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Shock

Specialties > Child health

Differential Diagnosis Schema 🧠

Hypovolemic Shock

  • Hemorrhagic shock: Caused by acute blood loss, e.g., trauma, gastrointestinal bleeding, ruptured aneurysm.
  • Non-hemorrhagic shock: Due to loss of fluids through vomiting, diarrhea, burns, or third-spacing.
  • Dehydration: Prolonged inadequate fluid intake leading to hypovolemic shock.

Cardiogenic Shock

  • Myocardial infarction: Severe reduction in cardiac output due to significant myocardial damage.
  • Cardiomyopathy: Deterioration in heart muscle function leading to poor cardiac output.
  • Arrhythmias: Tachyarrhythmias or bradyarrhythmias causing inadequate cardiac output.
  • Valve dysfunction: Acute valvular disorders, such as mitral regurgitation or aortic stenosis.
  • Cardiac tamponade: Fluid accumulation in the pericardium compresses the heart, reducing output.
  • Pulmonary embolism: Obstruction of pulmonary arteries leading to right heart failure.
  • Acute myocardial rupture: Catastrophic complication of myocardial infarction or trauma.

Distributive Shock

  • Septic shock: Systemic infection causing widespread vasodilation and capillary leakage.
  • Anaphylactic shock: Severe allergic reaction causing vasodilation and fluid extravasation.
  • Neurogenic shock: Loss of sympathetic tone following spinal cord injury, leading to vasodilation.
  • Toxic shock syndrome: Toxin-mediated shock, often from bacterial toxins.
  • Addisonian crisis: Acute adrenal insufficiency causing hypotension and shock.
  • Drug-induced: Overdose or adverse reactions to drugs leading to vasodilation.
  • Systemic inflammatory response syndrome (SIRS): Can progress to distributive shock in severe cases.

Obstructive Shock

  • Pulmonary embolism: Massive PE can obstruct blood flow, leading to obstructive shock.
  • Tension pneumothorax: Accumulated air in the pleural space compresses the heart and great vessels.
  • Cardiac tamponade: Pressure from fluid in the pericardium restricts cardiac filling.
  • Constrictive pericarditis: Chronic pericardial inflammation leading to impaired ventricular filling.
  • Aortic dissection: Blood entering the aortic wall causes reduced blood flow to vital organs.
  • Intrathoracic mass: Tumors or other masses can compress the heart or great vessels, leading to shock.
  • Air embolism: Air entering the circulation can obstruct blood flow, leading to shock.
  • Abdominal compartment syndrome: Increased intra-abdominal pressure can reduce venous return and cardiac output.
  • Superior vena cava syndrome: Obstruction of the superior vena cava leading to impaired venous return and shock.

Key Points in History 🥼

History of Presenting Complaint

  • Onset: Determine if the shock symptoms (e.g., hypotension, tachycardia) started suddenly or gradually.
  • Recent illness or injury: Inquire about recent infections, surgeries, trauma, or known cardiac issues.
  • Symptoms: Explore symptoms such as chest pain, shortness of breath, fever, or abdominal pain that may point to the underlying cause.
  • Fluid loss: Investigate signs of fluid loss, including vomiting, diarrhea, or bleeding.
  • Medication use: Review current and recent medications that could affect hemodynamics (e.g., anticoagulants, antihypertensives).
  • Allergies: Determine if there has been any exposure to allergens, which could suggest anaphylaxis.
  • Social history: Consider alcohol and drug use, particularly substances that could depress cardiovascular function.
  • Past medical history: Review for any history of cardiovascular, pulmonary, endocrine, or renal disease.
  • Travel history: Inquire about recent travel, which may suggest exposure to pathogens or other environmental factors contributing to shock.
  • Trauma history: Investigate any recent or past trauma that could contribute to hypovolemic or obstructive shock.
  • Recent surgery or procedures: Consider the possibility of post-operative complications, including hemorrhage or infection.
  • Family history: Explore any family history of genetic disorders, particularly those affecting cardiovascular function.
  • Environmental exposure: Investigate potential exposure to toxins, chemicals, or extreme temperatures that could precipitate shock.

Background

  • Medical history: Review chronic conditions such as heart disease, diabetes, renal impairment, or chronic lung disease.
  • Surgical history: Consider any previous surgeries, especially cardiac or abdominal procedures.
  • Medication history: Assess long-term use of medications that could impact cardiovascular function or contribute to shock.
  • Substance use: Review for use of alcohol, recreational drugs, or over-the-counter medications that may exacerbate or mimic shock.
  • Family history: Consider genetic predispositions to conditions like cardiomyopathy or aortic aneurysms.
  • Social history: Explore factors such as diet, exercise, and stress levels that could influence overall cardiovascular health.
  • Psychosocial factors: Assess the impact of stress, anxiety, or depression on the patient’s cardiovascular status.
  • Environmental exposure: Consider exposure to extreme environments, including high altitude, that may predispose to shock.
  • Occupational history: Investigate if the patient’s work involves exposure to physical or chemical hazards that could precipitate shock.
  • Vaccination status: Particularly important in patients with possible infectious causes of shock (e.g., sepsis).
  • Recent infections: Inquire about recent or ongoing infections that could lead to septic shock.
  • Allergies: Document any known allergies, particularly if anaphylaxis is a concern.
  • Nutritional status: Poor nutrition, especially in older adults or those with chronic illness, can contribute to shock.
  • Travel history: Consider the possibility of tropical or travel-related infections contributing to shock.

Possible Investigations 🌡️

Initial Investigations

  • Full blood count (FBC): To identify anemia, infection, or other hematological abnormalities.
  • Urea and electrolytes (U&E): To assess renal function, electrolyte imbalances, and acid-base status.
  • Blood gases: Arterial blood gases (ABG) to assess oxygenation, ventilation, and acid-base balance.
  • Liver function tests (LFTs): To identify liver dysfunction, which may occur in shock or as a result of underlying disease.
  • Blood cultures: Essential in suspected septic shock to identify causative organisms.
  • Lactate: Elevated lactate levels are indicative of tissue hypoperfusion and are used to assess the severity of shock.
  • Coagulation screen: To identify coagulopathy, which can occur in septic shock or disseminated intravascular coagulation (DIC).
  • Troponins: Elevated in cardiogenic shock due to myocardial infarction or strain.
  • Chest X-ray: To assess for pulmonary edema, pneumothorax, or other thoracic causes of shock.
  • ECG: To identify arrhythmias, ischemic changes, or other cardiac causes of shock.
  • Echocardiogram: To assess cardiac function, valvular abnormalities, or the presence of tamponade or other structural abnormalities.
  • CT scan: Consider if there is suspicion of pulmonary embolism, aortic dissection, or intra-abdominal pathology.
  • Ultrasound (FAST scan): To rapidly assess for free fluid in the abdomen or pericardial effusion in trauma settings.
  • D-dimer: Useful in the assessment of suspected pulmonary embolism or disseminated intravascular coagulation.
  • Urinalysis: To identify renal dysfunction or infection contributing to shock.
  • Toxicology screen: Consider if there is a suspicion of drug overdose or poisoning contributing to the shock state.
  • Cortisol levels: May be indicated in cases of suspected adrenal insufficiency (Addisonian crisis).
  • Microbiological cultures: For identification of the source of infection in septic shock (e.g., urine, sputum, wound swabs).
  • Blood glucose: Hyperglycemia or hypoglycemia can exacerbate shock and needs to be corrected promptly.
  • TTE/TOE: Transthoracic or transesophageal echocardiography can help identify cardiac causes of shock in more detail.
  • Serum osmolality: Can be useful in assessing cases of shock related to dehydration or hyperosmolar states.
  • Arterial line: Continuous blood pressure monitoring and frequent blood sampling in critically ill patients.
  • Central venous catheterization: To assess central venous pressure and guide fluid resuscitation in shock.

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