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Shock states

Shock states. Cardiovascular management Understand mechanisms and definition of shock states Signs of circulatory failure General principles of management Pharmacology and volume treatment. Schematic representation of the circulatory system. Frank-Starling.

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Shock states

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  1. Shock states • Cardiovascular management • Understand mechanisms and definition of shock states • Signs of circulatory failure • General principles of management • Pharmacology and volume treatment

  2. Schematic representation of the circulatory system

  3. Frank-Starling

  4. Basic functions of the circulatory system • Total (heart, veins, arteries) • Heart (muscle, valves) • Altered myocardial states

  5. Definition of the circulatory insufficiency Complex picture: left ventricular and neurohormonal dysfunction with signs of limited exercise capacity, fluid retention and increse mortality rate

  6. Signs of circulatory insufficiency • Changes in filling pressure • Systolic and/or diastolic dysfunction • Emptying disturbances

  7. Compensation mechanisms • Increase vascular volume • Increase filling pressures • Tachykardia • Hypertrophia

  8. Altered myocardial states

  9. Classification • Hypovolemic • Obstructive • Cardiogenic • Distributive • Endocrine

  10. Clinical signs • HR • BP • Temperature • Urine output • Pulse oximetry

  11. Invasive monitoring • Swan-Ganz • Pressure (PAP-PCWP) • Volume (CO) • Oxygenation (SvO2)

  12. Definition of the ejection fraction

  13. Calculations • EDV=150 ml • ESV=50 ml • EF= 150-50/150 = 0.66 = 60-70%

  14. Inotropic state • Ino = fibre, tropos = movement • Increase contractility = increase the power of contraction (under preload, afterload and HR) • MV02 • Interaction between calcium and troponins

  15. Preload • Load just before contraction • Venous return • Increase LV • Increase power of contraction • Increase of the HR • Example: exercices or i.v. infusion • Relation to venous return

  16. Afterload • Systolic pressure • Ventricular tension • Periferal resistance

  17. Relaxation failure • 30-40% pts • Definition: failure of filling • Examples: • pericarditis • degeneration • ischemia • stiffness

  18. Treatment principles • Preload • Contractility • Afterload • Oxygen delivery

  19. Potential errors in preload estimation • CVP (EF) • LVEDV (compliance) • LVEDP (MS,MI) • LAP (elevated pulmonary pressure) • PAOP (catheter position)

  20. Drugs for treatment of circulatory failure • Vasodilators • Diuretics • Glycosides • Fosfodiesteraze inhibitors • Calcium synthetizers • Agonist beta and DM • Antagonists beta

  21. Vasodilators • ACE Inhibitors: captopril, enalapril • Nitrovasodilatators: NTG, NPS, molsidomina, hydralazyna • Calcium channel blockers • Potassium channel activators: diazoxide, minoxidil, pinacidil, cromakalin

  22. Nitrate sides of action

  23. Inotropic drugs

  24. Fosfodiesteraze inhibitors • Amrinone (1,5 - 2,5 mg/ kg) • Milrinone (10 x more powerful) • increse of cAMP, calcium concentration and sensitivity, blood vessels dilatation • Main indication: diastolic dysfunction of the heart

  25. Calcium sensitizers • Pinobendan, Simendan, Levosimendan • Saving energy (ATP) • No influence on calcium homeostasis • Drug of choice in “myocardial stunning” • Contraindication: diastolic dysfunction

  26. Coronary flow • CPP DP - LVEDP • CBF = = • CVR CVR

  27. Case 1 • 70 years old man 1 hour after car accident: conscious, HR 130/min, ABP 80/60 mmHg, CVP 1 mmHg, no diuresis.

  28. Case 2 • 25 years old woman after penicillin administration: collapse, ABP 70/40, HR 70/min, CVP 2 mmHg, rush on the skin.

  29. Case 3 • 56 years old man 3 days after MI, dyspnea, ABP 80/70, HR 110/min, CVP 10 mmHg, PCWP 25 mmHg, oliguria.

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