Obstructive shock | ACLS-Algorithms.com
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(PALS Review) Obstructive Shock

Obstructive Shock Overview:

Obstructive shock occurs when adequate oxygen and nutrient delivery to the organs and tissues of the body is compromised as a direct result of an obstruction to blood flow into or out of the heart.

If blood flowing INTO the heart is obstructed, it causes a decrease in cardiac output because of impaired diastolic filling. If blood flowing OUT of the heart is obstructed, it causes a decrease in cardiac output because of excessive afterload.

The most common causes of obstructive shock in children are tension pneumothorax, pulmonary embolism, and cardiac tamponade. There are also several congenital abnormalities that can cause obstructive shock. Examples include critical aortic stenosis and coarctation of the aorta.

Both signs and symptoms of obstructive shock and the management and treatment of obstructive shock are dependent upon the cause. Click each cause to review the signs, symptoms, and management of each major cause is reviewed.

Tension Pneumothorax:

Review signs, symptoms, and mgt.

Tension pneumothorax is the accumulation of air within the pleural space.

Causes of tension pneumothorax in children include trauma, asthma, cystic fibrosis, pneumonia and excessive positive pressure during manual or mechanical ventilation.

Once a tension pneumothorax occurs air can continue to accumulate within the pleural space but cannot escape. This continued accumulation of air increases pressure and ultimately obstructs venous blood return to the heart. The obstruction results in decreased diastolic filling.

Signs and Symptoms:

The following list provides other signs and symptoms of tension pneumothorax using the primary assessment model (ABCDE).

  1. Airway: tracheal deviation toward the contralateral side
  2. Breathing: increased work of breathing, increased respiratory rate, respiratory distress, and diminished lung sounds on the affected side
  3. Circulation: neck vein distention, rapid and severe hypotension, tachycardia rapidly degrades into bradycardia, and PEA
  4. Disability: decreased level of consciousness
  5. Exposure: pale and cool extremities

Management of Tension Pneumothorax:

The definitive treatment for obstructive shock caused by tension pneumothorax is needle decompression and chest tube placement to the affected area.

Cardiac Tamponade:

Review signs, symptoms, and mgt.

Cardiac Tamponade is the accumulation of fluid or blood within the pericardial sac.

As fluid accumulates, the increased pressure decreases venous return to the heart and causes right ventricular compression which results in a progressive decline in right ventricular end-diastolic volume. The decreased end- diastolic volume compromises cardiac output which results in shock symptoms.

Signs and Symptoms:

The following list provides other signs and symptoms of cardiac tamponade using the primary assessment model (ABCDE).

  1. Airway: may have compromised airway if level of consciousness is decreased
  2. Breathing: increased work of breathing and respiratory rate; respiratory distress
  3. Circulation: tachycardia, decreased peripheral pulses, jugular vein distention, poor capillary refill, muffled heart sounds, narrow pulse pressure
  4. Disability: decreased level of consciousness
  5. Exposure: cool extremities

Management of Cardiac Tamponade:

The primary treatment for cardiac tamponade is pericardiocentesis. If cardiac tamponade is suspected and the patient is not in cardiac arrest, expert consultation should take place.

If cardiac arrest is ongoing or impending and cardiac tamponade is suspected, emergency pericardiocentesis can be performed.

Pulmonary Embolism:

Review signs, symptoms, and mgt.

Pulmonary embolism occurs when the pulmonary artery or its branches become partially or totally occluded. Common causes of pulmonary embolism include blood clots (most prevalent), air, and fat.

Children who have existing risk factors are at higher risk for pulmonary embolism. Some risk factors include indwelling central venous catheters, sickle cell disease, and coagulation disorders.

Signs and Symptoms:

The following list provides signs and symptoms of pulmonary embolism using the primary assessment model (ABCDE).

  1. Airway: may have compromised airway if level of consciousness is decreased
  2. Breathing: increased work of breathing and respiratory rate; respiratory distress
  3. Circulation: tachycardia, cyanosis, chest pain, and hypotension. Venous congestion – Right-sided (hepatomegaly, ascites, abdominal pain, pleural effusion, edema, jugular venous distention)
  4. Disability: decreased level of consciousness
  5. Exposure: cool extremities

Management of Pulmonary Embolism:

Pulmonary embolism must be confirmed by CT scan with contrast, or echocardiography, or angiography.

The primary treatment for pulmonary embolism is anticoagulant therapy, but since anticoagulant therapy does not act immediately, fibrinolytic therapy should be considered for severe cases of pulmonary embolism.

Fundamentals of Shock Management:

As with all forms of shock, the management of obstructive shock should center around the fundamental components for the treatment of shock.

The following should be considered: positioning, airway and breathing, vascular access, fluid resuscitation, monitoring, frequent reassessment, lab studies, medication therapy, and expert consultation.

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