Circulatory Failure - Shock
Case Presentation
56 year old man with a past history of type
2 diabetes and hypertension. Presented
to the ER with a 12 hour history of
epigastric pain, nausea and vomiting. He
had recently eaten some fish at a
questionable restaurant downtown.
His vitals at the triage desk are 96/52,
heart rate 119, respiratory rate 18,
temperate 38.6 C and saturation 91%
What is the differential diagnosis for his
presentation?
Is this man in shock?
– What is the definition of shock?
– What further information do you need to
determine that he is in shock?
After being taken to an examination room,
the patient complains of being lightheaded and that the fire truck in the room
is taking up too much space. On
examination, he is in moderate respiratory
distress, clammy, with tenderness in the
epigastric area to palpation, scattered
crackles in both bases and a faint S3.
Lactate 5.9 on the first blood gas.
What are the four main types of shock?
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Hypovolemic
Cardiogenic
Distributive
Obstructive
What is the differential diagnosis for each type of
shock?
Describe the characteristic findings in preload,
afterload, cardiac output and tissue perfusion for
each type of shock.
What would be your initial approach to this
patient?
Over the course of the next 30 minutes, the
patient’s level of consciousness continues to
decline and his shortness of breath worsens.
On examination, the crackles are higher up the
chest and his oxygen saturations are 90% on
flush oxygen.
ECG demonstrates inferior wall ST segment
elevation myocardial infarction.
Describe the physiology and outline the
management of shock due to:
– Left ventricular failure
– Anaphylaxis
– Hemorrhage
– Sepsis
– Massive pulmonary embolism
– Tension pneumothorax
The patient is taken urgently to the
angiography suite and undergoes PTCA of
the right coronary artery. After the
procedure, he remains hypotensive,
lactating, and obtunded. He is started on
a norepinephrine and dobutamine infusion
while awaiting a balloon pump.
What is the main mechanism of action and use
for the following vasopressors/inotropes:
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–
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Norepinephrine
Vasopressin
Phenylephrine
Ephedrine
Epinephrine
Dobutamine
What is the difference between a vasopressor
and an inotrope?
Questions?