myocarditis and cardiogenic shock the 急性心肌炎心源性休克课件

CARDIOGENIC SHOCK Aditya Badheka, PL-1 ETIOLOGY Pump Failure Ductal dependent lesions Myocardial failure myocarditis cardiomyopathy electrolyte abnormalities ischemia Restrictive: Tamponade Abnormalities in heart rate PHYSIOLOGIC PRINCIPLES lFrank-Starling Phenomenon lCardiac Output lOxygen delivery and utilization 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 CARDIOGENIC SHOCK Cardiac output is inadequate to meet tissue demands Phases: Early, compensated Late, uncompensated Hypotension and bradycardia are the signs C.O. = STROKE VOLUME X HEART RATE Stroke volume: Preload Myocardial contractility Afterload: systemic and pulmonary resistance blood viscosity Heart Rate Bradycardia Sustained tachycardia 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. CAUSES OF MYOCARDITIS Infectious: Viral: adenovirus (2&5), enterovirus, CMV, RSV Bacterial: meningococcus, TB, Legionella, Leptospira Rickettsial Protozoal: T. cruzi Non-infectious: toxic, drugs, hypersensitivity/ autoimmune Acute Viral Myocarditis Heart Failure Complete Recovery No Symptoms Chronic Dilated Cardiomyopathy Dysrhythmias/ Conduction Disorders Sudden Death Clinical Presentation of Myocarditis PATHOPHYSIOLOGY OF MYOCARDITIS THE DOMINO EFFECT Viral Infection Inflammation and Injury Decreased Myocardial Contractility Heart Enlarges: LVEDV Cardiac Output Sympathetic Tone CHF LAP Pulm. edema Scarring Dysrhythmias ISCHEMIC HEART DISEASE IN CHILDREN ALCAPA Anomalous Left Coronary Artery arising from the Pulmonary Artery Kawasaki Disease Aneurysms Other vasculitis ELECTROLYTE/METABOLIC ABNORMALITIES Hyperkalemia Hypocalcemia Hypermagnesemia Hypoxia Metabolic Acidosis VENTRICULAR FUNCTION CURVES NORMAL AND FAILING LV Cardiogenic Shock - Arrhythmias lCheck pulses: rapid lCheck EKG SVT CARDIOGENIC SHOCK HIGH AFTERLOAD Tamponade: pulsus paradoxus Pulmonary hypertension massive PE High or low Systemic Vascular Resistance Septic shock LV failure from chronic hypertension 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 MANAGEMENT ABCS Airway and breathing Circulation fluid bolus ? inotropic support WHAT MAY BE HARMFUL? Albuterol Diuretics Fluid restriction CARDIOGENIC SHOCK INOTROPIC AGENTS Dobutamine Dopamine Epinephrine Milrinone Norepinephrine Digoxin Vasopressin (?) MANAGEMENT Tamponade Fluid bolus Increase heart rate Pericardiocentesis SVT Vagal maneuvers Adenosine Cardioversion Correct electrolyte abnormaliti