1. Shock - Emergency Approach-
Part II

2. Cardiogenic shock - etiology
Contractility:
AMI
Aneurysm LV
Cardiomiopathy
Myocardium contusion
Acute myocarditis
LV dysfunction (toxics, drugs)
Arrhythmia/ AVB

3. Cardiogenic shock - etiology
Mechanic problems:
Post partum
Acute mitral regurgitation capillary muscles break/dysfunction
ASo
HCM
Aorta dissection
Ventricular septum break
Pre partum
Mitral stenosis
Atria mixom
Massive pulmonary embolism
Heart break with tamponade
Aorta dissection with pericardia tamponade
Pericardia tomponade

4. Pathophysiology- Shock in AMI

5. Physiopathology AMI classes- Forrester:
I- CO normal + preload normal ( reperfusion treatment)- mortality 3 %
- II- CO normal + pulmonary edema (vasodilatations, diuretic)- mortality 9 %
III- low CO, normal preload (volume, inotrop positive)- mortality 23 %
IV- low CO, preload high ( inotrop positive, vasodilatation) - mortality > 50 %

6. Clinic framework Cardiac disease signs: angina pain, dispnea, asthenia
Shock signs
Signs of acute left ventricular insufficiency and right acute ventricular insufficiency

7. Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia.
Hypotension due to decrease in cardiac output.
A rapid, weak, thready pulse due to decreased circulation combined with tachycardia.
Cool, clammy, and mottled skin (cutis marmorata), due to vasoconstriction and subsequent hypoperfusion of the skin.
Distended jugular veins due to increased jugular venous pressure.
Oliguria (low urine output) due to insufficient renal perfusion if condition persists.
Rapid and deep respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis.
Fatigue due to hyperventilation and hypoxia.
Pulmonary edema, involving fluid back-up in the lungs due to insufficient pumping of the heart.

8. Diagnosis Physical exam Ecg 12 leads
Thoracic radiography – pulmonary overloading, ICT
Arterial gases
Myocardium enzymes
Transthoracic and trans esophageal echocardiography
Hemodynamic invasive monitoring

9. Treatament Cardiac diseases: trombolysis, PTCA, cardiovascular surgery
APE: mechanic ventilation, vasodilatators, diuretic
Positive inotropic support: dopamine, dobutamine, aortic contra pulsation balloon
Emergency surgeries

11. Neurogenic shock - definition
Hypotension and bradycardia appeared after acute lesion of the spine with sympathic influx interruption
Spinal shock – temporary loss of medullar reflex activity appeared after a total spine lesion
Epidemiology – close traumas (car, motobike accidents), open traumas (white weapons, fire weapons)

12. Physiopathology Traumatic event: spine compression, dilaceration
Medullar secondary lesions (days, weeks)-ischemia, local arterial lesions, intra-arterial thromboses
Sympathic tonus loss with emphasis on the parasympathic one
Hypotension, bradycardia

13. Clinic framework Traumatic context (close or open)
Hypotension with warm and dry teguments, possibly hypothermia
Bradycardia
Lesion upper than T1- blocking of whole SNVS
Lesion T1-L3 – partial interruption of SNVS
Different framework in penetrative trauma (hemorrhagic component)

14. Treatament A- with cervical spine protection
B- ventilation, oxygenation
C- fluids resuscitation: crystalline solutions
D- neurological evaluation
E- secondary evaluation of a patient with trauma
Corticotherapy metilprednisolon 30 mg/kg during the first hour then 5,4 mg/ kg/h ,23h
Vasopressor support - dopamine, dobutamine

16. Obstructive shock Cardiac tamponade Tension pneumotorax
Massive Pulmonary Embolism
How to recognize?
How to treat?

17. Tromboliza sau embolectomie
high risc PE
(shock or hypotension)
CT available immediate * no
yes
Echocardiography
R V distension
CT available no
yes CT
CT no availble* alte teste sau pacient instabil
pozitiv
negativ
Cercetarea altor cauze
Tromboliza/ embolectomia nejustificate
Tratamentul specific al EP este justificat
Tromboliza sau embolectomie
Cercetarea altor cauze
Tromboliza/ embolectomia nejustificate