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 ShockShock TypeSkinWedge Pressure (PCWP) (Preload)Systemic Vascular Resistance (SVR) (Afterload)Cardiac OutputHyovolemic 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