Cardiology - Shock

Question 1

Discuss the presentation of vasovagal syncope

Answer 1

Trigger
- fear, pain
- coughing, swallowing
- urinating
Presentation
- pre-syncopal symptoms (lightheadedness, dizziness, pallor, nausea)
- last for seconds to minutes
- abrupt recovery

Question 2

Discuss the presentation of orthostatic syncope

Answer 2

Trigger
- lying to sitting
- sitting to standing
- previous blood loss, hypovolemia, or autonomic neuropathy
Presentation
- No prodrome and last seconds to minutes
- Abrupt recovery
- Postural hypotension (sys drop by 20, dia drop by 10, HR increase by 30)
- hypovolemia

Question 3

Discuss the presentation of cardiac syncope

Answer 3

Trigger
- exertional
- have history of cardiac disease or sudden cardiac death in family
Presentation
- have chest pain, palpittions, SOB
- lasts <30 seconds
- abrupt recovery
- Abnormal cardiac exam or ECG

Question 4

Discuss the San Fransisco Syncope Rule

Answer 4

Admitted if any of the following

• Acute decompensated heart failure
• shortness of breath
• systolic BP <90
• abnormal ECG
• hemotocrit <30

Question 5

Discuss the presentation and management of septic shock

Answer 5

Presentation
- warm shock so have tachycardia and increase pulse pressure (SBP-DBP)
- fever
- infectious symptoms
Diagnosis
- Systemic Inflammatory Response Syndrome >=2
- Temperature <36 or >38
- HR >90
- RR >20 or PaCO2 <32
- WBC <4 or >12
- sepsis when SIRS + source of infection
- septic shock when sepsis + SBP <90 refractory to fluids
Management
- Abx
- large volume IV crystalloid 3-5L
- if inadequate response (MAP <65 after 2L) then pRBC or vasopressor (dopamine or norepinephrine)

Question 6

Discuss the presentation and management of hypovolemic shock

Answer 6

Presentation
- cold shock so tachycardia and decreased pulse pressure
- Decreased JVP, dry mucous membranes, dry axilla, decreased skin tugor
Management
- large volume crystalloids
- pRBCs if bleeding

Question 7

Discuss the presentation and management of obstructive shock

Answer 7

Etiology
- tension pneumothorax
- cardiac tamponade 
- pulmonary embolism
Presentation
- cold shock
- increased JVP and peripheral edema
Management
- large volume IV crystalloid 
- relieve obstruction

Question 8

Discuss the presentation and management of cardiogenic shock

Answer 8

Etiology
- ACS
- Arrhythmia
- Valvular pathology
Presentation
- Cold shock
- increased JVP, peripheral edema
Management
- small IV boluses of crystalloids (250-500) with monitoring of RR (as have risk for pulmonary edema)
- vasopressors

Question 9

Discuss the management for shock

Answer 9

- ABC
IMOPH
- IV
- Monitors (ECG, pulse, foley)
- Oxygen
- Pressure
- Help
Fluids
- IV crystalloid fluids
- if inadequate response after 2L require vasopressors
Investigations
- CBC
- electrolytes
- glucose
- lactate
- creatinine, BUN
- LFT
- INR
- CK
- Troponin
- ECG
- urinalysis
- CXR