Shock

Cardiogenic & Obstructive

105001041 黃昱睿、 105001160 簡新語
Definition of shock
• A state of cellular and tissue hypoxia due to reduced oxygen
delivery and/or increased oxygen consumption or inadequate
oxygen utilization.
Cellular hypoxia
• 1.Cell membrane ion pump dysfunction
• 2.Intracellular edema
• 3.Leakage of intracellular contents into the extracellular space
• 4.Inadequate regulation of intracellular pH

膜的破壞，代謝的停止造成後續細胞結構的損傷無法修復，細胞內
部的積液和酸鹼讓情況更加嚴重，細胞死亡。
Feature of shock 常見休克特徵
• Features that are highly suspicious of shock include:
Hypotension 低血壓
Tachycardia 心率過快
Oliguria 寡尿
Abnormal mental status 精神狀況異常
Tachypnea 呼吸急促
Cool, clammy, cyanotic skin 皮膚冰冷、病態、發紺
Metabolic acidosis 代謝性酸中毒
Hyperlactatemia 高乳酸鹽血症

Most clinical features are neither sensitive nor specific for the diagnosis of
shock.
 • compensatory responses to diminished tissue perfusion
• Tachycardia
• peripheral vasoconstriction
Pre-shock • Asymptomatic, normal blood pressure(total effective arterial blood volume↓)
• reversible

• compensatory mechanisms become overwhelmed

Shock • signs and symptoms of organ dysfunction
• tachycardia, dyspnea, restlessness…

• irreversible organ damage

End-organ • multiorgan failure (MOF)
dysfunction • Death
• irreversible
Need to do
• Shock is a life-threatening condition of circulatory failure. The
effects of shock are initially reversible, but rapidly become
irreversible, resulting in multiorgan failure (MOF) and death.

• It is important that the clinician immediately initiate therapy

while rapidly identifying the etiology so that definitive therapy
can be administered to reverse shock and prevent MOF and
death.
Category of shock
• Distributive—characterized by severe peripheral vasodilatation
• Cardiogenic—intracardiac causes of cardiac pump failure
• Hypovolemic—reduced intravascular volume
• Obstructive—due to extracardiac causes of cardiac pump
failure

• many patients with circulatory failure have a combination of

more than one form of shock
Obstructive shock
阻塞性休克
Etiology
• Obstructive shock is mostly due to extracardiac causes of
cardiac pump failure and often associated with poor right
ventricle output. The causes of obstructive shock can be divided
into the following two categories (pulmonary vascular and
mechanical)

• 阻塞性休克主要是心臟以外的器官或組織造成血液循環障礙
• Pulmonary vascular: 肺部阻塞造成血流困難
• Mechanical: 心肌、心包、氣胸等症狀讓前負荷下降所形成的循環
阻塞
1. pulmonary vascular
• Most cases of obstructive shock are due to right ventricular
failure from hemodynamically significant pulmonary embolism
(PE) or severe pulmonary hypertension (PH)
• Patients with severe stenosis or with acute obstruction of the
pulmonary or tricuspid valve may also fall into this category.
肺循環的狹窄 / 阻塞、三尖瓣構造病症所導致的衰竭
2. mechanical
• Patients in this category present clinically as hypovolemic shock because
their primary physiological disturbance is decreased preload, rather than
pump failure.

(1)Tension pneumothorax 氣胸
(2)Pericardial tamponade 心包填塞
(3)Constrictive pericarditis 充血性心肌炎
(4)Restrictive cardiomyopathy 限制型心肌症

通常是組合性的發生，同時具有 pulmonary vascular 和 mechanical 的機制

Feature & primary diagnose

Pneumothorax

Pleuritic chest pain

Dyspnea

Pulmonary embolism

Loud P2
shock Elevated JVD
Right parasternal Pulmonary hypertension
heave

Quiet heart sound

Pericardial temponade
Elevated JVD
常見理學特徵 :
• 1.Pcwp( 肺泡微血管嵌塞壓 )= 左心房壓 : normal or reduced
• 2.CO: normal or reduced
• 3.SVR(systemic vascular resistance): increased
• 4.SV: <65%
Diagnostic evaluation

• Chest radiography
• CT
• MRI
Cardiogenic shock(CS)
心因性休克
Etiology of Cardiogenic shock
intracardiac cause
Cardiomyopathic 肌肉性 Arrhythmic 心律性 Mechanical 機械性
• MI • Tachyarrhythmia • AR
• Severe RV infarction
• Bradyarrhythmia • MR
• AHF from DCM
• stunned myocardium • severe VSD
心肌震顫 • myxoma
• myocarditis

cardiac pump failure(LV/RV dysfunction)

CO↓(hypoperfusion)
Clincial manifestion of CS
• hypotension
• systolic blood pressure <80~90 mmHg
• mean arterial pressure 30 mmHg lower than baseline
• cardiac index↓
• <1.8 L · min−1 · m−2 without support
• <2.0~2.2 L · min−1 · m−2 with support
• 代償作用： systemic vascular resistance (SVR)↑ (>1400 dynes
per second/cm5)→afterload↑
Clincial manifestion of CS
• filling pressure↑
• LVEDP>18 mmHg
• pulmonary congestion
→ PCWP↑ (>15 mmHg) →preload↑
→ hypoxemia 低氧血症→ mixed venous oxygen saturation(SvO2)↓ (<70 percent)
• RVEDP>10~15 mmHg
• systemic venous congestion→ central venous pressure(CVP)↑ (>12 mmHg)
• manifestations of pulmonary edema
• diffuse lung crackles(abnormal lung sounds)
• CVP↑→distended neck veins(JVD)
Cardiomyopathic CS
 PCWP↑

SVR↑
Pathophysiology-MI
• most common cause of CS
• myocardial muscle dysfunction
→LV/RV 無法輸出足夠的血液→ LVEF ≈30%
→ Hypotension/tissue hypoperfusion
pulmonary congestion→PCWP↑
systemic venous congestion→CVP↑
• 代償作用： SVR↑
Clincial manifestion-MI
• 症狀
• anterior crushing chest pain 沉重、壓迫痛
• respiratory distress 呼吸窘迫
• ECG: ST elevation
• 血液檢查 : troponin/creatine phosphokinase↑
• CXR: pulmonary edema
Arrhythmic CS
Etiology of arrhythmic CS

Tachyarrhythmia Bradyarrhythmia
• Atrial tachycardias • Complete heart block
• Fibrillation • Mobitz type II second degree
• Flutter heart block
• reentrant tachycardia
• ventricular tachycardia and
fibrillation
Pathophysiology & Clincial manifestion-
arrthymia
• significant rhythm disturbances→CO↓→Hypotension
• underlying rhythm→CO absent→cardiac arrest 心搏停止

• sudden in onset with palpitations 心悸 or syncope 昏厥

• ECG
Mechanical CS
Etiology of mechanical CS

valvular defect septum others

• AR • VSD • atrial myxoma
• Aortic dissection • rupture of IVS • ruptured
• MR ventricular
• rupture of aneurysm
papillary
muscle/chordae
tendineae
Pathophysiology-acute AR
• forward stroke volume↓→CO↓→shock, hypotension
• LVEDP↑→MV 提早關閉→ diastolic filling time↓→forward stroke
volume↓
• LVEDP↑→pulmonary edema
Clincial manifestion-AR
• 症狀
• chest pain
• Hypotension
• low-pitched early diastolic murmur
• POC Ultrasonography/Echocardiography
• aortic dissection
• tearing chest or back pain
• CT
• TEE
• MRI
Pathophysiology-others
• Myxoma
• complete obstruction of the mitral valve orifice→shock
• ruptured ventricular aneurysm
• reduced output from the left ventricle
• obstructive shock
reference
• UpToDate
• Definition, classification, etiology, and pathophysiology of shock in
adults
• Evaluation of and initial approach to the adult patient with
undifferentiated hypotension and shock
• Harmony R. Reynolds and Judith S. Hochman Cardiogenic
Shock: Current Concepts and Improving Outcomes
Circulation. 008;117:686–697 連結