EM in 5: Shock

Author: Anna Pickens, MD (@AnnaEMin5, Creator of EM in 5) // Edited by: Alex Koyfman, MD (@EMHighAK), Brit Long, MD (@long_brit), and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s edition of EMin5 by Dr. Anna Pickens. Today we are focusing on the 4 types of shock.


Video:

To better understand and manage patients in shock, we can think about splitting them into 4 categories: Hypovolemic, Cardiogenic, Distributive, Obstructive.

 

Let’s go through each type…

Hypovolemic:

This is an issue with low circulating volume and includes patients who have been bleeding, vomiting, having diarrhea, or are generally volume down.

 

Cardiogenic:

This is a problem with poor cardiac pump function, and can be caused by a number of different things including acute MI, valve failure, arrhythmias, cardiomyopathy, and pericarditis/myocarditis.

 

Distributive:

This is the one that we probably think about most commonly, and includes a wide range of categories.  But they all share something in common, and therefore are managed in a similar fashion – they all have a problem with severe peripheral vascular vasodilation.  Examples include sepsis, anaphylaxis, neurogenic shock, and various drugs and toxins. 

 

Obstructive:

 

In this type of shock, there is no problem with the peripheral vasculature or the heart – it’s a problem with something obstructing the flow of blood.  For example, a PE, tamponade, or a pneumothorax.  

 

Here’s a summary of how these 4 types of shock affect the circulatory system:

 

Once we have decided what type of shock we are dealing with in our patient, we can start to think about how to treat it.

  • Hypovolemic shock needs fluids or blood transfusions.
  • Cardiogenic shock can be very difficult to manage, but to give a general summary, you usually need to treat with a delicate balance of fluids (go slow!), norepinephrine (vasoconstriction) and dobutamine (inotrope).
  • Distributive shock treatment needs to target the peripheral vasculature, so pressors it is!
  • Obstructive shock needs a specific problem fixed. If your patient has a pneumothorax or tamponade, it needs a needle.  If your patient has a PE, consider heparin, thrombolytics or thrombectomy.  In each of these cases, you can usually start with some fluids (preload dependent) to stabilize the blood pressure while you take your definitive actions.

 

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