OBSTRUCTIVE SHOCK

• Obstructive shock is also characterized by a reduction in oxygen

delivery related to reduced CO, but in this case the etiology of the
reduced CO is an extracardiac processes impairing blood flow.
Processes that can impede venous return to the heart and reduce CO
include tension pneumothorax (PTX), cardiac tamponade, and
restrictive pericarditis. Similarly processes that obstruct cardiac
outflow, such as pulmonary embolism (right heart) or aortic dissection
(left heart), are included in this shock type category.

Harrisons Principles of Internal Medicine

 • Tension pneumothorax is a clinical not radiographic diag-nosis
characterized by unilateral decreased breath sounds, unilateral chest
hyperresonance, and tracheal deviation in the setting of respiratory
distress and shock. Treatment is immediate needle decompression
followed by chest tube thoracostomy placement.
• Pericardial tamponade likewise should be considered early in the
evaluation of undifferentiated shock. Patients with blunt or penetrating
chest trauma can rapidly de-compensate with minimal bleeding into the
pericardium, while those with uremia and cancer usually develop an
effusion over time. Symptoms include hypotension, elevated right side
pressures (JVD) pulsus paradoxus (a fall in systolic blood pressure in
inspiration), and Kussmaul’s sign (increased jugular venous pressure on
inspiration). Bedside U/S is extremely sensitive in detecting pericardial
fluid and can be instrumental in guiding pericardiocentesis, although in
the patient in extremis, blind pericardiocentesis might be lifesaving
CURRENT Lange Diagnosis & Treatment Emergency
Medicine
 • Massive PE presents as chest pain, syncope, tachypnea, and
hypotension with signs of acute right ventricular overload with JVD
and ECG changes. Fluid administration might worsen right ventricular
failure and should be given only cautiously. Blood pressure should be
augmented with an appropriate vasopressor such as norepinephrine
0.5–1 μg/min titrated to response. Immediate surgical embolectomy
is sometimes effective but not usually feasible. Shock complicating PE
is an indication for thrombolytics if no other contraindication exists.

CURRENT Lange Diagnosis & Treatment Emergency

Medicine
 Treatment Obstructive Shock
• Cardiac Tamponade
Administer 1-2 L of normal saline followed by emergent bedside pericardiocentesis.
Perform an emergency department thoracotomy in patients with penetrating thoracic
trauma who fail to respond.
• Pulmonary Embolism
Administer small boluses of normal saline (250-500 mL) followed by vasopressor
support in unstable patients. Fibrinolysis is the treatment of choice for massive PE
presenting with profound hypotension (MAP <60), severe refractive hypoxemia (Sp02
<90 despite supplemental 02), or cardiac arrest.
• Tension Pneumothorax
Administer 1-2 L of normal saline while performing emergent needle thoracostomy
followed by chest tube placement.
Lange Clinical Emergency Medicine