Distributive Shock

Question 1

Four broad categories of shock:

Answer 1

 Hypovolemic
 Obstructive
 Distributive
 Cardiogenic

Question 2

all the mechanisms of blood flow are interconnected. if tehre is a decreased preload, what mechanisms compensate? (ex in hypovolemic shock)

Answer 2

everything else compensates– there is an elevated afterload through constriction, increase in rate, increase in contractiltiy. All of these to try and match the VQ

Question 3

49 year old man presents to
ER with a 4 hour history of
hematemesis and melena
 Has a history of peptic ulcer
disease  Not on any therapy  Hurt shoulder playing
recreation hockey last week
and has been using ibuprofen
for MSK pain.

•  He is very pale and semi conscious
   HR 130, BP 85/65
   RR 28
   JVP is not visible
   Mucous membranes are dry- what to do first?

Answer 3

RESUSCITATION!

 A,B,C’s
 His intravascular volume must be restored
 Volume Resuscitation:
 Good IV access = short, large bore and more than one
 Good IV Fluid = physiological osmolality (not D5W, .5 NS,
ect)  Give a lot in a hurry! 2 L is a good place to start  Restoring blood pressure with pharmacological agents is
NOT the right approach!

Question 4

external and interal causes of hypovolemic shock

Answer 4

external; excretion reducing preload, ex/ epistaxis, diuretics, burns

interanl; hemothorax, hemoperitoneum/blood pooling where it shouldnt be and it doesnt make it sway to the heart.

Question 5

overall first tests to do for someone in hypovolemic shock state

Answer 5

Question 6

distributive shock:

 Vasodilation leads to loss of ___ and
maldistribution of blood flow

Answer 6

 Vasodilation leads to loss of afterload and
maldistribution of blood flow
 Hypotension
 Diversion of blood from the ‘noble’ organs
 Increases in HR and contractility will attempt to
offset the reduction in preload
 Vasoconstriction cannot occur as a
compensation mechanism as this is the primary
problem!

Question 7

if someone is in distributive shock, there is a reduced afterload. what compensatory mechanisms occurs?

Answer 7

decreased afterload– in distributive shock, they can’t just constriv their blood vessels because this is the exact system that is down. instead, they gotta increase the contractility, and increase the rate.

Question 8

3 premisis of resuscitating sepsis

Answer 8

1. volume resuscitaiton
2. recommended to aim for CVP =8-12
3. increase blood pressure with a MAP>65.

Question 9

what kind of pharmacological assistance can be used during resusciation during sepsis

Answer 9

• alpha agonist to increase vascular tone and thus increase afterload

(ex/ NE, vasopressin, phenylephirne)
- if a less than adequate cardiac response is seen, consider inotropes because this person might be getting septic myocardial respression or they might have underlying heart disease.

Question 10

methods of measuring end organ perfusion while youre treating someone wiht distributive shock / underoging resuscitation after sepsis

Answer 10

• urine output
• bp restoration
• drop in heart rate
• lactic acidosis
• mixed venous oxygen
• intravital microscopy.

Question 11

when fixing sepsis, resusciation and physiological support are the first steps. what is next?

Answer 11

1. antibiotics
2. source control– clean it if a wound is tehre
3. steroids if this is an AI issue
4. glucose contol
5. recombinant human activated protein C (anticoagulant and anti-inflammatoyr0

Question 12

cuases of distributive shock

Answer 12

Infection.

Burns.

Surgery.

Trauma.

Pancreatitis.

Fulminant hepatic failure.

Question 13

tests when someone is in distributive shock

Answer 13

Question 14

what is obstructive shock

Answer 14

This term is used to describe states where
preload cannot enter the right or left ventricle

Question 15

right ventricle causes of obstructive hsock

Answer 15

tamponade, tension pneumo, obstruction of the vena cava

Question 16

left venticle causes of obstructive shock

Answer 16

massive pulmonary emoboism

Question 17

obstructive shock is due to a reduced ___. what are the mechanism used to compensate?

Answer 17

reduced preload. there is thus a compensatory incresae in aftelroad, rate, and contractility to adequately distriut ethe blood that can enter the heart into the systemic systems.

Question 18

 38 year old man
 Presents after falling out of a tree while
attempting to prune the branches
 Has a large contusion over his right chest

 Awake and uncomfortable
 Short of breath
 HR 130, BP 70/58, RR 30
 JVP ++ elevated
 Trachea is deviated to left
 No breath sounds on the right with lack of
movement on inspiration

type of shock and underlying problem? how would you treat?

Answer 18

• obviously deviated trachea.
• hyperlucency in right lung.

this is a tension pneumothorax.

this can cause obstructive shock.

need to address ABCs and stabilize the tension pneumo! needle decompression or chest tube placement.

Question 19

tests when you suspect obstructive shock

Answer 19

tests are things to rule out or find the cause of obstructive shock!
 CXR:
 Should not delay the management of a tension pneumothorax

 Echocardiogram
 Will support the diagnosis of tamponade

 ECG
 May support the diagnosis of tamponade
 Electrical alternans  Low voltages
 May support the diagnosis of PE
 Right heart strain  S1Q3T3

 CT or VQ
 To diagnose PE
 If large enough to cause obstructive shock clot should be seen on CT and
possible on transesophageal echo