cardiogenic shock university of medicine and pharmacy, iasi school of medicine anesthesia and...
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CARDIOGENIC SHOCK
University of Medicine and Pharmacy, IasiSchool of MedicineANESTHESIA and INTENSIVE CAREConf. Dr. Ioana Grigoras
MEDICINE4th year
English ProgramSuport de curs
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CARDIOGENIC SHOCK
• Definition• Etiology• Pathophysiology• Clinical signs• Monitoring• Positive şi etiological diagnosis• Differential diagnosis• Principles of treatment
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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
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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
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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
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PATHOPHYSIOLOGY
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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
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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
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MONITORING
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MONITORING
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MONITORING
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MONITORING
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MONITORING
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MONITORING
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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
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DIAGNOSIS
• positive diagnosis clinical signs
hemodynamic parametres
• etiological diagnosis ECG
Hemodynamic parameters Myocardial enzymesEchocardiography
others investigations
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DIFFERENTIAL DIAGNOSIS
HR
BP CO CVP PAOP SVR Da-vO2 SvO2
Hypovolemic shock
↑ ↑ ↑
Cardiogenic shock
↑ ↑ ↑ ↑ ↑
septic shock ↑ ↑ N N N ↑
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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
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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
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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
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PRINCIPLES OF TREATMENT
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PRINCIPLES OF TREATMENT
• myocardial reperfusion– Thrombolysis
– PTCA
– Cardiac surgery: emergency coronary artery by-pass
correction of mechanical defects
cardiac transplant
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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.