00:01
Let's take a look at the other two
major shocks here.
00:02
Once again, what is now causing
decreased oxygenation every tissue?
We either have cardiogenic,
or you have obstructive.
00:09
Let's go to each one.
00:10
And the reason that these
are put in the same row
is because many of the features
are going to be comparable.
00:18
And there are certain features
that are absolutely distinct.
00:21
So, let's first go
through cardiogenic.
00:24
Obviously, the causes are
going to be different, right?
If it's cardiogenic,
what happened?
Oh, my goodness,
you or the patient has suffered
a myocardial infarction.
00:33
If there's a myocardial infarction,
one of the post MI complications
include your CHF
and acute
congestive heart failure.
00:41
You would have then a
decreased in cardiac output
You have a decrease
in cardiac output,
what then happens to yout tissue?
That's improperly being oxygenated.
00:49
Okay, what other
issues do we have here?
Acute MI, valvular
dysfunction, arrhythmias.
00:55
See if your heart stops,
then where do you begin here?
It's on hemorrhaging,
a decreased cardiac output.
01:01
And where does some
of this fluid go?
Oh, yeah. It backs up
into maybe the pulmonary.
01:08
Alright, pulmonary edema.
01:10
If it's cardiogenic,
it will be transiting
maybe if it's bad enough, may result
in alveolar hemorrhage in company,
but decreased cardiac output.
01:18
Here, once again,
what happens to your stretch?
Decreased.
01:21
What do you want from your medulla?
You want sympathetic.
01:26
Okay,
so this is example number two,
where it's a shock,
we have increased in your
sympathetic and so therefore,
I want you to now move into
your diagnosis here.
01:37
And you would expect to find
cold and clammy.
01:39
But that's not specific,
because it's sympathetic.
So let's go into diagnosis
for each of the shocks,
your cardiogenic obstructive,
before we move on.
01:49
Let's just make sure that
we're clear about obstructive,
and why the heart
might not be properly
or the cardiovascular
and the pulmonary system
are not properly functioning
as they should.
02:02
And obstructive cardiac tamponade.
02:04
What happened here?
Oh, maybe the patient had
a myocardial infarction,
oh, maybe there was a scar
formation, but was weakened,
so resulting in
ventricular aneurysm,
and maybe there was
ventricle wall rupture.
02:17
And so therefore,
how quickly is this
pericardial cavity being filled up?
Way too quick.
02:22
What do we have here?
Cardiac tamponade.
02:25
What is this?
Obstructive type.
02:27
And then we have
pulmonary embolism.
02:29
Pomi. embolism would also be
considered an obstructive type.
02:33
Let's talk about the diagnosis.
02:34
So apart from the cold and clammy
because of why?
Sympathetic.
02:39
Let's talk about
congestive heart failure
In CHF, well, what's that heart
sound that you're going to create
when you have a
very large left ventricle?
And so now at this point, as soon
as you have diastole, early on,
this mitral valve opens
and blood rushes
into left ventricle creating...
02:56
S3.
02:58
Whereas S3,
in relation to S1,S2
Good after S2.
03:04
So, S2 would be the closure of the
aortic and, right after closure,
you're opening up your mitral
valve and you're going to create
massive flow of blood
from left atrium
and to left ventricle
creating your S3 gallop.
03:18
Hopefully that's clear.
03:20
Next, well, say that your heart
is not functioning properly,
you're going to backup,
where?
Lungs.
03:27
One side or two sides?
Both sides, with what?
Good pulmonary edema.
03:34
Number one, if it's
the right side that affected
then you're going to have
what's this right here when your
intrajugular vein can
be seen to be pulsating?
You should never normally be able
to see the internal jugular vein.
03:47
But if you find it to be pulsating
as your positive JVP,
jugular venous pulse.
03:53
Are we clear?
Heart issues? cardiogenic.
03:57
Okay, what about
obstructive and company?
And here because
it's obstructive well,
if your pericardial cavity is being
filled up, you cannot properly hear
your heart sounds,
so therefore, it'll be muffled.
04:10
Okay, now, my problem is this.
04:12
Now, don't memorize this.
Work with me.
04:14
The heart isn't working properly.
04:17
And if it's
congestive heart failure,
which is the best example
to give you at this point,
and then you know, the heart is
filled with blood, volume overload.
04:26
And so therefore, there's more blood
and your heart isn't there and CHF.
04:30
And so therefore, this has been
referred to as being preload.
04:34
You expect your pulmonary
capillary wedge pressure
or your central venous
pressure to be increased.
04:38
And that's what you're seeing here.
04:42
Next, well here,
if your heart's not working
either obstructive or cardiogenic,
you can expect your cardiac output
did the decreased severely.
04:50
And what kind of symptoms
are you finding here?
Or type of signs
cold and clammy, right?
Sympathetic nervous system.
04:58
What does that then doing to your
systemic vascular
resistance and arterioles.
05:02
Good, basic construction
increase in TPR.
05:06
Now, what treatment
obviously be different?
If it's congestive heart failure
and you're trying to
reestablish a pumping motion,
then obviously you want to use
a positive inotropic agent,
maybe something like
dobutamine beta-1 agonist.
05:19
And if you want
to try to take care of that edema,
you're thinking about, good,
furosemide, a diuretic.
05:27
In obstructive shock caused
by cardiac tamponade,
the diagnosis is usually made
by ultrasound
and supported by hearing
muffled heart sounds,
because the pericardial fluid
is blocking the passage of sound
from the heart to the chest wall.
05:40
When tension pneumothorax
is causing the obstruction,
the trachea will be deviated away
from the side with the pneumothorax.
05:47
A large pulmonary embolism
will have a respiratory
consequence of hypoxia,
and a hemodynamic
consequence of hypotension.
05:55
The patient will have dyspnea
and pleuritic chest pain.
05:58
All of these three causes will
result in an increase in the CVP
which is clinically seen as
an elevated jugular pressure
and the preload to the heart
will be decreased
because the venous return path
back to the heart is obstructed.
06:11
Naturally then the cardiac
output will be decreased
and the systemic vascular resistance
will be increased
by sympathetic hyperactivity.
06:19
The treatment for all
causes of obstructive shock
is immediate relief
of the obstruction.