PROACH TO UNDIFFERENTIATED SHOCK

by Nick Mark MD ONE

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· Shock occurs when there is inadequate blood flow (CO) & oxygen delivery (DO2) to meet version →
demands. Manifestations can be protean and may not initially include hypotension (cryptic Undifferentiated SHOCK @nickmmark
Hypotension (not required) MAP DETERMINANTS:
shock). Identifying the etiology of undifferentiated shock is essential to determine treatment. Preload Contractility Afterload
Organ dysfunction (AKI, shock liver, etc)
· Shock can be broken into 4 categories: cardiogenic, obstructive, distributive, hypovolemic Altered mental status
· Multiple causes may be present (e.g. sepsis in a patient with decompensated heart failure) and Lactic acidosis SV HR
some etiologies may cause mixed shock: Low urine output
CO SVR
· Endocrine (adrenal insuf., myxedma, thyrotoxicosis) ↓CO ↓SVR ↓ Preload
· Metabolic (hypothermia severe acidosis)
PIPES PROBLEM TANK PROBLEM MAP
PUMP PROBLEM
CARDIOGE OBSTRUCTI DISTRIBUT HYPOVOLE
• RATE/RHYTHM (bradycardia, VF, • TENSION • SEPSIS (may develop low CO later) • HEMORRHAGE (trauma,
NIC VE IVE surgical, GIB) MIC
ETIOLOGY

etc) PNEUMOTHORAX • ANAPHYLAXIS

• RV FAILURE (PE, PHTN) • CARDIAC TAMPONADE • INFLAMMATORY (SIRS, • SKIN LOSSES (burns, heat stroke,
• LV FAILURE (MI, myocarditis, etc) • PULMONARY pancreatitis, post-cardiac arrest, etc)
• VALVES (wide open MR, cordae EMBOLISM amniotic or fat embolism, cytokine • GI LOSSES (diarrhea, vomiting,
tendenae rupture, etc) • OUTFLOW release syndrome) drainage)
• TOXINS (CCB, βB, BRASH syndrome, OBSTRUCTION (HOCM, • NEUROGENIC (SCI, severe TBI, • THIRD-SPACING VOLUME
etc) critical AS) effect of neuraxial anesthesia) LOSS (pancreatitis, low albumin,
• TRAUMA (myocardial contusion) • DYNAMIC • LIVER FAILURE trauma)
HYPERINFLATION ( • ENDOCRINE (adrenal • RENAL LOSSES (salt-wasting,
insufficiency, thyrotoxicosis)
EXAM & POCUS & HEMODYNAMICS

auto- PEEP) hypoaldo, osmotic diuresis, diuretics)

• MEDICATIONS (anesthesia, • LOW PO INTAKE
HD ↑CVP, ↑PCWP, ↓CO, ↑SVR ↑CVP, ↑PCWP, ↓CO, ↑SVR var CVP,) var PCWP, var CO, ↓SVR
sedation ↓CVP, ↓PCWP, ↑CO, ↑SVR
± Reduced contractility ± RV dilation Reduced contractility
(see RUSH exam for more about POCUS in Shock)

Heart ± Wall motion abnormalities RV dilation (PE) ± septal D sign (p/v overload) Hyperdynamic Hyperdynamic
± Valvulopathy Pericardial effusion, RA collapse (tamponade) (hypodynamic in late sepsis)

IVC Plethoric IVC, reversal of flow in HV Plethoric IVC, reversal of flow in HV Variable IVC Small/collapsing IVC
Lungs B-line pattern + pleural effusions Lack of lung sliding ± lung point (PTX) A line pattern A line pattern

Other Pleural effusions (LV failure) DVT or clot in transit (PE) Evidence of infxn (cholecystitis, endocarditis, Blood or fluid in abdomen (FAST), Ectopic
etc), cirrhosis, pregnancy, Aortic dissection,
Skin Usually cool, Delayed cap refill Usually cool, Delayed cap refill Warm, flushed, Brisk cap refill Usually cool, Delayed cap refill
Neck Increased JVP Increased JVP Variable Flat neck veins
Weak pulses (narrow pulse pressure) Weak pulses (narrow pulse pressure)
Other Weak pulses (narrow pulse pressure) Lung and heart sounds are unreliable Bounding pulses (wide pulse pressure) Evidence of blood (pallor) or volume loss
indicators of tamponade or PTX. (axillary dryness)

PHYSIOLOGIC RESPONSES TO SHOCK USING GUYTON CURVES: (See Guyton Curves in Shock OnePager for more) CALCULATING SVR:
SVR can be useful to understand etiology. You

v1.0 (2021-05-11) CC BY-SA 3.0

with exercise
Cardiac Output

Cardiac Output
Venous Return

Venous Return
Cardiac Output
Venous Return
Cardiac Output
Venous Return

can either measure CO invasively (e.g. PAC) or

Increased estimate using POCUS (e.g. LVOT VTI)
contractility 𝑴𝑨𝑷=𝑪𝑶×
  𝑺𝑽𝑹
initial state ( 𝑴𝑨𝑷 − 𝑪𝑽𝑷)
Venoconstriction 𝑺𝑽𝑹
  = × 𝟖𝟎
RAP RAP RAP RAP 𝑪𝑶
Normally cardiac output (CO) CARDIOGENIC/OBSTRUCTIVE DISTRIBUTIVE HYPOVOLEMIC
dyn/cm/sec-5
determined by venous return &
contractility
with low CO, RA filling pressures
rise to (partially) compensate
vasodilation decreases filling,
hyperdynamic CO compensates
with low preload, venoconstriction
increased filling pressure compensates
  Wood units