Compensated vs. decompensated shock: what you need to know

When shock is suspected, it's important to identify which stage you're working with


The signs and symptoms of compensated and decompensated shock are different, and if shock is left untreated it can be lethal. For this reason, it is imperative that shock is treated as early as possible to avoid reaching the irreversible phase. 

Shock can occur in many emergency medical scenarios, including those with massive blood loss (internal or external). It can also occur when there are severe fractures, during a spinal, abdominal or chest injury, when a severe infection or major heart attack occurs, and during anaphylaxis. When shock is suspected or observed, taking frequent vital signs and assessing the mental state of the patient is the best way to monitor the progression of shock.  

Compensated shock

Carotidian pulse and recovery position (Photo/Wikimedia Commons)
Carotidian pulse and recovery position (Photo/Wikimedia Commons)

With compensated shock, the body is experiencing a state of low blood volume but is still able to maintain blood pressure and organ perfusion by increasing the heart rate and constricting the blood vessels. If responding to an emergency in which shock is suspected, a quick assessment of the patient should be completed to measure the level of consciousness, mental state and vital signs. 

Symptoms of compensated shock include:

  • Agitation, restlessness and anxiety
  • Altered mental status
  • Tachycardia or tachypnea
  • Change in pallor, cyanosis around the lips, or clammy skin
  • Nausea or vomiting 
  • Thirst
  • Weak, thready or absent pulse
  • Narrowing pulse pressure
  • Shallow, rapid breathing
  • Mental status may be normal, in the early stages

For treating compensated shock, the initial step is going to be identifying the cause of shock and treating it. Once that is done, measures to treat shock can be taken. During transport, this is typically applying high-flow oxygen and warming blankets to maintain a temperature in the normal range. Inadequate ventilation can be a major factor in the development and progression of shock. Continue to monitor vital signs and mental state every few minutes and note any changes. 

Decompensated shock

With compensated shock, the body is able to take measures to maintain blood pressure, however as shock worsens, the body becomes unable to keep up. At this point, perfusion of vital organs is no longer maintained. 

Symptoms of decompensated shock include:

  • Falling blood pressure (systolic of 90 mm Hg or lower with adults)
  • Tachycardia and tachypnea
  • Low urine output
  • Labored and irregular breathing
  • Weak, thready or absent peripheral pulses
  • Ashy or cyanotic pallor
  • Reduced body temperature
  • Decreased mental status
  • Dilated pupils

With decompensated shock, it may be necessary to request advanced life support measures for the patient. Priority should be given to management of the airway and treatment of the underlying cause of shock. A decrease in blood pressure is often an indication of late-stage shock and treatment should start well before this is detected. If the condition remains untreated, it will progress into irreversible shock which ultimately leads to death of the patient. 

The key toward successfully treating shock is a rapid response. If it can be treated before reaching the decompensated phase, that is best. In many major life-threatening situations, the development of shock should be anticipated. Many care providers will refer to a ‘golden hour’ or ‘golden period’ in which care should be delivered as quickly as possible and if it is, the patient will not suffer any lasting damage. This requires a speedy assessment of the patient and quick transport to a trauma facility.

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