Shock

Question 1

What non-cardiac conditions can mimic cardiogenic shock?

Answer 1

Aortic Dissection, Pulmonary Edema

Question 2

Broad causes of cardiogenic shock?

Answer 2

Traumatic - Cardiac Tamponade
Atraumatic - 1) Mechanical: LVOT, Acute MR, Ventricular septal/free wall/aneurym rupture. 2) Myopathic: AMI, Myocarditis, RVF, Dilated CM

Question 3

Clinical presentation of cardiogenic shock?

Answer 3

1) Shock features: Hypotension, Tachycardia (unless on beta blockers), Pallor, Diaphoretic, Cold and Clammy peripheries, Thready pulse, End Organ Dysfunction i.e. AMS, Oliguria
2) Cardiac features like Murmurs, S3 and those of LVF (pulmonary oedema): Dyspnea, Wheezing, Crackles, RVF: JV distension. Also, features of cardiac tamponade

Question 4

What is Beck’s Triad?

Answer 4

JV distension, Pulsus paradoxus, Muffled/distant heart sounds

Question 5

Management of Cardiogenic Shock?

Answer 5

1) Treat Shock to prevent Ischemia
2) Treat underlying cause

1) Treat shock:
- ABC - maintain airway, intubate if required, high flow oxygen via NBM to maintain SpO2 90%, Large bore IV cannula, Intravenous fluids (monitor progress with TTE findings on IVC) * do not be aggressive in case APO
- Morphine 2-4mg to relieve pain, sedate and reduce adrenergic discharge
- if SBP

Question 6

What class of shock is Neurogenic, and what other shocks fall under this class?

Answer 6

Distributive. Anaphylactic and septic shock.

Question 7

What are the two main effects of neurogenic shock and why?

Answer 7

Hypotension and Bradycardia, caused by injury/dysfunction of the sympathethic chain and loss of sympathetic tone from the level of injury downwards. This prevents tonic and reflexive vasoconstriction or tachycardia.

Question 8

Causes of Neurogenic shock?

Answer 8

Traumatic - Medullary Brainstem injury, cervical & upper thoracic spine injury
Atraumatic- Iatrogenic e.g. regional anesthesia, hemorrhagic shock.

Question 9

Classic clinical features of Neurogenic Shock?

Answer 9

• Hypotension + Bradycardia
• Warm and Flushed skin/peripheries
• Focal Neurological deficits
• Lax anal tone, priapism, loss of bulbocavernosus reflex

Question 10

Management of Neurogenic Shock

Answer 10

ABC, Monitor, High flow O2 via NBM, IV cannula and workup
1)Fill the tank - Intravenous IV crystalloids 1-2L
2)Strengthen the tank - Vasopressors like Dopamine in mod/high dose to concurrently provide chronotropic support.
Consider atropine for chronotropy too.
3)Consult Neurosurg and Ortho

Question 11

What is the main problem in Hypovolemic Shock?

Answer 11

Inadequate volume

Question 12

Mx of Hypovolemic shock?

Answer 12

1) Aggressive fluid resuscitation 1-2L crystalloids.

2) Then, pressers like IV Dopamine 5-20mcg/kg/min or Noradrenaline 0.5-30mcg/min

Question 13

What is the problem in Hemorrhagic shock?

Answer 13

Inadequate volume and oxygen binding capacity. Thus, fluid resuscitation alone will not help.

Question 14

Management of Hemorrhagic Shock

Answer 14

ABC, Vitals, High flow O2 via NBM, Large bore IV Cannula and work up including GXM, PT/PTT, U/E/Cr.

1) Localise and stop the bleed
2) Strategies: If BP normal- avoid aggressive fluid resuscitation as this can dislodge clots and dilute clotting factors; If BP low- fluid resuscitation, 6 units GXM and transfuse with Whole blood, pRBCs, FFP, Platelets.

Little place for vasopressors or inotropes.