8/13/2019 Cardiogenik Shock
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Shock, circulatory
DESCRIPTION:
Inadequate perfusion (oxygen supply) of tissues
which results in organ dysfunction, cellular and
organ damage and, if not corrected quickly, death of
the patient. Classification of shock:
ypo!olemic shock " cardiac output is se!erely
reduced due to loss of intra!ascular !olume whichresults in
reduced return of !enous #lood to the
heart. $ost often caused #y #lood loss.
Cardiogenic shock " cardiac output is se!erely
reduced due to a loss of myocardial muscle
function, !al!ular dysfunction or arrhythmia. $ost
often caused #y large myocardial infarctions.
%#structi!e shock " cardiac output is se!erely
reduced #y !ascular o#struction of !enous return to
the heart (!ena ca!a syndrome), compression of the
heart, (pericardial tamponade, tension
pneumothorax) or outflow from the heart (aorticdissection,
pulmonary em#olism)
&istri#uti!e shock " maldistri#ution of #lood flow
'enous pooling (most often due to spinal shock
or drug o!erdose) #eha!es much like hypo!olemic
shock, cardiac output se!erely reduced #ecause
#lood is pooled in peripheral !eins rather than #eing
returned to the heart
igh output or !asodilating shock (most often
due to sepsis or septic like states such as toxic
shock) is unique in that cardiac output is normal or
ele!ated, #ut not distri#uted appropriately, resulting
in o!er perfusion of some tissues and
underperfusion (to the point of critical ischemia) of
other tissues.
Predominant age:ll ages. &etermined #y
underlying diseases causing shock. $ore frequent
and less well tolerated in the elderly.
Predominant sex:$ale *emale
+I-+ -& +$/0%$+: 1nderlying disease:
1pper gastrointestinal (1I) #leeding (ulcer
pain, hematemesis, melena)
+epsis (fe!er, chills, dysuria and2or
costo!erte#ral angle 3C'4 tenderness with urinary
tract infection)
$yocardial infarction (chest pain, diaphoresis,
nausea, !omiting, +5 or +6 gallop, new heart
murmur, rales due to pulmonary edema)
1nderperfusion of organ systems:
7rain: confusion, anxiety, agitation, coma onlyif se!ere
8idney: oliguria
+kin: peripheral cyanosis, sluggish capillary
refill, mottling, coolness, may #e o!erly perfused
(flushed) in high output (septic) shock
I: a#sence of #owel sounds
Circulation: thready pulses, tachycardia,
hypotension (mean arterial pressure 9 ; torr or
systolic pressure 9 ugular"!enous distention (>'&),
pulsus paradoxus in
pericardial tamponade.
CAUSES:
ypo!olemic shock
7lood loss due to trauma or gastrointestinal
#leeding
0hird space loss of plasma !olume
(pancreatitis, #owel o#struction, infarction,
anaphylaxis) &iarrhea (e.g., in cholera like states)
7urns
Cardiogenic shock
cute myocardial infarction (= 5;? of @'
mass)
rrhythmia (heart #lock, !entricular
tachycardia, atrial fi#rillation with rapid !entricular
response, etc.)
cute !al!ular dysfunction (mitral !al!e due to
papillary muscle rupture following inferior $IAs or
chordal rupture) aortic or mitral !al!e due to
#acterial endocarditis
'entricular septal rupture following
anterior2septal $IAs
%#structi!e shock
/ericardial tamponade
Inferior2superior !ena ca!al o#struction usually
due to neoplasms
ortic dissection
$assi!e pulmonary em#olism
&istri#uti!e shock 'enous pooling is due to a loss of !enous
tone
caused #y loss of sympathetic ner!ous system
acti!ity due to acute spinal inBury, general or spinal
anesthesia or o!erdose of sedati!e drugs
igh output shock is due to sepsis, toxic shock
or anaphylaxis (once plasma !olume normalied)
RISK FACTORS:
Included with Causes
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
8/13/2019 Cardiogenik Shock
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-2
@7%D0%D:
+pecific to shock
Ele!ated lactate (= F mmol2@) indicates
anaero#ic meta#olism due to underperfusion of
tissues
Deduced mixed !enous /;F (9 FG mm g) (9
6.H k/a) o#tained from the pulmonary arteryindicates !igorous
extraction of oxygen from tissues
due to underperfusion
1nderlying diseases responsi#le to shock
EC, C/8 (serial)
Chest x"ray
rterial #lood gases
ram stain and culture of infected sites
7lood cultures
C7C (serial determination of g#2ct in
#leeding patients)
Drugs that may alter lab results:-2
Disorders that may alter lab results:-2
PATHOLOGICAL FINDINGS:
-2
SPECIAL TESTS:
Certain tests are essential to making correct and
prompt diagnosis in order to dictate specific therapy
of disease states producing shock. *or example:
Endoscopy2Dadioisotope #leeding scans ena#le
localiation of ongoing #leeding which may direct
surgical inter!ention. 0he endoscopist may
inter!ene directly !ia the endoscope. (e.g., inBection
of sclerosants into !arices or ulcers).
Echocardiograms may detect and2or quantify
pericardial effusions in shock due to pericardial
tamponade. /ericardiocentesis can then #e
performed under echocardiographic guidance. lsouseful for
detection of !al!ular failure.
@ung scans and2or pulmonary arteriography for
the detection of massi!e pulmonary em#olism
/ulmonary artery (+wan"an) catheteriation for
serial measurement of cardiac output, central
!enous, pulmonary arterial and pulmonary arterial
occlusion pressures (left atrial pressure) and
!ascular resistance. $ixed !enous #lood gases can
#e drawn from the catheter. Indicated when the
etiology of shock is uncertain, in cardiogenic and
septic shock, or when initial therapy of shock failsto pro!ide
for rapid correction of perfusion failure.
TREATMENT
APPROPRIATE HEALTH CARE:
Emergency room or intensi!e or coronary care
unit
Continuous electrocardiographic monitoring with
frequent assessment of #lood pressure, respiratory
status, and urine output
GENERAL MEASURES: 0herapy must proceed quickly #efore
extensi!e
damage to !ital organs occur. 0herapy is directed
simultaneously to correct #oth the deficit in tissue
perfusion and the underlying disease causing shock
(see ssociated conditions).
$aintain +a%F =
