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Shock states
• Cardiovascular management
• Understand mechanisms and definition of shock states
• Signs of circulatory failure
• General principles of management
• Pharmacology and volume treatment
Basic functions of the circulatory system
• Total (heart, veins, arteries)
• Heart (muscle, valves)
• Altered myocardial states
Definition of the circulatory insufficiency
Complex picture: left ventricular and
neurohormonal dysfunction with signs of
limited exercise capacity, fluid retention
and increse mortality rate
Signs of circulatory insufficiency
• Changes in filling pressure
• Systolic and/or diastolic dysfunction
• Emptying disturbances
Compensation mechanisms
• Increase vascular volume
• Increase filling pressures
• Tachykardia
• Hypertrophia
Altered myocardial states
Ischaemia/Reperfusion
MINo function
StunningRecovery of function
HibernationRecocvery of function
Inotropic state
• Ino = fibre, tropos = movement
• Increase contractility = increase the power of contraction (under preload, afterload and HR)
• MV02
• Interaction between calcium and troponins
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
Relaxation failure
• 30-40% pts
• Definition: failure of filling
• Examples:
• pericarditis
• degeneration
• ischemia
• stiffness
Potential errors in preload estimation
• CVP (EF)
• LVEDV (compliance)
• LVEDP (MS,MI)
• LAP (elevated pulmonary pressure)
• PAOP (catheter position)
Drugs for treatment of circulatory failure
• Vasodilators
• Diuretics
• Glycosides
• Fosfodiesteraze inhibitors
• Calcium synthetizers
• Agonist beta and DM
• Antagonists beta
Vasodilators
• ACE Inhibitors: captopril, enalapril
• Nitrovasodilatators: NTG, NPS, molsidomina, hydralazyna
• Calcium channel blockers
• Potassium channel activators: diazoxide, minoxidil, pinacidil, cromakalin
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
Calcium sensitizers
• Pinobendan, Simendan, Levosimendan
• Saving energy (ATP)
• No influence on calcium homeostasis
• Drug of choice in “myocardial stunning”
• Contraindication: diastolic dysfunction
Case 1
• 70 years old man 1 hour after car accident: conscious, HR 130/min, ABP 80/60 mmHg, CVP 1 mmHg, no diuresis.
Case 2
• 25 years old woman after penicillin administration: collapse, ABP 70/40, HR 70/min, CVP 2 mmHg, rush on the skin.