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51 Cards in this Set
- Front
- Back
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Signs/symptoms of shock:
JVD is present if it is ... or ... in origin |
obstructive
cardiogenic |
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look at slide 5
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ok
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Pathogenesis:
Decreased CO with ... SVR to maintain adequate systemic press to heart and brain at expense of other tissues (esp GI) Increased NE will cause vaso... Decreased vagal activity causes ... HR and CO Inc epi causes ... glycogenolysis and gluconeogenesis ACTH stimulates ... release: enhances lipolysis and gluconeogenesis |
increased
constriction incr incr cortisol |
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What is the leading cause of death in pts hospitalized after MI?
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cardiogenic shock
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shock: types
... -Insufficient circulatory volume -Due to internal or external vascular fluid or blood loss *Bleeding *High output fistula *Severe ... (all the vessels vasodilate and you become leaky) |
Hypovolemic
burn |
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Shock types:
... -Cardiac ...; Constrictive ... *prevents heart from adequately expanding to diastole -... *Inadequate venous return to heart due to increased intrathoracic pressure -Massive ... *Blood is clotted in lung and less blood flows through to reenter heart -... *Obstructed ventricular outflow tract |
Obstructive
tamponade pericarditis Tension Pneumothorax PE Aortic stenosis |
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Shock types:
... - Relative hypovolemia due to dilation of blood vessels -... shock *Endotoxin causes vasodilation -... shock *Histamine release with vasodilation -... shock *Trauma to spinal cord with resultant loss of autonomics and sympathetic tone to vessels |
Distributive
Septic Anaphylactic Neurogenic |
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Shock types:
... -Hypothyroidism (decreased CO) -Thyrotoxicosis (cardiomyopathy) -Adrenal insufficiency (low corticosteroids decrease CO) |
Endocrine
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Shock types:
... -Heart not pumping effectively to deliver adequate circulation of blood -Most commonly due to ... |
Cardiogenic
AMI (acute MI) |
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Cardiogenic shock: Causes
-Damage to ... (large MI) -... –heart cannot effectively coordinate pumping -... –heart muscle pathology -Valve disorder -Ventricular outflow obstruction *Aortic stenosis, aortic dissection -Ventriculoseptal defect -... (usually a viral cause) |
myocardium
Arrhythmias Cardiomyopathy Myocarditis |
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Cardiogenic Shock:
Leading cause of death in patients hospitalized after MI -Shock due to impaired myocardial ... *Usually assoc with loss of more than ...% of LV myocardium -More common with ... MI -... failure accounts for 80% of CS after AMI |
contractility
40 ST elevation LV |
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Pathophysiology of CS due to AMI:
1) Ischemia to myocardium with depression of myocardial ... (... dysfunction) 2) Hypoperfusion to myocardial cells 3) Further ischemia and decreased CO 4) Decreased myocardial ... with impaired ... function |
contractility
systolic compliance diastolic |
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Pathophysiology:
Release of catecholamines -Stimulate cardiac myocytes to increase ... (... inotropism) -Increased inotropism and HR: *Increases myocardial oxygen demand and ultimately increases cardiac ... -Increases ... (vasoconstriction to maintain SBP): *Increases ... and impairs cardiac performance |
contractility
positive ischemia SVR afterload |
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Pathophysiology:
... salt and water retention by kidneys -Renin-angiotensin system -... intravascular volume in attempt to increase perfusion Kidneys sense decreased volume, so they try to keep salt and water in. Increases .... Good short term, but eventually it could overload the heart. |
Increased
Increases preload |
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Pathophysiology:
Systemic inflammatory response -Release of ... (NO) *Induces ... which worsens shock -Increased ... (metabolic acidosis) *Due to hypoperfusion and hypoxia *Acidosis decreases efficacy of ... |
cytokines
vasodilation lactic acid catecholamines |
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Pathophysiology:
Arrhythmias -Increased stimulation to myocardium: ... *Less efficient pumping increases shock -Ischemia involving conduction system: ... *Worsens shock |
tachyarrhythmia
bradyarrhythmia |
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patient profile who is at increased risk of developing cardiogenic shock:
... age ... -Males have absolute increased incidence, but females have higher % increase h/o previous ... DM ... infarction |
Older
Female MI Anterior |
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Incidence and Morbidity:
...-...% pts with AMI will develop CS ...-...% mortality Increased risk of CS if AMI with: -Altered sensorium -Cold clammy skin -... (diminished excretion of urine) -... age -Prior ... |
5-10
80-90 Oliguria Increased MI |
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Coronary Artery anatomy:
L Ventricle: -anterior -... -Posterior -... R Ventricle: ... |
LAD
L circ coronary a RCA |
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Causes of CS: ...
-Non contractile wall leads to decreased systolic function -Later, scarring leads to restriction and decreased diastolic function -Subacutely, weakened wall may rupture prior to adequate scar formation |
Myocardial infarction
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Causes of CS: ...
-Excessive fluid or blood in pericardial sac will restrict diastolic filling -either due to pericarditis or bleeding from trauma or if you dissect into the wall of the aorta |
Pericardial effusion
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Causes of CS: ...
Proximal R coronary artery occlusion Small % of cardiogenic shock due to ... failure -Absence of pulmonary congestion -Increased pressure in R atrium -RV dilatation ... will increase preload and help perfusion |
Right ventricular MI
RV IVF (IV fluids) |
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Cardiomyopathy: ...
-LV hypertrophy due to chronic HTN -Leads to inability of ventricle to adequately expand during ... -Decreased ... due to poor ventricular filling |
Restrictive
diastole CO |
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Cardiomyopathy: ...
-Expansion of ventricular wall prevents adequate contractile motion of cardiac myocytes -Poor ... function -Poor ... function due to anatomic distortion |
Dilated
systolic valvular |
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...:
-Caused by hypertrophic cardiomyopathy or dilated cardiomyopathy -(also pericardial effusion) We want it to be less than ... of the entire space. |
Cardiomegaly
1/3 |
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Valve disorder:
Aortic regurg/insufficiency: -During ..., blood sucks back into LV from aorta -... pressure in aorta during diastole and ... forward flow of ejected blood -... develops |
diastole
Decreases decreases LVH |
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Valve disorder:
Mitral regurg: -During ..., blood pushes back from LV into L atrium -Develop ... -Decreased CO |
systole
L atrial enlargement |
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Valve disorder:
-Stenotic aorta increases ... (pressure LV must push against) -LV develops ... -... CO and alters architecture of LV |
afterload
hypertrophy Diminishes |
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Outflow Obstruction: Aortic Dissection
Increases ... as LV pumps against partially obstructed aorta |
afterload
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Ventriculoseptal Defect:
-... pumps blood partially into ... -Excessive pulmonary blood flow and pulmonary pressure -Increased LV ... -Reduced systemic ... -RV will develop ... |
LV
RV preload CO hypertrophy |
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...:
-Cardiac function impaired due to inflammation/infection of cardiac muscle -... population -Viral or bacterial cause (can be idiopathic also) -Inflammation or weakness of heart muscle causes failure -May be associated with pericarditis -can impair both diastole and systole |
Myocarditis
Younger |
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...:
-Respirations oscillate between apnea (retaining CO2) and hyperpnoea (blowing off CO2) -Due to changing concentrations of O2 and CO2 in blood and poor perfusion to brain |
Cheyne-Stokes respirations
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normal pulse pressure is about ...mmHg
in cardiogenic shock, we will have a low ... BP with a ... pulse pressure: “narrow PP” < ... mmHg |
40
systolic decreased 30 |
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Pulse Pressure:
Increases with ... stroke volume -... increases while ... remains same -i.e. exercise: PP up to 100mmHg Decreases with ... stroke volume -CHF or shock -Aortic stenosis ... resting PP with -Stiffness of aorta (calcification) -Aortic regurgitation or arteriovenous malformation *... DBP -High resting PP is harmful to organs |
increased
SBP DBP decreased Increased Elevated |
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...:
-Can be associated with CS or ... failure -Overwhelmed LV causes pressure to backup to lungs (engorgement of pulm. vessels) -Fluid leaks from pulmonary capillaries into interstitium and alveoli (effusion) -Impaired oxygenation --> ... -Increased pulmonary vascular pressure leads to increased ... on R ventricle -R ventricle failure develops with subsequent backup of pressure to body -... develops (distal extremities; liver) -#1 cause of RV failure = ... |
Pulmonary edema
LV hypoxia afterload Peripheral edema LV failure |
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Pulmonary Edema: Physical Findings
Crackles/rales heard beginning at lung ... May also have wheezing May have ... on cardiac exam -Occurs at ... of diastole just after S2 -Due to rapid filling and expansion of LV because of increased ...* If ... heart failure present, edema to distal extremities and JVD |
bases
S3 beginning preload Right |
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Pulmonary Edema: Treatment
... ... – dilates the air spaces. Helps w/ O2 diffusion ...: -Pt breathes through face mask with continuous flow of airway pressure -Support for pt with increased work of breathing May require ... |
Oxygen
Albuterol Positive pressure ventilation endotracheal intubation |
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Pulmonary Edema: treatment
***Reduction of ...*** -Decreasing venous return to R heart will decrease pressure in pulmonary vasculature -... - more venodilitation than arterial dilation -... diuretic (...) *Diuresis and venodilation Reduction of afterload -... (...) – only give if the pt has a normal BP w/ pulmonary edema. Don’t give if person is in shock or if they have a low BP. |
preload
Nitrates –(NTG) Loop furosemide ACE-Inhibitor (captopril) |
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Pulmonary Edema: treatment
inotropic medications -if patient is hypotensive, use ... -if patient is not hypotensive, use ... |
dopamine
dobutamine |
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if patient has been given dopamine and they still remain hypotensive, add on ...
if patient is not responding to any other meds, this is when you should use ... |
norepinephrine
epinephrine |
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Pulmonary Edema: tx
Inotropic medications -Dopamine/Dobutamine *Cardiac inotropism *... also induces vasoconstriction *... –no BP support (also induces some vasodilation) -... (also induces vasodilation). Decreases afterload and BP. Care should be taken not to induce hypotension in normotensive pt |
Dopamine
Dobutamine Milrinone |
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Initial Management of CS:
IV, O2, invasive monitoring -Central line catheter -Arterial line to measure BP -Swan-Ganz catheterization EKG IVF to support BP (unless ... present) Labs |
pulmonary edema
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Laboratory Findings:
Increased .../... with renal hypoperfusion Increased ... enzymes (markers of cellular damage) -bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) ... acidosis due to lactic acidosis |
BUN/creat
liver Anion gap |
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Lab findings:
ABG: -Hypoxemia and acidosis -Increased ... deficit correlates with severity of shock (measures degree of lactic acidosis) Elevated ... enzymes -CK, CKMB, troponin Increased serum ... level (indicates degree of hypoperfusion) |
base
cardiac lactate |
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Management:
... and ... ... -Abnormal cardiac silhouette? -Abnormal aortic appearance/mediastinal widening? -Pulmonary edema? May require ... -to assess anatomy of coronary arteries and need for urgent revascularization |
EKG and echocardiography
Chest XR coronary angiography |
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Medications:
... (makes blood thin) and ... (prevents further clotting); ... (helps break up clots that are already present) -If AMI ... medications (MAP 60-65 for adequate renal profusion) -Dopamine (DA), NE, epinephrine ... if BP adequate and need positive inotropism -Will not increase myocardial O2 demand as much as ... |
Aspirin
heparin glycoprotein IIb/IIIa inhibitor Vasopressor Dobutamine DA |
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Medications: ...
NE and epi precursor Varied effects depending on dose -<5 mcg/kg/min: renal vasodilation, mesentaric and coronary vasodilation (renal dose) -5-10 mcg/kg/min: beta 1-adrenergic effects (+ inotropism) *Increase cardiac contractility and HR -10 mcg/kg/min: alpha-adrenergic effects *Arterial vasoconstriction and elevation on BP *Can decrease splanchnic profusion and increase pulmonary arterial pressure |
Dopamine (DA)
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Medications:
... -Alpha-adrenergic agonist with minimal beta-adrenergic agonist effects (clamps down on vessels and increases SVR) -Increases BP -Add to DA if pt remains hypotensive |
Norepinephrine (NE)
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Medications:
... -Increases cardiac index and SV -Increases SVR and HR -May increase oxygen delivery and consumption -Decreases splanchnic blood flow -Use only in pts not responding to other meds |
Epinephrine
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Medications: Inotropic support therapy
...: Increased inotropism with decreased afterload; increases CO -Beta 1-agonist with some beta2-agonism and minimal alpha activity *Positive inotropism *Mild peripheral vasodilation (decreased afterload) -May increase myocardial O2 demand; careful in AMI setting -Avoid in pts with ... |
Dobutamine
hypotension |
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Medications:
... (...) and ... -Inotropic agent with vasodilating property (decreased afterload) -Reduction in pulmonary vascular resistance |
Inamrinone (amrinone) and Milrinone
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