Approach To Undifferentiated Circulatory Shock

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In addition to a focused assessment of the ABC’s during resuscitation,
special attention should be paid to “the pump,” “the tank,” and “the All About Epilepsy and
pipes” to provide a systematic approach to the hypotensive patient. Seizures: From Diagnosis to
Treatment
Early recognition of the etiology of hypotension and timely intervention can (https://manualofmedicine.com
prevent significant morbidity and mortality, as untreated shock is almost /topics/neurology/all-about-
always a fatal diagnosis. epilepsy-seizures-diagnosis-

treatment/)
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Definition of Shock electrolytes/)
Shock is broadly defined as an imbalance in tissue oxygen demand Cardiology

and tissue oxygen supply. This imbalance results in cellular injury with
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toxic increases in intracellular calcium, anaerobic respiration, lactate
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Causes, Classification and Clinical Features of Shock
Hypovolemic shock may be due to hemorrhage in the setting of trauma or

due to fluid losses from severe vomiting or diarrhea.
Cardiogenic shock results from decreased cardiac output due to an
intrinsic heart defect, often from myocardial infarction, valvular rupture, or
congestive heart failure.
Obstructive shock results from a physical obstruction that reduces
cardiac output, and may occur due to cardiac tamponade, massive
pulmonary embolism, or tension pneumothorax.
Distributive shock is most commonly due to sepsis
(https://manualofmedicine.com/topics/emergency-acute-medicine/sepsis-
algorithm-differential-diagnosis/) and overwhelming infection, though it may
also be caused by anaphylaxis or neurogenic shock in spinal cord injury.
The early identification of the type of shock can often be elicited through
patient history, physical exam, laboratory investigations, ECG findings,
chest x-ray, and bedside ultrasound.
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Shock Resuscitation
The initial step in the resuscitation of the patient in undifferentiated shock

includes obtaining peripheral venous access and ensuring adequate
ventilation and oxygenation. This may involve endotracheal intubation, as
the failure of mask ventilation or positive pressure ventilation in the
hypotensive patient may result in respiratory failure and circulatory
collapse.
A trial bolus of crystalloid solution should be considered, as even those

patients in acute cardiogenic shock may be intravascularly depleted.
Careful monitoring of clinical response to fluid should be maintained, as

pulmonary edema can be an unintended consequence of fluid
administration.
“The Pump” (The Heart)
An early focus on “the pump” helps discriminate between the four broad
classifications of shock and decreases time to lifesaving interventions.
An ECG should be performed early to assess for STEMI as a cause of

cardiogenic shock that necessitates immediate percutaneous coronary
intervention (PCI). ECG may also demonstrate right heart strain suggesting
massive pulmonary embolism or electrical alternans suggesting cardiac
tamponade.
Bedside cardiac ultrasound quickly demonstrates the presence of

pericardial effusion and provides an assessment of cardiac contractility.
The presence of a large pericardial effusion with right ventricular collapse
suggests cardiac tamponade causing obstructive shock, and immediate
pericardiocentesis is indicated to aid diastolic filling.
An acutely dilated right ventricle may suggest massive pulmonary

embolism causing right heart strain and obstructive shock.
A hyperdynamic heart with normal or high contractility suggests distributive

or hypovolemic shock.
A hypodynamic heart with decreased contractility and dilated cardiac

chambers suggests cardiogenic shock.
“The Tank” (intravascular volume)
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Following evaluation of “the pump,” an assessment of “the tank” helps

determine intravascular volume status and fluid responsiveness.
Physical exam findings may provide clues as to whether “the tank” is

empty or full. Elevated jugular venous pressure, bilateral rales on lung
auscultation, or lower extremity edema suggest fluid overload but may not
be entirely representative of intravascular volume. A passive leg raise may
be performed to temporarily increase venous return and determine fluid
responsiveness.
Bedside ultrasound provides valuable clues regarding a patient’s

intravascular status. An inferior vena cava width < 2 cm, as measured 2 to
3 cm distal from the right atrial junction, with inspiratory collapse of >50%
suggests the patient is intravascularly depleted and may benefit from
intravenous fluids. This finding is also suggestive of hypovolemic or
distributive shock. As a caveat, IVC evaluation must be performed prior to
intubation as positive pressure ventilation makes IVC assessment
unreliable.
Further evaluation of “the tank” for intraperitoneal free fluid and pleural fluid
may suggest hemorrhage as a cause of hypovolemic shock.
Ultrasound may be used to reassess intravascular status after fluid

resuscitation. Vasopressors may be necessary should a patient continue to
be hypotensive despite adequate fluid repletion.
“The Pipes” (vessels)
Finally, evaluation of “the pipes” should be considered in the patient with

undifferentiated shock.
Physical exam may reveal a pulsatile abdominal mass suggestive of aortic
aneurysm, though this finding is not sensitive.
Bedside ultrasound may be used to evaluate the abdominal aorta for
aneurysm or dissection, and in the setting of hypotension a ruptured AAA
must be considered.
Ultrasound of “the pipes” of the lower extremities may be performed to
assess for deep vein thrombosis, which may suggest massive pulmonary
embolism and obstructive shock.
Key Points
Remember the four classifications of shock: hypovolemic, distributive,

cardiogenic, and obstructive.
Use a systematic approach to “the pump,” “the tank,” and “the pipes” to
determine classification of shock.
Integrate the use of bedside ultrasound into resuscitation of patients with
undifferentiated shock to help make the diagnosis and guide interventions.
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Circulatory Shock Recent Posts

Stroke and TIA: From

always a fatal diagnosis. epilepsy-seizures-diagnosis-

Shock is broadly defined as an imbalance in tissue oxygen demand Cardiology

Emergency and Acute

Hematology and Oncology

Types of Shock Nephrology and Urology

Earn CME Neurology

The four broad classifications of shock are: /)

(https://manualofmedicine.com/circulatory-shock-differential-diagnosis/) Spot Diagnosis – Case

Causes, Classification and Clinical Features of Shock

Hypovolemic shock may be due to hemorrhage in the setting of trauma or

The initial step in the resuscitation of the patient in undifferentiated shock

A trial bolus of crystalloid solution should be considered, as even those

Careful monitoring of clinical response to fluid should be maintained, as

“The Pump” (The Heart)

An ECG should be performed early to assess for STEMI as a cause of

Bedside cardiac ultrasound quickly demonstrates the presence of

An acutely dilated right ventricle may suggest massive pulmonary

A hyperdynamic heart with normal or high contractility suggests distributive

A hypodynamic heart with decreased contractility and dilated cardiac

“The Tank” (intravascular volume)

Following evaluation of “the pump,” an assessment of “the tank” helps

Physical exam findings may provide clues as to whether “the tank” is

Bedside ultrasound provides valuable clues regarding a patient’s

Ultrasound may be used to reassess intravascular status after fluid

“The Pipes” (vessels)

Finally, evaluation of “the pipes” should be considered in the patient with

Remember the four classifications of shock: hypovolemic, distributive,

Non-Cardiac Causes of Chest Shock Algorithm

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