There can be no cardiogenic shock. Causes, symptoms and emergency care for cardiogenic shock

Cardiogenic shock is a severe condition caused by severe heart failure, accompanied by a significant decrease blood pressure and a decrease in myocardial contractility. In this state, a sharp decrease in the number of minute and stroke blood volume is so pronounced that it cannot be compensated by an increase in vascular resistance. Subsequently, this condition causes severe hypoxia, a decrease in blood pressure, loss of consciousness and serious disturbances in the circulation of vital organs and systems.

Thromboembolism of large branches of the pulmonary artery can cause cardiogenic shock in a patient.

Cardiogenic shock in almost 90% of cases can lead to the death of the patient. The reasons for its development can be:

• acute valvular insufficiency;
• acute stenosis of the heart valves;
• myxoma of the heart;
• severe forms;
• septic shock, provoking dysfunction of the heart muscle;
• rupture of the interventricular septum;
• heart rhythm disturbances;
• rupture of the ventricular wall;
• squeezing;
• cardiac tamponade;
• tense pneumothorax;
• hemorrhagic shock;
• rupture or dissection of the aortic aneurysm;
• coarctation of the aorta;
• massive.

Classification

Cardiogenic shock is always caused by a significant violation of the contractile function of the myocardium. There are such mechanisms for the development of this serious condition:

1. Decreased pumping function of the myocardium. With extensive necrosis of the heart muscle (during myocardial infarction), the heart cannot pump the required volume of blood, and this causes severe hypotension. The brain and kidneys undergo hypoxia, as a result of which the patient faints and has urinary retention. Cardiogenic shock can occur when 40-50% of the myocardial area is affected. Tissues, organs and systems abruptly cease their functioning, DIC syndrome develops and death occurs.
2. Arrhythmic shock (tachysystolic and bradystolic). This form of shock develops with paroxysmal tachycardia or complete atrioventricular blockade with acutely frolicking bradycardia. Violation of hemodynamics occurs against the background of a violation of the frequency of ventricular contraction and a decrease in blood pressure to 80-90 / 20-25 mm. rt. Art.
3. Cardiogenic shock with cardiac tamponade. This form of shock occurs when the septum ruptures between the ventricles. The blood in the ventricles mixes and the heart loses its ability to contract. As a result, blood pressure is significantly reduced, hypoxia in tissues and organs increases and leads to disruption of their function and death of the patient.
4. Cardiogenic shock caused by massive pulmonary embolism. This form of shock occurs when the pulmonary artery is completely blocked by a thrombus, in which blood cannot flow into the left ventricle. As a result, blood pressure drops sharply, the heart stops pumping blood, oxygen starvation of all tissues and organs increases, and the patient dies.

Cardiologists distinguish four forms of cardiogenic shock:

1. True: accompanied by a violation of the contractile function of the heart muscle, microcirculatory disorders, metabolic shift and a decrease in urine output. May be complicated by severe (cardiac asthma and pulmonary edema).
2. Reflex: due to reflex influence pain syndrome on the function of the myocardium. It is accompanied by a significant decrease in blood pressure, vasodilation and sinus bradycardia. Microcirculatory and metabolic disorders are absent.
3. Arrhythmic: develops with severe brady or tachyarrhythmias and is eliminated after the elimination of arrhythmic disorders.
4. Areactive: it is fast and difficult, even intensive therapy for this condition often does not work.

Symptoms

At the first stages, the main signs of cardiogenic shock largely depend on the cause of the development of this condition:

• with myocardial infarction, the main symptoms are pain and a feeling of fear;
• in case of heart rhythm disturbances - interruptions in the work of the heart, pain in the region of the heart;
• with thromboembolism of the pulmonary artery - pronounced shortness of breath.

As a result of a decrease in blood pressure, the patient develops vascular and autonomic reactions:

• cold sweat;
• pallor turning into cyanosis of the lips and fingertips;
• severe weakness;
• restlessness or lethargy;
• fear of death;
• swelling of the veins in the neck;
• cyanosis and marbling of the scalp, chest and neck (with pulmonary embolism).

After the complete cessation of cardiac activity and respiratory arrest, the patient loses consciousness, and, in the absence of adequate assistance, death may occur.

The severity of cardiogenic shock can be determined by indicators of blood pressure, duration of shock, severity of metabolic disorders, body response to drug therapy and severity of oliguria.

• I degree - the duration of the shock state is about 1-3 hours, blood pressure drops to 90/50 mm. rt. Art., insignificant severity or absence of symptoms of heart failure, the patient quickly reacts to drug therapy and relief of the shock reaction is achieved within an hour;
• II degree - the duration of the shock state is about 5-10 hours, the blood pressure drops to 80/50 mm. rt. Art., peripheral shock reactions and symptoms of heart failure are determined, the patient responds slowly to drug therapy;
• III degree - long-term shock reaction, blood pressure drops to 20 mm. rt. Art. or not determined, signs of heart failure and peripheral shock reactions are pronounced, in 70% of patients there is pulmonary edema.

Diagnostics

The following indicators are becoming generally accepted criteria for diagnosing cardiogenic shock:

1. Decrease in systolic pressure to 80-90 mm. rt. Art.
2. Decrease in pulse (diastolic pressure) up to 20-25 mm. rt. Art. and below.
3. A sharp decrease in the amount of urine (oliguria or anuria).
4. Confusion, agitation, or fainting.
5. Peripheral signs: pallor, cyanosis, marbling, cold extremities, threadlike pulse on the radial arteries, collapsed veins on the lower extremities.

If it is necessary to perform surgery to eliminate the causes of cardiogenic shock, carry out:

• Echo-KG;
• angiography.

Urgent care

If the first signs of cardiogenic shock appear in a patient outside the hospital, then it is necessary to call a cardiological ambulance. Before her arrival, the patient must be laid on a horizontal surface, his legs raised and ensured peace and fresh air flow.

Emergency help with cardiogenic care is started by the ambulance workers:

During drug therapy for continuous monitoring of the functions of vital organs, a urinary catheter is installed in the patient and cardiac monitors are connected, which record the indicators of heart rate and blood pressure.

If it is possible to use specialized equipment and the ineffectiveness of drug therapy for the provision of emergency care to a patient with cardiogenic shock, the following surgical techniques can be prescribed:

• intra-aortic balloon counterpulsation: to increase coronary blood flow during diastole, blood is pumped into the aorta using a special balloon;
• percutaneous transluminal coronary angioplasty: through a puncture of an artery, patency is restored coronary vessels, this procedure is recommended only in the first 7-8 hours after the acute period of myocardial infarction.

One of the most common and dangerous complications myocardial infarction is a cardiogenic shock. This is a difficult condition of the patient, which in 90% of cases ends in death. To avoid this, it is important to correctly diagnose the condition and provide emergency assistance.

What is it and how often is it observed?

Extreme phase acute failure circulation is called cardiogenic shock. In this state, the patient's heart does not perform the main function - it does not provide all organs and systems of the body with blood. This is usually an extremely dangerous result. acute heart attack myocardium. At the same time, experts provide the following statistics:

• in 50%, the state of shock develops in 1-2 days of myocardial infarction, in 10% - at the pre-hospital stage, and in 90% - at the hospital;
• if myocardial infarction with Q wave or ST segment elevation, the state of shock is observed in 7% of cases, and after 5 hours after the onset of symptoms of the disease;
• if myocardial infarction is without a Q wave, the shock state develops up to 3% of cases, and after 75 hours.

To reduce the likelihood of developing a shock state, thrombolytic therapy is performed, in which blood flow in the vessels is restored due to the lysis of a thrombus inside the vascular bed. Despite this, unfortunately, the probability of death is high - at the hospital, mortality is observed in 58-73% of cases.

The reasons

There are two groups of reasons that can lead to cardiogenic shock - internal (problems inside the heart) or external (problems in the vessels and membranes that envelop the heart). Let's consider each group separately:

Internal

Such external reasons can provoke cardiogenic shock:

• an acute form of myocardial infarction of the left stomach, which is characterized by long-term intact pain syndrome and an extensive area of \u200b\u200bnecrosis, provoking the development of heart weakness;

If the ischemia spreads to the right stomach, this leads to a significant worsening of the shock.

• arrhythmia of paroxysmal species, which is characterized by a high pulse frequency with fibrillation of the gastric myocardium;
• blockage of the heart due to the inability to conduct impulses that the sinus node must supply to the stomachs.

External

Row external causesleading to cardiogenic shock is as follows:

• the pericardial bag (the cavity where the heart is located) is damaged or inflamed, which leads to compression of the heart muscle as a result of accumulation of blood or inflammatory exudate;
• the lungs are torn, and air enters the pleural cavity, which is called pneumothorax and leads to compression of the pericardial bag, and the consequences are the same as in the previously cited case;
• thromboembolism of the large trunk of the pulmonary artery develops, which leads to impaired blood circulation through the small circle, blockage of the right stomach and tissue oxygen deficiency.

Symptoms of cardiogenic shock

Signs indicating cardiogenic shock indicate impaired blood circulation and externally manifest themselves in the following ways:

• the skin turns pale, and the face and lips become grayish or bluish;
• cold clammy sweat is released;
• there is a pathologically low temperature - hypothermia;
• hands and feet get cold;
• consciousness is disturbed or inhibited, and short-term excitement is possible.

In addition to external manifestations, cardiogenic shock is characterized by the following clinical signs:

• blood pressure is critically reduced: in patients with severe arterial hypotension, the systolic pressure is below 80 mm Hg. Art., and with hypertension - below 30 mm Hg. Art .;
• the pressure of pulmonary capillary wedging exceeds 20 mm Hg. Art .;
• the filling of the left ventricle increases - from 18 mm Hg. Art. and more;
• cardiac output decreases - the cardiac index does not exceed 2-2.5 m / min / m2;
• pulse pressure drops to 30 mm Hg. Art. and below;
• the shock index exceeds 0.8 (this is an indicator of the ratio of heart rate and systolic pressure, which is normally 0.6-0.7, and in shock it can even rise to 1.5);
• a drop in pressure and vascular spasms lead to a low urine output (less than 20 ml / h) - oliguria, and complete anuria is possible (cessation of urine flow into bladder).

Classification and types

The state of shock is classified into various types, the main among which are the following:

Reflex

The following phenomena occur:

1. The physiological balance between the tone of the two divisions of the vegetative nervous system - sympathetic and parasympathetic.
2. The central nervous system receives nociceptive impulses.

As a result of such phenomena, a stressful situation arises, which leads to an insufficient compensatory increase in vascular resistance - reflex cardiogenic shock.

This form is characterized by the development of collapse or severe arterial hypotension, if the patient has suffered myocardial infarction with intact pain syndrome. A collaptoid state is manifested by vivid symptoms:

• pale skin;
• excessive sweating;
• low blood pressure;
• increased heart rate;
• low pulse filling.

Reflex shock is short-lived and, thanks to adequate anesthesia, is quickly delivered to relief. To restore central hemodynamics, small vasopressor drugs are administered.

Arrhythmic

Paroxysmal tachyarrhythmia or bradycardia develops, which leads to hemodynamic disturbances and cardiogenic shock. There are violations of the heart rhythm or its conduction, which becomes the cause of a pronounced disorder of the central hemodynamics.

The symptoms of shock will disappear after the disturbances are arrested, and the sinus rhythm is restored, as this will lead to a rapid normalization of the superficial function of the heart.

True

Extensive myocardial damage occurs - necrosis affects 40% of the mass of the left stomach myocardium. This is the reason for a sharp decrease in the pumping function of the heart. Often such patients suffer from a hypokinetic type of hemodynamics, in which symptoms of pulmonary edema often appear.

The exact signs depend on the pressure of the pulmonary capillary wedge:

• 18 mmHg Art. - congestive manifestations in the lungs;
• from 18 to 25 mm Hg Art. - moderate manifestations of pulmonary edema;
• from 25 to 30 mm Hg Art. - pronounced clinical manifestations;
• from 30 mm Hg. Art. - the whole complex of clinical manifestations of pulmonary edema.

As a rule, signs of true cardiogenic shock are detected 2-3 hours after a myocardial infarction has occurred.

Areactive

This form of shock is similar to the true form, with the exception that it is accompanied by more pronounced pathogenetic factors that are of a prolonged nature. With such a shock, the body is not affected by any therapeutic measures, which is why it is called areactive.

Myocardial rupture

Myocardial infarction is accompanied by internal and external myocardial ruptures, which is accompanied by the following clinical picture:

• pouring out blood irritates the pericardial receptors, which leads to a sharp reflex drop in blood pressure (collapse);
• if an external rupture occurs, cardiac tamponade prevents the heart from contracting;
• if an internal rupture occurs, certain parts of the heart receive a pronounced overload;
• the contractile function of the myocardium falls.

Diagnostic measures

The complication is recognized by clinical signs, including the shock index. In addition, the following survey methods can be carried out:

• electrocardiography to identify the localization and stage of infarction or ischemia, as well as the extent and depth of damage;
• echocardiography - ultrasound of the heart, in which the ejection fraction is assessed, and the degree of decrease in myocardial contractility is also assessed;
• angiography - contrast X-ray examination blood vessels (radiopaque method).

Algorithm of emergency care for cardiogenic shock

If the patient has symptoms of cardiogenic shock, before the arrival of the ambulance workers medical care it is necessary to carry out the following actions:

1. Lay the patient on their back and raise their legs (for example, lay them on a pillow) to ensure a better flow of arterial blood to the heart:

1. Call the resuscitation team, describing the patient's condition (it is important to pay attention to all the details).
2. Ventilate the room, free the patient from tight clothing or use an oxygen bag. All these measures are necessary to ensure that the patient has free access to air.
3. Use non-narcotic analgesics for pain relief. For example, such drugs are Ketorol, Baralgin and Tramal.
4. Check the patient's blood pressure if a blood pressure monitor is available.
5. If there are symptoms of clinical death, carry out resuscitation measures in the form of chest compressions and artificial respiration.
6. Transfer the patient to a healthcare professional and describe his condition.

Further, the first emergency aid is already provided by medical workers. With a severe form of cardiogenic shock, transportation of a person is impossible. They are taking all measures to bring him out of a critical state - they stabilize the heart rate and blood pressure. When the patient's condition is normalized, he is transported in a special resuscitation machine to the intensive care unit.

Health care providers can do the following:

• introduce narcotic analgesics, which are Morphine, Promedol, Fentanyl, Droperidol;
• intravenously inject 1% Mezaton solution and at the same time subcutaneously or intramuscularly Cordiamine, 10% caffeine solution or 5% ephedrine solution (drugs may need to be injected every 2 hours);
• prescribe intravenous drip infusion of 0.2% norepinephrine solution;
• prescribe nitrous oxide to relieve a painful attack;
• carry out oxygen therapy;
• give Atropine or Ephedrine in case of bradycardia or heart block;
• intravenously inject 1% lidocaine solution in case of ventricular extrasystole;
• conduct electrical stimulation in case of heart block, and if ventricular paroxysmal tachycardia or gastric fibrillation is diagnosed - electrical defibrillation of the heart;
• connect the patient to a ventilator (if breathing has stopped or severe shortness of breath is noted - from 40 per minute);
• conduct surgeryif the shock is caused by injury and tamponade, while it is possible to use analgesics and cardiac glycosides (the operation is performed 4-8 hours after the onset of the heart attack, restores the patency of the coronary arteries, the myocardium is preserved and interrupts the vicious circle of shock development).

The patient's life depends on the rapid provision of first aid, aimed at relieving the pain syndrome, which causes the shock.

Further treatment is determined depending on the cause of the shock and is carried out under the supervision of a resuscitator. If everything is in order, the patient is transferred to the general ward.

Preventive measures

To prevent the development of cardiogenic shock, you must adhere to these tips:

• timely and adequately treat any cardiovascular diseases - myocardium, myocardial infarction, etc.
• eat properly;
• follow the scheme of work and rest;
• to refuse from bad habits;
• engage in moderate physical activity;
• fight stressful conditions.

Cardiogenic shock in children

This form of shock is not typical in childhood, but can be observed in connection with a violation of the contractile function of the myocardium. As a rule, this condition is accompanied by signs of insufficiency of the right or left stomach, since children are more likely to develop heart failure with congenital heart disease or myocardium.

In this condition, a decrease in voltage on the ECG and a change in the ST interval and T wave, as well as signs of cardiomegaly on the chest according to the results of X-ray, are recorded in the child.

To save the patient, you need to perform the emergency steps according to the previously given algorithm for adults. Further, health workers conduct therapy to increase myocardial contractility, for which inotropic drugs are administered.

So, a frequent continuation of myocardial infarction is cardiogenic shock. This condition can be fatal, so the patient needs to provide the correct emergency care to normalize his heart rate and increase myocardial contractility.

Cardiogenic shock is a life-threatening condition that develops as a result of a sharp violation of the contractile function of the left ventricle, a decrease in the cardiac output and stroke volume, as a result of which the blood supply to all organs and tissues of the body is significantly impaired.

Cardiogenic shock is not an independent disease, but develops as a complication of heart pathologies.

The reasons

The cause of cardiogenic shock is a violation of myocardial contractility (acute myocardial infarction, hemodynamically significant arrhythmias, dilated cardiomyopathy) or morphological disorders (acute valvular insufficiency, rupture of the interventricular septum, critical aortic stenosis, hypertrophic cardiomyopathy).

The pathological mechanism of the development of cardiogenic shock is complex. Violation of the contractile function of the myocardium is accompanied by a decrease in blood pressure and activation of the sympathetic nervous system. As a result, the contractile activity of the myocardium increases, and the rhythm becomes more frequent, which increases the heart's need for oxygen.

A sharp decrease in cardiac output causes a decrease in blood flow in the pool renal arteries... This leads to fluid retention in the body. The increasing volume of circulating blood increases the preload on the heart and provokes the development of pulmonary edema.

Long-term inadequate blood supply to organs and tissues is accompanied by the accumulation of under-oxidized metabolic products in the body, as a result of which metabolic acidosis develops.

Mortality in cardiogenic shock is very high - 85-90%.

Kinds

According to the classification proposed by Academician E.I. Chazov, the following forms of cardiogenic shock are distinguished:

1. Reflex. It is caused by a sharp drop in vascular tone, which leads to a significant drop in blood pressure.
2. True. The main role belongs to a significant decrease in the pumping function of the heart with a slight increase in peripheral total resistance, which, however, is not enough to maintain an adequate level of blood supply.
3. Areactive. It occurs against the background of extensive myocardial infarction. The tone of peripheral blood vessels sharply increases, and microcirculation disorders are manifested with maximum severity.
4. Arrhythmic. Deterioration of hemodynamics develops as a result of a significant disturbance of the heart rhythm.

Signs

The main symptoms of cardiogenic shock:

• a sharp decrease in blood pressure;
• threadlike pulse (frequent, weak filling);
• oligoanuria (decrease in the amount of urine excreted less than 20 ml / h);
• lethargy, up to a coma;
• pallor (sometimes marbling) of the skin, acrocyanosis;
• decrease in skin temperature;
• pulmonary edema.

Diagnostics

The diagnostic scheme for cardiogenic shock includes:

• coronary angiography;
• radiography chest (concomitant pulmonary pathology, size of the mediastinum, heart);
• electro- and echocardiography;
• computed tomography;
• a blood test for heart enzymes, including troponin and phosphokinase;
• analysis of arterial blood for gas composition.

Cardiogenic shock is not an independent disease, but develops as a complication of heart pathologies.

Treatment

• check the patency of the airways;
• install intravenous catheter wide diameter;
• connect the patient to a cardiac monitor;
• deliver humidified oxygen through a face mask or nasal catheters.

After that, activities are carried out aimed at finding the cause of cardiogenic shock, maintaining blood pressure, cardiac output. Drug therapy includes:

• analgesics (allow you to stop pain syndrome);
• cardiac glycosides (increase the contractile activity of the myocardium, increase the stroke volume of the heart);
• vasopressors (increase coronary and cerebral blood flow);
• phosphodiesterase inhibitors (increase cardiac output).

If indicated, other drugs are prescribed (glucocorticoids, volemic solutions, β-blockers, anticholinergics, antiarrhythmic drugs, thrombolytics).

Prevention

Prevention of the development of cardiogenic shock is one of the most important measures in the treatment of patients with acute cardiopathology, it consists in the rapid and complete relief of pain syndrome, restoration of the heart rhythm.

Potential consequences and complications

Cardiogenic shock is often accompanied by the development of complications:

• sharp mechanical damage heart (rupture of the interventricular septum, rupture of the wall of the left ventricle, mitral insufficiency, cardiac tamponade);
• severe left ventricular dysfunction;
• right ventricular infarction;
• violations of conduction and heart rhythm.

Mortality in cardiogenic shock is very high - 85-90%.

Cardiogenic shock is characterized by a sudden dysfunction of the heart. Since this is the main pump of human life, this situation has serious consequences, because significant damage to the heart occurs.

This leads to a blockage of blood circulation, due to which such essential organs as the brain and kidneys do not receive the necessary nutrients.

The vessels lose their tone, therefore, in turn, they are not able to deliver oxygen and blood to these organs and even to the heart itself. This is just a superficial consideration of simple but important functions that stop working as they should, but in fact everything happens much more complicated, so the consequences are not long in coming.

If we consider the normal operation of our internal pump, then in one contraction it pushes out a certain amount of blood, which is described as a stroke volume. On average, the heart contracts 70 times per minute, that is, it pumps the minute volume. Thus, it is possible to describe the main indicators of the pumping function of the heart muscle. Now is the time to understand what happens during certain disorders, that is, to see what the pathogenesis of cardiogenic shock is.

The reasons

The thing is that any catastrophe that happens in our body leads to a dramatically increased demand for oxygen, which can be compensated for with the help of an increased contraction of the heart, higher blood pressure and rapid breathing. If an imbalance occurs, and the heart or blood vessels are unable to cope with it, then stroke and minute volume or blood pressure drops. This is because an important system of the heart is disturbed.

It is important to remember that the heart has its own conducting system, a complete blockage of which leads to the termination of the heart. The rhythm of excitation is disrupted, or impulses, so the cells are not excited in their rhythm, which can be described as arrhythmia.

Damage to the heart itself contributes to the disruption of full muscle contraction, and this occurs due to impaired nutrition of the heart cells or necrosis. The more necrosis, the more likely it is to develop shock.

If the closure of the artery occurs gradually, shock may also occur with delay. It is also important to understand that when the heart muscle is ruptured, the contraction of the heart is greatly disrupted. It can be concluded that cardiogenic shock is a consequence of necrosis of 40% of the LV myocardium, which, by the way, is rarely compatible with life.

The role of various mechanisms responsible for the development of cardiogenic shock in MI

This is a general picture that allows you to understand why and how the work of the heart goes astray. It can be seen that all processes are interconnected and a violation of one of them can lead to shock, therefore there are still other causes of cardiogenic shock, consider some.

• Myocarditis, that is, inflammation of cardiomyocytes.
• Accumulation of fluid in the heart sac. Between the pericardium and the myocardium, there is a small space containing some fluid, thanks to which the heart moves freely, that is, without strong friction. With pericarditis, this fluid increases, and a sharp increase in volume leads to tamponade.
• Pulmonary embolism. A thrombus that has flown back clogs the artery of the lungs, which leads to blockage of the right heart ventricle.

Symptoms

The classification of cardiogenic shock includes five forms of this condition:

1. Arrhythmic shock. Arterial hypotension develops due to low cardiac output, there is a connection with tachy- or bradyarrhythmia. There is a predominant tachysystolic and bradystolic form of arrhythmic shock.
2. Reflex shock. It is characterized by strong pain. The pressure drops due to the reflex effect of the affected area of \u200b\u200bthe heart muscle. This form is easily docked. effective ways, therefore, some experts do not attribute it to cardiogenic shock.
3. True cardiogenic shock. This form is 100% fatal, because the mechanisms of development lead to irreversible disorders that are incompatible with life.
4. Shock due to myocardial rupture. In this case, a reflex drop in blood pressure and cardiac tamponade occurs. There is also an overload of the left cardiac departments and a decrease in myocardial contractile function.
5. Areactive shock. This is an analogue of true shock, however, there are differences in the greater severity of pathogenetic factors, therefore, the course is especially severe.

In this regard, the clinic for cardiogenic shock is presented as follows:

• decrease in blood pressure below 80 mm Hg. Art., and if a person suffers from arterial hypertension, then below 90;
• oliguria;
• dyspnea;
• loss of consciousness;
• pallor.

The severity of a patient's condition can be determined by its duration and the person's response to pressor amines. If cardiogenic shock lasts more than five hours and cannot be treated with drugs, and arrhythmia and pulmonary edema are observed, areactive shock occurs.

However, it is important to understand that a drop in blood pressure is a relatively late sign. First, cardiac output decreases, then reflex sinus tachycardia develops and pulse arterial pressure decreases. At the same time, vasoconstriction of the vessels of the skin, kidneys and brain develops.

Vasoconstriction can help maintain an acceptable level of blood pressure. The deterioration of perfusion of tissues and organs, and, of course, of the myocardium, will progressively increase. Against the background of pronounced vasoconstriction, a noticeable decrease in blood pressure is determined by auscultation, although the intra-arterial pressure, which is determined by puncture of the arteries, remains normal.

This means that if invasive pressure control is not possible, it is best to palpate the large arteries, that is, the femoral and carotid arteries, since they are not so susceptible to vasoconstriction.

Diagnostics

It is very easy to identify cardiogenic shock, since this is done on the basis of the clinic. If we take into account the severity of the patient's condition, the doctor simply does not have time to examine him in detail, therefore the diagnosis is based on objective data.

1. The skin color is marbled, pale, cyanosis is observed.
2. Decreased body temperature.
3. Cold, clammy sweat.
4. Difficulty, shallow breathing.
5. The pulse is fast, threadlike, poorly palpable, tachyarrhythmia, bradyarrhythmia.
6. Muffled heart sounds.
7. A sharply reduced systolic blood pressure, diastolic blood pressure may be less than 20.
8. MI on ECG.
9. Decreased urine output or anuria.
10. Pain in the region of the heart.

Fast diagnostics allows you to take the necessary measures in a timely manner

However, it is important to understand that cardiogenic shock manifests itself in different ways, we have given only the most common symptoms. Such diagnostic tests, like an ECG, coagulogram, ultrasound and so on, are necessary in order to understand how to proceed. They are carried out in a hospital setting, if the ambulance team managed to deliver the patient to the hospital.

Treatment

Treatment of cardiogenic shock is primarily based on emergency care, so anyone should be familiar with the symptoms of this condition and know how to proceed. You cannot confuse it, for example, with alcohol intoxication, such a disorder can cost your life.

Myocardial infarction and subsequent shock can occur anywhere. We sometimes see a person lying on the street who may need resuscitation. Let's not pass by, because a person may be minutes away from death.

So, if there are signs of clinical death, you must immediately proceed to resuscitation actions... You also need to immediately call ambulance, it can be done by another person so as not to waste time.

Emergency care includes artificial respiration and indirect cardiac massage. Take the time to explore how it's done and even practice with someone at your leisure.

However, anyone can call an ambulance. In this case, the dispatcher needs to describe all the symptoms that are observed in a person.

The algorithm of actions of ambulance specialists depends on how the cardiogenic shock proceeds, but resuscitation measures begin immediately, that is, in the intensive care unit itself.

1. The patient's legs are raised at an angle of 15 degrees.
2. They supply it with oxygen.
3. Intubate the trachea if the patient is unconscious.
4. Start to infusion therapy, if there are no such contraindications as pulmonary edema and swelling of the veins of the neck. Such therapy is based on the use of a solution of rheopolyglucin, prednisolone, thrombolytics and anticoagulants.
5. Vasopressors are administered to maintain blood pressure at least at a minimal level.
6. They stop the attack if the rhythm is disturbed. With tachyarrhythmias, electro-pulse therapy is performed, with bradyarrhythmias, accelerating cardiac stimulation is used.
7. Defibrillation of pi VF is used.
8. Do an indirect heart massage if the heart stops working.

Cardiogenic shock is treated not only depending on the pathogenesis, but also on the basis of symptoms. For example, if pulmonary edema is observed, diuretics, nitroglycerin, adequate pain relief, and alcohol are administered. If there is severe pain, promedol and other drugs are used.

Effects

Even if the cardiogenic shock did not last long, complications such as pulmonary infarction, rhythm disturbances, skin necrosis, and so on can rapidly develop. The condition can proceed in the form of moderate severity, but there is no mild degree as such. Even the moderate severity of the condition does not allow us to speak of a good prognosis. Even if the body responds well to treatment, this can quickly turn into a worse picture.

The severe form of shock does not allow talking about survival. Unfortunately, in this case, the patient does not respond to treatment, so about 70% of patients die in the first 24 hours, mostly within six hours. The rest die after two or three days. Only 10 out of 100 people can overcome this condition and stay alive, but many of them subsequently die from heart failure.

In this regard, it becomes clear how necessary it is to carefully monitor your health, starting from childhood, however, it is never too late to change your lifestyle and start all over again!

Cardiogenic shock is the worst degree of acute circulatory failure, when the heart ceases to fulfill its main function of providing all organs and systems with blood. Most often, this complication develops in acute widespread myocardial infarction in the first or second days of the disease.

Conditions for the development of cardiogenic shock can arise in patients with defects, during operations on large vessels and the heart. Despite the achievements of modern medicine, mortality in this pathology remains up to 90%.

The reasons

The causes of cardiogenic shock occur inside the heart or in the surrounding vessels and membranes.

TO internal reasons relate:

• Acute myocardial infarction of the left ventricle, which is accompanied by a long-term intractable pain syndrome, the development of severe weakness of the heart muscle in connection with an extensive area of \u200b\u200bnecrosis. The extension of the ischemic zone to the right ventricle significantly aggravates the shock.
• Paroxysmal types of arrhythmias with a high frequency of impulses with fibrillation and ventricular fibrillation.
• Complete heart block due to the inability to conduct impulses from the sinus node to the ventricles.

External reasons are considered:

• Various inflammatory or traumatic injuries of the pericardial bag (the cavity in which the heart lies). The result is an accumulation of blood (hemopericardium) or inflammatory exudate that squeezes the outside of the heart muscle. In such conditions, reductions become impossible.
• Pneumothorax (air in pleural cavity due to lung rupture).
• The development of thromboembolism of the large trunk of the pulmonary artery disrupts blood circulation through the small circle, blocks the work of the right ventricle, and leads to tissue oxygen deficiency.

Pathology development mechanisms

The pathogenesis of the appearance of hemodynamic disorders differs depending on the form of shock. There are 4 varieties.

1. Reflex shock - caused by the body's reaction to severe pain... In this case, there is a sharp increase in the synthesis of catecholamines (substances similar to adrenaline). They cause a spasm peripheral vessels, significantly increase the resistance to the work of the heart. Blood accumulates in the periphery, but does not feed the heart itself. Energy reserves of the myocardium are rapidly depleted, and acute weakness develops. This variant of pathology can occur with a small heart attack zone. Differs in good treatment results if pain is quickly relieved.
2. Cardiogenic shock (true) - associated with damage to half or more of the muscle mass of the heart. If even part of the muscle is excluded from the work, this reduces the strength and volume of blood ejection. With a significant lesion, the blood coming from the left ventricle is not enough to feed the brain. It does not enter the coronary arteries, the supply of oxygen to the heart is disrupted, which further impairs the possibility of myocardial contraction. The most severe pathology. Reacts poorly to ongoing therapy.
3. Arrhythmic form- impaired hemodynamics caused by fibrillation or rare cardiac contractions. Timely use of antiarrhythmic drugs, the use of defibrillation and electrical stimulation allows you to cope with this pathology.
4. Areactive shock - more often occurs with repeated heart attacks. The name comes from the lack of response from the body to therapy. In this form, irreversible tissue changes, the accumulation of acid residues, and slagging of the body with waste substances join the violation of hemodynamics. With this form, death occurs in 100% of cases.

Depending on the severity of the shock, all the described mechanisms are involved in the pathogenesis. The result of the pathology is a sharp decrease in the contractile ability of the heart and severe oxygen deficiency. internal organs, brain.

Clinical manifestations

Symptoms of cardiogenic shock indicate the manifestation of impaired blood circulation:

• the skin is pale, the face and lips have a grayish or bluish tint;
• cold clammy sweat is released;
• hands and feet are cold to the touch;
• varying degrees of impairment of consciousness (from lethargy to coma).

When measuring blood pressure, low numbers are revealed (the upper one is below 90 mm Hg), a typical difference with the lower pressure is less than 20 mm Hg. Art. The pulse on the radial artery is not determined, on the carotid artery - with difficulty.

With a drop in pressure and vasospasm, oliguria (low urine output) occurs, until complete anuria.

The ambulance is required to deliver the patient to the hospital as soon as possible after providing assistance

Classification

Classification of cardiogenic shock according to the severity of the patient's condition implies three forms:

Clinical manifestations	1st degree (light)	2nd degree (moderate)	3rd degree (heavy)
Duration of shock	less than 5 hours	from 5 to 8 hours	more than 8 hours
BP in mm Hg. Art.	at the lower limit of the norm 90/60 or up to 60/40	upper at 80-40, lower at 50-20	not defined
Tachycardia (beats per minute)	100–110	up to 120	muffled tones, thready pulse
Typical Symptoms	poorly expressed	predominantly left ventricular failure, possible pulmonary edema	pulmonary edema
Treatment response	good	slow and unstable	absent or short-term

Diagnostics

Diagnosis in cardiogenic shock is based on typical clinical findings. It is much more difficult to determine the true cause of the shock. This must be done to clarify the scheme of the forthcoming therapy.

At home, the cardiological team does an ECG study, the signs of an acute heart attack, the type of arrhythmia or blockade are determined.

In a hospital, an ultrasound of the heart is performed on emergency indications. The method reveals a decrease in the contractile function of the ventricles.

On the X-ray of the chest organs, you can establish pulmonary embolism, altered contours of the heart with defects, pulmonary edema.

During treatment, doctors of the intensive care unit or intensive care unit check the degree of oxygen saturation of the blood, the work of internal organs in general and biochemical analyzes, take into account the allocated amount of urine.

How to provide first aid to a patient

Help with cardiogenic shock from loved ones or bystanders may be to call an ambulance as soon as possible, a full description of the symptoms (pain, shortness of breath, state of consciousness). The dispatcher can dispatch a specialized cardiology team.

Laying the patient down with raised legs is necessary to improve the blood supply to the brain

As a first aid, you should take off or untie a tie, unfasten a tight collar, a belt, give Nitroglycerin for pain in the heart.

First aid goals:

• elimination of pain syndrome;
• blood pressure support with drugs at least at the level of the lower limit of the norm.

To do this, "Ambulance" is administered intravenously:

• pain relievers from the group of nitrates or narcotic analgesics;
• drugs from the group of adrenergic agonists are carefully used to increase blood pressure;
• with sufficient pressure and pulmonary edema fast-acting diuretics are needed;
• oxygen is given from a cylinder or pillow.

The patient is urgently taken to the hospital.

Treatment

Treatment of cardiogenic shock in the hospital continues the therapy started at home.

During fibrillation, a defibrillator is delivered urgently

The algorithm of actions of doctors depends on a quick assessment of the work of vital organs.

1. Inserting a catheter into subclavian vein for infusion therapy.
2. Elucidation of the pathogenetic factors of the state of shock - the use of painkillers with the continuation of pain, antiarrhythmic drugs in the presence of a disturbed rhythm, elimination of tense pneumothorax, cardiac tamponade.
3. Lack of consciousness and own respiratory movements - intubation and transition to artificial ventilation of the lungs using a breathing apparatus. Correction of oxygen content in the blood by adding it to the breathing mixture.
4. Upon receipt of information about the onset of tissue acidosis, the addition of sodium bicarbonate solution to therapy.
5. Placement of a catheter in the bladder to control the amount of urine excreted.
6. Continuation of therapy aimed at increasing blood pressure. For this, Norepinephrine, Dopamine with Reopolyglucin, Hydrocortisone are carefully injected drip.
7. Control over the injected fluid is carried out, with the onset of pulmonary edema it is limited.
8. Heparin is added to restore the impaired coagulating properties of blood.
9. The lack of response to the applied therapy requires an urgent question about the operation of intra-aortic counterpulsation by introducing a balloon into the descending part of the aortic arch.

The method allows you to maintain blood circulation before the operation of coronary angioplasty, stent insertion or deciding whether to perform coronary artery bypass grafting for health reasons.

The only way that helps with non-reactive shock may be an emergency heart transplant. Unfortunately, the current state of health care development is still far from this stage.

International symposia and conferences are devoted to the organization of emergency aid. Governments are being asked to increase the cost of bringing cardiac specialist therapy closer to the patient. Early initiation of treatment is critical to keeping the patient alive.