angiography revealed moderate left main and severe 3-vessel coronary artery disease (CAD) with an occluded left anterior descending (LAD) artery. Due to hemodynamic instability, an intra-aortic balloon pump (IABP) was placed and, after an unsuccessful attempt at PCI of the LAD (felt to be chronic or sub-acutely occluded), the patient was referred for further management including consideration of high risk coronary artery bypass surgery. She arrived to the coronary care unit on multiple inotropes and vasopressors with ongoing hemodynamic instability.
Questions • What kind of shock the patient is suffering from? • What is the cause of this type of shock? • List the possible management that is been done for this patient?
Cardiogenic Shock (CS) • Cardiogenic shock is a state of inadequate cardiac output despite adequate intravascular volume, resulting in hypoxia. • When the heart is damaged and unable to supply sufficient blood to the body. • CS is a state of end-organ hypo-perfusion due to cardiac failure
Cont.. • The definition of CS includes hemodynamic parameters are: Parameters Values Persistent hypotension SBP <80 to 90 mmHg than base line, or Mean Arterial pressure 30 mm Hg than baseline Severe reduction in Cardiac output and cardiac index CO <4 L/min, and CI < 1.8 L/min urine output <30 mL/h extremities cool SVR and PCWP > 1400 and ≥15 mm Hg LOC Decrease/altered Reynolds. H., Hochman. J. 2018; AHA, Circulation, 2017
Causes • MI with LV failure (most common) • CHF • Severe LV or RV dysfunction • Cardiomyopathy • Pericarditis • Endocarditis • Coronary artery disease • Valvular regurgitation and stenosis • Massive pulmonary embolism • Arrhythmias (life-threatening)
Management • Fibrinolytics (Streptokinase) • Anticoagulants (Aspirin, Heparin, Clopidogrel) • Percutaneous coronary interventions(Angiography & Angioplasty): Door to Balloon time: <90 mins) • Coronary Artery Bypass Grafting
Cont.. • Hemodynamic Management: • Pulmonary Artery Catheter (Swan-Ganz) • Pharmacology: • Inotropic and vasopressor agents : norepinephrine, dopamine and dobutamine • Mechanical Support: • Intra-aortic Balloon Pump (IABP): improves coronary and peripheral perfusion
Case Scenario 2 • A 30 years old male received in ER unconscious and with gunshot injury on his abdomen. On arrival he was profusely bleeding visibly and intra-abdominally as well that was revealed by ultrasound. Cardiac monitored showed BP 80/40, MAP 58, HR 160/mins, cold and clammy. Multiple blood transfusion were given in ER and then he was immediately transferred to Operation Room for laparotomy and further surgical management.
Questions • What kind of shock the patient is suffering from? • What is the cause of this type of shock?
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