PURPOSE: The prompt diagnosis of shock states leads to early, goal directed therapy and decreased morbidity and mortality. The accuracy of physical examination in differentiating shock syndromes is not well established. The aim of this study was to determine the accuracy of examination parameters in different shock syndromes.
METHODS: Retrospective review of 30 patients in shock admitted to a tertiary care intensive care unit with 10 patients in each of the major shock classes; distributive, cardiogenic, and hypovolemic. Screening of shock was performed according to following criteria: systolic blood pressure of < 90 or a drop ≥40 mmHg from baseline on two successive measurements 10 minutes apart in the absence of vasoactive medications, or a shock index (heart rate/systolic blood pressure) >1, or a lactate >3 mg/dL regardless of blood pressure. Trauma patients, patients with an age <16, or those without research authorization were excluded. Data on demographics, heart rate, blood pressure, jugular venous distention (JVD), the presence of warm or cold skin temperature, rales on lung examination, and an S3/S4 gallop were recorded.
RESULTS: Patients with hypovolemic shock were older compared to distributive or cardiogenic shock patients (p<0.02). No difference in mean arterial pressure existed between the three groups. Patients with cardiogenic shock were more likely to have JVD (80% vs. 20% vs. 0%; p<0.02), cold skin (57.1% vs. 14.3% vs. 28.5%; p<0.003), and pulmonary rales (75% vs. 16.7% vs. 8.3%; p<0.0002) compared to those with distributive and hypovolemic shock. Patients with distributive shock trended toward a higher median shock index compared to hypovolemic and cardiogenic shock patients (1.28 vs. 1.21 vs 1.02; p<0.056).
CONCLUSION: Patients in cardiogenic shock present with jugular venous distention, rales, and cool skin and patients with distributive shock may have higher shock indexes.
CLINICAL IMPLICATIONS: Accurate physical examination findings may lead to an earlier diagnosis and therapy of a shock state. Prospective studies are needed to determine the sensitivity and specificity of specific physical findings.
DISCLOSURE: Richard Patch, No Financial Disclosure Information; No Product/Research Disclosure Information