ESSENTIALS OF DIAGNOSIS
Hypotension, tachycardia, oliguria, altered mental status.
Peripheral hypoperfusion and impaired oxygen delivery.
Four classifications: hypovolemic, cardiogenic, obstructive, or distributive.
Shock occurs when the rate of arterial blood flow is inadequate to meet tissue metabolic needs. This results in regional hypoxia and subsequent lactic acidosis from anaerobic metabolism in peripheral tissues as well as eventual end-organ damage and failure.
Table 12–1 outlines common causes and mechanisms associated with each type of shock.
Table 12–1.Classification of shock by mechanism and common causes. ||Download (.pdf) Table 12–1. Classification of shock by mechanism and common causes.
Fracture (femur and pelvis)
Ectopic pregnancy rupture
Skin integrity loss (toxic epidermal necrolysis)
Hyperosmolar states (eg, hyperosmolar hyperglycemic state)
Third spacing (eg, ascites, pancreatitis)
Bradycardias and blocks
Left or right ventricular infarction
Aortic regurgitation from dissection
Papillary muscle rupture from ischemia
Acute valvular rupture from abscess
Ventricular aneurysm rupture
Ventricular septum rupture
Ventricular free wall rupture
High-risk (massive) PE
Severe pulmonary hypertension
Auto PEEP from mechanical ventilation
Distributive (vasodilatory) shock
Hypovolemic shock results from decreased intravascular volume secondary to loss of blood or fluids and electrolytes. The etiology may be suggested by the clinical setting (eg, trauma) or by signs and symptoms of blood loss (eg, GI bleeding) or dehydration (eg, vomiting or diarrhea). Compensatory vasoconstriction may transiently maintain the blood pressure but unreplaced losses of over 15% of the intravascular volume can result in hypotension and progressive tissue hypoxia.
Cardiogenic shock results from cardiac failure with the resultant inability of the heart to maintain adequate tissue perfusion. The clinical definition of cardiogenic shock is evidence of tissue hypoxia due to decreased cardiac output (cardiac index less than 2.2 L/minute/m2) in the presence of adequate intravascular volume. This is most often caused by MI but can also be due to cardiomyopathy, myocardial contusion, valvular incompetence or stenosis, or arrhythmias. See Chapter 10.
Pericardial tamponade, tension pneumothorax, and massive PE can cause an acute decrease in cardiac output resulting in shock. These are medical emergencies requiring prompt diagnosis and treatment.
Distributive or vasodilatory ...