Types of Shock | Hypovolemic, Cardiogenic, & Obstructive Shock

iron engineers in this video we're 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 there's not enough blood flow going to the tissues and because of that because there's not enough adequate tissue perfusion there's 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 there's 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 there's usually the actual beginning compensating stages of shock so how you're 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 can't restore the blood pressure and that's the deadly part that's 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 let's now go ahead and dive in to each different type of shock in general I want you guys to remember though I'm 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 it's 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 there's two ways and that's 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 you're 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 there's 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 it's dependent upon heart rate and stroke volume okay so now that we understand that this is critical because we're 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 it's a loss of volume now when we're 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 that's 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 2x4 or if I got shot or something like that I'm 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 woman's 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 you're losing a lot of blood so another one is what's called postpartum hemorrhage that's another one okay so that's another cause another situation besides this could even be what's called an egg ectopic pregnancy this is another really bad one this is terrible since we're 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 let's say for some terrible reason the actual cilia didn't 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 what's called hemoptysis this is basically coughing up blood this could be dude a lot of different things there's certain situations if a gentleman or a female has what's called esophageal varices and they rupture or if the person has it's called goodpasture's syndrome which is a collagen connective tissue disorder that could also do it even pulmonary embolisms if they're very severe - so you're losing a lot of blood that way what's another way another one could be due to non fluids blood loss I'm 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 that's 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 you're peeing out your butthole right so then you got diarrhea that's another situation where you're losing a lot of fluid another type of situation could be like a bowel obstruction if you have a bowel obstruction it's 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 we're not going to go over all of them what I'm going to say though is is that whenever there's pancreatitis the print pancreatic protease is which are in the pancreas become undesirably activated and they start digesting the pancreatic tissue and there's a lot of pancreatic fluid that starts getting leaked out into the abdominal cavity terrible situation another one is what's called diabetic ketoacidosis your diabetes you have a lot of tall high glucose levels what's 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 it's 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 can't 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 you're 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 let's 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 I'm 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 they're 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 what's 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 we're losing blood volume which is decreasing our blood pressure now if we increase the actual systemic vascular resistance we're going to increase our BP so it's going to try to stabilize it here's the problem though another thing is going to try to do is going to try to go to the heart and it's going to try to increase the contractility of the heart and it's going to try to go and increase the actual heart rate here's the problem now in this situation what is shrub volume dependent upon if you guys remember it's 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 don't have enough blood volume so even though we're 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 doesn't matter it's not going to affect it so in these individuals who have this hypovolemic shock they're going to try to increase their cardiac output but it's not going to help them and it's not actually going to increase significantly at all it's 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 you'll see one is it going to see a decrease in the cardiac output you're also going to notice that they're going to have an increase in the systemic vascular resistance that's another thing to really notice what else will you notice you'll also notice that these individuals they're going to try to increase their heart rate right they're going to try to increase the heart rate to try to increase the cardiac output but it's 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 you'll 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 don't actually losing a lot of plasma as they lose a lot of plasma there's a lot more red blood cells per plasma composition so because of that you're going to notice that they have what's called heme oh concentration which just means that they're actually losing a lot of fluid whereas if they have a low hematocrit all that's telling you is that they're 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 i'ma rupture all these different things could we do a ton of different things but just understanding that there another really important thing you're going to notice that the person will have what's called cyanosis so you're also going to do is what the person will have what's called cyanosis what is cyanosis it's 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 that's certain things that you'll notice within this person because why what did we say is the problem shock there's 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 they're losing blood okay now because of that there's decreased tissue perfusion that means that there's 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 it's 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 you're going to want to do is you're 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 they'll do is they'll do actually let's 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 you're going to want to put them on fluids right away so you're 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 you're 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 we're gonna start losing a lot of water into the tissue spaces that's Meg that can even make the blood volume go down even more so big thing make sure you put them in I've IV give them a lot of fluids to stabilize them and other things you're 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 it's going to be the same scheme for the rest of them but one of the other things that can happen whenever there's low BP right whenever there's 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 I'm 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 it's 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 you're aware the mechanisms are going to be the same as it is whenever there's actually that low blood pressure as they're trying to compensate for the situation by trying to increase the heart rate and the contractility it's not going to have any effect though the vasomotor Center will be activated to constrict the blood vessels that'll 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 it's 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 it's actually due to in the actual work so it's a problem it's a problem that's 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 that's 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 I'm 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 it's 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 there's two types there's actually a tacky and then there's the bratty arrhythmias right so what happens in this is in tachyarrhythmia you're trying to increase the heart rate but you're not getting the hard enough time to fill with blood as you don't get enough time for the heart filip blood it's not going to be able to contract enough blood out so it's 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 it's going to decrease your credit output which is going to decrease the amount of blood is being pumped out of the heart so again it's 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 there's 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 that's the overall concept now what's 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 they're not pumping an adequate volume of blood out into the circulation so what's happening to the volume blood that's being circulated there's a decreased volume circulate circulating if there's a decreased volume of blood circulating that means that you're having systemic hypotension because if there's a decrease in blood volume that means that there's 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 they're 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 you're going to try to increase the actual vascular resistance so what's another thing that they're going to try to do they're going to try to increase the systemic vascular resistance so you notice that these people are going to have some tachycardia they're going to have some congestion of blood within the heart they're gonna have a low BP they're not going to have an adequate volume circulating in the actual blood stream why is this a problem because if there's a decreased blood volume coming to the tissues that means it's not going to deliver enough oxygen if you don't 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 it's just a circle constantly so because of that if you're not giving oxygen to the tissues what's the consequence of not getting oxygen to the tissues so if you're 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 I'm 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 what's called lactic acid so if you're not getting enough oxygen to the tissues you're 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 what's the problem with protons they're 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 that's another negative influence now these are the causes this is what's leading to this and it's leading to a decrease in BP a decrease in the cardiac output an increase in the heart rate is a compensating mechanism so let's actually put this over here since the heart rate is trying to increase it's one of the compensation mechanisms even though it's not going to be enough so they're going to try to increase their heart but it's not going to be enough to fix the issue it's actually going to make it worse in certain situations if they're 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 they've had a myocardial infarction what would you do about that how would you treat that you'd want to definitely instantly have so sometimes you're gonna have to treat the underlying cause so let's say that one of the underlying causes just for an example here let's say it's an airline let's 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 that'll break up the clot okay so that's kind of some of the big things there next thing how would you treat them in general regardless if there's animal how would you treat them in general the big thing that you're gonna want to do right away with these people is you're definitely gonna want to try to put them on oxygen so some of the treatment here is you're 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 they're not losing blood volume they're just not able to circulate in the blood throughout the heart there's not a problem of decreased blood volume it's the problem that the heart can't 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 you're 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 it's 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 it's called amber noon remember I told you that there was different stages this is also going to increase the contractility it's 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 it's not responding you can put them on amber note amber known is really good because it's 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 isn't coming into the cells fast it's going to start slowing down the contractility ok so that's 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 what's called an intra-aortic balloon like pump and it's 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 isn't getting enough oxygen so by using that pump that balloon pump it actually spreads out whenever the heart's 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 that's one of the big things therefore cardiogenic alright so that's that one I hope that one made sense let's move on to the next one what's go into obstructive all right guys so now we're going to move into the last one here that we're going to talk about in this video in the next video we'll actually talk about distributive shock shocks those different types now obstructive shock is really really important the reason why is you can tell what it's due to right in the name there's 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 it's supplying so it's again it's 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 we'll talk about that so let's go ahead and get started on that so one of the big ones here it's called a tension pneumothorax I'm 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 we're not going to go into super detail on this but just to make it simple it's some type of situation in which there's let's say that there's a stab wound and what happens is remember we talked about this in the actual wrestling system we said that there's 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 let's say for the some type of situation where there's 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 it's right around 756 mm Hg and so in out here in the atmosphere it's around 760 mmHg where is what's 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 it's 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 they're exhibiting what's 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 you're 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 what's this one vessel right here that brings blood up into the heart right here inferior vena cava if this is pushing it'll start compressing it what's 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 that's 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 you'll also they do like a little percussion they kind of tap on the end of it it'll put basically tap and try to listen for sounds when they tap they hear this sound it's like a hyper resonance a little bit it's 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 what's 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 they'll have decreased breath sounds on that affected side also since it's compressing the actual superior vena cave in the inferior vena cava the blood is having a hard time coming back into the heart so what's 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 that's cool you'll see it because they're 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 I'm 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 what's called the pericardial cavity so let's see here's 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 it's supposed to be a normal amount but for whatever reason in 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 it's going to do do you think that this heart is going to be able to fill with blood adequately no because I'm squeezing it so I'm decreasing the volume of my heart chambers so me trying to get blood into the heart is going to be a lot harder and it's 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 they're gonna have a hard time contracting the heart and feeling the heart with blood now a pericardial tamponade it actually kind of I don't know there's some guy I guess it seems back and he came up with a triad of things that comes about during the pericardial tamponade so let's say I put a triangle here so this is called Beck's triad and this is usually identifiable for someone who's 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 they're going to have a high blood pressure so they're going to I'm sorry not a high blood pressure they're not being able to pump enough blood onto the tissues so because of this they have a low blood pressure because again the heart's not filling with blood adequately and it's 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 you're 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 it's actually moving from a farther distance so we call it muffled or distant heart sounds okay so that's some of the things that you'll see within a person with having pericardial tamponade so again with this person there's an obstruction they're having a hard time getting the blood out another super super terrible one is a massive massive pulmonary embolism let's say that a person develops an unfortunate embolism right here in the pulmonary trough you know that's actually called that's called a saddle embolism so let's say to develop some type of massive PE okay so if they have a massive PE there's 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 what's 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 can't pump enough out and it can't fill properly you can see how this one can cause hypotension because the same thing hard is it filling properly it's not contracting properly in this situation there's 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 it's the same thing you're not going to get a lot of blood out of the ventricles that's 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 they're 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 aren't able to get this to that area they aren't 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 don't have a lot of blood flow coming through this area if you don't have a lot of blood flow coming through this area what's 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 that's the perfusion in this case the perfusion is decreasing if the perfusion is decreasing what's 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 you're 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 there's a VQ mismatched what happens to the oxygenation of the blood doesn't oxygenate properly and this person can develop what's called hypoxemic hypoxia another negative thing can come about from this right and if you develop hypoxia what does that mean you're not going to be able to live adequate oxygen to the tissues if you can't get adequate oxygen to the tissues the tissues become ischemic if they become ischemic they become necrotic if the patient's 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 it's called an ABG in arterial blood gas if you do an ABG you're going to notice that these people have a very low ABG so they're 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 that's one thing that you might notice here also you might not even notice they might have some elevated lactic acid levels - okay because again they're 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 I'm not going to really include two here because it's not one of the serious ones but it can be that's 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 that's 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 can't contract enough blood into the circulation so they're not ejecting enough blood out into the peripheral circulation so their volume that circulating is decreasing that's going to cause hypotension as this happens they're 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 that's going to decrease their actual cardiac output and it's going to decrease the about amount of volume coming back to the left side of the heart so they're going to have a hard time being able to get blood out to and we shouldn't actually include in this pulmonary capillary wedge pressure it's 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 we're not going to really talk about the pulmonary capillary wedge pressure in this one but seriously we just need to understand here if there's a massive PE and it's 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 what's 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 you're 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 you're going to treat these people what would you do you depending upon each underlying cause but other ones is you'd want to give oxygen give them oxygen the next thing is you can put them on isotonic fluids that's another really important one and same thing with these individuals there you're 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 isn't 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 we're 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

Channel: Ninja Nerd

Views: 1,451,818

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

Id: t_RLS6sSFrE

Length: 45min 5sec (2705 seconds)

Published: Fri Aug 04 2017