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UNIVERSIDAD RICARDO PALMA FACULTAD DE MEDICINA HUMANA. V CURSO INTERNACIONAL DE ACTUALIZACIÓN EN MEDICINA Y CIRUGIA – IV JORNADA DE EDUCACIÓN MÉDICA UNIVERSITARIA CONFERENCIA: “SHOCK CARDIOGÉNICO” DOCTOR ALFREDO PALACIO

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Universidad ricardo palma facultad de medicina humana

UNIVERSIDAD RICARDO PALMAFACULTAD DE MEDICINA HUMANA

V CURSO INTERNACIONAL DE ACTUALIZACIÓN EN MEDICINA Y CIRUGIA – IV JORNADA DE EDUCACIÓN MÉDICA UNIVERSITARIA

CONFERENCIA:

“SHOCK CARDIOGÉNICO”

DOCTOR

ALFREDO PALACIO

I N C A P U E E S

INSTITUTO NACIONAL DE CARDIOLOGIA FACULTAD DE MEDICINA

“ALFREDO PALACIO” “ENRIQUE ORTEGA MOREIRA”

GUAYAQUIL – ECUADOR


Shock cardiogenico
SHOCK CARDIOGENICO

  • DEFINICION:

    • EVIDENCIA CLINICA DE HIPOPERFUSION

    • CON PRESION ARTERIAL SISTOLICA < 90 mm Hg>30 min

    • NECESIDAD DE TERAPIA PARA MANTENER PAS > DE 90 mmHg

    • IC < 2.2 L/ min / m2

    • PCP (en cuña) > 15 mm Hg

THE SHOCK TRIAL JAMA 2001; 285: 190-2


Shock cardiogenico1
SHOCK CARDIOGENICO

*SIGUE SIENDO LA 1ª CAUSA DE MUERTE – IH – EN EL IMA

(TAMI) I TRIAL CIRCULATION 1988; 77: 1090-90

NEJM 1991; 325: 1117-22

JACC 1992; 20: 1982-9


Shock cardiogenico2
SHOCK CARDIOGENICO

  • CAUSAS

    • EXTENSION DEL IMA (40% VI)

    • IMA DE VENTRICULO DERECHO

    • RM AGUDA (RUPTURA DE MP)

    • CIV AGUDA

    • RUPTURA DE PARED LIBRE

    • TAPONAMIENTO CARDIACO


Shock cardiogenico3
SHOCK CARDIOGENICO

  • PRIMER RX

    • LIMITAR TAMAÑO DEL IMA

    • RESTABLECER REPERFUSION CORONARIA

    • CONTROLAR RESPUESTAS INJURIOSAS

      • ACTIVIDAD SIMPATICA

      • SISTEMA SRA

      • RESISTENCIA PERIFERICA

      • POST CARGA


Shock cardiogenico4
SHOCK CARDIOGENICO

CURVAS DE PRESION Y DE PERFUSION CORONARIA


Shock cardiogenico ima
SHOCK CARDIOGENICOIMA

  • Injuria Miocardica Irreversible 15 - 20 min

  • Injuria completa area de riesgo 4 - 6 Hrs

  • Mayor magnitud del daño 2 - 3 Hrs

  • Restauración del flujo para

    obtener mayor beneficio 1 - 2 Hrs

  • Hipóteis de arteria abierta

    flujo normal mortalidad

  • Tamaño de infarto lo anterior mas colaterales


Emergency Management of Complicated STEMI

Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema

Most likely major underlying disturbance?

Hypovolemia

Low Output -

Cardiogenic Shock

Arrhythmia

Acute Pulmonary Edema

  • Administer

  • Furosemide IV 0.5 to 1.0 mg/kg

  • Morphine IV 2 to 4 mg

  • Oxygen/intubation as needed

  • Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP greater than 100 mm Hg

  • Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to 100 mm Hg and signs/symptoms of shock present

  • Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 to 100 mm Hg and no signs/symptoms of shock

Bradycardia

Tachycardia

  • Administer

  • Fluids

  • Blood transfusions

  • Cause-specific interventions

  • Consider vasopressors

Check Blood Pressure

First line of action

ACC/AHA Guidelines for Patients With ST-Elevation Myocardial Infarction

Check Blood Pressure

Systolic BP

Greater than 100 mm Hg

Systolic BP

70 to 100 mm Hg

NO signs/symptoms

of shock

Systolic BP

70 to 100 mm Hg

Signs/symptoms

of shock

Systolic BP

less than 70 mm Hg Signs/symptoms of shock

Systolic BP

Greater than 100 mm Hg

and not less than 30 mm Hg

below baseline

Second line of action

Norepinephrine

0.5 to 30 mcg/min IV

Nitroglycerin

10 to 20 mcg/min IV

Dobutamine

2 to 20 mcg/kg per minute IV

Dopamine

5 to 15 mcg/kg per minute IV

ACE Inhibitors

Short-acting agent such as captopril (1 to 6.25 mg)

Further diagnostic/therapeutic considerations (should be considered in nonhypovolemic shock)

Diagnostic Therapeutic

♥ Pulmonary artery catheter ♥ Intra-aortic balloon pump

♥ Echocardiography ♥ Reperfusion/revascularization

♥ Angiography for MI/ischemia

♥ Additional diagnostic studies

Circulation 2000;102(suppl I):I-172-I-216.

Third line of action


All cause mortality

0.4

ACE-I

0.35

Placebo

0.3

0.25

0.2

0.15

0.1

0.05

0

4

0

1

2

3

SAVERadionuclideEF £ 40%

AIREClinical and/or radiographic signs of HF

TRACEEchocardiographicEF £ 35%

All-Cause Mortality

Probability of Event

Placebo: 866/2971 (29.1%)

ACE-I: 702/2995 (23.4%)

OR: 0.74 (0.66–0.83)

Years

ACE-I 2995 2250 1617 892 223

Placebo 2971 2184 1521 853 138

Flather MD, et al. Lancet. 2000;355:1575–1581


SHOCK CARDIOGENICOIMA

When NOT to give Nitroglycerin

Nitrates should not be administered to patients with:

Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48

hours for tadalafil).

  • systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline

  • severe bradycardia (< 50 bpm)

  • tachycardia (> 100 bpm) or

  • suspected RV infarction.


Evidence grading

SHOCK CARDIOGENICOIMA

EVIDENCE GRADING

BENEFICIAL HARMFUL

A B C

RANDOMIZED EXPERT OPINION


PCI for Cardiogenic Shock

Cardiogenic Shock

Early Shock, Diagnosed on Hospital Presentation

Delayed Onset Shock Echocardiogram to Rule Out Mechanical Defects

Fibrinolytic therapy ifall of the followingare present:

1. Greater than 90 minutes to PCI

2.Less than 3 hours post STEMI onset

3. No contraindications

Arrange prompttransferto invasive procedure-capable center

Arrange rapid transfer to invasive procedure-capable center

IABP

Cardiac Catheterization and Coronary Angiography

1-2 vessel CAD

Moderate 3-vessel CAD

Severe 3-vessel CAD

Left main CAD

PCI IRA

PCI IRA

Immediate CABG

Cannot be performed

Staged Multivessel PCI

Staged CABG


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SHOCK CARDIOGENICO

  • BALON DE CONTRAPULSACION AORTICO (IABP)

CLASE IA

  • < 75 AÑOS

    • ST

    • BCRI

    • SHOCK < 36 HS DEL IMA

    • INTERVENCION < 18 HORAS

    • REVASCULARIZACION TEMPRANA


Shock cardiogenico6

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SHOCK CARDIOGENICO

BALON INTRAORTICO DE CONTRAPULSACION (IABP)

CLASE IB

  • STEMI + PAS < 90 mm Hg

  • PAm < 30 mm Hg

  • STEMI + ESTADO DE BAJO GASTO CARDIACO

  • STEMI + SHOCK SIN RESPUESTA FARMACOLOGICA

CLASE IC

  • STEMI + DOLOR PRECORDIAL

  • ISQUEMIA RECURRENTE

  • INESTABILIDAD HEMODINAMICA

  • FUNCION VENTRICULAR DEPRIMIDA

  • AREA MIOCARDICA DE RIESGO GRANDE

  • IACB + CAT + CIRUGIA


Shock cardiogenico7
SHOCK CARDIOGENICO

BALON INTARORTICO DE CONTRAPULSACION (IABP)

CLASE II a

  • STEMI + TAQUICARDIA VENTRICULAR POLIMORFA

  • STEMI + ICC



SHOCK CARDIOGENICOIMA

ACP PRIMARIA O DE RESCATE EN STEMI:

  • DEBE REALIZARSE –IB-

  • en pacientes severa (ICC) (Killip clase 3)

  • con Sx < 12 horas

  • La ACP Primaria debe realizarse -IA-

  • en pacientes< 75 años

  • con elevación ST o BCRI

  • SHOCK <36 horaspost MI,

  • ACP realizable <primeras 18 horas del shock.

  • En pacientes >75 años: -IIa B-


SHOCK CARDIOGENICOIMA

APC POSTERIOR A FIBRINOLISIS

APC debe ser realizada en pacientes con:

Evidencia objetiva deIMA recurrente

Isquemia miocardica moderada o severa, yasea espontanea o provocada,durante la recuperacion STEMI

Shockcardiogenico o inestabilidad hemodinamica.


Fibrinol sis reperfusi n

FIBRINOLÍSISREPERFUSIÓN


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SHOCK CARDIOGENICO

CLASE I

  • FIBRINOLISIS

    • CUANDO INTERVENCION ESTA CONTRAINDICADA

  • MONITOREO HEMODINAMICO INTRAARTERIAL

  • ECOCARDIOGRAFIA

    • (EVIDENCIAR COMPLICACIONES MECANICAS)


Shock cardiogenico9
SHOCK CARDIOGENICO

REVASCULARIZACION

(P=0.11)

(P<0.03)

THE SHOCK TRIAL


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SHOCK CARDIOGENICO

CLASE II

  • REVASCULARIZACION TEMPRANA

    • < 75 AÑOS

    • ST

    • BCRI

    • SHOCK < 36 HS DEL IMA

    • INTERVENCION < 18 HORAS

    • > 75 AÑOS INDICACION IIaB

  • CATETER PULMONAR


Right ventricular infarction
Right Ventricular Infarction

Clinical findings:Shock with clear lungs, elevated JVPKussmaul sign

Hemodynamics: Increased RA pressure (y descent)Square root sign in RV tracing

ECG:ST elevation in R sided leads

Echo:Depressed RV function

Rx:Maintain RV preloadLower RV afterload (PA---PCW)Inotropic supportReperfusion

V4R

Modified from Wellens. N Engl J Med 1999;340:381.


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SHOCK CARDIOGENICO

SOSPECHA DE IMA VD STEMI + INESTABILIDAD HEMODINAMICA

INFERIOR

CLASE I

  • EKG + V4R

  • ECOCARDIOGRAMA

  • REPERFUSION TEMPRANA ACP

  • CORREGIR BRADICARDIA Y ASINCRONIA AV

  • PRECARGA DERECHA

    • CARGA INICAL RESPUESTA POSITIVA

    • OPTIMIZAR VOLUMEN

    • PV < NORMAL

  • POSCARGA DERECHA

  • OPTIMIZAR FUNCION V IZQ.

  • ASISTENCIA INOTROPICA

    • CUANDO SOBRECARGA DE VOLUMEN ES INSUFICIENTE


Ventricular septal rupture

Mitral Regurgitation(Pap. M. dysfunction)

Free WallRupture

Ventricular Septal Rupture

Incidence 1-2% 1-6% 1-2%Timing 3-5 d p MI 3-6 d p MI 3-5 d p MIPhy Exam murmur 90% JVD, EMD murmur 50%Thrill Common No RareEcho Shunt Peric. Effusion Regurg. JetPA cath O2 step up Diast Press Equal. c-v wave in PCW

Images:Courtesy of W D Edwards (Mayo Foundation)Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.


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SHOCK CARDIOGENICO

REGURGITACION MITRAL

  • RUPTURA DE MUSCULO PAPILAR

    • CIRUGIA URGENTE

Mitral Regurgitation(Pap. M. dysfunction)

  • CONCOMITANTE CABG


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SHOCK CARDIOGENICO

RUPTURA SEPTAL O DE PARED LIBRE

Ventricular Septal Rupture

  • CIRUGIA URGENTE

  • CABG


Shock cardiogenico14

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SHOCK CARDIOGENICO

ANEURISMA VENTRICULAR

  • STEMI + AV + ARRITMIA INTRATABLE Y/O SHOCK

    • ANEURISMECTOMIA + CABC


Atacado de fiebres un indio de Loja llamado Pedro de Leyva, bebió, para calmar los ardores de la sed, del agua de un remanso, en cuyas orillas crecían algunos árboles de quina … Con sudescubrimiento vino a Lima y lo comunicó a un jesuita, el que, realizando la feliz curación de la virreina, prestó a la Humanidad mayor servicio que el fraile que inventó la pólvora.

Mendiburo dice que, al principio, encontró el uso de la quina fuerte oposición en Europa, y que en Salamanca se sostuvo que caía en pecado mortal el médico que la recetaba, pues sus virtudes eran debidas a pacto de los peruanos con el diablo.


PAZ MUNDIAL Leyva, bebió, para calmar los ardores de la sed, del agua de un remanso, en cuyas orillas crecían algunos árboles de


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