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Shock

In medicine, shock (hypoperfusion) is a life-threatening medical emergency characterized by inability of the circulatory system to supply enough oxygen to meet tissue requirements. Hypotension is usually, though not always, present. Without prompt medical treatment, shock usually causes death. more...

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Types of shock

  • Hypovolemic shock. The single most common cause of shock is blood volume loss, resulting from a serious wound or a severe burn leading to hypovolemic shock. This may also be referred to as haemmorhagic shock.
  • Cardiogenic shock is caused by the failure of the heart to pump effectively. This can be due to damage to the heart muscle, most often from a large myocardial infarction. Other causes of cardiogenic shock include arrhythmias, or cardiac valve problems.
  • Distributive shock. As in hypovolemic shock there is an insufficient volume of blood. This form of relative hypovolaemia is the result of dilation of bloodvessels. Examples of this form of shock are:
    • Septic shock is caused by overwhelming infection leading to vasodilation. It is treated by antibiotics, fluid replacement, and vasoconstrictors.
    • Acute adrenal insufficiency is not infrequently the result of discontinuing corticosteroid treatment without tapering the dosage.
    • Less commonly severe anaphylactic reactions may cause anaphylactic shock as allergens trigger widespread vasodilation and movement of fluid out of the blood into the tissues.
    • The rarest cause of shock is acute spinal cord injury leading to neurogenic shock. Neurogenic shock is caused by the sudden loss of the sympathetic nervous system signals to the smooth muscle in vessel walls. Without this constant stimulation the vessels relax resulting in a sudden decrease in peripheral vascular resistance and decreased blood pressure.
  • Obstructive shock. Hereby the flow of blood is obstructed. Several conditions result in this form of shock.
    • Cardiac tamponade, in which blood in the pericardium prevents inflow of blood into the heart (venous return). Or constrictive pericarditis which has the same effect.
    • Tension pneumothorax. Through increased intrathoracic pressure bloodflow to the heart is prevented (venous return).
    • Massive pulmonary embolism is the result of a thromboembolic incident in bloodvessels of the lungs and hinders the return of blood to the heart.

Symptoms and signs

The external signs and symptoms of shock are:

  • feeling of thickness, weakness, thirst;
  • pallor, especially visible at the inner side of the lips when the casualty has a dark skin;
  • rapid pulse (tachycardia, more than 120 beats per minute), the radial pulse is difficult to feel;
  • when pressing a finger nail, it takes more than two seconds for the color to come back;
  • confusion or anxiety;

Other signs can be evaluated:

  • decreased urine production
  • low blood pressure.

Patients with hypovolaemic or cardiogenic shock will have cold and clammy hands and feet. Septic, anaphylactic and neurogenic shock may present with warm extremities.

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Clinical impact of early goal-directed echocardiography in shock patients performed by noncardiologist intensivists
From CHEST, 10/1/05 by Anthony Manasia

PURPOSE: Circulatory shock is life-threatening requiring immediate therapeutic intervention. Real time assessment of cardiac function and volume provides information to guide fluid and vasopressor therapy. Early bedside transthoracic or transesophageal echocardiography performed by non-cardiologist intensivists has the potential to improve the management of patients with acute hemodynamic instability. * The purpose of this study is to determine the clinical impact of limited, goal-directed bedside echocardiography performed by non-cardiologist intensivists in ICU patients in shock.

METHODS: Eighteen (n=18) patients in shock admitted to the surgical and neurosurgical ICUs were enrolled after informed written consent was obtained. Shock was defined as hypotension (MAP<65 mmHg, or SBP<90 mmHg) or need of vasopressor therapy, associated with either hyperlactatemia, oliguria/anuria or an increase in serum creatinine. A treatment plan was instituted by the ICU team. Each patient then underwent a limited echocardiographic exam (transthoracic or transesophageal), to assess left ventricular function and to estimate cardiovascular volume status (preload). The echocardiographic exam was performed by an echo-trained intensivist not involved in the patient's care. A second echo exam was performed 24 hours later. Changes in medical management were recorded following each echo. Data were analyzed and presented in proportions using descriptive statistics.

RESULTS: The first echo changed the treatment plan in 38.8% (7/18) of the patients when compared to the initial management instituted by the primary ICU team. The treatment plan was changed in 11.7% (2/17) of patients following the second echo exam. The mean time from enrolling patients into the study to performing the first echo was 5.1 [+ or -] 4.1 hours.

CONCLUSION: In evaluating patients in shock, an early limited, goal-directed echocardiographic exam performed by trained intensivists, provides new information and significantly changes medical management.

CLINICAL IMPLICATIONS: The performance of an early, limited, goal-directed echocardiographic exam by non-cardiologist intensivists, has the potential to improve the hemodynamic management of patients in shock. * J Cardiothoracic Vasc Anesth 12 (1) 10-15, 1998.

DISCLOSURE: Anthony Manasia, None.

Anthony Manasia MD * Dragos Cucu MD John Oropello MD Rosanna DelGiudice RN Jerry Hufanda RN Ernest Benjamin MD Mount Sinai School of Medicine, New York, NY

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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