Updated: 1/25/2019

Shock

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Overview
 
Different Types of Shock
Shock Type Skin 

Wedge Pressure (PCWP) (Preload)

Systemic Vascular Resistance (SVR) (Afterload)
Cardiac Output
Hyovolemic Cold and clammy skin
 ↓↓ 
Cardiogenic ↑ or ↓
↓↓
Obstructive
Distributive Warm or dry skin
↓ 
↓↓ 
↓ (dry)
↑ (warm)


Introduction
  • Clinical definition
    • decreased oxygen delivery, increased oxygen consumption, or impaired oxygen utilization that results in cellular and tissue hypoxia
      • this occurs in cases of reduced tissue perfusion (e.g., hemorrhage)
      • there are 4 types of shock
        • cardiogenic
        • hypovolemic
        • distributive
        • obstructive
Cardiogenic
  • Clinical definition
    • shock secondary to intracardiac causes results in a decreased cardiac output
      • self-perpetuating since
        • hypotension will result in decreased perfusion to the coronary vessels thus
          • worsening ischemia
        • decreased stroke volume will in turn increase the amount of blood in the left ventricle (LV) which
          • increases LV size and thus myocardial oxygen demand
  • Etiology
    • causes of cardiogenic shock can be divided into three categories
      • cardiomyopic
        • myocardial infarction (e.g., > 40% of the LV mass is infarcted)
        • heart failure exacerbations (e.g., dilated cardiomyopathy)
        • myocarditis
        • stunned myocardium in the setting of prolonged ischemia
        • drug induced (e.g., β-blockers)
      • arrhythmic
        • tachyarrhythmias (e.g., atrial fibrillation)
        • bradyarrhythmias (e.g., Mobitz type II second degree heart block)
      • mechanical
        • valvular pathology (e.g., valvular rupture, insufficiency, and severe stenosis)
        • atrial myxoma
  • Clinical findings
    • cold and clammy skin
  • Treatment
    • intravenous inotropes (e.g., dobutamine) 
    • intra-aortic balloon pump in certain cases
    • percutaneous left ventricular assist device (LVAD)
      • in cases where more extensive and prolonged support is needed to achieve hemodynamic stability
Hypovolemic
  • Clinical definition
    • shock secondary to reduced intravascular volume 
      • the reduced preload results in a decreased cardiac output
  • Etiology
    • causes of hypovolemic shock can be divided into
      • hemorrhagic (e.g., trauma and gastrointestinal bleeding)
      • non-hemorrhagic
        • decreased intravascular volume not due to loss of blood
          • gastrointestinal losses (e.g., diarrhea)
          • skin loss (e.g., heat stroke and burns)
  • Clinical findings 
    • cold and clammy skin
  • Treatment
    • intravenous fluids
Distributive
  • Clinical definition 
    • shock secondary to severe peripheral vasodilation
  • Etiology
    • septic shock
    • non-septic causes include
      • systemic inflammatory response syndrome (SIRS)
      • neurogenic shock (e.g., traumatic brain and spinal cord injury and neuro-axial anesthesia)
      • anaphylaxis
  • Clinical findings
    • warm or dry skin
  • Treatment
    • intravenous fluids and vasopressors
Obstructive
  • Clinical definition
    • shock secondary to extracardiac causes of pump failure (most common)
      • typically is associated with impaired right ventricular output
  • Etiology
    • causes of obstructive shock can be divided into
      • pulmonary vascular (e.g., severe pulmonary embolism and pulmonary hypertension)
      • mechanical (e.g., tension pneumothorax, pericardial tamponade, and constrictive pericarditis
  • Clinical findings
    • cold and clammy skin
  • Treatment
    • manage the obstruction
 

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(M1.PA.14.36) A 73-year-old male is brought into the ED unconscious with cold, clammy skin. His blood pressure is 65 over palpable. There is no signs of blood loss. You recognize the patient is in acute shock and blood is drawn for investigation as resuscitation is initiated. Which of the following might you expect in your laboratory investigation for this patient? Tested Concept

QID: 100101
1

Increased arterial pH

7%

(21/286)

2

Increased serum bicarbonate

6%

(16/286)

3

Increased serum ketones

14%

(40/286)

4

Decreased hemoglobin

8%

(22/286)

5

Increased blood lactate

65%

(185/286)

M 1 D

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