Shock Syndromes II

Patient Cases

A 54-year-old man with an unknown medical history presents after a rollover automobile accident. On pri-

mary survey, his respiratory rate is 34 breaths/minute, SBP is 79 mm Hg, and Glasgow Coma Scale score

is 3. The FAST examination is positive, an MTP is initiated, and the patient is taken to the operating room

for an emergency exploratory laparotomy. In the operating room, he is found to have grade 5 splenic injury,

so the spleen is removed. Four hours after admission, he has received 14 units of PRBCs, 12 units of fresh

frozen plasma, and 10 units of platelets. His laboratory values include aPTT 66 seconds, INR 1.7, fibrinogen

176 mg/dL, Plt 160,000/mm3, and ionized calcium 1.1 mmol/L. The TEG is normal except for an LY30 of

0% (normal 0.8%–8%). The patient’s wife arrives at the hospital and clarifies that he was out for a Sunday

afternoon ride. She also shares that the patient has a history of atrial fibrillation and takes dabigatran (last

dose this morning). Which is the best pharmacologic treatment of his ongoing hemorrhagic shock?

infused over 8 hours.

B.P is a 76-year-old man (120 kg) with atrial fibrillation on warfarin admitted to the ED with weakness and

hematemesis. Pertinent vital signs on admission are as follows: blood pressure 79/52 mm Hg, heart rate 136

beats/minute with a rhythm of sinus tachycardia, and respiratory rate 26 breaths/minute. Frank red blood

is noted on nasogastric lavage. On physical examination, the patient is confused, with clammy extremities.

Pertinent laboratory values are as follows: Hgb 6.3 g/dL, INR 9.2, and Plt 300,000/mm3. In addition to intra-

venous phytonadione, which therapy is most appropriate for managing warfarin reversal in this patient?

Obstructive shock occurs because of extracardiac obstruction to flow in the cardiovascular system.

tension pneumothorax, or constrictive pericarditis) or impaired systolic contraction (e.g., massive PE,

acute or chronic PH or aortic dissection).

Obstructive shock is relatively rare, and only about 2% of patients requiring vasoactive medications

have this type of shock.

The pathophysiologic hemodynamic hallmark of obstructive shock is decreased CO.

obstruction but are generalized as follows: