Types of Shock | Hypovolemic, Cardiogenic, & Obstructive Shock | Part 1

when treating an 80-year-old patient who is in shock, it is important to remember that:
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iron engineers in this video were going to talk about the various types of shock now first off how would we describe shock just in general before we go into each different type of shock we can say that shock is any situation in which there is an inadequate tissue perfusion in other words theres not enough blood flow going to the tissues and because of that because theres not enough adequate tissue perfusion theres not an adequate amount of oxygen delivery to the tissues so because of that the tissues start developing a certain type of ischemia okay and ischemia if it happens over a long period of time the tissue can start becoming in the chronic in other words can die and then tissues are what make up organs so if that tissue starts becoming deprived for a long period of time organs can start failing so in general how would we generally classify shock we can say shock is any situation in which theres inadequate tissue perfusion that can result in ischemia followed by necrosis and then possibly even organ failure if not reversed also shock and progress in various stages not going to talk about that in this video but I want you to understand that shock is actually a progressive process so whenever shock comes about theres usually the actual beginning compensating stages of shock so how youre trying to compensate for this significant decrease in blood pressure the next one is it gets more progressive you start actually declining okay and then after that it goes into a really really negative point which is called the refractory component of shock where sometimes even though despite all the efforts of the care you cant restore the blood pressure and thats the deadly part thats the part that can actually lead to death if not if not reversed so again understanding that about shock is very very crucial all right so lets now go ahead and dive in to each different type of shock in general I want you guys to remember though Im going to write this up here at the top you guys need to remember this shock is going to cause low BP if you guys have not already watched it I strongly encourage you to go watch our when we talk about the compensation mechanisms for low blood pressure because its going to make so much sense okay so shock can lead to low blood pressure but the question is how can it lead to this decrease in blood pressure theres two ways and thats where some of these shocks differ one way is there could be a decrease in the cardiac output okay so if you decrease your cardiac output youre going to decrease the blood pressure the other one is a decrease in the systemic vascular resistance or you might have even heard me write it as total peripheral resistance same thing okay so I want you to understand that shock is when theres a low blood pressure and this low blood pressure could be due to a low cardiac output or a low systemic vascular resistance okay and then remember what cardiac output is dependent upon its dependent upon heart rate and stroke volume okay so now that we understand that this is critical because were going to go ahead and get started on hypovolemic how would we consider hypovolemic shock well decipher the word hypo means low or below the normal volume range so its a loss of volume now when were losing blood volume it can come in two different flavors here look at this one could be due to blood loss so one could actually be due to blood loss what are some certain causes of this blood loss one of them could actually be due to maybe a GI bleed so the GI bleed is definitely a very very common cause of this actual blood loss for example a very severe peptic ulcer or duodenal ulcer thats perforated and emptying into the actual peritoneal cavity another one is an abdominal aortic aneurysm if those suckers rupture they can spill a lot of blood into the abdominal cavity you can lose a lot of blood very very fast another one could possibly be trauma okay so if I got hit in the back of the head with a with a 2×4 or if I got shot or something like that Im definitely going to start losing some blood so certain types of trauma other kind of weird ones here is um you know postpartum hemorrhage or postpartum hemorrhage is basically whenever the womans giving birth after the childbirth around 24 hours after the childbirth if the woman starts losing significant volumes of blood like about 500 ml to about a thousand MLS they consented to be postpartum hemorrhage because youre losing a lot of blood so another one is whats called postpartum hemorrhage thats another one okay so thats another cause another situation besides this could even be whats called an egg ectopic pregnancy this is another really bad one this is terrible since were on this topic of getting in this area ectopic pregnancy normally whenever the the ovary has ejected from the whenever the ovum the OA site is ejected from the ovary it goes into the fallopian tubes right where the ampulla is and it waits for the sperm cell to fertilize it and then when the sperm cell fertilizes it it gets beaten by the silly within the fallopian tubes towards the endometrium of the uterus Kapiti is where it implants okay but lets say for some terrible reason the actual cilia didnt beat it towards the uterine cavity and it implanted in the actual fallopian tubes this fetus will actually be aborted over certain period of time and it can actually cause a lot of blood loss it even could lead to another condition called pelvic inflammatory disease so this could be another one another thing is on whats called hemoptysis this is basically coughing up blood this could be dude a lot of different things theres certain situations if a gentleman or a female has whats called esophageal varices and they rupture or if the person has its called goodpastures syndrome which is a collagen connective tissue disorder that could also do it even pulmonary embolisms if theyre very severe – so youre losing a lot of blood that way whats another way another one could be due to non fluids blood loss Im sorry not blood loss but fluid other than blood okay so non blood fluid loss so what could be that kind of cause so other causes could be due to non blood fluid loss so this is like common examples of like if someone has a very severe third-degree burn so like third-degree burns thats actually one of the biggest things whenever someone get a burn first things you want to take care of is that to prevent them from being coming too hydrated you got to get them fluids as quickly as possible right another common causes excessive vomiting or just go out the other hole youre peeing out your butthole right so then you got diarrhea thats another situation where youre losing a lot of fluid another type of situation could be like a bowel obstruction if you have a bowel obstruction its affecting not only the absorption activities but also food from coming down so that can initiate vomiting it can affect the absorption activity and bowel obstructions can actually pull fluid into the GI tract which is also pulling fluid from your body so bowel obstructions oh pancreatitis Accu pancreatitis is also a very terrible one many different causes of pancreatitis were not going to go over all of them what Im going to say though is is that whenever theres pancreatitis the print pancreatic protease is which are in the pancreas become undesirably activated and they start digesting the pancreatic tissue and theres a lot of pancreatic fluid that starts getting leaked out into the abdominal cavity terrible situation another one is whats called diabetic ketoacidosis your diabetes you have a lot of tall high glucose levels whats that called hyperglycemia one hyperglycemia whenever your blood glucose levels get really really high remember we talked about in the kidney this was called a transport maximum generally its right around 375 milligrams per minute that can be filtered it can filter that much glucose and reabsorb it back into the blood in certain situations when the glucose levels are so so so high that it exceeds the transport maximum we cant reabsorb it and it gets lost into the earth why is that a problem because what gluon glucose leaves guess who else leaves water water leaves also and when you have that you have an increased urine output youre losing a lot of sugar and water so you have nice little sugary water all right now these are some of the main situations that are kind of causing this hypovolemic shock so this kind of different causes the question is so now we are the causes lets write this up here these are kind of the etiology of the causes of hypovolemic shock the next question that we have to ask yourself is very quickly how does the body compensate work super quickly when your blood volume decreases what are these receptors over here called baroreceptors remember these Bayer receptors that were located within the aortic sinus in the carotid sinus again guys Im going to fly through this because you know we should already have talked about this so these guys are coming to the actual imaginary center and doing what theyre stimulating the actual medullary centers to send out action potentials from the actual medulla to do two things one is to go to the actual smooth muscle within the tunica media the actual blood vessels and release chemicals like norepinephrine that try to cause the actual blood vessel to constrict if this happens if you try to constrict the blood vessel whats that going to do to the actual resistance it increases the resistance if you increase the systemic vascular resistance what does that do to the blood pressure it increases the blood pressure and hypovolemic shock the problem is that were losing blood volume which is decreasing our blood pressure now if we increase the actual systemic vascular resistance were going to increase our BP so its going to try to stabilize it heres the problem though another thing is going to try to do is going to try to go to the heart and its going to try to increase the contractility of the heart and its going to try to go and increase the actual heart rate heres the problem now in this situation what is shrub volume dependent upon if you guys remember its dependent upon two big things we can kind of just say EBV – the ESV this is depending upon the filling and this is depending upon how much it pushes out the problem is is that we have a very low e DV why because we dont have enough blood volume so even though were going to try to increase the contractility to the heart push as much blood out as possible the blood volume is so low that the e DV is so low that it doesnt matter its not going to affect it so in these individuals who have this hypovolemic shock theyre going to try to increase their cardiac output but its not going to help them and its not actually going to increase significantly at all its actually going to kind of decrease because their blood volume is dropping so there viii is dropping so their stroke volume is dropping so their cardiac output will drop so in these people what are going to notice so far what some clinical manifestations that youll see one is it going to see a decrease in the cardiac output youre also going to notice that theyre going to have an increase in the systemic vascular resistance thats another thing to really notice what else will you notice youll also notice that these individuals theyre going to try to increase their heart rate right theyre going to try to increase the heart rate to try to increase the cardiac output but its not going to help but you will notice that the person is going to have an elevated heart rate what is that called tachycardia okay what else would you see here besides these type of situations if you run a CBC okay if you do a CBC on this person you can notice two different things within the CBC when then the CBC youll notice two different things they could have a high hematocrit or they can have a low hematocrit if their hematocrit is really really high so that means that their red blood cells are kind of it looks like they might have a lot more red blood cells but they dont actually losing a lot of plasma as they lose a lot of plasma theres a lot more red blood cells per plasma composition so because

of that youre going to notice that they have whats called heme oh concentration which just means that theyre actually losing a lot of fluid whereas if they have a low hematocrit all thats telling you is that theyre actually are losing red blood cells okay so if you see your high hematocrit all the right they might actually be losing like fluid non blood fluid loss their hematocrit slow oh they might be hemorrhaging they might be losing blood in some different type away all right which way maybe could GI be a GI bleed abdominal aortic aneurysm ima rupture all these different things could we do a ton of different things but just understanding that there another really important thing youre going to notice that the person will have whats called cyanosis so youre also going to do is what the person will have whats called cyanosis what is cyanosis its basically a bluish cast of certain skin areas so like on their fingertips on their toes around their lips certain mucous membranes so you might notice cyanosis around the lips maybe even the tongue maybe even the actual ah but you know the fingertips okay fingertips or even the toes so thats certain things that youll notice within this person because why what did we say is the problem shock theres a decreased tissue perfusion in this case is due to a decreased blood volume so the overall problem here is that these people are having a very low blood volume because theyre losing blood okay now because of that theres decreased tissue perfusion that means that theres not going to get enough oxygen to the tissues so this would develop hypoxia also so another thing that might come up within this individual is they might have some hypoxia now if this continues if the actual blood volume is not resuscitated this can cause a negative effect where it starts causing ischemia leads to necrosis and then it can possibly lead to a multi-system organ failure so its very very very dangerous if not treated quickly last thing now is how do you treat them what do you do for them first thing that youre going to want to do is youre going to want to put them on fluids you have to give them well you have to restore their blood volume so one of the things that theyll do is theyll do actually lets start an IV so they do an IV whether it be like a central line or they do like a large-bore IV line which are just a bigger gauge needle to get a lot of fluid in there fast but give them an IV definitely got to start giving them IV and then resuscitating the volume so youre going to want to put them on fluids right away so youre probably want to put them on crystalloids and these crystalloids are going to be really important that you put them on like normal saline or a ringers lactate solution so these are some really really important things that youre gonna want to do right away at immediately try to get them on fluids sometimes if you need to be able to stabilize their oncotic pressure sometimes you can give certain types of plasma volume expanders like you can give albumin you can give albumin or you can even give another compound called head of starch this kind of stabilizes the colloid osmotic pressure so this is trying to be able to stabilize stabilize the colloid osmotic pressure you want to try to stabilize that because this is controlling the amount of blood I mean the amount of water is actually leaving the blood stream if we lose a lot of our buin and head of starts were gonna start losing a lot of water into the tissue spaces thats Meg that can even make the blood volume go down even more so big thing make sure you put them in Ive IV give them a lot of fluids to stabilize them and other things youre going to want to watch out for what is in these individuals is make sure that you prevent them from going into hypothermia because as you start losing blood volume as you start losing the blood volume it actually starts decreasing significantly it affects you being able to regulate your internal body temperature and so because that the person can develop hypothermia so you want to make sure that you actually watch out for that and control the hemorrhage if they start losing too much blood you might have to do a transfusion so before we move onto cardiogenic I want to hit one more thing real quick because like I said we did cover a lot of this in low blood pressure but its going to be the same scheme for the rest of them but one of the other things that can happen whenever theres low BP right whenever theres hypotension it can stimulate the kidneys right and the kidneys will start producing a chemical called renin and then we said eventually ran and got converted to angiotensin one Im sorry we should say Renan actually converted angiotensinogen into angiotensin one angiotensin one got converted to angiotensin 2 angiotensin 2 did two things if you remember one is he went over here and bind it on to these actual receptors to cause of AIDS or constriction to increase the systemic vascular resistance to increase the BP another thing is he went over here to the actual adrenal cortex and caused the production of a hormone called aldosterone and aldosterone if you remember went to the kidneys and increase the actual reabsorption of sodium and water to try to increase the blood volume he also came over here to the actual pituitary gland and stimulated the release of another hormone and this woman was called the antidiuretic hormone the antibiotic woman also went to the kidney and increased the reabsorption of water to increase the blood volume and increase the blood pressure and at the same time its going to try to activate certain centers that are going to trigger thirst so the person might be a little bit more thirsty to try to consume fluids so just so that youre aware the mechanisms are going to be the same as it is whenever theres actually that low blood pressure as theyre trying to compensate for the situation by trying to increase the heart rate and the contractility its not going to have any effect though the vasomotor Center will be activated to constrict the blood vessels thatll work a little bit the Rendon is going to be released this rainin angiotensin aldosterone ADH system is going to come into play to try to pull a lot of water out of the out of the kidneys into the blood a lot of sodium out of the water into the blood and its going to also try to constrict the blood vessels okay this is going to be the same for how all these guys are trying to compensate during the shock okay next one next one is going to be cardiogenic shock so you can actually hear what its actually due to in the actual work so its a problem its a problem thats actually due to the heart not being able to generate a certain amount of power so you know the heart is responsible for contracting and propelling blood out into the actual systemic and peripheral and pulmonary circulation thats its responsibility it is the pump of the heart so this guy is our pump the ventricles are the pump in certain situations the pump is failing in cardiogenic shock what situations could cardiogenic shock be due – it could be due to various things cardiogenic shock could actually be due to if we talked about some of the causes one could actually be due to myocarditis myocarditis is an inflammation of the myocardium most common cause of this is like a Coxsackie B virus which is like an entero virus another one could be due to massive or multiple Mis myocardial infarctions so if someone has multiple mild cardial in Fortunes Im going to put here M eyes or even really severe in mice this could also be another cause another situation here could be certain types of valve dysfunctions so you know like a or DIC valve stenosis or aortic stenosis so aortic valve stenosis is a big one or maybe even mitral valve stenosis so even mitral valve okay so even the mitral valve stenosis is another situation there too because its again putting an increased workload on the heart and the heart can actually start becoming very weak and not very good at this job other causes besides this could even be due to arrhythmias so arrhythmia is another really really dangerous one because what happens is in arrhythmias theres two types theres actually a tacky and then theres the bratty arrhythmias right so what happens in this is in tachyarrhythmia youre trying to increase the heart rate but youre not getting the hard enough time to fill with blood as you dont get enough time for the heart filip blood its not going to be able to contract enough blood out so its affecting the filling and the ejection of blood out of the heart so in tachyarrhythmia this is also a negative influence and if your heart rates really slowing down its going to decrease your credit output which is going to decrease the amount of blood is being pumped out of the heart so again its due to a pump failure other common causes could be due to dilated cardiomyopathy so dilated cardiomyopathy is another terrible condition here and what happens is the actual ventricular muscle becomes very weak and actually becomes very flabby and not very good at being able to pump at all or even congenital heart disease so other ones could even be due to congenital heart diseases like ventricular septal defect or truncus arteriosus theres many of those but again they could also contribute to this problem here too if not completely treated so congenital heart diseases or somewhere down the line for these individuals so thats the overall concept now whats the problem because we just said these people are having a hard time being able to pump blood out of the heart so then trying to pump blood out into the circulation theyre not pumping an adequate volume of blood out into the circulation so whats happening to the volume blood thats being circulated theres a decreased volume circulate circulating if theres a decreased volume of blood circulating that means that youre having systemic hypotension because if theres a decrease in blood volume that means that theres a decrease in the blood pressure so in these people what are you gonna notice right away they are going to have low blood pressure theyre going to have a low cardiac output their heart rate is going to try to go up to compensate for them right what else is going to try to compensate for them what was that other mechanism the renin-angiotensin-aldosterone ADH system is also going to try to come into play and youre going to try to increase the actual vascular resistance so whats another thing that theyre going to try to do theyre going to try to increase the systemic vascular resistance so you notice that these people are going to have some tachycardia theyre going to have some congestion of blood within the heart theyre gonna have a low BP theyre not going to have an adequate volume circulating in the actual blood stream why is this a problem because if theres a decreased blood volume coming to the tissues that means its not going to deliver enough oxygen if you dont deliver enough oxygen that can cause the scheme ischemia can lead to necrosis and the kosis of tissues can lead to organ failure if not treated you see how its just a circle constantly so because of that if youre not giving oxygen to the tissues whats the consequence of not getting oxygen to the tissues so if youre not getting oxygen to the tissues you know a lot of our metabolic pathways in the body depend upon oxygen to produce ATP so as ATP levels decrease two things can happen Im sorry has oxygen levels decrease two things can happen you can develop a decrease in ATP this is really bad another thing that can happen is you can develop an increase in whats called lactic acid so if youre not getting enough oxygen to the tissues youre not producing enough ATP by cellular respiration this can decrease a lot of activities within the cell if you linked almost complete cellular dysfunction right protein synthesis transport pumps muscular contraction neuron transmissions all that kind of stuff another thing is your body shifts from aerobic cellular respiration making ATP to an aerobic cellular respiration making a lot of lactic acid why is lactic acid bad because lactic acid can actually do what it can disassociate and give up protons as you produce a lot of

lactic acid you produce a lot of protons whats the problem with protons theyre very acidic this can lead to metabolic acidosis so the problem with having a lot of protons is a decrease of the pH and it leads to metabolic acidosis and this has a negative effect of the heart also this can actually depress the actual contractile activity of the heart also as well as in the heart rate so thats another negative influence now these are the causes this is whats leading to this and its leading to a decrease in BP a decrease in the cardiac output an increase in the heart rate is a compensating mechanism so lets actually put this over here since the heart rate is trying to increase its one of the compensation mechanisms even though its not going to be enough so theyre going to try to increase their heart but its not going to be enough to fix the issue its actually going to make it worse in certain situations if theyre not getting an adequate volume of blood delivered to the tissues this can actually lead to lactic acid buildup a PP decrease in if it happens for a long period of time what did we say organ failure okay so this is why it can become so dangerous if it happens for a long period of time question is how do you treat it what do you do about it okay well the big thing is is you have to be able to sometimes might have to treat the issue if theyve had a myocardial infarction what would you do about that how would you treat that youd want to definitely instantly have so sometimes youre gonna have to treat the underlying cause so lets say that one of the underlying causes just for an example here lets say its an airline lets say that you have it in mind what do you do about the in mind you can either do an angioplasty or they go in and actually kind of remove the actual embolus within the coronary vessels or you just put them on thrombolytics so certain types of things like tissue plasminogen activator or heparin or things like that thatll break up the clot okay so thats kind of some of the big things there next thing how would you treat them in general regardless if theres animal how would you treat them in general the big thing that youre gonna want to do right away with these people is youre definitely gonna want to try to put them on oxygen so some of the treatment here is youre going to want to put them on oxygen give them oh – okay this is very very critical give them o2 maybe give them a little bit of fluids so very little isotonic fluids because the reason why is theyre not losing blood volume theyre just not able to circulate in the blood throughout the heart theres not a problem of decreased blood volume its the problem that the heart cant push enough blood on to the circulation so you can give them a little bit of isotonic Sleuth to help the heart out a little bit but again main thing is giving them oxygen Oh real big one give them vasopressors these oppressors are really important in cardiogenic shock because they have a hard time being able to get the heart to contract very powerfully so youre probably want to give them things like epinephrine so epinephrine is actually going to be really important here because epinephrine is actually going to be two things one is its a positive inotrope meaning that it can increase the contractility of the heart the other one is it can increase the systemic vascular resistance by constricting those blood vessels other drugs that you could give is like dobutamine dobutamine actually acts just like epinephrine but it actually is primarily a positive inotrope so it tries to bind on to the beta-1 adrenergic receptors and increase the contractility another one that you can use some unfortunate one its called amber noon remember I told you that there was different stages this is also going to increase the contractility its a positive buying the troupe this one is an unfortunate one that if you have to use or you can even use atropine also which is inhibiting the muscarinic receptors amber tone is unfortunate if you go into the refractory period so the refractory period that point aware can become irreversible even no matter how much how hard the doctor the PA is trying to be able to revive the blood pressure its not responding you can put them on amber note amber known is really good because its a phosphodiesterase 3 inhibitor so it inhibits phosphodiesterase and if you remember this we said the phosphodiesterase breaks down cyclic A&P cyclic AMP es will controls the protein kinase a levels if you break down cyclic a and PUD creeps protein kinase a which decreases the calcium coming into the cell if calcium isnt coming into the cells fast its going to start slowing down the contractility okay so thats another thing that you could do there enough another one that you could actually do in certain situations is you could if they really need it you could do whats called an intra-aortic balloon like pump and its a device that you actually kind of throw up in the aorta right in the abdominal aorta and when you throw it up into the aorta what it does is whenever your heart contracts it stays deflated but whenever the heart relaxes it inflates and it starts actually expanding the whole purpose of it is that whenever the person is in cardiogenic shock their myocardium their heart isnt getting enough oxygen so by using that pump that balloon pump it actually spreads out whenever the hearts relaxing which pushes some of the blood into the coronary vessels which helps to be able to get some blood to the actual myocardial to save the myocardium from irreversible damage okay so thats one of the big things therefore cardiogenic alright so thats that one I hope that one made sense lets move on to the next one whats go into obstructive all right guys so now were going to move into the last one here that were going to talk about in this video in the next video well actually talk about distributive shock shocks those different types now obstructive shock is really really important the reason why is you can tell what its due to right in the name theres either some type of internal obstruction or some of external obstruction of the heart the chambers of the heart or due to the great vessels that its supplying so its again its due to some type of internal obstruction or external obstruction that is affecting the blood flow out of the heart or into the actual grave vessels and well talk about that so lets go ahead and get started on that so one of the big ones here its called a tension pneumothorax Im sure unless you guys have heard this at some point time if you watch TV you probably hear it a lot like on certain medical shows right but a big one here is tension pneumo thorax were not going to go into super detail on this but just to make it simple its some type of situation in which theres lets say that theres a stab wound and what happens is remember we talked about this in the actual wrestling system we said that theres two types of pressures we said that there was two called the pepole which was the intra pulmonary pressure and we called the P IP which was the intrapleural pressure we said that the intrapleural pressure is usually negative 4 mm Hg and we said the peephole is usually 0 mm Hg we also said that you never want the intrapleural pressure to become equal to or greater than the inter pulmonary pressure what happens lets say for the some type of situation where theres damage to the actual parietal pleura which may be due to a stab wound what happens is air from the atmosphere you know atmospheric air is right around 760 millimeters of mercury whereas in the P IP its right around 756 mm Hg and so in out here in the atmosphere its around 760 mmHg where is whats higher pressure the P IP or the P of the atmosphere the atmosphere and things like to go from areas of high pressure to areas of low pressure so what happens is the air starts moving into the actual pleural cavity where it normally is containing fluid as that happens the air starts accumulating in this cavity and what starts happening to the intrapleural pressure the intrapleural pressure starts increasing and it starts going from negative 4 possibly to around maybe zero or plus 1 mm Hg why is that dangerous because now its becoming greater than the pressure inside of the actual lungs what that starts trying to do is is it starts pushing on the lungs and it starts compressing this way it starts shifting so it starts trying to shift the mediastinum to the opposite or contralateral side so one thing that can happen is as the pneumothorax develops the air occupies this pleural cavity pushing the loans and it can shift the mediastinum or it can even shift the trachea this way too to the contralateral side so what is this person exhibiting theyre exhibiting whats called a mediastinal shift or a tracheal shift okay now why is that bad if you shift this what are you going to be doing youre going to be compressing the heart in the vessels that are actually bringing blood into it and taking blood out so as this starts happening the tension pneumothorax starts pushing on the chambers of the heart and some of the blood vessels that are trying to bring the blood up whats this one vessel right here that brings blood up into the heart right here inferior vena cava if this is pushing itll start compressing it whats the blood vessel that brings blood into the right atrium from the top there are superior vena cava in certain types of situations where the pneumothorax is really really pushing and compressing on the heart it can affect the heart from being able to get filled with blood and it puts a lot of stress on the heart and restricts the heart from being able to eject the blood out okay so two problems with the tension pneumothorax is it could actually compress the blood coming into the heart and compress the heart so it has a hard time pushing blood out okay thats at in tension pneumothorax as though these are really dangerous if it comes really really if it becomes really really bad what you can actually do is youll also they do like a little percussion they kind of tap on the end of it itll put basically tap and try to listen for sounds when they tap they hear this sound its like a hyper resonance a little bit its a low pitch but kind of like a louder resonance and it actually is called timpani and that sound is identifiable that there might be some type of gas or air within that cavity that there percussing that is one of the signs that they can actually do during the physical exam to see oh maybe this person does have a pneumothorax obviously they have to go send them to do certain types of maybe like an x-ray to check that out but the whole concept is that you might hear whats called hyper resin when they do the percussion technique also they might have decreased breath sounds because the lung is collapsing is that if that lung is collapsing theyll have decreased breath sounds on that affected side also since its compressing the actual superior vena cave in the inferior vena cava the blood is having a hard time coming back into the heart so whats another sign that you might see for tension pneumothorax you might say that the person will have a high jugular venous pressure you probably okay well thats cool youll see it because theyre next veins will be a little distended – okay all right cool that covers the tension pneumothorax next one is a called getting call it pericardial tamponade or cardiac tamponade Im just going to write here pericardial tamponade pericardial tamponade is due to some type of situation in which a lot of fluid starts developing with inside of whats called the pericardial cavity so lets see heres the cavity right here you have the different parts of the pericardial cavity like the serious layer and then you have the actual outer parietal layer or you called the visceral layer and the outer parietal layer here in between those layers of the pericardium you have this actual serous fluid pericardial fluid in certain situations its supposed to be a normal amount but for whatever reason

these individuals they start having a lot of fluid accumulation in here and the flu starts getting so much in this area that actually starts compressing on the heart strangulating the heart squeezing the heart so as to starts happening it starts really really putting a lot of pressure onto the heart what do you think its going to do do you think that this heart is going to be able to fill with blood adequately no because Im squeezing it so Im decreasing the volume of my heart chambers so me trying to get blood into the heart is going to be a lot harder and its actually squeezing the heart so that the heart is gonna have a hard time being able to contract – same thing in this situation you have a hard time filling the heart with blood and the heart is so restricted because of this this actual pericardial tamponade squeezing and strangling the heart then it even has a hard time contracting to problems with this person again is going to be theyre gonna have a hard time contracting the heart and feeling the heart with blood now a pericardial tamponade it actually kind of I dont know theres some guy I guess it seems back and he came up with a triad of things that comes about during the pericardial tamponade so lets say I put a triangle here so this is called Becks triad and this is usually identifiable for someone whos going to have some type of pericardial tamponade what are these symptoms here one is because the heart is having a hard time filling with blood that that actual is due to superior vena cava inferior vena cava are probably being compressed so their jugular vein is going to be actually distended right so they can have a high jugular venous pressure another one is theyre going to have a high blood pressure so theyre going to Im sorry not a high blood pressure theyre not being able to pump enough blood onto the tissues so because of this they have a low blood pressure because again the hearts not filling with blood adequately and its not squeezing and pushing enough blood out so because of that the amount of blood is being pumped out of the heart is very very low so they can have hypotension another one is because if you had to do is called oscillation youre trying to listen to the heart sounds that fluid is making a lot thicker so you trying to hear the sound is not going to be as well it sounds like its actually moving from a farther distance so we call it muffled or distant heart sounds okay so thats some of the things that youll see within a person with having pericardial tamponade so again with this person theres an obstruction theyre having a hard time getting the blood out another super super terrible one is a massive massive pulmonary embolism lets say that a person develops an unfortunate embolism right here in the pulmonary trough you know thats actually called thats called a saddle embolism so lets say to develop some type of massive PE okay so if they have a massive PE theres a big old embolus blocking the actual pulmonary artery blood flow so this person is going to try to be able to pump blood from the right side of the heart up into the lungs but whats the problem they got this big old embolus blocking the way so the amount of blood flow getting passed through this area is very very low which means that very little fluid is coming back to the – left ventricle in very little fluid is coming back to the left ventricle what happens to the edv the edv is going to decrease significantly as the EDD decreases what happens to disrobe fully the stroke light decreases as that decreased what happens to the cardiac output that decreases that decreases what happens to the BP that decreases so you can see how this can cause hypotension – you can see how this causes the hypotension because the heart cant pump enough out and it cant fill properly you can see how this one can cause hypotension because the same thing hard is it filling properly its not contracting properly in this situation theres an embolism blocking blood flow to the left side of the heart decreasing the BP also think about this you got a big old embolism is there gonna be a lot of blood coming out of the right ventricle either no its the same thing youre not going to get a lot of blood out of the ventricles thats one problem but then you got another big problem what if this embolism is so bad that the pressure starts accumulating in this area so high the pulmonary capillary wedge pressure these people have a high pulmonary capillary wedge pressure which is the pressure theyre trying to push blood back to the left atrium if this pressure is really really high in this situation right because the actual trying to get to that area is really really being negatively affected here they arent able to get this to that area they arent able to get the blood to that area that pulmonary capillary wedge pressure can start getting a little high in this situation and it can actually rupture some of those capillaries and as it starts rupturing a lot of those capsule you can cause the spinning up of that blood that hemoptysis also if you dont have a lot of blood flow coming through this area if you dont have a lot of blood flow coming through this area whats going to happen to the actual ventilation perfusion process not going to be good so these guys remember we did this in respiration we said that there was the VT ratio and it was equals normally about 0.8 well what is cute thats the perfusion in this case the perfusion is decreasing if the perfusion is decreasing whats happening to the overall number then then the overall number is going to be greater than point eight what do we say happens in this type of situation in that type of situation the ventilation has to decrease so now the ventilation is going to decrease what does that mean the bronchioles might start constricting so youre gonna have a lot of you can have a really hard time breathing so there might be some respiratory distress that could come about in this situation also theres a VQ mismatched what happens to the oxygenation of the blood doesnt oxygenate properly and this person can develop whats called hypoxemic hypoxia another negative thing can come about from this right and if you develop hypoxia what does that mean youre not going to be able to live adequate oxygen to the tissues if you cant get adequate oxygen to the tissues the tissues become ischemic if they become ischemic they become necrotic if the patients become necrotic the organs can start failing so you can see why this is just a consistent repeat of everything other things that you might see within this person is because they have hypoxia macaques it if you do it like its called an ABG in arterial blood gas if you do an ABG youre going to notice that these people have a very low ABG so theyre gonna have a partial pressure of oxygen their partial pressure of oxygen is actually going to be a lot less than 80 millimeters of mercury thats one thing that you might notice here also you might not even notice they might have some elevated lactic acid levels – okay because again theyre not getting oxygen to the tissues so their body is shifting from aerobic respiration to anaerobic respiration and again if not treated this can cause the person to go in multiple system organ failure right depending upon the organ that could be devastating another one Im not going to really include two here because its not one of the serious ones but it can be thats very very close to us if you get a proximal aortic dissection a proximal aorta dissection can actually be very very close to the heart if it actually starts dissecting it can squeeze on some of the vessels supplying the heart and that can affect the actual filling of the heart and it could affect the actual ability to eject blood into the aorta as well so thats another situation so again to recap this one it could be due to a tension pneumothorax which causes a mediastinal tracheal shift which compresses the heart and squeezes the harden has the heart has a hard time filling with blood because it has a hard time filling with blood it cant contract enough blood into the circulation so theyre not ejecting enough blood out into the peripheral circulation so their volume that circulating is decreasing thats going to cause hypotension as this happens theyre not able to deliver enough oxygen to the tissues and this can result in an actual ischemia pericardial tamponade as the fluid is accumulating there and strangulating the heart causing the same situation as this tension pneumothorax and then we said the worst one is a massive pulmonary embolism like for example like a saddle embolism blocking right there at the pulmonary trunk which is affecting the blood flow towards the actual left side of the heart now the right side the heart has a hard time getting blood out thats going to decrease their actual cardiac output and its going to decrease the about amount of volume coming back to the left side of the heart so theyre going to have a hard time being able to get blood out to and we shouldnt actually include in this pulmonary capillary wedge pressure its not really significant into this one really the important one where the pulmonary capillary wedge pressure can be included is going to be in cardiogenic shock so were not going to really talk about the pulmonary capillary wedge pressure in this one but seriously we just need to understand here if theres a massive PE and its occluding the blood flow to this area it can decrease the volume coming back to the left side of the heart which is decreasing edv decreasing the stroke volume decrease in the cardiac output and decrease in the blood pressure if that volume is being circulated out to the actual peripheral tissues is decreasing in cause ischemia can lead to the necrosis and can cause a serious organ failure how would you treat these people it obviously depends upon the actual cause if they have a tension pneumothorax do a needle decompression so insert a needle in there and equalize the pressures that you can get the air out of the actual pleural cavity if they have a pericardial tamponade do whats called a pericardiocentesis where you actually drain the actual fluid out of the pericardial cavity if they have a massive pulmonary embolism you might have to give them thrombolytics you might have to do some type of embolectomy you might have to give them heparin to be able to prevent that from actually becoming very dangerous right and cause sudden death there and if they have some type of approximately ordered dissection youre gonna have to go in there and do some type of surgical intervention but same thing here with these people put them on oxygen what would you do here so the last thing is the treatment here we said that if youre going to treat these people what would you do you depending upon each underlying cause but other ones is youd want to give oxygen give them oxygen the next thing is you can put them on isotonic fluids thats another really important one and same thing with these individuals there youre going to have to give them some basal pressors so in this situation give them some vasopressors to increase the inotropic action the contractility of the heart and drugs that can actually cause the vascular constriction and if you start causing vasoconstriction going to increase the resistance and increase the blood pressure alright so what we did in this video is we talked about the types of shock that is usually a result of some type of decrease in the cardiac output where the heart rate isnt sustaining enough and the stroke volume is that sustaining enough to increase that where these people have high systemic vascular resistance in the next video where we talk about distributive shock were going to see how this shock is actually more due to actually a decrease in the systemic vascular resistance so now the blood vessels are excessively dilated and how that can affect tissue perfusion so initiatives I hope to see you there where we talk about distributive shock and degrade detail thanks for watching this video I hope that you guys really did enjoy it if you guys did please hit the like button comment down the comment section and please subscribe as always ninja nerds until next time

tags:
hypovolemic shock, cardiogenic shock, obstructive shock, types of shock
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