Cardiogenic shock: first aid, symptoms, treatment algorithms for acute myocardial infarction

Cardiogenic shock, the most frequent and formidable complication of large-focal acute myocardial infarction( AMI).An immediate severe shock condition develops suddenly and in nine out of ten cases( !) Leads to a fatal outcome. The life and death of the patient is in the hands of the features of the disease itself - the pathology of the heart, and in the hands of the doctor who provides the first emergency aid.

It's good, when a whole reanimation team of doctors fighting for the life of the patient struggles, having all the necessary medicines, equipment and devices for the return of a person to life, but even with all that is possible. .. the chances of salvation are still insignificant.

Cardiogenic shock: causes of

Cardiogenic shock, manifested by acute arterial hypotension, sometimes reaching its extreme degree, is a complex, often uncontrolled condition that develops as a result of "small cardiac output syndrome"( acute failure of contractile function of the myocardium).

The most unpredictable period of time in terms of the occurrence of complications of acute myocardial infarction is the first hours of the disease, because then at any time myocardial infarction can result in cardiogenic shock, which usually accompanies the following clinical symptoms:

1. Microcirculation disorders and central hemodynamics;
2. Acid-base imbalance;
3. Shifts of the water-electrolyte state of the organism;
4. Changes in neurohumoral and neural-reflex regulatory mechanisms;
5. Disorders of cellular metabolism.

In addition to the cardiogenic shock caused by myocardial infarction, there are other causes of the development of the shock state:

• Primary impairment of the pump function of the left ventricle( damage to the valve apparatus of various origins, cardiomyopathy, myocarditis);
• Disturbances in the filling of the heart cavities, which occurs with cardiac tamponade, myxome or intracardiac thrombus, pulmonary embolism( PE);
• Arrhythmia of any etiology.

Forms of cardiogenic shock

Classification of cardiogenic shock is based on the grading of severity( I, II, III - depending on the clinic, heart rate, blood pressure, diuresis, duration of shock) and the types of hypotensive syndrome thatit is possible to present so:

1. Reflex shock ( a syndrome of hypotension-bradycardia), which develops against a background of severe pain, some specialists actually do not consider shock as it is easily stopped by effective methods, and the reflex effects of the affected area of ​​the myocardium are the basis of the drop in arterial pressure;
2. Arrhythmic shock , in which arterial hypotension is caused by a small cardiac output and is associated with brady- or tachyarrhythmia. Arrhythmic shock is represented by two forms: the predominant tachysystolic and especially unfavorable - bradisystolic, which occurs against the background of an antrioventricular blockade( AV) in the early period of myocardial infarction;
3. True cardiogenic shock , giving a lethality about 100%, as the mechanisms of its development lead to irreversible changes incompatible with life;
4. The reactive shock of in pathogenesis is an analogue of true cardiogenic shock, but somewhat differs by a greater degree of pathogenetic factors, and, consequently, by the special severity of the flow;
5. Shock due to rupture of the myocardium , which is accompanied by a reflex drop in blood pressure, cardiac tamponade( blood pours into the pericardial cavity and creates obstacles to cardiac contractions), overload of the left heart and the contraction of the contractile function of the heart muscle.

Cardiogenic shock: clinical criteria, symptoms

Thus, it is possible to single out the generally accepted clinical criteria for shock in myocardial infarction and present them in the following form:

• Reduction in systolic blood pressure below the permissible level of 80 mm Hg. Art.(for those suffering from arterial hypertension - below 90 mm Hg);
• Diuresis less than 20ml / h( oliguria);
• Paleness of skin;
• Loss of consciousness.

However, the severity of the patient's condition, which developed a cardiogenic shock, can be judged more by the duration of and shock of the patient's response to the introduction of pressor amines than the level of arterial hypotension.

If the duration of the shock condition exceeds 5-6 hours, is not stopped by drugs, and the shock itself is combined with arrhythmias and pulmonary edema, this shock is called asactive .

Cardiogenic shock: the pathogenesis of the onset of

The leading role in the pathogenesis of cardiogenic shock belongs to reducing the contractility of the cardiac muscle and reflex effects from the affected area. The sequence of changes in the left department can be represented as follows:

1. Reduced systolic ejection includes a cascade of adaptive and compensatory mechanisms;
2. Amplified production of catecholamines leads to generalized narrowing of blood vessels, especially arterial vessels;
3. Generalized spasm of arterioles, in turn, causes an increase in the total peripheral resistance and promotes centralization of blood flow;
4. Centralization of blood flow creates conditions for increasing the volume of circulating blood in a small circle of blood circulation and gives an additional load to the left ventricle, causing its damage;
5. Elevated end-diastolic pressure in the left ventricle leads to the development of left ventricular heart failure.

The microcirculation pool in cardiogenic shock also undergoes significant changes due to arterial-venous bypass:

• The capillary bed is impoverished;
• Metabolic acidosis develops;
• There are marked dystrophic, necrobiotic and necrotic changes in tissues and organs( necrosis in the liver and kidneys);
• Capillary permeability is increased, which results in a massive release of plasma from the bloodstream( plasmorrhagia), whose volume in the circulating blood naturally decreases;
• Plasmorrhagia lead to an increase in hematocrit( the ratio between plasma and red blood) and a decrease in blood flow to the cardiac cavities;
• Coronary artery blood flow is reduced.

Events occurring in the microcirculation zone inevitably lead to the formation of new ischemia sites with the development of dystrophic and necrotic processes in them.

Cardiogenic shock, as a rule, is characterized by rapid flow and quickly captures the entire body. Due to disorders of erythrocytic and platelet homeostasis, micro-clotting of blood in other organs begins:

1. In the kidneys with the development of anuria and acute renal failure - as a result;
2. In the lungs with the formation of a syndrome of respiratory disorders( pulmonary edema);
3. In the brain with its edema and the development of the brain coma.

As a result of these circumstances, fibrin begins to be consumed, which goes to the formation of microthrombi forming the DIC syndrome( disseminated intravascular coagulation) and leading to bleeding( more often in the gastrointestinal tract).

Thus, the combination of pathogenetic mechanisms leads the state of cardiogenic shock to irreversible consequences.

Symptoms: diagnosis of cardiogenic shock

Given the severity of the patient's condition, there is not much time for a detailed examination at the doctor, therefore, the primary diagnosis( in most cases, prehospital) is based entirely on objective data:

• The color of the skin ( pale, marble, cyanosis);
• Body temperature ( lowered, sticky cold sweat);
• Breathing ( frequent, superficial, obstructed - dyspnea, against a background of falling blood pressure stagnant phenomena develop with the development of pulmonary edema);
• Pulse ( frequent, small filling, tachycardia, with a decrease in blood pressure becomes threadlike, and then ceases to be probed, tachy- or bradyarrhythmia may develop);
• Arterial pressure ( systolic - sharply reduced, often does not exceed 60 mm Hg, and sometimes it is not determined at all, pulse, if it turns out to be diastolic, is below 20 mm Hg);
• Heart sounds ( deaf, sometimes catch a third tone or melody of the proto-diastolic rhythm of the canter);
• ECG ( more often picture IM);
• Kidney function ( diuresis is decreased or anuria occurs);
• Painful sensations in the heart ( can be quite intense, patients groan loudly, restless).

Naturally, for each type of cardiogenic shock, there are inherent signs, here are only general and most common.

Diagnostic tests( coagulogram, oxygen saturation, electrolytes, ECG, ultrasound, etc.) that are necessary for the correct tactics of patient management are already conducted in the inpatient setting if the ambulance team manages to deliver it there, since death on the way to the hospital is notsuch a rare thing in such cases.

Cardiogenic shock: emergency care, treatment algorithm, treatment of

Before starting emergency care for cardiogenic shock, any person ( not necessarily a doctor) should somehow orient in the symptoms of cardiogenic shock without confusing menacinglife state with the state of alcohol intoxication, for example, because myocardial infarction and the subsequent shock can happen anywhere.

Sometimes you have to see at the stops or on the lawns of lying people who may need the most emergency care of resuscitators. Some pass by, but many stop and try to provide first aid.

Of course, if there are signs of clinical death, it is important to immediately begin resuscitation( indirect cardiac massage, artificial respiration).

However, unfortunately, few people know the technique, and they are often lost, so in similar cases the best first aid will be a phone call to the number "103" , where it is very important to correctly describe the dispatcher's condition, based on the signs that may beare characteristic of a severe heart attack of any etiology:

1. Extremely pale complexion with a grayish tinge or cyanosis;
2. Cold sticky sweat covers the skin;
3. Decreased body temperature( hypothermia);
4. There is no reaction to surrounding events;
5. A sharp drop in blood pressure( if there is a possibility of measuring it before the arrival of an ambulance team).

So, once again we will stop and focus on the fact that for a passer-by person , who is not a medical worker with a set of necessary resuscitative drugs and funds. The witness of an accident without injuries, when the injured person simply seized or fell down, does not have enough air for breathing, he is very ill, he is pale, to render the first possible emergency help, it is necessary to do:

1. Call the number "103 "or" 030 "and call an ambulance.

2. Located near the victim before the arrival of the medical team.

Before hospital care for cardiogenic shock

The algorithm of action depends on the shape and symptoms of cardiogenic shock, resuscitation measures usually begin immediately, right in the reanimobile:

• At an angle of 15 degrees, raise the patient's legs;
• Give oxygen;
• If the patient is unconscious, the trachea is intubated;
• In the absence of contraindications( cervical vein swelling, pulmonary edema), infusion therapy is performed with a solution of rheopolyglucin. In addition, prednisolone, anticoagulants and thrombolytics are administered;
• To maintain blood pressure, at least at the lowest level( at least 60/40 mm Hg), vasopressors are administered;
• In case of rhythm disturbance - arrest of an attack depending on the situation: tachyarrhythmia - electropulse therapy, bradyarrhythmia - accelerating pacemaking;
• In case of ventricular fibrillation - defibrillation;
• With asystole( cessation of cardiac activity) - indirect cardiac massage.

Treatment of cardiogenic shock

Treatment of cardiogenic shock should be not only pathogenetic but also symptomatic:

1. When pulmonary edema is prescribed nitroglycerin , diuretics , adequate analgesia , introduction of alcohol to prevent the formation of foamy fluid in the lungs;
2. Severe pain syndrome is treated with promedol , with morphine , fentanyl with with droperidol .

Urgent hospitalization is carried out under constant supervision in the intensive care unit, bypassing the waiting room! Of course, if it was possible to stabilize the patient's condition( systolic pressure 90-100 mm Hg).

What are the predictions and chances for a patient's life?

Against the backdrop of even a short-term cardiogenic shock, other complications can rapidly develop in the form of rhythm disturbances( tachy- and bradyarrhythmias), thrombosis of large arterial vessels, pulmonary infarctions, spleen, necrosis of the skin, hemorrhages.

Depending on how the blood pressure is lowering, how marked are the signs of peripheral disorders, what reaction of the patient's body to medical measures is accepted to distinguish between cardiogenic shock of moderate severity and severe, which is classified as areactive in the classification. An easy degree for such a serious disease, in general, somehow not provided.

However, even in the case of a shock of moderate severity, there is no need to flatter yourself. Some positive response of the body to therapeutic effects and an encouraging increase in blood pressure to 80-90 mm Hg. Art.can quickly change to the reverse picture: against a background of increasing peripheral manifestations, AD starts to fall again.

Patients with a severe form of cardiogenic shock are practically deprived of any chance of surviving , as they absolutely do not react to medical measures, so the vast majority( about 70%) die on the first day of illness( usually within 4-6 hours from the onset of shock).Individual patients can survive 2-3 days, and then death occurs.

Only 10 patients out of 100 manage to overcome this condition and survive. But to win this really terrible disease is destined only to units, since some of those who return from the "other world" soon die of heart failure.

Related Videos

How does cardiogenic shock occur?

Here is a professional medical animation of cardiogenic shock, what happens inside the heart!

Acute myocardial infarction: cardiogenic shock, lecture one and two

Source of publication: site http: //sosudinfo.ru/serdce/ kardiogennyj-shok /