CARDIOGENIC SHOCK

CARDIOGENIC SHOCK Aditya Badheka, PL-1

Etiology • Pump Failure • Ductal dependent lesions • Myocardial failure • myocarditis • cardiomyopathy • electrolyte abnormalities • ischemia • Restrictive: Tamponade • Abnormalities in heart rate

PHYSIOLOGIC PRINCIPLES • Frank-Starling Phenomenon • Cardiac Output • Oxygen delivery and utilization

Frank-Starling Phenomenon “In the normal heart, the diastolic volume (preload) is the principal force that governs the strength of ventricular contraction.” Otto Frank and Ernest Starling

Cardiogenic Shock • Cardiac output is inadequate to meet tissue demands • Phases: • Early, compensated • Late, uncompensated • Hypotension and bradycardia are the signs

C.O. = Stroke volume x Heart rate • Stroke volume: • Preload • Myocardial contractility • Afterload: • systemic and pulmonary resistance • blood viscosity • Heart Rate • Bradycardia • Sustained tachycardia

Acute Myocarditis - Definition • A process characterized by inflammatory infiltrates of the myocardium, with necrosis and/or degeneration of myocytes which is very different from the ischemic damage observed in ischemic heart disease.

CAUSES OF MYOCARDITIS • Infectious: • Viral: adenovirus (2&5), enterovirus, CMV, RSV • Bacterial: meningococcus, TB, Legionella, Leptospira • Rickettsial • Protozoal: T. cruzi • Non-infectious: toxic, drugs, hypersensitivity/ autoimmune

Acute Viral Myocarditis Dysrhythmias/ Conduction Disorders No Symptoms Heart Failure Chronic Dilated Cardiomyopathy Complete Recovery Sudden Death Clinical Presentation of Myocarditis

Viral Infection Inflammation and Injury Scarring Decreased Myocardial Contractility Heart Enlarges:  LVEDV LAP Dysrhythmias Pulm. edema  Cardiac Output  Sympathetic Tone CHF PATHOPHYSIOLOGY OF MYOCARDITISTHE DOMINO EFFECT

Ischemic Heart Disease in Children • ALCAPA • Anomalous Left Coronary Artery arising from the Pulmonary Artery • Kawasaki Disease • Aneurysms • Other vasculitis

Electrolyte/Metabolic Abnormalities • Hyperkalemia • Hypocalcemia • Hypermagnesemia • Hypoxia • Metabolic Acidosis

VENTRICULAR FUNCTION CURVESNORMAL AND FAILING LV

Cardiogenic Shock - Arrhythmias • Check pulses: rapid • Check EKG SVT

Cardiogenic ShockHigh Afterload • Tamponade: • pulsus paradoxus • Pulmonary hypertension • massive PE • High or low Systemic Vascular Resistance • Septic shock • LV failure from chronic hypertension

Signs and Symptoms • Shocky, but no history of volume loss • Vital signs: tachycardia, hypotension • Poor perfusion • WHEEZING • Metabolic acidosis • Heart size on CXR may be normal

ManagementABC’s • Airway and breathing • Circulation • fluid bolus ? • inotropic support

What May be Harmful? • Albuterol • Diuretics • Fluid restriction

CARDIOGENIC SHOCKINOTROPIC AGENTS • Dobutamine • Dopamine • Epinephrine • Milrinone • Norepinephrine • Digoxin • Vasopressin (?)

Management • Tamponade • Fluid bolus • Increase heart rate • Pericardiocentesis • SVT • Vagal maneuvers • Adenosine • Cardioversion • Correct electrolyte abnormalities

CARDIOGENIC SHOCKMECHANICAL SUPPORT • ECMO • IABP Counterpulsation • Ventricular assist devices

Intraaortic balloon pump counterpulsation

Thank you…….

CARDIOGENIC SHOCK