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1、Outline,Overview of shock Hemodynamic Parameters PA catheter, complications Differentiating Types of Shock Cardiogenic Shock Etiologies Pathophysiology Clinical Findings Treatment,SHOCK= Inadequate Tissue Perfusion,Mechanisms: Inadequate oxygen delivery Release of inflammatory mediators Further micr
2、ovascular 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) Centr
3、al Venous Pressure (CVP),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 artery Arrhythmias RBBB PA rupture PAC related infection Pulmonary infarction,Cardio
4、genic 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,Etiologies,Acute myocardial infarcti
5、on/ischemia LV failure VSR Papillary muscle/chordal rupture- severe MR Ventricular free wall rupture with subacute tamponade,Other conditions complicating large MIs Hemorrhage Infection Excess negative inotropic or vasodilator medications Prior valvular heart disease Hyperglycemia/ketoacidosis Post-
6、cardiac arrest Post-cardiotomy Refractory sustained tachyarrhythmias Acute fulminant myocarditis End-stage cardiomyopathyHypertrophic cardiomyopathy with severe outflow obstruction Aortic dissection with aortic insufficiency or tamponade Pulmonary embolu Severe valvular heart disease -Critical aorti
7、c or mitral stenosis, Acute severe aortic or MR,Pathophysiology,Clinical Findings,Physical Exam: elevated JVP, +S3, rales, oliguria, acute pulmonary edema Hemodynamics: dec CO, inc SVR, dec SvO2 Initial evaluation: hemodynamics (PA catheter), echocardiography, angiography,4 Potential Therapies,Press
8、ors Intra-aortic Balloon Pump (IABP) Fibrinolytics Revascularization: CABG/PCI Refractory shock: ventricular assist device, cardiac transplantation,Pressors do not change outcome,Dopamine 10 vasoconstriction (alpha effects) Dobutamine positive inotrope, vasodilates, arrhythmogenic at higher doses No
9、repinephrine (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,IABP is a temporizing measure,Augments coronary blood flow in diastole Balloon collapse in sys
10、tole creates a vacuum effect decreases afterload Decrease myocardial oxygen demand,Indication for IABP,Contraindications to IABP,Significant aortic regurgitation or significant arteriovenous shunting Abdominal aortic aneurysm or aortic dissection Uncontrolled sepsis Uncontrolled bleeding disorder Se
11、vere bilateral peripheral vascular disease Bilateral femoral popliteal bypass grafts for severe peripheral vascular disease.,Complications of IABP,Cholesterol Embolization CVA Sepsis Balloon rupture Thrombocytopenia Hemolysis Groin Infection Peripheral Neuropathy,Revascularization SHOCK trial,Overal
12、l 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,