Correct!
4. Obstructive shock

Shock is a life-threatening manifestation of circulatory failure leading to cellular and tissue hypoxia (1). It is a life-threatening condition and most commonly manifested as hypotension (systolic blood pressure less than 90 mm Hg or MAP less than 65 mmHg). There are mainly four broad categories of shock: distributive, hypovolemic, cardiogenic, and obstructive. The wide range of etiologies can contribute to each of these categories. Undifferentiated shock means that the diagnosis of shock has been made; however, the underlying etiology has not been uncovered.

In this case of undifferentiated shock, we suspected obstructive shock because of the history of endocarditis and the rapid increase in blood pressure to 2 liters of fluid.

Obstructive shock is usually due to a decrease in the left ventricular cardiac output due to pulmonary or mechanical causes.

1. Pulmonary vascular - due to impaired blood flow from the right heart to the left heart. Examples include hemodynamically significant pulmonary embolism, severe pulmonary hypertension.
2. Mechanical - impaired filling of right heart or due to decreased venous return to the right heart due to extrinsic compression. Examples include tension pneumothorax, pericardial tamponade, restrictive cardiomyopathy, constrictive pericarditis.

What is appropriate to do next? (Click on the correct answer to be directed to the third of six pages)

1. Blood cultures with empiric antibiotics
2. Echocardiogram
3. CT Chest / Angio
4. 1 and 3
5. All of the above

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