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1、Outline,Overview of shock Hemodynamic ParametersPA catheter,complicationsDifferentiating Types of ShockCardiogenic ShockEtiologiesPathophysiologyClinical FindingsTreatment,SHOCK=Inadequate Tissue Perfusion,Mechanisms:Inadequate oxygen delivery Release of inflammatory mediatorsFurther microvascular c
2、hanges,compromised blood flow and further cellular hypoperfusionClinical Manifestations:Multiple organ failureHypotension,Hemodynamic Parameters,Systemic Vascular Resistance(SVR)Cardiac Output(CO)Mixed Venous Oxygen Saturation(SvO2)Pulmonary Capillary Wedge Pressure(PCWP)Central Venous Pressure(CVP)
3、,Normal Values,Differentiating Types of Shock,PA Catheter Complications,Path of PAC:central venous circulation R heart pulmonary artery.The proximal port is in R atrium,distal port in pulm arteryArrhythmiasRBBBPA rupturePAC related infectionPulmonary infarction,Cardiogenic Shock,Systemic hypoperfusi
4、on secondary to severe depression of cardiac output and sustained systolic arterial hypotension despite elevated filling pressures.,Cardiogenic Shock,EtiologiesPathophysiologyClinical/Hemodynamic CharacteristicsTreatment Options,Etiologies,Acute myocardial infarction/ischemiaLV failureVSRPapillary m
5、uscle/chordal rupture-severe MRVentricular free wall rupture with subacute tamponade,Other conditions complicating large MIsHemorrhageInfectionExcess negative inotropic or vasodilator medicationsPrior valvular heart diseaseHyperglycemia/ketoacidosisPost-cardiac arrestPost-cardiotomyRefractory sustai
6、ned tachyarrhythmiasAcute fulminant myocarditisEnd-stage cardiomyopathyHypertrophic cardiomyopathy with severe outflow obstructionAortic dissection with aortic insufficiency or tamponadePulmonary emboluSevere valvular heart disease-Critical aortic or mitral stenosis,Acute severe aortic or MR,Pathoph
7、ysiology,Clinical Findings,Physical Exam:elevated JVP,+S3,rales,oliguria,acute pulmonary edemaHemodynamics:dec CO,inc SVR,dec SvO2Initial evaluation:hemodynamics(PA catheter),echocardiography,angiography,4 Potential Therapies,PressorsIntra-aortic Balloon Pump(IABP)FibrinolyticsRevascularization:CABG
8、/PCIRefractory shock:ventricular assist device,cardiac transplantation,Pressors do not change outcome,Dopamine 10 vasoconstriction(alpha effects)Dobutamine positive inotrope,vasodilates,arrhythmogenic at higher dosesNorepinephrine(Levophed):vasoconstriction,inotropic stimulant.Should only be used fo
9、r refractory hypotension with dec SVR.Vasopression vasoconstrictionVASO and LEVO should only be used as a last resort,IABP is a temporizing measure,Augments coronary blood flow in diastoleBalloon collapse in systole creates a vacuum effect decreases afterloadDecrease myocardial oxygen demand,Indicat
10、ion for IABP,Contraindications to IABP,Significant aortic regurgitation or significant arteriovenous shunting Abdominal aortic aneurysm or aortic dissection Uncontrolled sepsis Uncontrolled bleeding disorder Severe bilateral peripheral vascular disease Bilateral femoral popliteal bypass grafts for s
11、evere peripheral vascular disease.,Complications of IABP,Cholesterol EmbolizationCVA Sepsis Balloon ruptureThrombocytopeniaHemolysisGroin InfectionPeripheral Neuropathy,Revascularization SHOCK trial,Overall 30-Day Survival in the Study,Hochman J et al.N Engl J Med 1999;341:625-634,SHOCK trial,Hochman J et al.N Engl J Med 1999;341:625-634,Copyright restrictions may apply.,Hochman,J.S.et al.JAMA 2006;295:2511-2515.,Kaplan-Meier Long-term Survival of All Patients and Those Discharged Alive Following Hospitalization,SHOCK 6 years later,Question 1,Answer,Question 2,Answer,Question 3,Answer,
