2. Cardiogenic Shok

3. Some Notes Develops in 10% to 20% of patients hospitalized AMI Mortality of such patients approximately 80% or higher Very few patients develop shock immediately after AMI About half of the patients develop shock within 24h

5. Pathology

6. Clinical signs ECG shows the pattern of AMI or acute coronary insufficiency The SBP < 80 mm Hg * Pulse rate is 100 per min or faster** The urinary output is low, 30 ml or less per hour There are clinical signs of peripheral circulatory collapse

7. Differential diagnosis Massive pulmonary embolism Acute dissecting aneurism of the aorta Acute cardiac tamponade Acute hemorrhage Cerebrovascular thrombosis Diabetic acidosis Acute pancreatitis Acute adrenal insufficiency

8. Starlings law of the heart The ability of the heart to increase its output in response to an increase in venouse return represents a positive feedback in which altered blood flow to the heart leads to a corresponding change in blood flow leaving the heart.

9. Emergency treatment The first priority in treating cardiogenic shock is to expand the circulating blood volume with IV fluids, using the PWP or CVP as a basic guide

10. Initial treatment 1.Position the patient* 2.Make certain that there is an adequate airway** 3.Maintain adequate oxygenation*** 4.Start an IV infusion of D5W,using a regular drip bulb at a minimal flow rate 5.Insert a Swan – Ganz catheter into the PA 6.Draw blood for the tests

11. 1.Insert a Foley catheter into the urinary bladder to obtain accurate measurements of urinary output* 2.Monitor the patient continuously** 3.Relieve pain*** 4.Relieve agitation**** 5.Take portable X – ray films of the chest Initial treatment

12. Definitive treatment Correction of hypovolemia Treatment of arrhythmias Treatment of hypotension Treatment of metabolic acidosis Treatment of electrolyte disturbances Mechanical circulatory assist

13. Correction of hypovolemia PWP less than 15 mm Hg PWP remain stable.16 mm Hg Initial PWP is between 15 – 18 mm Hg PWP is 20 mmHg or higher* Rise in PWP to 16 mm Hg or higher PWP is low approximately 5 mm Hg Pulmonary edema**

17. Schematic guide Group 1 Group 1 Low PWP without PE - IV fluids indicated Group 2 Group 2 Low PWP with PE - IV fluids indicated Grout 3 Grout 3 High PWP without PE - Vasodilatators, MCD Group 4 Group 4 High PWP with PE - Treatment as G3

18. Eugene Yevstratov MD Phone: 0054111540682712 (ARG) Private: 0030372236344 / 0030372231698(UKr) Fax: 001 775 796 2780 (USA) Email: ostlandfox@yahoo.de / ostlandfox@medscape.comostlandfox@yahoo.de ostlandfox@medscape.com Link: http://myprofile.cos.com/eugenefoxhttp://myprofile.cos.com/eugenefox