Talk:Shock (medical)

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This article needs to mention psychological shock. -- Tarquin

Why, in medical terms shock refers to the physical part. However, if you feel the need to mention Post-traumatic stress disorder feel free to explain why. Nomen Nescio 15:54, 16 March 2006 (UTC)

mental shock is one type of medical shock. Post-traumatic is by definition, post-traumatic. not the same thing, is it? Also, that article doesn't use the word 'shock' once. -- Tarquin 16:33, 16 March 2006 (UTC)

If you do not refer to PTSD, what exactly do you mean? And in what Medical Textbook (Cecil, Harrison, Oxford Textbook of Medicine, et cetera) can I find this "mental shock?" As far as I know "shock" in medicine only refers to what this article discusses, although the popular use (this is not the same as what doctors use) is limited to the psychological disorder. Nomen Nescio 17:00, 16 March 2006 (UTC)

Perhaps Tarquin refers to someone who is catatonic? If someone says "psychological shock" that's what I would think of. —Traal 02:22, 18 September 2006 (UTC)

I agree with Tarquin – the word "shock" is used in a medical context to describe the body's physical reaction to immediate psychological stress. For example, you witness a terrible car accident. Over the course of the following two or three hours, you vomit several times and feel faint. This would be called "shock", and it has nothing to do with post-traumatic stress disorder. Witnesses to horrific events are often said to "have sustained no injury, but were treated for shock". Clearly this is a MAJOR medical usage of the term that should be included in the article! --Ecksemmess 14:34, 18 September 2006 (UTC)

I'm confused about the topic of shock. A friend of mine was hit by a car a few years back, and she told me that when she was 'in shock' she couldn't feel any pain and was having fun fiddling around with her broken pinky. That's about all she could tell me, but I want to know more. I looked here, but this article has no mention of it. The disambig page led to PTSD, but I don't think that's quite it either. In short, I agree with Ecksemmess that another section should be added. This is supposed to be a friggin' encyclopedia! If it is a major medical term, why isn't it explained or at least mentioned?

I would further like to point out that when you type "define:shock" into Google the very first definition is:

the feeling of distress and disbelief that you have when something bad happens accidentally;
"his mother's death left him in a daze"; "he was numb with shock"

Very good, but this is NOT! clinical shock, just as it isn't an electrical shock. The disambiguation link is there for this very reason, if you feel a page on Shock (psychological) is required, feel free. Also just looked through the Oxford Handbook of Clinical Medicine, and the only reference to shock is the clinical shock discussed here. So as a "major medical term" not being included in the major publication doctors here in Britain use is surely an indication that the medical fraternity do not use shock in this way. Panthro 01:51, 12 December 2006 (UTC)

Contents 1 Four 2 Revert 3 Revert 4 So... 5 Third Opinion 6 Clean slate 7 Dead Horse? 8 Simplify? 9 Infobox 10 References & Notes

[edit] Four

I would like to remind all editors that shock is divided in FOUR types, as the article says. It would be helpfull if we keep all of these forms of shock and not delete the fourth: obstruction. Nomen Nescio 00:42, 27 March 2006 (UTC)

Is this POV or do you have verifiable sources as all the books and journals I have read state only three. I will leave it for now, but remove it unless you provide the said sources. Thanks. Panthro 19:17, 27 March 2006 (UTC)

Another point.. for obstructive shock Google has 864 hits. These factors stated CAUSE shock.. the same way that haemorrhagic shock is not a type in itself but part of hypovolaemic shock. But I am open to discussion on the matter. Panthro 19:24, 27 March 2006 (UTC)

• Incorrect, my Google says about 678,000 for obstructive shock. Nomen Nescio 01:59, 28 March 2006 (UTC)

If you wrap quotations around it - you will get the 800 odds... simply putting onstructive shock means google looks for "obstructive" and "shock". 893 for google.com, 899 for google.co.uk which compares to 146,000 for hypovolemic and 1,000,000+ for septic shock. I understand that this is not evidence per se, but it is interesting Even so, you have proven yourself the term exists (eMedicine is a very good site) and was not invented by me. Nomen Nescio 19:55, 29 March 2006 (UTC)

It is quite incorrect to state that distibutive shock is similar to hypovolaemia, undoubtedly they will lead on to hypovolaemia due to the compensatory mechanisms affecting the body.

Consider this: take a 1 liter bottle, fill it with water and you will have 1 liter of water with no room to spare. Then take a 2 liter bottle and empty the original 1 liter bottle into it. If I am not mistaken we will have 1 liter of water in a 2 liter bottle. Now, the amount of water is insufficient to fill the bottle, although we have not changed the volume of water. We change the volume the bottle can take and this is exactly what happens in distributive shock. By vasodilatation the volume our bloodvessels can take increases, but the volume of blood remains the same. Just as in the bottles there is a mismatch of volume and relative to the new volume of circulation there is not enough blood: hence relative hypovolemia! Nomen Nescio 19:55, 29 March 2006 (UTC)

"An internal source may be haemorrhage, intestinal obstruction, paralytic bowel or gross ascites."

I assume you deleted the above again on a whim of one piece of evidence.

Ascites - look it up if you don't know what it is. This is a massive fluid shift into the abdomen - occasionally called "third shifting".

Re: intestibal obstuction and paralytic ileus - this causes the accumulation of fluid in the bowel (it isn't getting absorbed vy the villi) - as a result there is dehydration and deranged electrolytes. Usually it is also results in vomiting - all leading to a decrease in circulating volume and therefore HYPOVOLAEMIA.

Do not revert something on a whim simply because you don't understand... a good editor will look up verifiable sources and then initiate a discussion.

I am sorry that some of your good changes to the previous revert have been removed - I will try to add them in..... Panthro 19:49, 27 March 2006 (UTC)

Oh and another thing, if you so strongly support the four shock types idea, then why have you stated under the treatment for obstructive shock

" fluid deficit is medically compensated by intravenous resuscitation"

Surely this is hypovolaemic shock?????? Panthro 19:53, 27 March 2006 (UTC)

First of all you might consider a less aggressive tone. For a student nurse to make such bold statements without having read one medical textbook on the subject is rather presumptuous.

How do you know I havent read "medical" textbooks? Who is being presumptive now?

I will gladly put the references in of the medical, pathophysiological, pathological textbooks and journal articles which state three types of shock.Panthro 18:50, 28 March 2006 (UTC)

Second, as to why I insist on four types is because that is what doctors have agreed upon.

Which doctors? In these textbooks? Panthro 18:50, 28 March 2006 (UTC)

Although I appreciate your effort and concede your sources have not heard of it the details can be found in the following medical textbooks: Intensive Care Medicine by Irwin and Rippe, The ICU Book by Marino, Fundamental Critical Care Support, A standardized curriculum of Critical Care, by the Society of Critical Care Medicine. Please read them before assuming I am wrong. Furthermore, your description of symptoms is not entirely correct based on my personal experience working in intensive care.

Cannot access those materials but I will give you the benefit of the doubt Panthro 18:50, 28 March 2006 (UTC)

Third, "An internal source may be haemorrhage, intestinal obstruction, paralytic bowel or gross ascites." is incorrect. Ileus leads to extravasation of fluid and dehydration, but seldom, if ever, to distributive shock.

hypovolaemic shock, not distributivePanthro 18:50, 28 March 2006 (UTC)

Remember hypovolaemia is not equivalent to shock. Why ascites leads to distributive shock entirely escapes me. Can you explain the mechanism? Ascites developes over time and many patients (cirrhosis, lymphoma or other malignancy) are not acutely ill.

I think if I remember correctly, it was gross untreated ascites, i.e. a massive fluid shift into the abdomen... Panthro 18:50, 28 March 2006 (UTC)

Fourth, "fluid deficit is medically compensated by intravenous resuscitation" was not inserted by me. Nomen Nescio 23:54, 27 March 2006 (UTC)

apologies for that... and for my tone. Panthro 18:50, 28 March 2006 (UTC)

Some observations:

1 In medicine doctors use the following textbooks as reference:

• Harrison's Principles of Internal Medicine, this is considered the principal resource for any condition in internal medicine
• Cecil Textbook of Medicine
• The Oxford Textbook of Medicine

2 In intensive care medicine doctors use these references

• Intensive Care Medicine by Irwin and Rippe, again the principal resource
• The ICU Book by Marino is a succinct book used a reference by those unable/unwilling to buy the Irwin and Rippe

3 You surely have looked in textbooks, however, since the ones I mention are the primary, if not only, references among doctors for any problem in internal medicine, I would suggest we adopt whatever these textbooks provide as definition and forms of shock.

4 Although you are correct in pointing out you referred to hypovolaemic shock, this still does not alter the fact that your assertions are incorrect. Both ileus and ascites do not present an acute and massive shift of fluid into the extravasal space. Hence they will cause dehydration (decrease of intravascular volume) but not shock.

5 Apologies accepted and do continue editing. But please consider your literature may not present an accurate and comprehensive discussion on medical conditions. Feel free to read about the conditions that are listed as examples of the types of shock. Nomen Nescio 20:21, 28 March 2006 (UTC)

[edit] Revert

Sorry to hinder your work yet again, but you are making several mistakes. 1 An Intra-aortic balloon pump[1] is inserted through the arteria femoralis and NOT the v. jugularis or v. subclavia. These are used when inserting a central venous catheter. 2 Again you delete acute adrenal insufficiency. Please read what this condition is (addisonian crisis). 3 Deleting therapy as suggested in Irwin and Rippe is odd when that is THE source of information in critically ill patients. Nomen Nescio 21:52, 28 March 2006 (UTC)

IABP - This is where the tip LIES, not where it is inserted

Adrenal insufficiency - in the wrong place - should be in treatmentPanthro

1 Acute adrenal insufficency causes shock and therapy consists of corticosteroids, since cortisol is lacking.

2 The IABP is inserted through the groin (a. femoralis) and the tip lies just caudal to the arcus aortae. Hence the name intra-aortic.

3 Therapy taken from Irwin and Rippe:

• Cardiogenic shock: Depending on the type of myocardal infarction one can infuse fluids or inotropica. Should that not suffice an Intra aortic balloon pump can be considered or a left ventricular assist device.
• Hypovolemic shock: In case of bleeding it is necessary to immediately control the bleeding and restore the victims blood volume by giving infusions of balanced salt solutions. Blood transufion 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. Hypovolemic shock 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 (and prevent 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 the knowing that blood volume is returning to normal.
• Distributive shock: In sepsis the infection is treated and supportive care is given. Anaphylaxis is treated with adrenalin and corticosteroids. Adrenal insufficienty is treated with corticosteroids. In neurogenic 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: the only therapy consist of removing the obstruction.

4 Give me some time and I will insert references at all locations so you'll know where it is from. 5 Remeber you are a student nurse and it is not impossible you do not know everything. Nomen Nescio 22:18, 28 March 2006 (UTC)

[edit] Revert

Sorry to hinder your work yet again, but you are making several mistakes. 1 An Intra-aortic balloon pump[2] is inserted through the arteria femoralis and NOT the v. jugularis or v. subclavia. These are used when inserting a central venous catheter. 2 Again you delete acute adrenal insufficiency. Please read what this condition is (addisonian crisis). 3 Deleting therapy as suggested in Irwin and Rippe is odd when that is THE source of information in critically ill patients. Nomen Nescio 21:52, 28 March 2006 (UTC)

IABP - This is where the tip LIES, not where it is inserted

Adrenal insufficiency - in the wrong place - should be in treatmentPanthro

1 Acute adrenal insufficency causes shock and therapy consists of corticosteroids, since cortisol is lacking. Alot of things cause shock, is it necessary to mention them all? How prevalent is acute adrenal insufficiency in the formation of shock?Panthro

It is relatively common, read about it if you please. Nomen Nescio 22:50, 28 March 2006 (UTC)

More to the point, every patient on corticosteroid therapy that requires surgery or is acutely ill, should be seen by an internist to adjust the dosage. If not, adrenal insufficiency is a real possibility. The use of corticosteroid therapy and surgery are not uncommon things so this condition is not a rare complication. Nomen Nescio 19:45, 29 March 2006 (UTC)

2 The IABP is inserted through the groin (a. femoralis) and the tip lies just ventral to the arcus aortae. Hence the name intra-aortic. distal to the subclavian and ventral to the aortic arch is the same place.... Panthro

It is also ventral from the spine and distal from the larynx. No doctor uses the description you use. BTW the aorta descendens bends dorsal from the aorta ascendens, which makes "ventral to the aortic arch" incorrect. Nomen Nescio 22:50, 28 March 2006 (UTC)

3 Therapy taken from Irwin and Rippe:

• Cardiogenic shock: Depending on the type of myocardal infarction one can infuse fluids or inotropica. Should that not suffice an Intra aortic balloon pump can be considered or a left ventricular assist device.IN ARTCILE Panthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

• Hypovolemic shock: In case of bleeding it is necessary to immediately control the bleeding and restore the victims blood volume by giving infusions of balanced salt solutions.IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

Blood transufion 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. Hypovolemic shock due to burns, diarrhea, vomiting, etc. is treated with infusions of electrolyte solutions that balance the nature of the fluid lost. IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

Sodium is essential to keep the fluid infused in the extracellular and intravascular space (and prevent water intoxication and brain swelling).IN ARTCILE - FURTHER EXPANSIONBut rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

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. IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

It is best treated by rapidly restoring intravascular volume and perfusion as above.IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

Inotropic and vasoconstrictive drugs should be avoided, as they may interfere in the knowing that blood volume is returning to normal. Distributive shock: In sepsis the infection is treated and supportive care is given.IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

Anaphylaxis is treated with adrenalin and corticosteroids.MOSTLY IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

Adrenal insufficienty is treated with corticosteroids. In neurogenic shock because of asodilation 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.WHY PUT THIS IN IF IT DOES NOT WORK???Panthro

Because many erroneously use Trendelenburg. Nomen Nescio 22:50, 28 March 2006 (UTC)

More suitable would be the use of vasopressors.IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

Obstructive shock: the only therapy consist of removing the obstruction.IN ARTCILEPanthro

But rewritten by you in a less accurate way. Nomen Nescio 22:50, 28 March 2006 (UTC)

[edit] So...

For the rather minor points above, you have reverted the whole article? I will gladly add them in..Panthro 22:37, 28 March 2006 (UTC)

The main reason is your deletion of parts of types of shock. Addisionian crisis is important, many doctors have missed the diagnosis and thought it was septic shock. Nomen Nescio 22:53, 28 March 2006 (UTC)

[edit] Third Opinion

Can't you add these parts in? I am not going to revert it anymore, In order to resolve this dispute I have asked for a third opinion Wikipedia:Third opinion

Mediation is always a good way to resolve disputes. Thank you. Nomen Nescio 22:54, 28 March 2006 (UTC)

Can either of you boil this down to a specific dispute? I see you're both reverting each other's changes, but I'm not quite sure what the source of your disagreement is. Fagstein 04:12, 29 March 2006 (UTC)

The following problems arise:

1 There are four types of shock used by physcicians. An editor with insufficient medical knowledge thinks there are three, and first deleted the fourth[3] and now advocates it is suggested there are four types of shock.

2 Acute adrenal insufficiency causes what is called distributive shock. This editor not only repeatedly removed this condition, but falsely states that it does not result in shock.

• Have corrected this, part of endocrine shock.18:07, 29 March 2006 (UTC)

3 Then this editor completely rewrites medical therapies for these conditions into:[4]

• Cardiogenic shock: Intra-aortic balloon pump - Balloon placed in the distal left sub-clavian junction which assists in left ventricular ejection by increasing intra-aortic pressure. This assertion is incorrect, the balloon is placed between the aortic arch and renal arteries.
• Hypovolemic shock: In case of bleeding it is necessary to immediately control the bleeding and restore the victims blood volume by giving infusions of balanced salt solutions. Blood transufion 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. Hypovolemic shock 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 (and prevent 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 the knowing that blood volume is returning to normal. is deleted and turned into a elaborate discussion.
• Distributive shock: In sepsis the infection is treated and supportive care is given. Anaphylaxis is treated with adrenalin and corticosteroids. Adrenal insufficienty is treated with corticosteroids. In neurogenic 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. This is deleted and replaced by less accurate therapies.

4 Although I suggested the original, and current , version was taken from medical textbooks, (I named them in the previous discussions and marked what is taken from them in the article) apparently that is insufficient cause for a student nurse which has not read these books to accept that he might be making incorrect edits based on physology and nursing textbooks. Nomen Nescio 13:33, 29 March 2006 (UTC)

Reread Irwin and Rippe, since I must confess my comments were based on memory and experience, and discovered a flaw in my argument. There are five types of shock. Therefore I have corrected that section to reflect what is presented in Irwin and Rippe (added note). Nomen Nescio 18:06, 29 March 2006 (UTC)

[edit] Clean slate

I have no problem with the content, it is the sentence structure, grammar and paragraphs that are my problem. Please, revert any mistakes I have made, but reverting the ENTIRE article is wrong in my opinion. And add the parts I have deleted, intentionally or not.

My medical knowledge is limited and I am the first to say that, but I think my English skills are quite good. Articles MUST be factually accurate, but they must also make sense.—The preceding unsigned comment was added by Panthro (talk • contribs).

Let's start with a clean slate. Discussing what we think could be improved is indeed more constructive. Please, explain what part you would like to change and make a suggestion how you would change it.

You may have noticed I did use some of your edits and repaired your image. Nomen Nescio 20:49, 29 March 2006 (UTC)

---

The article is fine now, IMO, but we need a signs and symptoms for endocrine.

Oh and I have found a site which lists "Respiratory shock" - the credibility of which I am not sure...

Respiratory Shock is when there is not enough oxygen getting into the lungs. When this happens an insufficient amount of oxygen is carried on the red blood cells, and the tissues of the body fail to receive the amount of oxygen they require to survive. This will cause cyanosis (bluish tinge to the skin) to develop, initially in the hands and feet, then around the mouth and on the face, then if not corrected, centrally on the body. Respiratory shock can be caused by trauma, but the most common culprits are: airway obstructions, asthma, congestive heart failure (CHF), pulmonary edema (PE), other diseases of the lungs like Chronic Obstructive Pulmonary Disease (COPD), and inhalation of gases other than oxygen, i.e. carbon monoxide or nitrous oxide that has not been diluted with O2. Some signs and symptoms to look for are cool, clammy skin, pale or cyanotic color, use of accessory muscles to breath, inspiratory stridor (sounds like a high pitched crowing sound when the patient inhales), wheezing, rhonchi, or rales. —The preceding unsigned comment was added by Panthro (talk • contribs).

Never heard of it, but it does fit the definition: mismatch between oxygen required by and oxygen delivered to tissues. What site is it, can you show the link?

BTW, don't forget to sign your posts here, otherwise nobody knows who said what. Four tildes. Nomen Nescio 21:35, 29 March 2006 (UTC)

---

http://www.alpharubicon.com/med/shockpalehorse.htm Panthro

• Although it has some good points it surely has more amateuristic qualities and we must not use it. Nomen Nescio 21:47, 29 March 2006 (UTC)

Agreed. Panthro 22:00, 29 March 2006 (UTC)

Higher up this page I have also explained the why distributive shock has relative hypovolemia, you may want to read. Nomen Nescio 22:04, 29 March 2006 (UTC

[edit] Dead Horse?

HI - I don't think "Endocrine Shock" should have its own heading. Its not a widely used term in clinical practice and the types of shock described therein can be reclassified into the the more recognised categories. For instance - hypo and hyper thyroidism cause shock through thier effects on the heart - cardiogenic. Likewise lack of cortisol causes a form of distributive shock. Any thoughts?SkinnyB 22:32, 7 June 2006 (UTC)

Although you are correct that it is not well-known, please consider the fact that this is the classification offered by Irwin and Rippe. Since that Textbook is to intensive care medicine what the Harrison is to internal medicine I think we should adopt their view. Nomen Nescio^{Gnothi seauton} 11:09, 8 June 2006 (UTC)

[edit] Simplify?

Is it possible to simplify part of the introduction so that laymen like me could actually understand what shock is? I don't advocate dumbing down the entire entry, but a couple sentences written so that someone with limited knowledge of physiology could understand the concept would be nice.

[edit] Infobox

Disease Infobox restored. I assume it was removed along with vandalism on 6/10. The infobox template provides a compact set of references and links - it may not be self-evident yet but is being refined - see Template_talk:Infobox_Disease#Suggestion Finavon 20:54, 9 October 2006 (UTC)

[edit] References & Notes

Several of the "footnotes" (often to a full paragraph) also appear in the references list. Can they be combined without losing the ability to support individual statements? Finavon 23:14, 9 October 2006 (UTC)