Updated: 11/1/2018

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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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.PA.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? Review Topic

QID: 100101
1

Increased arterial pH

7%

(14/198)

2

Increased serum bicarbonate

6%

(12/198)

3

Increased serum ketones

15%

(29/198)

4

Decreased hemoglobin

8%

(16/198)

5

Increased blood lactate

63%

(125/198)

M1

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