Cardiogenic shock, orthostatic hypotension, syncope

"You can't fly a helicopter if you're passing out, that's just good advice"

shock

shock

Inadequate tissue perfusion causing oxygen dysfunction

hypovolemic

loss of intravascular volume

cardiogenic

pump failure of the heart

distributive

vasodilation and decreased vascular resistance

Obstructive shock

physical obstruction to blood flow

advance age, chronic comorbidities, immunosupression, infection, major trauma/burns/hemorrhage, CVD, obstructive condition

Risk factors for shock

hypotension (MAP under 65), tachy, AMS

General signs of shock

cool, clammy skin

What skin changes do you see in hypovolemic and cardiogenic shock

warm, flushed skin

What skin changes do you see in distributive shock?

oliguria, acidosis, increased lactate

Signs of organ dysfunction in shock

dry mucous membranes, poor skin turgor

What is specific to hypovolemic shock

JVD, pulmonary edema

What is specific to cardiogenic shock

fever, bounding pulses, DIC

What is specific to distributive shock

dyspnea, unilateral breath sounds, muffled heat tone

What is specific to obstructive shock?

CBC, CMP, Lactate, ABG, CXR, POCUS, CT scan, EKG, bp monitoring, CVP

Basic shock workup

hematocrit, coag studies

Orders specific to hypovolemic

trop, echo

Orders specific to cardiogenic

blood cultures, procalcitonin

Orders specific to distributive

d-dimer, CT angio

Orders specific to obstructive

restore perfusion, address underlying

General game plan for shock

Norepi (septic), dopamine, dobutamine (cardiogenic), epi, broad spectrum antibiotics, corticosteroids (severe sepsis, adrenal insufficiency)

Meds for shock

fluids, O2/mechanical ventilation, pericardiocentesis, chest tube, thrombolysis

Non-med treatment for shock

fluids, transfusion, hemorrhage control

Specific treatments for hypovolemic

revascularization, mechanical support

Specific treatments for cardiogenic

pressors, treat underlying

Specific treatments for distributive

relieve obstruction

Specific treatments for obstructive

monitor for organ recovery, reassess volume status, evaluate for complications, long term management

Follow up plan for shock

orthostatic hypotension

A drop in bp when standing more than 20 systolic, 10 diastolic within 1-3 minutes of standing

failure of compensatory mechs

Pathophys for orthostatic hypotension

volume depletion, autonomic dysfunction, medications

What causes orthostatic hypotension

65+, DM, Parkinson’s, kidney disease, Anti-HTNs, diuretics, antidepressants, dehydration, prolonged bed rest

Risk factors for orthostatic hypotension

neurodegenerative diseases, DM, amyloidosis

What are some of the primary causes of orthostatic hypotension

dehydration, blood loss, Anti-HTNs, diuretics, antidepressants,

What are some of the secondary causes of orthostatic hypotension

Bp measurements supine and standing, CBC, CMP, ECG, Echo, tilt table

77 y/o male presents to the ER for syncope. He states that he stood up after eating and was dizzy and lightheaded and then all of a sudden his vision went dark. He states that he is on metoprolol and furosemide for his bp. What diagnostics do you want

neurogenic

Which cause of orthostatic hypotension is characterized by a LACK of compensatory heart rate increase

vasovagal/reflex syncope, arrhythmias, seizures, TIAs, POTS, medication side effects, anxiety, hypoventilation

DDX for orthostatic hypotension

elevate head of bed, small meals, gradual positional changes, increase salt and fluid intake, avoid triggers, compression garments

Lifestle mods for orthostatic hypotension

fludrocortisone, midodrine, droxidopa

Medication options for orthostatic hypotension

Falls!

Concerning orthostatic hypotension what do we need to watch for

syncope

Abrupt transient loss of consciousness and postural tone with rapid spontaneous recovery caused by transient global cerebral hypoperfusion

neurocardiogenic (most common - vasovagal), orthostatic, cardiac (most severe), mixed

Types of syncope

60+, CVD, DM, Parkinson’s, anti-HTNs, diuretics, fam hx of sudden cardiac death

Risk factors for syncopes

emotional stress, pain, prolonged standing, coughing, micturition, swallowing

Underlying causes of neurocardiogenic syncope

parkinson’s, DM, dehydration, hemorrhage, diuretics, vasodilators

Underlying causes of orthostatic syncope

tachycardia, bradycardia, aortic stenosis, cardiomyopathy

Underlying causes of cardiac syncope

subclavian steal syndrome, vertebrobasilar TIA

Cerebrovascular causes of syncope

dizziness, lightheadedness, nausea, warmth, diaphoresis, blurred vision

Prodrome of syncope

abrupt loss of consciousness, loss of postural tone, short duration

Symptoms of syncope episode

rapid return to baseline, no confusion, maybe fatigue or mild weakness

Post-syncope recovery

EKG, orthostatic vitals, echo, tilt table, holter monitor, CBC, CMP, brain MRI/CT if head strike, vascular studies

Syncope workup

San Francisco syncope rule, ROSE rule, OESIL score

Risk stratification tools for syncope

seizures, hypoglycemia, stroke, TIA, psychogenic pseudosyncope, intoxication, vertebrovasilar insufficiency, acute anemia

DDX for syncope

underlying cause, avoid driving, fall precautions

General tips and tricks for syncope

patient education, increase salt and fluid, physical counterpressure maneuvers

Neurocardiogenic syncope treatment plan

correct volume depletion/anemia, adjust meds, compression stockings, midodrine, fludorocortisone

Orthostatic syncope treatment plan

pacemaker, defibrillator, ablation, valve replacement, surgical repair

Cardiac syncope treatment syncope

refer to cardio/neuro, holter monitor, hospitalization, monitor for reoccurance

Game plan for high risk syncope patients