Shock - Emergency Shock - Emergency Approach-Approach-

Part IIPart II

Cardiogenic shock - etiologyCardiogenic shock - etiology

• Contractility:Contractility:•AMIAMI

•Aneurysm LVAneurysm LV

•Cardiomiopathy Cardiomiopathy

•Myocardium contusionMyocardium contusion

•Acute myocarditisAcute myocarditis

•LV dysfunction (toxics, drugs)LV dysfunction (toxics, drugs)

•Arrhythmia/ AVBArrhythmia/ AVB

Cardiogenic shock - etiologyCardiogenic shock - etiology• Mechanic problems:Mechanic problems:

– Post partumPost partum– Acute mitral regurgitation capillary muscles Acute mitral regurgitation capillary muscles

break/dysfunctionbreak/dysfunction– ASoASo– HCMHCM– Aorta dissectionAorta dissection– Ventricular septum breakVentricular septum break

– Pre partumPre partum– Mitral stenosisMitral stenosis– Atria mixomAtria mixom– Massive pulmonary embolismMassive pulmonary embolism– Ventricular septum breakVentricular septum break– Heart break with tamponadeHeart break with tamponade– Aorta dissection with pericardia tamponadeAorta dissection with pericardia tamponade– Pericardia tomponadePericardia tomponade

Pathophysiology- Shock in Pathophysiology- Shock in AMIAMI

PhysiopathologyPhysiopathology

• AMI classes- Forrester:AMI classes- Forrester:– I- CO normal + preload normal I- CO normal + preload normal

( reperfusion treatment)- mortality 3 %( reperfusion treatment)- mortality 3 %

- II- CO normal + pulmonary edema - II- CO normal + pulmonary edema (vasodilatations, diuretic)- mortality 9 %(vasodilatations, diuretic)- mortality 9 %

– III- low CO, normal preload (volume, III- low CO, normal preload (volume, inotrop positive)- mortality 23 %inotrop positive)- mortality 23 %

– IV- low CO, preload high ( inotrop positive, IV- low CO, preload high ( inotrop positive, vasodilatation) - mortality > 50 %vasodilatation) - mortality > 50 %

CCliniclinic framework framework

• Cardiac disease signs: angina pain, Cardiac disease signs: angina pain, dispnea, astheniadispnea, asthenia

• Shock signsShock signs

• Signs of acute left ventricular Signs of acute left ventricular insufficiency and right acute insufficiency and right acute ventricular insufficiencyventricular insufficiency

• Anxiety, restlessness, altered mental state due to Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia.decreased cerebral perfusion and subsequent hypoxia.

• Hypotension due to decrease in cardiac output.Hypotension due to decrease in cardiac output.

• A rapid, weak, thready pulse due to decreased circulation A rapid, weak, thready pulse due to decreased circulation combined with tachycardia.combined with tachycardia.

• Cool, clammy, and mottled skin (cutis marmorata), due to Cool, clammy, and mottled skin (cutis marmorata), due to vasoconstriction and subsequent hypoperfusion of the vasoconstriction and subsequent hypoperfusion of the skin.skin.

• Distended jugular veins due to increased jugular venous Distended jugular veins due to increased jugular venous pressure.pressure.

• Oliguria (low urine output) due to insufficient renal Oliguria (low urine output) due to insufficient renal perfusion if condition persists.perfusion if condition persists.

• Rapid and deep respirations (hyperventilation) due to Rapid and deep respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis.sympathetic nervous system stimulation and acidosis.

• Fatigue due to hyperventilation and hypoxia.Fatigue due to hyperventilation and hypoxia.

• Pulmonary edema, involving fluid back-up in the lungs Pulmonary edema, involving fluid back-up in the lungs due to insufficient pumping of the heart.due to insufficient pumping of the heart.

DiagnosDiagnosisis

• Physical examPhysical exam• Ecg 12 leadsEcg 12 leads• Thoracic radiography – pulmonary Thoracic radiography – pulmonary

overloading, ICT overloading, ICT • Arterial gasesArterial gases• Myocardium enzymesMyocardium enzymes• Transthoracic and trans esophageal Transthoracic and trans esophageal

echocardiography echocardiography • Hemodynamic invasive monitoringHemodynamic invasive monitoring

TrTreeatamentatament

• Cardiac diseases: trombolysis, PTCA, Cardiac diseases: trombolysis, PTCA, cardiovascular surgerycardiovascular surgery

• APE: mechanic ventilation, APE: mechanic ventilation, vasodilatators, diureticvasodilatators, diuretic

• Positive inotropic support: dopamine, Positive inotropic support: dopamine, dobutamine, aortic contra pulsation dobutamine, aortic contra pulsation balloonballoon

• Emergency surgeriesEmergency surgeries

Neurogenic shock - Neurogenic shock - definitiondefinition• Hypotension and bradycardia Hypotension and bradycardia

appeared after acute lesion of the appeared after acute lesion of the spine with sympathic influx spine with sympathic influx interruptioninterruption

• Spinal shock – temporary loss of Spinal shock – temporary loss of medullar reflex activity appeared medullar reflex activity appeared after a total spine lesionafter a total spine lesion

• Epidemiology – close traumas (car, Epidemiology – close traumas (car, motobike accidents), open traumas motobike accidents), open traumas (white weapons, fire weapons) (white weapons, fire weapons)

PhysiopathologyPhysiopathology

• Traumatic event: spine compression, Traumatic event: spine compression, dilacerationdilaceration

• Medullar secondary lesions (days, Medullar secondary lesions (days, weeks)-ischemia, local arterial weeks)-ischemia, local arterial lesions, intra-arterial thromboseslesions, intra-arterial thromboses

• Sympathic tonus loss with emphasis Sympathic tonus loss with emphasis on the parasympathic oneon the parasympathic one

• Hypotension, bradycardiaHypotension, bradycardia

CCliniclinic framework framework

• Traumatic context (close or open)Traumatic context (close or open)

• Hypotension with warm and dry teguments, Hypotension with warm and dry teguments, possibly hypothermiapossibly hypothermia

• BradycardiaBradycardia

• Lesion upper than T1- blocking of whole Lesion upper than T1- blocking of whole SNVSSNVS

• Lesion T1-L3 – partial interruption of SNVSLesion T1-L3 – partial interruption of SNVS

• Different framework in penetrative trauma Different framework in penetrative trauma (hemorrhagic component)(hemorrhagic component)

TrTreeatamentatament

• A- with cervical spine protectionA- with cervical spine protection

• B- ventilation, oxygenationB- ventilation, oxygenation

• C- fluids resuscitation: crystalline solutionsC- fluids resuscitation: crystalline solutions

• D- neurological evaluationD- neurological evaluation

• E- secondary evaluation of a patient with E- secondary evaluation of a patient with traumatrauma

• Corticotherapy metilprednisolon 30 mg/kg Corticotherapy metilprednisolon 30 mg/kg during the first hour then 5,4 mg/ kg/h ,23hduring the first hour then 5,4 mg/ kg/h ,23h

• Vasopressor support - dopamine, dobutamineVasopressor support - dopamine, dobutamine

Obstructive shockObstructive shock

• Cardiac tamponadeCardiac tamponade

• Tension pneumotoraxTension pneumotorax

• Massive Pulmonary EmbolismMassive Pulmonary Embolism

• How to recognize?How to recognize?

• How to treat?How to treat?

high risc PE high risc PE

(shock or hypotension)(shock or hypotension)

CT available immediate *CT available immediate *

EchocardiographyEchocardiography

R V distensionR V distension

no yes

CT available CT available

pozitiv negativ

Cercetarea Cercetarea altor cauzealtor cauze

Tromboliza/ Tromboliza/ embolectomiembolectomi

a a nejustificatenejustificate

Cercetarea altor Cercetarea altor cauzecauze

Tromboliza/ Tromboliza/ embolectomia embolectomia nejustificatenejustificate

CT no availble* alte CT no availble* alte teste teste sausau pacient pacient

instabilinstabil

Tratamentul Tratamentul specific al EP specific al EP este justificat este justificat

Tromboliza Tromboliza sau sau

embolectoembolectomiemie

no yes CTCT