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Hypovolemia due to hemorrhage resulting in decreased preload
10%
2/20
Hypovolemia due to distributive shock and pooling of intravascular volume in capacitance vessels
5%
1/20
Impaired left ventricular filling resulting in decreased left ventricular stroke volume
80%
16/20
Increased peripheral vascular resistance, resulting in increased afterload
Acute valvular dysfunction resulting in a hyperdynamic left ventrical
0%
0/20
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This patient is presenting with Beck's triad of hypotension, distended neck veins, and muffled heart sounds, suggesting pericardial tamponade. This patient's cardiogenic shock is thus due to impaired left ventricular filling and resultant drop in left ventricular stroke volume. Cardiogenic shock is characterized by the inability of the heart to generate sufficient cardiac index to effectively perfuse tissues. Thus, any impairment in cardiac function can will result in similar physiology, whether due to innate cardiac failure (infarction, arrhythmia, or structural defect), or external compression from mediastinal or thoracic processes (tamponade, pneumothorax, hemothorax, etc.). In this patient, acute tamponade from trauma is preventing his left ventricle from filling, resulting in decreased preload and a drop in cardiac output. Cardiogenic shock will result in reflex vasoconstriction, as the vascular baroreceptors work to maintain blood pressure (answer 4), but these effects are secondary to the insult at hand. Tigle et al. review acute pericarditis. They note the importance of prompt diagnosis, and recommend the use of bedside ultrasonography as a useful first step in management. Acute pericarditis can present with chest pain, worsened by lying in repose, and EKG findings of diffuse ST segment elevations. These can usually be discerned from ACS, because the ST changes will be in no discernable vascular distribution. The ESC task force on the management of pericardial disease highlight a number of common causes of pericardial effusion and tamponade including viral pericarditis, malignancy, and trauma among others. They recommend prompt decompression either via needle pericardiocentesis or pericardial window to restore cardiac preload and function. Incorrect Answers: Answer 1: This patient has no evidence of large volume loss, and the physical exam findings are instead more consistent with cardiogenic shock due to tamponade. Answer 2: Distributive shock (as in anaphylaxis) is unlikely to explain this patient's physiology Answer 4: While this patient's peripheral vascular resistance will be increased in response to hypotension, it does not describe the primary insult. Answer 5: This patient's physical exam findings are more consistent with acute tamponade, instead of acute valvular insufficiency.
4.8
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