Cardiogenic shock; typically, although not always, there is a suggestive medical history. When you look at the patient you may in fact see a big scar running down the middle of their sternum. Always a warning sign that something has happened to their heart. So get a medical history. Tachycardia will essentially always be present unless the cause of their shock is that they are having a bradydysrhythmia. You can obviously be in shock because you have a heart rate of 30 and you are not tachycardic. You will have poor perfusion, again, the compensatory mechanism of vasoconstriction. Some clinical clues that in fact you are dealing with cardiogenic shock, rather than hypovolemic shock, will be pulmonary exam; you may hear rales throughout the lung fields, you may hear the heart shifted over and enlarged. You may have a gallop rhythm. Your heart may be large by chest x-ray. The liver might be quite large, and although we don’t typically look for jugular venous distention on children, you can certainly observe it. So look for it, you may find it. These are all things that would suggest a cardiac function problem rather than hypovolemia or other etiologies of shock.
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Septic shock; again, history may be very helpful. Certainly if somebody is very febrile it’s one of the things you will entertain. The findings will be similar in that you will be tachycardic. The thing that will be different oftentimes about septic shock, especially early on, is that you will have systemic vasodilation which will make your skin look very well perfused. So if someone shows up hypotensive, with instantaneous capillary refill, don’t be reassured by the capillary refill. It’s because they are inappropriately vasodilated and they are undoubtedly septic. Again, your heart and liver will be small early on. On laboratory examination you may see either a high white count or a low white count. Septic shock is really a combination of distributive shock where you have misdistribution of your fluids, cardiogenic shock where your heart doesn’t work so well, and hypovolemia where you likely have had volume loss.
A pure distributive shock will be a shock state where your blood flow is not appropriate for your body. You may have a history – if someone has a knife wound to their spinal cord, you might suspect that they’ve lost all their sympathetic enervation to the lower half of their body. They vasodilated and they are not distributing their blood flow appropriately. Anaphylactic shock where you have vasodilation is a form of distributive shock. Again, tachycardia. Very sensitive finding. You will be hypotensive and much like septic shock, you will be warm and well perfused, at least until your blood pressure begins to fall significantly.
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