Cardiogenic shock

1.1.
Lay the patient with raised under
angle 20
lower limbs.

1.3.
With angina pain – full
anesthesia.

1.4.
Heart rate correction (paroxysmal tachyarrhythmia
with a heart rate of more than 150 per min. – absolute
indication for EIT, acute bradycardia
with heart rate less than 50 per min – kEKS).

1.5.
Heparin 5000 U. Intra-jet.

2.1.
200 ml of 0,9% sodium chloride solution intravenously dropwise in 10 minutes. under
control of blood pressure, respiratory rate, heart rate,
auscultatory picture of the lungs and
heart (if possible – CVP).

2.2.
With persistent arterial hypotension
and the absence of signs of transfusion
hypervolemia – repeat administration
liquids by the same criteria.

2.3.
In the absence of signs of transfusion
hypervolemia (CVP below 15 mm water column)
infusion therapy is continued with
speed up to 500 ml/hour, controlling
indicated indicators every 15 min. If
Blood pressure cannot be stabilized quickly
move on to the next step.

2.4.
With moderate arterial hypotension
(systolic blood pressure of about 90 mmHg)
the drug of choice is dobutamine
(50 ml bottle with concentrate
for infusions 250 mg), with severe – dopamine
(Dopamine Giulini 50 – 50 mg of the drug,
in an ampoule of 5 ml .; Dopamine Solway 200 – 200 mg
drug, in an ampoule of 10 ml. Dopamine
hydrochloride 4% solution of 5 ml, 200 mg of the drug
in an ampoule).

Dopamine 200 mg in 400 ml of 5% glucose solution
administer intravenously using
infusomat, increasing the rate of infusion
from 5 mcg/(kg * min) to a minimum
sufficient arterial
pressure. In the absence of effect –
additionally prescribe norepinephrine
hydrotartrate 4 mg (2 ml 0,2% solution) in
200 ml of 5% glucose solution intravenously
drip infusomat, gradually
increase infusion rate from 0,5 mcg/min
to achieve the minimum sufficient
blood pressure values.

Note: if there is no micropump (infusomat),
ensuring dosage accuracy,
You can refer to the advice of M.Ya. Ores: 1-2
ml of a 0,2% solution of norepinephrine diluted
in 250-500 ml of physiological saline.
The speed is regulated depending on
reactions Blood pressure and heart rate. Indicative
initial rate of introduction of the mixture 10-15
cap. in minutes

If using
norepinephrine at a dose of 0,5-30 mcg per min. Arterial pressure
failed to raise to acceptable
level, recommend norepinephrine
replace dobutamine in a dose of 5-20 mcg/kg
in min. in combination with “renal”, then
have an enhancing renal blood flow
dosoidopamine (2-4 mcg/kg per minute).

Note:
dobutamine solution is prepared by
dilutions of 250 mg of the drug in 250 ml of 5-10%
glucose solution or reopoliglyukin.
Calculate dobutamine administration rate
You can: 1 mg (1000 mcg) of the drug contains
in 1 ml (20 drops) of solution. So if
dobutamine administration rate should
be 5 mcg/kg per min., then the patient weighing
80 kg must be administered 400 mcg of the drug
in minutes or 0,4 ml per min., i.e. 8 drops per
minutes.

Dopamine
hydrochloride 200 mg (4% solution of 5 ml in
ampoule) diluted in 400 ml of a 5% solution
glucose and administered intravenously
using an infusomat.

Speed ​​2,5-3
mcg/kg per minute is called “renal”,
there is an increase in renal
blood flow, glomerular filtration,
excretion of salts and water (dopaminergic
the effect).

Speed ​​5 mcg/kg
in minutes – “heart” speed,
1-adrenergic receptors are stimulated,
increased cardiac output without noticeable
effects on systemic vascular
resistance.

Speed ​​10 mcg/kg per minute. – “vascular”
speed, stimulation of ад -adrenoreceptors occurs,
overall peripheral increases
resistance (OPS), afterload and heart rate,
and cardiac output is reduced. Appropriate
use for arterial hypotension,
refractory to volemic load.


untimely diagnosis and onset
treatment;


inability to stabilize blood pressure;


pulmonary edema with increased blood pressure or iv
the introduction of fluid;


tachycardia, tachyarrhythmia, fibrillation
ventricles, asystole


relapse of anginal pain;


acute renal failure.

The main causes of cardiogenic shock

Krajnjaja stepen levozheludochkovoj nedostatochnosti harakterizujushhajasja rezkim snizheniem sokratitelnoj sposobnosti miokarda - Cardiogenic shock

Many are interested in the question: “What causes this severe and complex syndrome?”. In fact, there may be several reasons, and it is extremely desirable to know them, since there is every chance to avoid this ailment if the necessary measures are taken in time.

So, the reasons for the development of cardiogenic shock include:

  1. Of course, the main cause of the syndrome is myocardial infarction;
  2. inflammation in the myocardium;
  3. disturbances in the structure of the interventricular septum;
  4. heart valve problems, such as constriction;
  5. manifestation of thromboembolism.

Diagnostics. A marked decrease in blood pressure in combination with signs of impaired blood supply to organs and tissues. Systolic blood pressure is usually below 90 mmHg. Art., pulse – below 20 mm RT. Art.

Symptoms of peripheral circulation deterioration (pale cyanotic moist skin, collapsed peripheral veins, decreased skin temperature of the hands and feet) are noted; decrease in blood flow velocity (time of the disappearance of a white spot after pressing on the nail bed or palm – more than 2 s), decreased diuresis (less than 20 ml/h), impaired consciousness (from mild inhibition to the appearance of focal neurological symptoms and the development of coma).

Differential diagnosis. In most cases, true cardiogenic shock should be differentiated from its other varieties (reflex, arrhythmic, drug, with a slow-flowing myocardial rupture, rupture of the septum or papillary muscles, damage to the right ventricle), as well as from pulmonary embolism, hypovolemia, internal bleeding and hypotension without shock.

Emergency care must be carried out in stages, quickly moving to the next stage with inefficiency
previous:
1. In the absence of severe stagnation in the lungs:
– lay the patient with lower extremities raised at an angle of 20g (with severe stagnation in the lungs – see “Pulmonary edema”);
– carry out oxygen therapy;

2. In the absence of marked stagnation in the lungs and a sign of a sharp increase in CVP:
– Introduce 200 ml of 0,9% sodium chloride solution intravenously by bed for 10 minutes under the control of blood pressure, respiratory rate, heart rate, auscultatory picture of the lungs and heart (if possible, control the CVP and jamming pressure in the pulmonary artery);

– with persistent arterial hypotension and the absence of signs of transfusion hypervolemia – repeat the introduction of fluid according to the same criteria;
– in the absence of signs of transfusion hypervolemia (CVP below 15 cm of water. Art.), Infusion therapy is continued at a rate of up to 500 ml/h, monitoring these indicators every 15 minutes.
If blood pressure cannot be stabilized quickly, then go to the next stage.

3. Introduce dopamine 200 mg in 400 ml of a 5% glucose solution intravenously, increasing the infusion rate from 5 μg/(kg X min) until a minimum sufficient blood pressure is reached;

– no effect – additionally prescribe norepinephrine gyrotartrate 4 mg in 200 ml of a 5% glucose solution intravenously, increasing the infusion rate from 0,5 μg/min until a minimum sufficient blood pressure is reached.

4. Monitor vital functions: cardiomonitor, pulse oximeter.

5. Hospitalize after a possible stabilization of the condition.

The main hazards and complications:
– untimely diagnosis and initiation of treatment;
– the inability to stabilize blood pressure;
– pulmonary edema with increased blood pressure or intravenous fluid;
– tachycardia, tachyarrhythmia, ventricular fibrillation;
– asystole;
– relapse of anginal pain;
– acute renal failure.

Note. By minimally sufficient blood pressure, systolic pressure of about 90 mm Hg should be understood. Art. with signs of improved perfusion of organs and tissues.

!  Urine the color of meat slops - possible diseases and what to do

Glucocorticoid hormones in true cardiogenic shock are not indicated.

Although the results of the treatment of true cardiogenic shock remain unsatisfactory, intensive therapy must be persistently carried out in all (including the so-called hopeless!) Patients, starting from the prehospital stage.

Cardiogenic shock is the last stage of a disease such as left ventricular failure. A characteristic manifestation is a decrease in myocardial contractions. This leads to a sudden disruption in the functioning of the body and its decompensation.

It is important to understand that this violation is really extremely serious. It is characterized by an impressive reduction in stroke and minute blood volume. Returning it to its normal and complete level is incredibly difficult even in cases of early diagnosis of the problem.

In most cases, cardiogenic shock is a consequence of myocardial infarction. Also, sometimes it appears after a severe degree of myocarditis. Less often, it can occur in case of poisoning with substances or drugs of the cardiotoxic type. That is why experts do not recommend self-medication, and even more so to use any medications to eliminate the likelihood of complications.

Knowing the causes of a problem can help avoid it. Among the main distinguish the following:

  1. Acute myocarditis.
  2. Severe types of arrhythmia.
  3. Stenosis.
  4. Mitral insufficiency in acute form.
  5. Severe aortic insufficiency.
  6. The use of nitrates, ACE inhibitors, beta-blockers is too early for a heart attack.
  7. High percentage of necrotic tissue.

IV. Emergency care for anginal status (myocardial infarction)

The development mechanism of such a problem usually has four main options. Among them are the following:

  1. Massive thromboembolism of the pulmonary artery.
  2. Severe heart rhythm problems.
  3. Ventricular tamponade with edematous fluid, as well as bleeding localized in the heart bag.
  4. Impaired functioning of the pumping function of the heart.

If the problem appears after myocardial infarction, it can be diagnosed with confidence in the presence of the following indicators:

  1. Filamentous pulse.
  2. 80 mm Hg or less – systolic pressure.
  3. 25 mm Hg or less – diastolic pressure.
  4. 20 ml and below – oliguria.

At the same time, excessive sweating, pallor of the skin, and a feeling of coldness in the extremities become mandatory symptoms. In some cases, there are other clinical manifestations, which can be diagnosed by an experienced specialist.

Term
myocardial infarction determines death
(necrosis) of cardiomyocytes. Comes to light
biochemical markers (increase
cardiac specific enzyme levels
– troponin, MV-KFK, etc.), signs
loss of electrical activity
heart tissue (Q-wave appearance
ECG) and myocardial ischemia (changes
segment ST and tooth T),
abnormalities of the motion of the heart wall
(Echocardiography), decreased tissue perfusion
(myocardial scintigraphy).

Sore throat
status – intense sternal
pain or its equivalents, duration
attack for more than 20 minutes, reaction to reception
NG is incomplete or absent, often
heart rhythm disturbances and
conduction, arterial instability
pressure.

Expressed
anginal status

1.1.
Be sure to remove the ECG.

1.2.
Sore throat
pain is needed
eliminate as quickly and completely as possible:

nitroglycerine
0,5 mg sublingual tablet
or 0,4 mg as an aerosol, through
3-5 minutes reuse is possible;

acitylsalicylic
chew acid 0,25 g;

morphine
in a total dose of up to 10 mg (1% solution of 1 ml)
dilute to 20 ml with physiological
solution (1 ml of the resulting solution
contains 0,5 mg of active substance) and
inject intravenously slowly fractionally
in 2-3 stages (2 to 5 mg every 5 to 15 minutes).
Instead of the reference drug
morphine analgesics can be used
omnopon (20 mg omnopon is equivalent to 10
mg morphine) or promedol 20 mg (2% solution
1 ml) intravenously slowly fractionally in
2 stages;

via
20 minutes fentanyl 0,1 mg (0,005% solution 2
ml) intravenously slowly with droperidol
5 to 10 mg (0,25% solution of 2 to 4 ml).

Single
the dose of droperidol depends on the level
systolic blood pressure:

to
100 mmHg Art. – 1 ml;

to
120 mmHg Art. – 2 ml;

to
160 mmHg Art. – 3 ml;

above
160 mmHg Art. – 4 ml.

RџSЂRё
insufficient effect can additionally:

introduce
intravenous analgin 2,5 g (5 ml 50%
solution)

с
diazepam 5 mg (1 ml solution for
injection);

RџSЂRё
inefficiencies of previous activities:

via
45 minutes re-administration of fentanyl
with droperidol.

1.3.
To restore coronary
blood flow:

with
focal myocardial infarction with
raising the S – T segment as early as possible (in the first 6 hours, and when
recurrent pain up to 12 hours from onset
diseases) introduce streptokinase
1500000 IU intravenously drip on
for an hour. At increased risk
allergic complications before
administration of streptokinase
30 mg of prednisilone intravenously;

with
subendocardial myocardial infarction
with depression of the S – T segment as soon as possible 5000 PIECES of heparin intravenously, and then drip
1000 units per hour with an infusomat;

blockers
 -adrenoreceptors
in the absence of acute cardiac
failure, hypotension,
atrioventricular bolocada and other
contraindications apply at first
12 hours after a heart attack
myocardium.

● Intravenous
introduction upon admission to the hospital:
atenolol 5 mg for 5 minutes later
10 mg are reintroduced for 5 minutes
5 minutes. 10 minutes after completion
intravenous administration is prescribed inside
50 mg once a day.

Krajnjaja stepen levozheludochkovoj nedostatochnosti harakterizujushhajasja rezkim snizheniem sokratitelnoj sposobnosti miokarda - Cardiogenic shock

● In prehospital
-adrenoreceptor blockers
better administered under the tongue or inward
(this is the safest). Propranolol
(anaprilin) ​​in a dose of 20 – 40 mg under the tongue or
metoprolol (egilok) 25-50 mg 2 times a
day inside.

with
recurrent anginal pain and/or
acute left ventricular failure
nitroglycerin intravenously
(see section 1 “Hypostasis edema”, paragraph 2.3);

with
low blood pressure (systolic blood pressure below 90 mmHg) – dopamine 200 mg in 200 ml of physiological
infusion solution (initial velocity
3 mcg/kg/min, in the absence of effect
infusion rate increases by 3
mcg/kg/min, maximum speed – 12
mcg/kg/min) ilinoradrenaline 0,2% – 1 ml intravenously in 200 ml of physiological
solution at a rate of 2 ml/min .; speed
introductions are regulated depending on
reactions Blood pressure and heart rate. Indicative
initial rate of introduction of the mixture 10-15
cap. in minutes

with
complications – see relevant
recommendations.


nitroglycerin 0,5 mg sublingual
or 10 mg (1% solution of 1 ml) intravenously
drip in 100 ml of isotonic solution
sodium chloride in the absence of cerebral
symptoms at a rate of 8 to 12 drops
per minute under control of blood pressure or perfusion;


-blockers
– propranolol (anaprilin) ​​20-40 mg sublingual or metoprolol (egilok)
in the absence of acute cardiac
insufficiency and other contraindications.
Metoprolol is administered three times intravenously
5 mg (bolus) at intervals between
injections for 5 minutes. If heart rate
reductions are reduced to less than
60 per minute, and blood pressure drops below 100 mm
Hg. Art.

● enalaprilat
5 minutes intravenously
at a dose of 0,625 – 1,25 mg;

● quinaprilat
– at a dose of 2,5 to 5 mg intramuscularly.

2. With a persistent attack of angina pectoris

2.2.
Carry out oxygen therapy.

2.3.
With variant angina in addition
10 mg is prescribed for nitroglycerin
nifedipine (corinfarum) sublingually.

2.4.
With angina pectoris to eliminate
tachycardia and hypertension
-blockers can be used,
but with caution, considering all
contraindications: anaprilin 20-40 mg sublingual or metoprolol (egilok)
25-50 mg inside.

2.5.
Emotional stress may be
eliminated by taking di-azepam (seduxen)
5-10 mg orally, intramuscularly, intravenously
(2 ml ampoule contains 10 mg of the drug).

3.
With a protracted attack over 10
minutes and inefficiencies previous
events

3.1.
Aspirin (chew 250-500 mg of the drug,
uncoated) if not given
before.

3.2.
With severe pain persisting after
the use of nitroglycerin, – morphine
1% -1 ml (10 mg) intravenously or ilipromedol
2% – 1 ml (20 mg) intravenously.

3.3.
To potentiate the effects of narcotic
analgesics or if traditional
no narcotic analgesics,
can apply non-narcotic
drugs: analgin 50% solution
2-4 ml 5 mg droperidol (0,25% solution
2 ml) slowly intravenously or 50-100 mg
tramadol (1 ml ampoule contains 50 mg
preparation, 2 ml – 100 mg) with 5 mg of droperidol
intravenously slowly or fractionally.

3.4.
In the presence of changes in the ECG ischemic
character (S-T segment depression or T wave changes) – may be
70 jet units/kg (approximately 5000
ED). In doing so, make sure that
there are no contraindications
heparin.

!  Consequences and odds of survival after extensive myocardial infarction

acute
myocardial infarction;

sharp
heart rhythm disturbances or
conductivity (up to sudden
of death);

relapse
anginal pain;

arterial
hypotension (including drug);

acute
heart failure;

Violations
narcotic breathing
analgesics.

Types of shock

Some varieties of cardiogenic shock can be distinguished, depending on the features of the manifestation. The main ones are:

  1. Reflex. This is a mild form that can be treated. A sign is a drop in blood pressure. Lack of treatment provokes the following form.
  2. True. It appears due to extensive necrotic tissue of the left ventricle. If necrosis reaches 40-50%, this form becomes reactive.
  3. Arrhythmic. It is associated with acute bradyarrhythmia or paroxysm of tachycardia with atrioventricular block. Timely help is a guarantee of life.

Symptoms of this syndrome

Cardiogenic shock has typical symptoms that are easy to identify even for a person far from medicine. The main manifestation is a sharp decrease in systolic pressure to a level of 90 mm Hg or lower in 30 minutes. In this case, the symptoms of peripheral hyperperfusion are also observed.

With a more specific examination of the patient, ambulance specialists or loved ones may note the presence of the following symptoms:

  • dull tonality of the heart;
  • cyanosis of the mucous membranes and skin;
  • limb cooling;
  • fainting;
  • confusion;
  • tachycardia;
  • pallor of the skin;
  • increased sweating, cold, sticky sweat, skin moisture;
  • decreased urine output.

In accordance with the symptoms, shock is divided into three main stages. The first takes about 3-5 hours. The pressure in humans is in the range of 90/50-0/40. In the presence of hypertension, blood pressure may also have normal values. Proper measures in the first 50 minutes of this condition lead to the restoration of pressure indicators, a decrease in cyanosis, restoration of normal skin color, warming of the extremities.

The correct position of the patient

The second degree lasts up to 10 hours. Characteristic features – pressure in the range of 80/50-40/20. In this case, cyanosis, swelling and wheezing, malfunctioning in breathing and other pathological signs are observed. In addition, the second degree is characterized by an unstable or too slow reaction to drug therapy. Symptoms may return repeatedly throughout the day after emergency care.

The third degree is represented, first of all, by a sharp drop in pressure to 60/40 and below. Symptoms of cerebrovascular accident, acute heart failure, pulmonary edema increase at a tremendous rate. In most cases, drugs do not allow to cope. Unfortunately, often the patient dies within 1-3 days.

In order to be aware and prepared, you should be well aware and understand the existing signs by which you can determine the presence of this problem. In addition to standard chest pains, a person may experience the following symptoms:

  • low body temperature;
  • the patient’s pulse intensifies over time;
  • vague consciousness;
  • blood pressure is low;
  • rapid breathing;
  • bouts of fear (especially the patient is afraid of death);
  • poor urination
  • the manifestation of sweat, which is sticky;
  • external signs consisting in pallor, in various stains on the face, etc .;
  • loss of consciousness;
  • bloating, etc.

Cardiogenic shock, the symptoms of which can occur at any time and anywhere, is not an easy ailment, which is why there should be special awareness in this direction. This is especially true for those people who have had repeated heart problems.

How to provide emergency care?

First aid for cardiogenic shock should be provided immediately. This is the only way to normalize the condition and restore normal heart function. Assistance is provided in accordance with the established algorithm of actions in order to eliminate the likelihood of further harm to the patient. Emergency care for cardiogenic shock has the following algorithm:

  1. A person must be laid on any flat surface. It can be a bed or sofa, in their absence – the floor.
  2. It is important to raise the legs and head so that the tongue does not sink.
  3. Open the window for fresh air.
  4. Calling an ambulance carriage.
  5. If possible, it is necessary to listen to the lungs and heart, count the pulse, measure the pressure.
  6. When the doctors arrive, they should be given a list of drugs that the patient has taken over the past hours.

Further, all the work will be done by doctors: installing a dropper with glucose, saline, reopoliglyukin, placing a catheter into a vein, the use of a number of drugs under the condition of constant monitoring of the patient.

Now you know the emergency care algorithm required for cardiogenic shock. In cases where there is a person with acute heart disease in the family, you need to know what cardiogenic shock is and how first aid is provided. This allows you to save a life.

III. Emergency care for an attack of biliary colic

Cause of gall
colic may be biliary dysfunction
hypertensive bladder and sphincter of Oddi
type, gallstone disease, acute
cholecystitis, and sometimes pancreatitis.
Attack of biliary clique with functional
biliary tract disorders usually
starts suddenly with pain in the right
hypochondrium and the right side of the epigastrium,
which can radiate to the right
shoulder, right arm and shoulder blade last
about 20 min, not accompanied by signs
intoxication and fever.

I. Emergency care for an Asthma Attack

a)
short action (up to 6 hours)


salbutamol, albuterol, ventolin
(aerosol, tab., disk)


fenoterol, berotek (aerosol)

b)
long action (up to 12 hours)


salmeterol, serevent (aerosol, tab.)

Inhalation
salbutamol, repeated – after 20
minutes, up to 3 times in the first hour, then every
3 to 4 hours. Preferably through
spacer.

If the attack does not
stopped, then 2 to 4 breaths per
24 – 48 hours.

Are acting
later and have more side effects
(applies to 1, 2, 3)


atrovent 2 – 4 breaths every 3 – 4 hours,
better through a spacer;


troventol 2 – 4 breaths every 3 – 4 hours
through the spacer;


Berodual (atrovent berotek) 2 – 4 breaths
every 3 to 4 hours through a spacer.

β2agonists
short acting, oral:


Wolmac (tab. 4 mg, 8 mg, S1 teros);


saltos (tab.
6 mg, S 1 t
per os).

a)
long acting (theophylline)


teotard (tab. 200 mg, 350 mg, 500 mg), theodur,
theobilong;

b)
short action (not possible if sick
long takes theophylline)


aminophylline (tab. 0,15);

amyfillin
2,4% – 10,0 iv slowly on physical solution 10,0.

Attack
moderate severity

Salbutamol 2 – 4 breaths every 20 minutes during the first hour

Algoritm dejstvij zavisit ot formy i simptomov kardiogennogo shoka - Cardiogenic shock

prednisone 30 mg peros (oral HA);

atrovent (troventol) 2 – 4 ing.
(anticholinergic);

продолжить
salbutamol 6 – 10 breaths every 1 – 2
hours

Only
as an alternative – if the patient is not
received theophylline, can amufillin 2,4% –
10,0 iv slowly on physical solution 10,0.


salbutamol 2 – 4 breaths every 20 minutes
during the first hour through the spacer
it’s better;


add prednisone 30-40 mg peros;


repeat salbutamol: up to 10 breaths
every 1 to 2 hours;


add atrovent or troventol 2 – 4
ing .;


can amufillin if the patient did not receive
long-term theophyllines, 2,4% – 10,0 iv (only
as an alternative);

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Tatyana Jakowenko

Editor-in-chief of the Detonic online magazine, cardiologist Yakovenko-Plahotnaya Tatyana. Author of more than 950 scientific articles, including in foreign medical journals. He has been working as a cardiologist in a clinical hospital for over 12 years. He owns modern methods of diagnosis and treatment of cardiovascular diseases and implements them in his professional activities. For example, it uses methods of resuscitation of the heart, decoding of ECG, functional tests, cyclic ergometry and knows echocardiography very well.

For 10 years, she has been an active participant in numerous medical symposia and workshops for doctors - families, therapists and cardiologists. He has many publications on a healthy lifestyle, diagnosis and treatment of heart and vascular diseases.

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