CARDIOGENIC SHOCK University of Medicine and Pharmacy, Iasi School of Medicine ANESTHESIA and...
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Transcript of CARDIOGENIC SHOCK University of Medicine and Pharmacy, Iasi School of Medicine ANESTHESIA and...
CARDIOGENIC SHOCK
University of Medicine and Pharmacy, IasiSchool of MedicineANESTHESIA and INTENSIVE CAREConf. Dr. Ioana Grigoras
MEDICINE4th year
English ProgramSuport de curs
CARDIOGENIC SHOCK
• Definition• Etiology• Pathophysiology• Clinical signs• Monitoring• Positive şi etiological diagnosis• Differential diagnosis• Principles of treatment
DEFINITION
= clinical syndrome caused by an acute disturbance of heart function, which results in reduction of systemic blood pressure
and tissue hypoperfusion with consecutive dysfunction of systems and organs.
= systemic BP< 90mmHg or mean BP< cu 30mmHg compared with basic values
IC < 2,2l/min m2
PCPB > 15mmHg
ETIOLOGY• Decreased myocardial contractility
- Myocardial infarction- Cardiomiopathy- Drugs, metabolic/electrolytic/acid-base disturbances, post-extracorporeal circulation
• Ventricular outflow obstruction- Aortic stenosis- Hypertrofic subvalvular aortic stenosis
• Ventricular filling disturbances• Mitral stenosis• Atrial myxoma
• Valvular dysfunction• Acute mitral regurgitation• Acute tricuspid regurgitation
• Cardiac dysrhytmias• Tachyarrhytmias• Bradyarrhytmias
• Cardiac rupture• Myocardial infarction• Chest trauma
PATHOPHYSIOLOGY myocardial ischemia ± necrosis → LV, RV, both
• Systolic myocardial dysfunction→ contractility → cardiac output→ Cardiac Index → systemic BP
• Diastolic myocardial dysfunction → LV compliance→
↑ LVTDP → ↑ retrograde pressure → ↑ PCPB → pulmonary congestion→ hypoxemia
• Neuro-vegetative response→↑sympatic stimulation +↑ cortisol, ADH + ↑ SRAA → peripheral vasoconstriction → oliguria + metabolic acidosis
compensatory effects decompensatory effects
vicious circles = death spiral
PATHOPHYSIOLOGY
CLINICAL SIGNS
• Arterial hypotension• Signs of tissue hypoperfusion• Signs of pulmonary congestion
• altered mental status • Cyanosis, cold extremities, profuse sweating• Hypotension, low pulse amplitude• Tachypnea, dyspnea,pulmonary rales , turgescent jugular veins• Tachycardia, arrhythmias (brady-/tachyarrhytmias),heart murmurs or
overlapping heart sounds• Oliguria
MONITORING• clinical signs
– mental status, skin temperature and colour
• SpO2
• invasive BP• ECG• CVP• other hemodynamic parameters
– pulmonary artery pressure, PCPB, RVS, RVP, DC, SvO2
• echocardiography• urinary output• pH + blood gas analysis• function of organ and systems
– renal, liver, coagulation tests, electrolytes, Hb, Ht, WBC count, bllod glucose
MONITORING
MONITORING
MONITORING
MONITORING
MONITORING
MONITORING
MONITORING• clinical signs
– mental status, skin temperature and colour
• SpO2
• invasive BP• ECG• CVP• other hemodynamic parameters
– pulmonary artery pressure, PCPB, RVS, RVP, DC, SvO2
• echocardiography• urinary output• pH + blood gas analysis• function of organ and systems
– renal, liver, coagulation tests, electrolytes, Hb, Ht, WBC count, bllod glucose
DIAGNOSIS
• positive diagnosis clinical signs
hemodynamic parametres
• etiological diagnosis ECG
Hemodynamic parameters Myocardial enzymesEchocardiography
others investigations
DIFFERENTIAL DIAGNOSIS
HR
BP CO CVP PAOP SVR Da-vO2 SvO2
Hypovolemic shock
↑ ↑ ↑
Cardiogenic shock
↑ ↑ ↑ ↑ ↑
septic shock ↑ ↑ N N N ↑
ABBREVIATIONS:• HR – heart rate• BP – arterial blood pressure• CO – cardiac output• CVP –central venous pressure• PAOP – pulmonary artery occlusion pressure• SVR – systemic vascular resistance
• Da-v O2 – oxygen arterial-venous difference
• SvO2 – mixed venous blood oxygen saturation
PRINCIPLES OF TREATMENT
• early and aggresive treatment –
save time • Save functional myocardium
improvement of the myocardial oxygen supply/demand balance
• Save ischemic myocardium
Myocardial reperfusion
PRINCIPLES OF TREATMENT
• Improvement of the myocardial oxygen supply -demand relationship
• ↑ myocardial oxygen supply • Correction of hypoxemia – O2 therapy, ventilatory support (CPAP, PEEP)• Correction of hypotension – volemic therapy
vasoconstrictors• Improvement of cardiac output - inotropic agents
myocardial oxygen demand• Treatment of pain – opioids, analgesics • Treatment of cardiac dysrhythmias – cardioversion
antiarrhytmic agents pacing
• Other means of hemodynamic support• Intraaortic ballon counterpulsation• Mechanical ventricular assist devices
PRINCIPLES OF TREATMENT
PRINCIPLES OF TREATMENT
• myocardial reperfusion– Thrombolysis
– PTCA
– Cardiac surgery: emergency coronary artery by-pass
correction of mechanical defects
cardiac transplant
CONCLUSIONS
• Cardiogenic shock is most frequently, the consequence of acute myocardial infarction
• Mortality is high (40-80%)• The clinical picture consists of arterial hypotension, signs
of tissue hypoperfusion and signs of pulmonary congestion
• Invasive hemodynamic monitoring is essential for diagnosis and guidance of treatment
• Early start of treatment and early myocardial reperfusion – improved chances of survival
• Early PTCA - the treatment of choice.