CARDIOGENIC SHOCK

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CARDIOGENIC SHOCK

• Aditya Badheka, PL-1

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Etiology

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

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PHYSIOLOGIC PRINCIPLES

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

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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
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Cardiogenic Shock

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

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C.O. Stroke volume x Heart rate

• Stroke volume
• Preload
• Myocardial contractility
• Afterload
• systemic and pulmonary resistance
• blood viscosity
• Heart Rate
• Bradycardia
• Sustained tachycardia

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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.

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CAUSES OF MYOCARDITIS

• Infectious
• Viral adenovirus (25), enterovirus, CMV, RSV
• Bacterial meningococcus, TB, Legionella,
  Leptospira
• Rickettsial
• Protozoal T. cruzi
• Non-infectious toxic, drugs, hypersensitivity/
  autoimmune

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Clinical Presentation of Myocarditis
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PATHOPHYSIOLOGY OF MYOCARDITISTHE DOMINO EFFECT
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Ischemic Heart Disease in Children

• ALCAPA
• Anomalous Left Coronary Artery arising from the
  Pulmonary Artery
• Kawasaki Disease
• Aneurysms
• Other vasculitis

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Electrolyte/Metabolic Abnormalities

• Hyperkalemia
• Hypocalcemia
• Hypermagnesemia
• Hypoxia
• Metabolic Acidosis

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VENTRICULAR FUNCTION CURVESNORMAL AND FAILING LV
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Cardiogenic Shock - Arrhythmias

• Check pulses rapid
• Check EKG

SVT
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Cardiogenic ShockHigh Afterload

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

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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

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ManagementABCs

• Airway and breathing
• Circulation
• fluid bolus ?
• inotropic support

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What May be Harmful?

• Albuterol
• Diuretics
• Fluid restriction

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CARDIOGENIC SHOCKINOTROPIC AGENTS

• Dobutamine
• Dopamine
• Epinephrine
• Milrinone
• Norepinephrine
• Digoxin
• Vasopressin (?)

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Management

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

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CARDIOGENIC SHOCKMECHANICAL SUPPORT

• ECMO
• IABP Counterpulsation
• Ventricular assist devices

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Intraaortic balloon pump counterpulsation
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Thank you.