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Shock - Emergency Approach-

Shock - Emergency Approach-. Part II. Cardiogenic shock - etiology. Contractility: AMI Aneurysm LV Cardiomiopathy Myocardium contusion Acute myocarditis LV dysfunction (toxics, drugs) Arrhythmia/ AVB. Cardiogenic shock - etiology. Mechanic problems: Post partum

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Shock - Emergency Approach-

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  1. Shock - Emergency Approach- Part II

  2. Cardiogenic shock - etiology • Contractility: • AMI • Aneurysm LV • Cardiomiopathy • Myocardium contusion • Acute myocarditis • LV dysfunction (toxics, drugs) • Arrhythmia/ AVB

  3. Cardiogenic shock - etiology • Mechanic problems: • Post partum • Acute mitral regurgitation capillary muscles break/dysfunction • ASo • HCM • Aorta dissection • Ventricular septum break • Pre partum • Mitral stenosis • Atria mixom • Massive pulmonary embolism • Ventricular septum break • Heart break with tamponade • Aorta dissection with pericardia tamponade • Pericardia tomponade

  4. Pathophysiology- Shock in AMI

  5. Physiopathology • AMI classes- Forrester: • I- CO normal + preload normal ( reperfusion treatment)- mortality 3 % - II- CO normal + pulmonary edema (vasodilatations, diuretic)- mortality 9 % • III- low CO, normal preload (volume, inotrop positive)- mortality 23 % • IV- low CO, preload high ( inotrop positive, vasodilatation) - mortality > 50 %

  6. Clinic framework • Cardiac disease signs: angina pain, dispnea, asthenia • Shock signs • Signs of acute left ventricular insufficiency and right acute ventricular insufficiency

  7. Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia. • Hypotension due to decrease in cardiac output. • A rapid, weak, thready pulse due to decreased circulation combined with tachycardia. • Cool, clammy, and mottled skin (cutis marmorata), due to vasoconstriction and subsequent hypoperfusion of the skin. • Distended jugular veins due to increased jugular venous pressure. • Oliguria (low urine output) due to insufficient renal perfusion if condition persists. • Rapid and deep respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis. • Fatigue due to hyperventilation and hypoxia. • Pulmonary edema, involving fluid back-up in the lungs due to insufficient pumping of the heart.

  8. Diagnosis • Physical exam • Ecg 12 leads • Thoracic radiography – pulmonary overloading, ICT • Arterial gases • Myocardium enzymes • Transthoracic and trans esophageal echocardiography • Hemodynamic invasive monitoring

  9. Treatament • Cardiac diseases: trombolysis, PTCA, cardiovascular surgery • APE: mechanic ventilation, vasodilatators, diuretic • Positive inotropic support: dopamine, dobutamine, aortic contra pulsation balloon • Emergency surgeries

  10. Neurogenic shock - definition • Hypotension and bradycardia appeared after acute lesion of the spine with sympathic influx interruption • Spinal shock – temporary loss of medullar reflex activity appeared after a total spine lesion • Epidemiology – close traumas (car, motobike accidents), open traumas (white weapons, fire weapons)

  11. Physiopathology • Traumatic event: spine compression, dilaceration • Medullar secondary lesions (days, weeks)-ischemia, local arterial lesions, intra-arterial thromboses • Sympathic tonus loss with emphasis on the parasympathic one • Hypotension, bradycardia

  12. Clinic framework • Traumatic context (close or open) • Hypotension with warm and dry teguments, possibly hypothermia • Bradycardia • Lesion upper than T1- blocking of whole SNVS • Lesion T1-L3 – partial interruption of SNVS • Different framework in penetrative trauma (hemorrhagic component)

  13. Treatament • A- with cervical spine protection • B- ventilation, oxygenation • C- fluids resuscitation: crystalline solutions • D- neurological evaluation • E- secondary evaluation of a patient with trauma • Corticotherapymetilprednisolon 30 mg/kg during the first hour then 5,4 mg/ kg/h ,23h • Vasopressor support - dopamine, dobutamine

  14. Obstructive shock • Cardiac tamponade • Tension pneumotorax • Massive Pulmonary Embolism • How to recognize? • How to treat?

  15. high risc PE (shock or hypotension) CT available immediate * no yes Echocardiography R V distension CT available no yes CT CT no availble* altetestesaupacientinstabil pozitiv negativ Cercetarea altor cauze Tromboliza/ embolectomia nejustificate Tratamentul specific al EP este justificat Tromboliza sau embolectomie Cercetarea altor cauze Tromboliza/ embolectomia nejustificate

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