Updated: 12/3/2021

Obstructive Shock

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  • Snapshot
    • A 35-year-old woman presents to the emergency room with shortness of breath. She reports that she has had shortness of breath on exertion for a few weeks, which has progressively worsened. She also reports some chest pain. She has a history of breast cancer and is now post-chemotherapy and radiation therapy. Her blood pressure is 83/54 mmHg, pulse is 110/min, and respirations are 24/min. On physical exam, she has jugular venous distention, delayed capillary refill, and faint peripheral pulses. Her skin is cold and clammy. (Constrictive pericarditis)
  • Introduction
    • Clinical definition
      • shock secondary to extra-cardiac causes of pump failure
  • Etiology
    • Pulmonary vascular
      • associated with right ventricular failure
      • pulmonary embolism
      • severe pulmonary hypertension
    • Mechanical
      • tension pneumothorax
      • pericardial tamponade
      • constrictive pericarditis
      • restrictive cardiomyopathy
    • Pathogenesis
      • general concept
        • an underlying extra-cardiac event or process causes a cardiac outflow obstruction, resulting in ↓ cardiac output (CO)
        • ↓ CO results in compensatory ↑ systemic vascular resistance (SVR)
      • pulmonary vascular causes
        • ↑ pulmonary vascular resistance > right ventricular pressure
      • mechanical causes
        • ↓ preload and inadequate right ventricular filling
          • often presents like hypovolemic shock
  • Presentation
    • Symptoms
      • typically present with features of the underlying cause (e.g., pleuritic chest pain in pulmonary embolism)
    • Physical exam
      • hypotension
      • tachycardia
      • jugular venous distention
      • cold and clammy skin
  • Imaging
    • Echocardiography
      • indications
        • to detect underlying causes, such as pericardial tamponade
  • Studies
    • Pulmonary artery catheterization
      • findings
        • ↓ pulmonary capillary wedge pressure (PCWP < 15 mmHg) in most cases
        • ↑ PCWP in cardiac tamponade
        • normal or ↓ CO as severity progresses
        • ↑ SVR
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Differential
    • Different Types of Shock
      Shock TypeSkin

      Wedge Pressure (PCWP) (Preload)

      Systemic Vascular Resistance (SVR) (Afterload)
      Cardiac Output
      Hyovolemic Cold and clammy skin ↓↓
      Cardiogenic
      Obstructive ↑ or ↓ ↔ or ↓
      Distributive Warm or dry skin ↔ or ↓ ↓↓ ↓ or ↑
  • Treatment
    • Management approach
      • treat underlying cause
  • Complications
    • Death
    • Acute renal failure
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