direct relationship between time-to-treatment and the success of reperfusion (restoration of blood flow to the heart), including a time dependent reduction in the mortality and morbidity.In 1972 Hinshaw and Cox suggested the following classification which is still used today.[2] It uses four types of shock: hypovolemic, cardiogenic, distributive and obstructive shock:[3][4][5][8][10]
Hypovolemic shock – This is the most common type of shock and based on insufficient circulating volume. Its primary cause is loss of fluid from the circulation from either an internal or external source. An internal source may be haemorrhage. External causes may include extensive bleeding, high output fistulae or severe burns.
Cardiogenic shock – This type of 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, cardiomyopathy, congestive heart failure (CHF), contusio cordis, air embolus, or cardiac valve problems.
Distributive shock – As in hypovolaemic shock there is an insufficient intravascular volume of blood. This form of “relative” hypovolaemia is the result of dilation of blood vessels which diminishes systemic vascular resistance. Examples of this form of shock are:
Septic shock – This is caused by an overwhelming infection leading to vasodilation, such as by Gram negative bacteria i.e. Escherichia coli, Proteus species, Klebsiella pneumoniae which release an endotoxin which produces adverse biochemical, immunological and occasionally neurological effects which are harmful to the body. Gram-positive cocci, such as pneumococci and streptococci, and certain fungi as well as Gram-positive bacterial toxins produce a similar syndrome.
Anaphylactic shock – Caused by a severe anaphylactic reaction to an allergen, antigen, drug or foreign protein causing the release of histamine which causes widespread vasodilation, leading to hypotension and increased capillary permeability.
Neurogenic shock – Neurogenic shock is the rarest form of shock. It is caused by trauma to the spinal cord resulting in the sudden loss of autonomic and motor reflexes below the injury level. Without stimulation by sympathetic nervous system the vessel walls relax uncontrolled, resulting in a sudden decrease in peripheral vascular resistance, leading to vasodilation and hypotension.
Obstructive shock – In this situation the flow of blood is obstructed which impedes circulation and can result in circulatory arrest. Several conditions result in this form of shock.
Cardiac tamponade in which fluid in the pericardium prevents inflow of blood into the heart (venous return). Constrictive pericarditis, in which the pericardium shrinks and hardens, is similar in presentation.
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 the bloodvessels of the lungs and hinders the return of blood to the heart.
Aortic stenosis hinders circulation by obstructing the ventricular outflow tract
Recently a fifth form of shock has been introduced:[2]
Endocrine shock based on endocrine disturbances.
Hypothyroidism, in critically ill patients, reduces cardiac output and can lead to hypotension and respiratory insufficiency.
Thyrotoxicosis may induce a reversible cardiomyopathy.
Acute adrenal insufficiency is frequently the result of discontinuing corticosteroid treatment without tapering the dosage. However, surgery and intercurrent disease in patients on corticosteroid therapy without adjusting the dosage to accommodate for increased requirements may also result in this condition.
Relative adrenal insufficiency in critically ill patients where present hormone levels are insufficient to meet the higher demands
Signs and symptoms
Hypovolaemic shock
Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia
Hypotension due to decrease in circulatory volume
A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia
Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction
Rapid and shallow respirations due to sympathetic nervous system stimulation and acidosis
Hypothermia due to decreased perfusion and evaporation of sweat
Thirst and dry mouth, due to fluid depletion
Fatigue due to inadequate oxygenation
Cold and mottled skin (cutis marmorata), especially extremities, due to insufficient perfusion of the skin
Distracted look in the eyes or staring into space, often with pupils dilated
Cardiogenic shock, similar to hypovolaemic shock but in addition:
Distended jugular veins due to increased jugular venous pressure
Weak or absent pulse
Arrhythmia, often tachycardic
Obstructive shock, similar to hypovolaemic shock but in addition:
Distended jugular veins due to increased jugular venous pressure
Pulsus paradoxus in case of tamponade
Septic shock, similar to hypovolaemic shock except in the first stages:
Pyrexia (fever), due to increased level of cytokines
Systemic vasodilation resulting in hypotension (low blood pressure)
Warm and sweaty skin due to vasodilation
Systemic leukocyte adhesion to endothelial tissue
Reduced contractility of the heart
Diffuse capillary damage in the lung[
Activation of the coagulation pathways, resulting in disseminated intravascular coagulation
Increased levels of neutrophils
Neurogenic shock, similar to hypovolemic shock except in the skin’s characteristics. Ieurogenic shock, the skin is warm and dry or a clear sweat line exists, above which the skin is diaphoretic.
Anaphylactic shock
Skin eruptions and large welts
Localised edema, especially around the face
Weak and rapid pulse
Breathlessness and cough due to narrowing of airways and swelling of the throat
Treatment
Shock requires immediate interventions to preserve life. Therefore, the early recognition and treatment is essential even before a specific diagnosis is made(As a general rule, you should treat for a sustained wound and shock). Most forms of shock seen in trauma or sepsis respond initially to aggressive intravenous fluids ( ie.
Re-establishing perfusion to the organs is the primary goal through restoring and maintaining the blood circulating volume ensuring oxygenation and blood pressure are adequate, achieving and maintaining effective cardiac function, and preventing complications. Patients attending with the symptoms of shock will have, regardless of the type of shock, their airway managed and oxygen therapy initiated. In case of respiratory insufficiency (i.e. diminished levels of consciousness, hyperventilation due to acid-base disturbances or pneumonia) intubation and mechanical ventilation may be necessary. A paramedic may intubate in emergencies outside the hospital, whereas a patient with respiratory insufficiency in-hospital will be intubated usually by a respiratory therapist, paramedic, or physician.
The aim of these acts is to ensure survival during the transportation to the hospital; they do not cure the cause of the shock. Specific treatment depends on the cause.
Hypovolemic shock
In hypovolemic shock, caused by bleeding, it is necessary to immediately control the bleeding and restore the casualty’s blood volume by giving infusions of isotonic crystalloid solutions. Blood transfusions, packed red blood cells (RBCs), Albumin (or other colloid solutions), or fresh-frozen plasma are necessary for loss of large amounts of blood (e.g. greater than 20% of blood volume), but can be avoided in smaller and slower losses. Hypovolemia due to burns, diarrhea, vomiting, etc. is treated with infusions of electrolyte solutions that balance the nature of the fluid lost. Sodium is essential to keep the fluid infused in the extracellular and intravascular space whilst preventing water intoxication and brain swelling. Metabolic acidosis (mainly due to lactic acid) accumulates as a result of poor delivery of oxygen to the tissues, and mirrors the severity of the shock. It is best treated by rapidly restoring intravascular volume and perfusion as above. Inotropic and vasoconstrictive drugs should be avoided, as they may interfere in knowing blood volume has returned to normal
Regardless of the cause, the restoration of the circulating volume is priority. As soon as the airway is maintained and oxygen administered the next step is to commence replacement of fluids via the intravenous route. A size 14g intravenous in the arm will flow at twice the rate of a 16g central venous catheter.[
Opinion varies on the type of fluid used in shock. The most common are:
Crystalloids – Such as sodium chloride (0.9%), or Lactated Ringer’s. Dextrose solutions which contain free water are less effective at re-establishing circulating volume, and promote hyperglycaemia.
Colloids – For example, polysaccharide (Dextran), polygeline (Haemaccel), succunylated gelatin (Gelofusine) and hetastarch (Hespan). Colloids are, in general, much more expensive than crystalloid solutions and have not conclusively been shown to be of any benefit in the initial treatment of shock.
Combination – Some clinicians argue that individually, colloids and crystalloids can further exacerbate the problem and suggest the combination of crystalloid and colloid solutions.
Blood – Essential in severe hemorrhagic shock, often pre-warmed and rapidly infused.
It is to be noted that NO plain water should be given to the patient at any point, as the patient’s low electrolyte levels would easily cause water intoxication, leading to premature death. An isotonic or solution high in electrolytes should be administered if intravenous delivery of recommended fluids is unavailable.
Vasoconstrictor agents have no role in the initial treatment of hemorrhagic shock, due to their relative inefficacy in the setting of acidosis, and because the body, in the setting of hemorrhagic shock, is in an endogenously catecholaminergic state. Definitive care and control of the hemorrhage is absolutely necessary, and should not be delayed.
Shock – hypovolemic
Definition
Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.
Causes
Losing about 1/5 or more of the normal amount of blood in your body causes hypovolemic shock.
Blood loss can be due to:
Bleeding from cuts
Bleeding from other injuries
Internal bleeding, suсh as in the gastrointestinal tract
The amount of circulating blood in your body may drop when you lose too many other body fluids, which can happen with:
Burns
Diarrhea
Vomiting
Symptoms
Anxiety or agitation
Cool, clammy skin
Confusion
Decreased or no urine output
General weakness
Pale skin color (pallor)
Rapid breathing
Sweating, moist skin
Unconsciousness
The greater and more rapid the blood loss, the more severe the symptoms of shock.
An examination shows signs of shock, including:
Low blood pressure
Low body temperature
Rapid pulse
Tests that may be done include:
Complete blood count (CBC)
CT scan or x-ray of suspected areas
Echocardiogram
Endoscopy
Right heart (Swan-Ganz) catheterization
Treatment
Get immediate medical help. In the meantime, follow these steps:
Keep the person comfortable and warm (to avoid hypothermia).
Have the person lie flat with the feet lifted about
Do not give fluids by mouth.
If person is having an allergic reaction, treat the allergic reaction, if you know how.
If the person must be carried, try to keep him or her flat, with the head down and feet lifted. Stabilize the head and neck before moving a person with a suspected spinal injury.
The goal of hospital treatment is to replace blood and fluids. An intravenous (IV) line will be put into the person’s arm to allow blood or blood products to be given.
Medicines such as dopamine, dobutamine, epinephrine, and norepinephrine may be needed to increase blood pressure and the amount of blood pumped out of the heart (cardiac output).
Other methods that may be used to manage shock include:
Heart monitoring, including Swan-Ganz catheterization
Urinary catheter to collect and monitor how much urine is produced
Hypovolemic shock is always a medical emergency. However, symptoms and outcomes can vary depending on:
Amount of blood volume lost
Rate of blood loss
Ilness or injury causing the loss
In general, patients with milder degrees of shock tend to do better than those with more severe shock. In cases of severe hypovolemic shock, death is possible even with immediate medical attention. The elderly are more likely to have poor outcomes from shock.
Possible Complications
Kidney damage
Brain damage
Cardiogenic shock
In cardiogenic shock, depending on the type of myocardal infarction, one can infuse fluids such as or in shock refractory to infusing fluids, normal saline would be an example of said fluids[clarification needed] inotropic agents. Inotropic agents, which enhance the heart’s pumping capabilities, are used to improve the contractility and correct the hypotension. Should that not suffice, an intra-aortic balloon pump can be considered (which reduces the workload for the heart and improves perfusion of the coronary arteries) or a left ventricular assist device (which augments the pump-function of the heart.)
The main goals of the treatment of cardiogenic shock are the re-establishment of circulation to the myocardium, minimising heart muscle damage and improving the heart’s effectiveness as a pump. This is most often performed by percutaneous coronary intervention and insertion of a stent in the culprit coronary lesion or sometimes by cardiac bypass.
Although this is a protection reaction, the shock itself will induce problems; the circulatory system being less efficient, the body gets “exhausted” and finally, the blood circulation and the breathing slow down and finally stop (cardiac arrest). The main way to avoid this deadly consequence is to make the blood pressure rise again with
Fluid replacement with intravenous infusions;
Use of vasopressing drugs (e.g. to induce vasoconstriction);
Use of anti-shock trousers that compress the legs and concentrate the blood in the vital organs (lungs, heart, brain).
Use of blankets to keep the patient warm – metallic PET film emergency blankets are used to reflect the patient’s body heat back to the patient.
Shock – cardiogenic
Definition
Cardiogenic shock is a state in which the heart has been damaged so much that it is unable to supply enough blood to the organs of the body.
Causes
Shock occurs whenever the heart is unable to pump as much blood as the body needs.
The most common causes are serious heart complications. Many of these occur during or after a heart attack (myocardial infarction). These complications include:
Dangerous heart rhythms, such as ventricular tachycardia, ventricular fibrillation, or supraventricular tachycardia
Very slow heart rhythm (bradycardia) or heart conduction block
Tear or rupture of the wall (septum) between the left and right ventricle
Tear or rupture of the muscles or tendons that support the heart valves, especially the mitral valve
A large section of heart muscle that no longer moves well or does not move at all
Rupture of the heart muscle due to damage from the heart attack
Symptoms
Profuse sweating, moist skin
Rapid breathing
Rapid pulse
Restlessness, agitation, confusion
Skin that feels cool to the touch
Pale skin color or blotchy (mottled) skin
Weak (thready) pulse
Decreased mental status
Loss of ability to concentrate
Loss of alertness
Coma
An examination will reveal:
Low blood pressure (less than 90 systolic)
Blood pressure may drop more than 10 points when you stand up after lying down (orthostatic hypotension)
Weak (thready) pulse
To diagnose cardiogenic shock, a catheter (tube) may be placed in the pulmonary artery (right heart catheterization). Measurements often indicate that blood is backing up into the lungs and the heart is not pumping properly.
Tests include:
Coronary angiography
Echocardiogram
Electrocardiogram
Nuclear scans
Other tests may be recommended to determine why the heart is not functioning properly.
Laboratory tests include:
Arterial blood gas
Blood chemistry (chem-7, chem-20, electrolytes, cardiac enzymes)
CBC
Treatment
Cardiogenic shock is a medical emergency. Treatment requires hospitalization. The goal of treatment is to save your life and treat the cause of shock.
Medications may be needed to increase blood pressure and heart function, including:
Dopamine
Dobutamine
Epinephrine
Norepinephrine
When an arrhythmia is serious, urgent treatment may be needed to restore a normal heart rhythm. This may include:
Electrical “shock” therapy (defibrillation or cardioversion)
Implanting a temporary pacemaker
Medications given through a vein (intravenous)
You may receive pain medicine if necessary. Bed rest is recommended to reduce demands on the heart.
Getting oxygen lowers the workload of the heart by reducing tissue demands for blood flow.
You may receive intravenous fluids, including blood and blood products, if needed.
Other treatments for shock may include:
Cardiac catheterization with coronary angioplasty and stenting
Heart monitoring, including hemodynamic monitoring, to guide treatment
Heart surgery (coronary artery bypass surgery, heart valve replacement, left ventricular assist device)
Intra-aortic balloon counterpulsation (IABP) to improve heart and blood vessel function
Pacemaker
Outlook (Prognosis)
In the past, the death rate from cardiogenic shock ranged from 80% – 90%. In more recent studies, this rate has improved to between 50% – 75%.
When cardiogenic shock is not treated, the outlook is not good.
Possible Complications
Brain damage
Kidney damage
Liver damage
Distributive shock
In distributive shock caused by sepsis the infection is treated with antibiotics and supportive care is given (i.e. inotropica, mechanical ventilation, renal function replacement). Anaphylaxis is treated with adrenaline to stimulate cardiac performance and corticosteroids to reduce the inflammatory response. Ieurogenic shock because of vasodilation in the legs, one of the most suggested treatments is placing the patient in the Trendelenburg position, thereby elevating the legs and shunting blood back from the periphery to the body’s core. However, since bloodvessels are highly compliant, and expand as result of the increased volume locally, this technique does not work. More suitable would be the use of vasopressors
Obstructive shock
In obstructive shock, the only therapy consists of removing the obstruction. Pneumothorax or haemothorax is treated by inserting a chest tube, pulmonary embolism requires thrombolysis (to reduce the size of the clot), or embolectomy (removal of the thrombus), tamponade is treated by draining fluid from the pericardial space through pericardiocentesis.[2][3][4][5]
Endocrine Shock
Endocrine shock is defined as a significant (and usually life-threatening) disturbance to an animal’s endocrine (hormone production) system. Examples of conditions which may cause endocrine shock include hypothyroidism, hyperthyroidism (thyrotoxicosis) and acute adrenal deficiency. The major and generally accepted modalities for treatment of hyperthyroidism in humans involve initial temporary use of suppressive thyrostatics medication, and possibly later use of permanent surgical or radioisotope therapy. All approaches may cause under active thyroid function (hypothyroidism) which is easily managed with levothyroxine supplementation. Adrenal deficiencies are often treated with application of corticosteroids.
Prognosis
The prognosis of shock depends on the underlying cause and the nature and extent of concurrent problems. Hypovolemic, anaphylactic and neurogenic shock are readily treatable and respond well to medical therapy. Septic shock however, is a grave condition and with a mortality rate between 30% and 50%. The prognosis of cardiogenic shock is even worse.
Shock is said to evolve from reversible to irreversible in experimental hemorrhagic shock involving certain animal species (dogs, rats, mice) that develop intense vasoconstriction of the gut. Death is due to hemorrhagic necrosis of the intestinal lining when shed blood in reinfused. In pigs and humans 1) this is not seen and cessation of bleeding and restoration of blood volume is usually very effective; however 2) prolonged hypovolemia and hypotension does carry a risk of respiratory and then cardiac arrest. Perfusion of the brain may be the greatest danger during shock. Therefore urgent treatment (cessation of bleeding, rapid restoration of circulating blood volume and ready respiratory support) is essential for a good prognosis in hypovolemic shock.
