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What Type of Shock is This?

68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back. The pt is hypotensive, tachycardic, afebrile, with cool but dry skin. Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic Obstructive.

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What Type of Shock is This?

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  1. 68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back. The pt is hypotensive, tachycardic, afebrile, with cool but dry skin Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic Obstructive What Type of Shock is This? Hypovolemic Shock

  2. Hypovolemic Shock • ABCs • Establish 2 large bore IVs or a central line • Crystalloids • Normal Saline or Lactate Ringers • Up to 3 liters • PRBCs • O negative or cross matched • Control, if any bleeding • Arrange definitive treatment

  3. An 81 yo F resident of a nursing home presents to the ED with altered mental status. She is febrile to 39.40C, hypotensive with a widened pulse pressure, tachycardia, with warm extremities Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic Obstructive What Type of Shock is This? Septic

  4. Sepsis • Two or more of SIRS criteria • Temp > 380C or < 360C • HR > 90 beats /min • RR > 20 /min • WBC > 12,000 or < 4,000 / mm3 • Plus the presumed existence of infection • Blood pressure can be normal!

  5. Treatment of Septic Shock • 2 large bore IVs • NS IVF bolus- 1-2 L wide open (if no contraindications) • Supplemental oxygen • Empiric antibiotics, based on suspected source, as soon as possible

  6. Persistent Hypotension • If no response after 2-3 L IVF, start a vasopressor (norepinephrine, dopamine, etc) and titrate to effect • Goal: MAP > 60 • Consider adrenal insufficiency: hydrocortisone 100 mg IV

  7. A 55 yo M with hx of HTN, DM presents with “crushing” sub sternal Chest Pain, diaphoresis, hypotension, tachycardia and cool, clammy extremities Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic Obstructive What Type of Shock is This? Cardiogenic

  8. Signs: Cool, mottled skin Tachypnea Hypotension Altered mental status Narrowed pulse pressure Rales, murmur Defined as: SBP < 90 mmHg CI < 2.2 L/m/m2 PCWP > 18 mmHg Cardiogenic Shock

  9. Ancillary Tests • ECG • Chest X-Ray • CBC, Chemistry , cardiac enzymes, coagulation studies • Echocardiogram

  10. Treatment of Cardiogenic Shock • Goals- Airway stability and improving myocardial pump function • Cardiac monitor, pulse oximetry • Supplemental oxygen, IV access • Intubation may decrease preload and result in hypotension • Be prepared to give fluid bolus

  11. A 34 yo F presents to the ER after dining at a restaurant where shortly after eating the first few bites of her meal, became anxious, diaphoretic, began wheezing, noted diffuse pruritic rash, nausea, and a sensation of her “throat closing off”. She is currently hypotensive, tachycardic and ill appearing. Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic Obstructive What Type of Shock is This? Anaphylactic

  12. Anaphylactic Shock- Diagnosis • Clinical diagnosis • Defined by airway compromise, hypotension, or involvement of cutaneous, respiratory, or GI systems • Look for exposure to drug, food, or insect • Labs have no role

  13. Anaphylactic Shock- Treatment • ABC’s • Angioedema and respiratory compromise require immediate intubation • IV line , cardiac monitor, pulse oximetry • IVFs, oxygen • Epinephrine • Second line • Corticosteriods • H1 and H2 blockers

  14. A 41 yo M presents to the ER after an RTA complaining of decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremities Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic Obstructive What Type of Shock is This? Neurogenic

  15. Neurogenic Shock- Treatment • A,B,Cs • Remember c-spine precautions • Fluid resuscitation • Keep MAP at 85-90 mm Hg • If crystalloid is insufficient use vasopressors • Search for other causes of hypotension • For bradycardia • Atropine • Pacemaker

  16. A 24 yo M presents to the ED after an RTA c/o chest pain and difficulty breathing. On Physical examination, you note the patient to be tachycardic, hypotensive, hypoxic, and with decreased breath sounds on left Types of Shock Hypovolemic Septic Cardiogenic Anaphylactic Neurogenic Obstructive What Type of Shock is This? Obstructive

  17. http://ccmtutorials.com/scenarios/Shock/index.htm A great website Dr.Kaukb used a lot of the cases from this site Check it out All the best

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