Shock

Question 1

Differentiating Cardiogenic Shock

Answer 1

● History of cardiac abnormalities
● Physical exam findings: Enlarged liver, gallop, murmur.
● Chest X ray: Enlarged heart, pulmonary edema

Question 2

Cardiogenic Shock

n Etiology:

Answer 2

Etiology: – – – – – – –
Dysrhythmias Infection (myocarditis) Metabolic Obstructive Drug intoxication Congenital heart disease Trauma

Question 3

Warm Shock

Answer 3

Warm Shock
• Early compensated hyperdynamic state of septic shock • Warm extremities, bounding pulses, tachycardia, wide pulse
pressure, decreased systemic vascular resistance and increased cardiac output
• Often with hyperglycemia

Question 4

Cold Shock

Answer 4

Late uncompensated stage of septic shock with drop in cardiac
output
• Cold and clammy skin, rapid thready pulses, shallow breathing • Associated metabolic acidosis, hypoxia, coagulopathy,
hypoglycemia, capillary leak

Question 5

Septic Shock

Answer 5

Fluid boluses. ( 20 cc/kg) up to 60cc/kg • Correct hypoglycemia • Administer 1st dose of antibiotics • Consider vasopressor drip and stress dose
hydrocortisone

• IF NOT FLUID RESPONSIVE
Normotensive-Start Dopamine
Hypotensive vasodilated(warm shock)-
Norepinephrine Hypotensive vasoconstricted(cold shock)-
Epinephrine

Question 6

Shock Definition

Answer 6

Shock Definition: is a life-threatening state that occurs when oxygen
and nutrient delivery are insufficient to meet tissue metabolic demands

Question 7

Sequelae of shock

Answer 7

Sequelae of shock are:
1- Metabolic acidosis,
2- Organ dysfunction
3- Death

Question 8

Oxygen Delivery

Answer 8

Oxygen Delivery

Oxygen delivery=CO X Arterial oxygen
content
• CO=Heart rate X Stroke volume
• Stroke volume depends on preload, afterload
and contractility

Question 9

Clinical Presentation

Answer 9

Early diagnosis requires a high index of suspicion
Diagnosis is made through the physical examination focused on tissue perfusion
• Hypotension is a late sign
Physical Exam Findings
• Neurological: Fluctuating mental status, sunken
fontanel
• Skin and extremities: Cool, pallor, mottling, cyanosis,
poor cap refill, weak pulses, poor muscle tone.
• Cardio-pulmonary:Tachypnea tachycardia. • Renal: reduce urine output

Question 10

Directed History

Answer 10

● Past medical history
– Heart disease
– Surgeries
– Steroid use
– Past medical Medical problems ● Brief history of present illnes
– Onset and progression of symptoms
– Exposure
n Laboratory studies: – – – – – – –
ABG Blood sugar Electrolytes CBC PT/PTT Type and 
cross Cultures

Question 11

Mangment كلها

Answer 11

Management-Volume Expansion

• Optimize preload • Normal saline (NS) or lactated ringer’s (RL) • Except for myocardial failure use 10-ml/kg
every 15 minutes. Reasses after every bolus.
• At 60ml/kg consider: ongoing losses, adrenal
insufficiency, intestinal ischemia, obstructive
shock. Get CXR. May need inotropes.

Question 12

Hypovolemic Shock

Answer 12

Etiology: Hemorrhage, renal and/or GI fluid
losses, capillary leak syndromes
n Clinically, history of vomiting/diarrhea or
trauma/blood loss n Signs of dehydration: dry mucous
membranes, absent tears, decreased skin
turgor n Hypotension, tachycardia without signs of
congestive heart failure

Question 13

Hemorrhagic Shock

Answer 13

Hemorrhagic Shock
Management
• Normal Saline 20 cc/kg over 15 min • Repeat up to 60 cc/kg 
• If due to bleeding:
     Packed Red blood cells 15 cc/kg

Question 14

Bilateral rales

Answer 14

Bilateral rales= pulmonary edema