Shock: Classification, Pathophysiology, and Approach to Management

Multidetector CT Imaging Biomarkers as Predictors of Prognosis in Shock: Updates and Future Directions

A severe mismatch between the supply and demand of oxygen is the common sequela of all types of shock, which present a mortality of up to 80%. Various organs play a protective role in shock and contribute to whole-body homeostasis. The ever-increasing number of multidetector CT examinations in severely ill and sometimes unstable patients leads to more frequently encountered findings leading to imminent death, together called "hypovolemic shock complex". Features on CT include dense opacification of the right heart and major systemic veins, venous layering of contrast material and blood, densely opacified parenchyma in the right hepatic lobe, decreased enhancement of the abdominal organ, a dense pulmonary artery, contrast pooling in dependent lungs, and contrast stasis in pulmonary veins. These findings are biomarkers and prognostic indicators of paramount importance which stratify risk and improve patient outcomes. In this review, we illustrate the various CT patterns in shock and review the spectrum and prognostic significance of thoraco-abdominal vascular and visceral alarming signs of impending death with the intention of increasing awareness among radiologists and radiographers to prepare for immediate resuscitation when required.

Use of point-of-care ultrasound in the management of patients presenting with shock: the treatment implications of an early bedside diagnosis of pulmonary embolism

Point-of-care ultrasound has been used to identify real-time indicators of acute obstruction to right ventricular outflow and aid appropriate diagnosis and management of patients presenting with extensive pulmonary embolism in whom haemodynamic instability permits only bedside investigation. We present the case of a 70-year-old woman who presented with shock. A focused bedside echocardiography was performed and showed left ventricular septal wall flattening and a severely dilated right ventricle with impaired systolic function. The right atrium was dilated with a floating thrombus visible on the sub-xiphoid view. The patient was treated with intravenous systemic thrombolysis (alteplase) prior to undergoing CT pulmonary angiogram. This showed saddle pulmonary embolus, with extensive thrombus in the main and all lobar pulmonary arteries bilaterally, with evidence of right heart strain.