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.