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Hemodynamics
SHOCK= Inadequate Tissue Perfusion
Mechanisms:
Inadequate oxygen delivery
Release of inflammatory mediators
Further microvascular changes, compromised
blood flow and further cellular hypoperfusion
Clinical Manifestations:
Multiple organ failure
Hypotension
Hemodynamic Parameters
Systemic Vascular Resistance (SVR)
Cardiac Output (CO)
Mixed Venous Oxygen Saturation (SvO2)
Pulmonary Capillary Wedge Pressure (PCWP)
Central Venous Pressure (CVP)
Differentiating Types of Shock
Cardiogenic Shock
Systemic hypoperfusion secondary to severe
depression of cardiac output and sustained
systolic arterial hypotension despite elevated
filling pressures.
Cardiogenic Shock
Etiologies
Pathophysiology
Clinical/Hemodynamic Characteristics
Treatment Options
Pathophysiology
Cardiogenic
Shock
Clinical Findings
Physical Exam: elevated JVP, +S3, rales,
oliguria, acute pulmonary edema
1. Systemic Hypotension
systolic arterial pressure < 80 mmHg
2. Persistent Hypotension
at least 30 minutes
3. Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m/min
4. Tissue Hypoperfusion
Oliguria, cold extremities, confusion
5. Increased Left Ventricular Filling
Pulmonary capillary wedge pressure > 18 mmHg
Clinical Signs: Shock, Hypoperfusion, CHF, Acute Pulm Edema
Most likely major underlying disturbance?
Dopamine
<2 renal vascular dilation
<2-10 +chronotropic/inotropic (beta effects)
>10 vasoconstriction (alpha effects)
Dobutamine positive inotrope, vasodilates,
arrhythmogenic at higher doses
Norepinephrine (Levophed): vasoconstriction, inotropic
stimulant. Should only be used for refractory hypotension
with dec SVR.
Vasopression vasoconstriction
VASO and LEVO should only be used as a last resort
Pharmacologic Treatment of
Cardiogenic Shock
Class I
1. IABP is recommended for STEMI patients when
cardiogenic shock is not quickly reversed with
pharmacological therapy. The IABP is a stabilizing
measure for angiography and prompt
revascularization.
2. Intra-arterial monitoring is recommended for the
management of STEMI patients with cardiogenic
shock.
ACC/AHA Guidelines for Cardiogenic Shock
Class I
1. Early revascularization, either PCI or CABG, is
recommended for patients < 75 years old with ST
elevation or new LBBB who develop shock unless
further support is futile due to patients wishes or
unsuitability for further invasive care.
2. Fibrinolytic therapy should be administered to STEMI
patients with cardiogenic shock who are unsuitable for
further invasive care and do not have contraindications
for fibrinolysis.
3. Echocardiography should be used to evaluate
mechanical complications unless assessed by invasively
ACC/AHA Guidelines for Cardiogenic Shock
Class IIa
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