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Old 06-07-2011
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Emergency Car accident and a chest X ray, the type of shock!

A 25-year-old man is brought to the emergency department following a motor vehicle collision. The paramedics report that the vehicle struck a tree at 60 km/h (37 miles/hour). The patient was an unrestrained backseat passenger but was not ejected from the vehicle. He did not appear to have any life-threatening injuries at the scene and remained conscious during transportation to the hospital. Currently the patient is complaining of right-sided chest pain and increasing difficulty with breathing. Vital signs are: blood pressure (BP) 100/60 mm Hg, heart rate (HR) 120, respiration (R) 24, temperature (T) 38°C (100.4°F), oxygen saturation (SpO2) 92%. The patient appears anxious and short of breath. Physical examination is significant for decreased breath sounds on the right side, and bruising and tenderness of the right rib cage. Complete blood count (CBC), basic chemistry, prothrombin time (PT), and partial thromboplastin time (PTT) are within normal limits. Electrocardiogram (EKG) shows sinus tachycardia. The chest x-ray is shown below (see figure), and separate rib series x-rays demonstrate simple fractures of the right 7th and 8th ribs in the midclavicular line. No other injuries are identified. Without immediate intervention, what type of shock is this patient most at risk for?

Car accident and a chest X ray, the type of shock!-cxr002.jpg
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Answer Choices
A. Anaphylactic
B. Extrinsic cardiogenic (obstructive)
C. Hypovolemic
D. Intrinsic cardiogenic
E. Neurogenic
F. Septic
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i think its (b)
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extrinsic (tension pneumothorax)
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tension pneumothorax = B
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Default type of shock

b, extrinsic Cardiogenic shock from pneumothorax
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Yes. Indeed.

Extrinsice cardiogenic shock (ECS) due to tension pneumothorax.

Pericardial temponade can also give rise to ECS.
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Old 06-07-2011
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_______b_______________
_______b_______________
_______b_______________
_______b_______________
_______b_______________
_______b_______________
_______b_bbbbbb________
_______bb______b_______
_______b_______b_______
_______b_______b_______
_______b_______b_______
_______bb______b_______
_______b_bbbbbb________
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whats that Abou Saqr? a Kalashnikov?
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Quote:
Originally Posted by docoftheworld View Post
whats that Abou Saqr? a Kalashnikov?
no, rbbbbbbbj
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its B for sure
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bravooooooooooo


Option B (Extrinsic cardiogenic (obstructive)) is correct. Extrinsic cardiogenic or obstructive shock occurs when the heart cannot maintain cardiac output secondary to an extracardiac obstruction. This can be an obstruction in the circulatory system e.g. pulmonary embolism, or physical compression of the heart itself e.g. pericardial tamponade. In this case, the chest x-ray shows a right pneumothorax crossing the midline and displacing the structures in the mediastinum to the contralateral side. Because the thoracic cavity is a fixed volume, the expanding pneumothorax diminishes preload and decreases cardiac output. This condition is known as a tension pneumothorax and requires immediate needle decompression of the affected lung.

Option A (Anaphylactic) is incorrect. Anaphylactic shock is an immunoglobulin E (IgE)-mediated immune response to an allergen in a sensitized individual. This is also known as a type I hypersensitivity reaction. A systemic chemokine response leads to increased vascular permeability and loss of intravascular volume. By the same mechanism, angioedema of the respiratory tract can occur and compromise the airway. Classic anaphylactic allergens include insect bites and peanuts. The immediate treatment for life-threatening anaphylaxis is epinephrine. Impending shock in this patient is clearly secondary to trauma and not an anaphylactic reaction.

Option C (Hypovolemic) is incorrect. Hypovolemic shock refers to decreased tissue perfusion due to physical loss of intravascular volume. This is the most common cause of shock in the trauma patient. Hypovolemic shock can be caused by hemorrhage, excessive vomiting or diarrhea, or third spacing (e.g. burns). The immediate treatment for hypovolemic shock is repletion of intravascular volume using IV fluids and blood products as necessary. None of the above conditions have been identified in this patient and the chest x-ray indicates a tension pneumothorax.

Option D (Intrinsic cardiogenic) is incorrect. Intrinsic cardiogenic shock occurs when the heart itself is damaged or dysfunctional and cannot maintain adequate cardiac output. The most common causes are myocardial infarction, valvular rupture, and arrhythmias. Treatment is dependent on the specific etiology. In this case, the patient’s mechanism of injury, physical examination, EKG, and imaging do not lend any credible evidence to an intracardiac injury.

Option E (Neurogenic) is incorrect. Neurogenic shock is caused by spinal cord trauma or spinal anesthesia. Interruption of the sympathetic outflow from the spinal cord leads to unopposed parasympathetic stimulation of the circulatory system. This causes systemic vasodilation and relative hypovolemia. In addition, the heart cannot receive any chronotropic or inotropic signals associated with sympathetic stimulation. Thus, in contrast to other types of shock, neurogenic shock patients have warm, flushed skin and are bradycardic despite being hypotensive. This type of shock is acutely treated with IV fluids, pressors, and atropine. The patient in this case has no identified spinal injury and an obvious tension pneumothorax on chest x-ray.

Option F (Septic) is incorrect. Septic shock is the culmination of a systemic infection causing diffuse endothelial damage and loss of blood volume that is refractory to fluid resuscitation. It is treated with copious amounts of intravenous (IV) fluids and pressors. Patients are also empirically treated with broad spectrum antibiotics while awaiting a positive culture. The source of shock in this patient is clearly traumatic in origin and not infectious.

High-yield Hit 1
Pneumothorax
Causes
Primary: Due to subpleural apical blebs or Marfan's syndrome
Secondary: Due to COPD, asthma, tuberculosis (TB), trauma, or Pneumocystis carinii pneumonia
Iatrogenic: Due to thoracentesis, subclavian lines, positive pressure ventilation, or bronchoscopy
Symptoms and Signs
Patients complain of acute-onset of pleuritic chest pain and dyspnea
Physical findings include diminished breath sounds, hyperresonance to percussion, and decreased tactile fremitus
Tension pneumothorax presents with respiratory distress, falling O2 saturation, hypotension, and tracheal deviation
Evaluation (see Fig. 13-1B): Chest radiograph displays hyperlucency in the affected lung field, deviation of the trachea away from the affected lung, and flattening of the diaphragm on the affected side
Treatment
Small pneumothoraces can resolve spontaneously
Large or severely symptomatic pneumothoraces can be treated with chest tube insertion and supplemental O2. Recurrent pneumothorax can be treated surgically with pleurodesis (fusion of the pleural membranes)
Tension pneumothorax can be treated with immediate needle thoracostomy with a 14-gauge needle in the second or third intercostal space at the midclavicular line
Any patient with a pneumothorax on mechanical ventilation should have a chest tube inserted owing to the high risk of tension pneumothorax development
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