Cardiogenic shock – the extreme extent of display of an acute heart failure which is characterized by critical decrease in sokratitelny ability of a myocardium and perfusion in fabrics. Shock symptoms: falling HELL, tachycardia, short wind, blood circulation centralization signs (pallor, reduction of skin temperature, emergence of stagnant spots), consciousness violation. The diagnosis is made on the basis of a clinical picture, results of the ECG, a tonometriya. The treatment purpose – stabilization of haemo dynamics, restoration of a warm rhythm. Within urgent therapy beta-blockers, cardiotonics, narcotic analgetics, oxygenotherapy are used.
The Cardiogenic Shock (CS) – a sharp pathological state at which the cardiovascular system appears incapable to provide an adequate blood-groove. Necessary level of perfusion is temporarily reached at the expense of the exhausted organism reserves then there comes the decompensation phase. The state belongs to the IV class of heart failure (the most severe form of violation of warm activity), the lethality reaches 60-100%. Cardiogenic shock is registered in the countries with high rates of the cardiovascular pathology which is poorly developed by preventive medicine, lack of hi-tech medical aid more often.
Reasons of cardiogenic shock
Sharp decrease in sokratitelny ability of LZh and critical reduction of minute emission is the cornerstone of development of a syndrome that is followed by insufficiency of blood circulation. Enough blood does not come to fabrics, symptoms of oxygen starvation develop, the level of arterial pressure decreases, the characteristic clinical picture appears. KSh can burden the course of the following coronary pathologies:
- Myocardial infarction. Acts as the main reason for cardiogenic complications (80% of all cases). Shock develops mainly at krupnoochagovy transmuralny heart attacks with an exit from sokratitelny process of 40-50% of mass of heart. Does not arise at heart attacks with a small volume of the struck fabrics as the kardiomiotsita which remained intact compensate function of the died cells of a myocardium.
- Myocarditis. The shock involving the death of the patient meets in 1% of cases of the heavy infectious myocarditis caused by Koksaki's viruses, herpes, staphylococcus, a pneumococcus. The pathogenetic mechanism – defeat of kardiomiotsit infectious toxins, formation of protivokardialny antibodies.
- Poisoning with cardiotoxic poisons. The clonidine, , warm glycosides, insecticides, fosfororganichesky connections is among similar substances. At overdose of these medicines there is a weakening of warm activity, urezheny ChSS, falling of minute volume to indicators at which heart is incapable to provide the necessary level of a blood-groove.
- Massive TELA. Obstruction of large branches of a pulmonary artery blood clot is followed by violation of a pulmonary blood-groove and sharp right ventricular insufficiency. The disorder of haemo dynamics caused by excessive filling of the right ventricle and stagnation in it leads to formation of vascular insufficiency.
- Tamponada of heart. It is diagnosed at a perikardita, a haemo pericardium, stratification of an aorta, thorax injuries. The liquid congestion in a pericardium complicates work of heart ‒ it becomes a cause of infringement of a blood-groove and the shock phenomena.
Less often pathology develops at dysfunction of papillary muscles, defects of an interventricular partition, a rupture of a myocardium, cardiac arrhythmias and blockade. The factors increasing probability of cardiovascular accidents are atherosclerosis, advanced age, existence of diabetes, chronic arrhythmia, hypertensive crises, excessive physical activities at patients with cardiogenic diseases.
The pathogenesis is caused by critical falling of arterial pressure and the subsequent weakening of a blood-groove in fabrics. As the defining factor not hypotonia per se, but reduction of volume of the blood passing on vessels in a definite time acts. Deterioration in perfusion becomes the reason of development of compensatory and adaptive reactions. Reserves of an organism are aimed at providing vitals with blood: heart and brain. Other structures (skin, extremities, skeletal muscles) experience oxygen starvation. The spasm of peripheral arteries and capillaries develops.
Against the background of the described processes there is an activation of neuroendocrine systems, formation of acidosis, a delay of ions of sodium and water in an organism. The diuresis decreases to 0,5 ml/kg/h and less. At the patient reveal an oliguriya or an anury, work of a liver is broken, there is a polyorgan insufficiency. At late stages acidosis and emission of tsitokin provoke an excessive vazodilatation.
The disease is classified by pathogenetic mechanisms. At pre-hospital stages it is obviously possible to define version KSh not always. In the conditions of a hospital the etiology of a disease plays a crucial role in the choice of methods of therapy. Wrong diagnostics in 70-80% of cases terminates in the death of the patient. Distinguish the following options of shock:
- Reflex – violations are caused by a strong painful attack. It is diagnosed at the small volume of defeat since expressiveness of a pain syndrome not always corresponds to the sizes of the necrotic center.
- True cardiogenic – a consequence sharp to THEM with formation of the volume necrotic center. Sokratitelny ability of heart decreases that reduces minute volume. The characteristic complex of symptoms develops. Mortality exceeds 50%.
- Areactive – the most dangerous version. It is similar to true KSh, pathogenetic factors are expressed stronger. Badly gives in to therapy. A lethality – 95%.
- Aritmogenny – predictively is favorable. Is result of violation of a rhythm and conductivity. Arises at paroksizmalny tachycardia, AV blockade of III and II degrees, total cross block. After restoration of a rhythm symptoms disappear within 1-2 hours.
Pathological changes develop in steps. Cardiogenic shock has 3 stages:
- Compensations. Reduction of minute volume, moderate hypotonia, weakening of perfusion by peripheries. Blood supply is supported due to blood circulation centralization. The patient usually in consciousness, clinical manifestations moderate. There are complaints to dizziness, headache, heartache. At the first stage pathology is completely reversible.
- Decompensations. There is a developed simptomokompleks, perfusion of blood in a brain and heart is reduced. Level HELL is critically small. Irreversible changes are absent, however before their development there are minutes. The patient is in a sopor or unconscious. Due to weakening of a kidney blood-groove formation of urine decreases.
- Irreversible changes. Cardiogenic shock passes into a terminal stage. It is characterized by strengthening of the available symptomatology expressed by coronary and cerebral ischemia, formation of necroses in internals. The syndrome of disseminirovanny intra vascular folding develops, on skin petekhialny rash develops. There are internal bleedings.
Symptoms of cardiogenic shock
At initial stages the cardiogenic pain syndrome is expressed. Localization and character of feelings are similar to a heart attack. The patient complains of the squeezing pain behind a breast ("as though heart squeeze in a palm") extending to a left shoulder-blade, a hand, a side, a jaw. Irradiation on the right side of a body is not noted.
Respiratory insufficiency is shown by full or partial loss of ability to independent breath (cyanosis, breath frequency less than 12-15 in a minute, concern, fear of death, inclusion in process of breath of auxiliary muscles, retraction of wings of a nose). At development of alveolar hypostasis of lungs from a mouth of the patient white or pinkish foam is emitted. The person holds the compelled sitting position, with an inclination forward and an emphasis hands in a chair.
Decrease systolic HELL lower than 80-90 mm of mercury is noted., pulse - to 20-25 mm of mercury. Pulse is threadlike, weak filling and tension, tachycardia to 100-110 blows/minute. Sometimes ChSS falls to 40-50 beats/min. Patient's skin pale, cold and damp to the touch. The general weakness is expressed. The diuresis is lowered or completely is absent. Against the background of shock there is a consciousness violation, the sopor or a coma develops.
Cardiogenic shock is complicated by polyorgan insufficiency (PON). Work of kidneys, a liver is broken, reactions from a gastrointestinal tract are noted. System organ insufficiency is a consequence of untimely rendering to the patient of medical care or a heavy course of disease at which the undertaken measures for rescue are ineffective. PON symptoms – vascular asterisks on skin, vomiting "a coffee thick", a smell of crude meat from a mouth, swelling of jugular veins, anemia.
Diagnostics is performed on the basis of data of fizikalny, laboratory and tool inspection. At survey of the patient the cardiologist or the resuscitator notes external symptoms of a disease (pallor, perspiration, a skin mramornost), estimates a consciousness condition. Objective diagnostic actions include:
- Fizikalny inspection. At a tonometriya decrease in level HELL lower than 90/50 mm of mercury is defined., pulse indicator less than 20 mm of mercury. At an initial stage of a disease hypotonia can be absent that is caused by turning on of compensatory mechanisms. Warm tones deaf, in lungs are listened damp melkopuzyrchaty rattles.
- Electrocardiography. The ECG 12 assignments reveals characteristic symptoms of a myocardial infarction: decrease in amplitude of a tooth R, S-T segment shift, negative tooth of T. Symptoms of premature ventricular contraction, atrioventricular blockade can be noted.
- Laboratory researches. Estimate concentration of a troponin, electrolytes, creatinine and urea, glucose, hepatic enzymes. Level of troponin of I and T increases already during the first hours OIM. A symptom of the developing renal failure - increase in concentration of sodium, urea and creatinine in plasma. Activity of enzymes of a liver increases at reaction of gepatobiliarny system.
When performing diagnostics it is necessary to distinguish cardiogenic shock from the stratifying aneurism of an aorta, vazovagalny to a syncope. At stratification of an aorta pain irradiates along a backbone, remains for several days, has wavy character. At a syncope there are no serious changes on the ECG, in the anamnesis - painful influence or a psychological stress.
Treatment of cardiogenic shock
Patients with an acute heart failure and signs of a state of shock are urgently hospitalized in a cardiological hospital. As a part of crew of SMP leaving on similar calls there has to be a resuscitator. At a pre-hospital stage oxygenotherapy is carried out, the central or peripheral venous access is provided, according to indications it is carried out . In a hospital continue the treatment begun with crew of SMP which includes:
- Medicamentous correction of violations. For knocking over of hypostasis of lungs enter loopback diuretics. To reduce warm preloading, use nitroglycerine. Infusional therapy is carried out in the absence of hypostasis of lungs and TsVD it is lower than 5 mm of mercury. The volume of infusion is considered sufficient when this indicator reaches 15 units. Antiarrhytmic means (), cardiotonics, narcotic analgetics, steroid hormones are appointed. The expressed hypotonia is the indication for application of noradrenaline via the syringe perfusor. At permanent violations of a warm rhythm the cardioversion is applied, at heavy respiratory insufficiency – IVL.
- Hi-tech help. At treatment of patients with cardiogenic shock use such hi-tech methods as an intra aortal balloon kontrapulsation, an artificial ventricle, balloon angioplasty. The patient gets the acceptable chance to survive at timely hospitalization in specialized office of cardiology where there is an equipment, necessary for hi-tech treatment.
Forecast and prevention
The forecast is adverse. The lethality makes more than 50%. It is possible to lower this indicator in cases when first aid was given the patient within half an hour from an onset of the illness. Death rate in that case does not exceed 30-40%. Survival above among patients to whom the surgical intervention directed to restoration of passability of the damaged coronary vessels was carried out is reliable.
Prevention consists in prevention of development by IT, tromboemboliya, heavy arrhythmias, myocardites and injuries of heart. It is for this purpose important to take preventive courses of treatment, messages healthy and active lifestyle, to avoid stresses, to observe the principles of healthy food. At emergence of the first signs of warm accident the call of an ambulance crew is required.