CARDIOGENIC SHOCK University of Medicine and Pharmacy, Iasi School of Medicine ANESTHESIA and INTENSIVE CARE Conf. Dr. Ioana Grigoras MEDICINE 4th year English Program Suport de curs CARDIOGENIC SHOCK

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 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 SpO2 invasive BP ECG CVP 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 SpO2 invasive BP ECG CVP 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 etiological diagnosis ECG hemodynamic parametres etiological diagnosis ECG Hemodynamic parameters Myocardial enzymes Echocardiography 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.