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Presentation on theme: "CHAPTER 20 HEART FAILURE AND CIRCULATORY SHOCK Essentials of Pathophysiology."— Presentation transcript:


2 PRE LECTURE QUIZ True/False  Decreased cardiac output will lead to an increase in renal blood flow and glomerular filtration rate.  The endothelins are potent vasodilators that are released from the endothelial cells throughout the circulation.  Myocardial hypertrophy is a long-term mechanism by which the heart compensates for increased workload.  Afterload represents the force that the contracting heart must generate to eject blood from the filled heart.  Five major complications of severe shock are acute respiratory distress syndrome, acute renal failure, gastrointestinal ulceration, disseminated intravascular coagulation, and multiple organ dysfunction syndrome. F F T T T

3 PRE LECTURE QUIZ  In __________ heart failure, blood backs up in the systemic circulation, causing peripheral edema and congestion of the abdominal organs.  The most common cause of ____________ shock is myocardial infarction.  Examples of conditions that cause __________ shock include loss of whole blood (e.g., hemorrhage), plasma loss (e.g., severe burns), or extracellular fluid (e.g., gastrointestinal fluids lost in vomiting or diarrhea).  An increase in __________ rate is an early sign of shock.  A life-threatening condition, acute __________ edema is the most dramatic symptom of left heart failure and is characterized by capillary fluid moving into the alveoli. cardiogenic heart hypovolemic pulmonary right

4 STANDARD ECG WAVEFORM Atrial Contraction initiated Ventricular Contraction initiated Ventricular Relaxation Papillary Muscle Relaxation ST segment can indicate ischemia or infarction

5 ST SEGMENT ELEVATION ST Depression With a 12 lead ECG certain leads can be connected to each other to reverse the R wave and accentuate the ST Elevation

6 CORORNARY OCCLUSION total occlusion of the proximal segment of left anterior descending artery, and severe disease involving the proximal segment of the obtuse marginal branch Angiogram

7 TYPES OF HEART FAILURE  High-output versus low-output failure  Is cardiac output high or low?  Systolic or diastolic failure  Is the heart failing to pump out enough blood, or failing to accept enough blood from the body and lungs?  Right-sided or left-sided failure  Is the right or left side of the heart failing?

8 MANIFESTATIONS OF HEART FAILURE  Effects of impaired pumping  Effects of decreased renal blood flow  RAA pathway  Effects of the sympathetic nervous system AngioplastyAngioplasty CABGCABG

9 MANIFESTATIONS OF HEART FAILURE Orthopnea: Straight Breathing, ie. Must be straight upright, or difficult breathing occurs


11 SCENARIO:  Mr. M has heart failure and he complains of severe shortness of breath, and has fluid in his lungs. He has tachycardia, increased diastolic blood pressure, pale moist skin, and says he feels weak, dizzy, and anxious all the time. Question: Which of these signs and symptoms are due to decreased renal blood flow? Which are due to the sympathetic nervous system? Which side of his heart do you think is failing?

12 LEFT-SIDED HEART FAILURE Systolic: LV does not pump enough blood to body Diastolic: LV does not accept enough blood from lungs Body lacks blood Lungs fill with fluid right heart lungs left heart body Blood Flow

13 RIGHT-SIDED HEART FAILURE Systolic: RV does not pump enough blood to lungs Diastolic: RV does not accept enough blood from body Body fills with blood Lungs do not oxygenate enough blood right heart lungs left heart body Blood Flow

14 PULMONARY EDEMA  Capillary fluid moves into alveoli  Lung becomes stiffer  Harder to inhale  Less gas exchange in alveoli  Crackles  Frothy pink sputum  Hemoglobin not completely oxygenated

15 QUESTION Tell whether the following statement is true or false: The characteristic pink sputum produced is pulmonary edema is tinged with blood.

16 ANSWER True In pulmonary edema, the alveolar capillary membrane is damaged, and blood from the capillaries moves into the alveoli. The blood from the capillaries causes the sputum (produced from the lower respiratory tract) to appear pink or light red.

17 CARDIOGENIC SHOCK  Heart fails to pump blood adequately  Decreased cardiac output lowers BP  Sympathetic system responds  Vasoconstriction increases resistance to blood flow  Increased workload on heart worsens heart failure

18 TYPES OF SHOCK  Cardiogenic  Hypovolemic  Obstructive  Distributive  Septic

19 BLOOD PRESSURE BP = CO x PR  Which of the following affect CO, and which affect PR? Why?  Blood volume  Heart rate  Vasoconstriction  Angiotensin II  Aldosterone  Epinephrine  Histamine

20 SCENARIO:  Mr. M was injured in a motorcycle accident.  On his arrival at the hospital he presented with bleeding from the right leg, restlessness, pallor, sweating, elevated heart rate, weak pulse, rapid breathing, and lack of bowel sounds; his blood pressure was slightly elevated Question:  What has happened to this patient’s:  Stroke volume  Cardiac output  Sympathetic nervous system

21 SCENARIO (CONT.)  Although he was given 6 units of blood, Mr. M got worse  He became lethargic and his blood pressure began to fall; he still had no bowel sounds or urine production Question:  The intern ordered epinephrine, and Mr. M’s blood pressure increased. Why?  Later, you overhear the resident telling the intern that was not the best treatment. Why not, if it raised Mr. M’s blood pressure?

22 SCENARIO (CONT.)  Mr. M’s blood pressure went up a bit  He has been moved out of the ICU Question:  His chart says you should do a 24-hour urine collection. Why?

23 SCENARIO (CONT.)  Mr. M appears to be improving  He sleeps quite a lot, but his blood pressure has remained stable; he had a little urine production; and he did not eat his supper  Checking on him in the evening, you notice that he is slightly flushed, his respiration rate is a little high, and his temperature is elevated Question:  What is happening to his peripheral resistance?  What do you expect his heart rate to be like? Why?

24 DISTRIBUTIVE OR VASODILATORY SHOCK  Blood vessels dilate  There is not enough blood to fill the circulatory system  Blood flow decreases  Less blood is returned to the heart  Less blood is circulated to the body

25 QUESTION Which type of shock is caused by low blood volume? a. Cardiogenic b. Hypovolemic c. Distributive d. Septic

26 ANSWER b. Hypovolemic Hypo (low) volemia (blood volume) occurs when a patient has lost blood due to trauma, surgery, or third space fluid loss.

27 CAUSES OF DISTRIBUTIVE SHOCK  Decreased sympathetic activity: neurogenic  Brain or spine injury; anesthetics; insulin shock; emotion  Vasodilator substances in blood  Type I hypersensitivity (anaphylactic shock)  Inflammatory response to infection (sepsis)  Vessel damage from severe hypovolemia

28 MECHANISM OF TYPE I HYPERSENSITIVITY Mast cell Mast cell degranulates IgE attaches to mast cell Allergen attaches to IgE Allergen Granules released: Histamine, acetylcholine, kinins, leukotrienes, and prostaglandins all cause vasodilation

29 ANAPHYLAXIS  Systemic response to the inflammatory mediators released in type I hypersensitivity  Histamine, acetylcholine, kinins, leukotrienes, and prostaglandins all cause vasodilation º What will happen when arterioles vasodilate throughout the body?  Acetylcholine, kinins, leukotrienes, and prostaglandins all can cause bronchoconstriction º What will happen when the bronchioles constrict?

30 SEPSIS OR SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)  Inflammatory mediators released into the circulation  Tumor necrosis factor  Interleukins  Prostaglandins  Cause systemic signs of inflammation  Fever and increased respiration, respiratory alkalosis, vasodilation, warm flushed skin  Activate inflammatory pathways  Coagulation, complement

31 SEPSIS OR SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) (CONT.) Discussion:  Why is septic shock called distributive?  In the later phases of septic shock, blood volume decreases. What part of the inflammatory process explains this?


33 GUT BARRIER FAILURE decreased perfusion of the gut bacteria and toxins escape inflammatory response bacterial endotoxins in blood and lymph inflammatory mediators in blood and lymph vasodilation

34 SEPTIC SHOCK vasodilation decreased peripheral resistance decreased blood pressure SEPTIC SHOCK 40% mortality

35 SEPTIC SHOCK  Also called systemic inflammatory response syndrome (SIRS)  Inflammatory mediators also increase the metabolic rate of tissues, so they need more oxygen The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome

36 (Aird, W. C. [2003.] The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome. Blood 101[10], Retrieved February 10, 2004, from inflammatory mediators vascular endothelial cells respond and: promote clot formation create adhesive molecules more WBCs move out into the tissues and release more inflammatory mediators produce more vasodilation substances (NO) more vasodilation The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome

37 SEPTIC SHOCK (CONT.) “Despite the prompt implementation of appropriate antibiotic therapy, sepsis mortality remains high, in the range of 28% to 50%.” (Aird, W. C. [2003.] The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome. Blood 101[10], Retrieved February 10, 2004, from “Second, patients with culture-positive and culture- negative sepsis or septic shock have comparable mortality rates.”

38 SEPTIC SHOCK (CONT.) “Third, administration of anti-endotoxin antibodies in large, clinical trials did not improve survival.” (Aird, W. C. [2003.] The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome. Blood 101[10], Retrieved February 10, 2004, from

39 QUESTION Which type of shock is the result of a severe allergic reaction? a. Cardiogenic b. Obstructive c. Anaphylactic d. Septic

40 ANSWER c. Anaphylactic Anaphylactic shock is caused when inflammatory mediators are released (type I hypersensitivity reaction). The mediators include histamine, acetylcholine, kinins, leukotrienes, and prostaglandins, all of which cause vasodilation.

41 ACTIVATED PROTEIN C  Drotrecogin alpha - a recombinant form of human activated protein C that has anti-thrombotic, anti- inflammatory, and profibrinolytic properties - a treatment for severe sepsis  Blocks clotting  Blocks inflammation  Increases survival of the most seriously ill sepsis patients  May cause bleeding! The main function of protein C is its anticoagulant property as an inhibitor of coagulation factors V and VIII

42 COMPLICATIONS OF SHOCK Scenario:  A doctor has been called in to treat Mr. M and has started him on fluid and antibiotics  You are warned to watch him carefully for any signs of respiratory distress Question:  Why would blood pressure imbalances cause respiratory distress?

43 COMPLICATIONS OF SHOCK (CONT.)  Acute respiratory distress syndrome  Acute renal failure  Gastrointestinal complications  Disseminated intravascular coagulation  Multiple organ dysfunction syndrome

44 ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)  Exudate enters alveoli  Blocks gas exchange  Makes inhaling more difficult  Neutrophils enter alveoli  Release inflammatory mediators  Release proteolytic enzymes

45 ACUTE RENAL FAILURE (ARF)  Renal vasoconstriction cuts off urine production  Acute renal failure  Continued vasoconstriction cuts off renal oxygen supply  Renal tubular cells die  Acute tubular necrosis

46 DISSEMINATED INTRAVASCULAR COAGULATION (DIC) coagulation pathways activated clots in many small blood vessels microinfarcts, ischemia platelets and clotting proteins used up bleeding problems

47 MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)  The most frequent cause of death in the noncoronary intensive care unit  Mortality rates vary from 30% to 100%  Mechanism not known

48 QUESTION Tell whether the following statement is true or false: Treatment for ARDS often includes breathing assistance using mechanical ventilation.

49 ANSWER True Because alveoli are filled with exudate and blood that has leaked from the capillary, the surface area available for gas exchange is greatly reduced. Most patients will require ventilatory support until the process reverses. ARDS has a high mortality rate because it is difficult to ventilate these patients.

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