Physiology Cardiodynamics and Shock

Bill Cayley MD MDiv University of Wisconsin

Learning Objectives
Participants will be able to
Describe normal cardiac function Describe and differentiate types of shock Discuss the significance of cardiac rate and pressure parameters Discuss appropriate medical and surgical management of the patient in shock

John
50 year old traffic accident victim
Awake, moderate distress, c/o chest pain & SOB PMH: Hypertension, diabetes. SH: ppd cigarettes, taxi driver Exam: HR 120, BP 80/40. PERRLA. Lips cut. Heart irregular. Chest has wet crackles. Abdomen tender.

What is the clinical syndrome? What could be the underlying diagnoses? Why? What do you do? Why?

Shock
Insufficient circulation of oxygenated blood to meet metabolic demands.

Shock
Hypovolemic Cardiogenic

Obstructive

Distributive

Shock
Hypovolemic
Hemorrhage Aortic dissection Anemia

Cardiogenic
Decompensated CHF Acute coronary syndrome Dysrhythmia
Bradycardia Tachycardia Fibrillation

Obstructive
Aortic valve stenosis

Distributive
Sepsis Thyrotoxicosis Shunt syndromes

Valvular regurgitation Myocarditis, Cardiomyopathy Tamponade

Normal cardiac function

Normal cardiac function

Stroke volume (SV)
Volume per cycle

Cardiac Output (CO)

CO = SV x HR

Typical 70 kg adult
70cc/cycle X 70 cycles/min 4900 cc/minute

Stroke volume determinants

Preload
Due to venous return
Blood volume Venous tone

Afterload
Due to systemic vascular resistance (SVR)

Contractility (inotropy)

Stroke volume determinants

Frank-Starling Law
Contraction proportional to stretch (to a point)

Blood pressures
CVP
Central venous pressure Right ventricular preload

MAP = (SV x HR) x SVR

Blood pressures
PAOP
Pulmonary artery occlusion pressure RV output LV preload
Left Ventricular End Diastolic Pressure (LVEDP)

MAP = (SV x HR) x SVR

Blood pressures
MAP
Mean Arterial Pressure MAP =DBP +(PP/3) MAP = CO x SVR

MAP = (SV x HR) x SVR

?
?

Preload

Inotropy

Shock
MAP = (SV x HR) x SVR

Afterload

?
What types of shock will affect each of the cardiac parameters?

Hypovolemic Hemorrhage Anemia Cardiogenic CHF ACS Dysrhythmia Valve Dz Cardiac tamponade Distributive Sepsis Thyrotoxicosis Shunt syndromes Obstructive Aortic valve stenosis

Preload

Inotropy

Shock
MAP = (SV x HR) x SVR

Afterload
Hypovolemic Cardiogenic Low CVP Low CO High SVR High CVP Low CO High SVR Distributive Obstructive Low CVP HIgh CO Low SVR Low CVP Low CO +/- SVR

Shock: ACLS approach

Quadrad 1: Primary BLS
A, B, Cs Defibrillation

Quadrad 4:
Temperature , HR, BP, Respirations

Quadrad 2: Secondary BLS

A, B, Cs Diagnosis

Quadrad 5:
Tank (volume) Tank (resistance) Pump (inotropy) Rate

Quadrad 3:
Oxygen, IV, Monitor, Fluids

Acute shock

Volume

Pump

Resistance

Rate
Bradycardia? Tachycardia?

Fluids? Transfusion? Vasopressors? Hypertension Nitrates Hypotension Norepinephrine Dopamine

Hypovolemic shock
Dehydration
Emesis and diarrhea Environmental losses (perspiration)

Hemorrhage
Traumatic
External, Internal

Gastrointestinal malignancy, ulcer, varices Obstetric or gynecologic previa, ectopic, cyst Vascular rupture of AAA Pulmonary PE, cavitary tuberculosis

Classification of hemorrhage
Class Parameter I II III IV

Blood loss (ml) Blood loss (%)

<750 <15%

7501500 1530%

15002000 >2000 3040% >40%

Pulse rate (beats/min)

Blood pressure Respiratory rate (breaths/min) Urine output (ml/hour) Mental status

<100

>100

>120

>140

Normal Decreased Decreased Decreased 1420 >30 2030 2030 3040 515 Confused >35 Negligible Lethargic

Normal Anxious

Hypovolemic shock: physiology

Reduced blood volume Reduced preload Reduced stroke volume Reduced cardiac output

Response to shock - physiology

Cathecholamines, ADH Vasoconstriction, tachycardia Improve venous return and CO MAP = (SV x HR) x SVR

Hypovolemic shock: management

Hemostasis
AMPLE H&P
Allergies Medications Past illnesses /Pregnancy Last meal Events / Environment
What happened? When? Where?

Volume restoration
IV crystalloid
Saline Ringers lactate

Transfusion
If no response to 2 Liters of crystalloid If Class III hemorrhage Critically ill pt with Hb < 8

Treat source of bleeding!

If no T&C available
O pos males O neg females

MAP = (SV x HR) x SVR

Cardiogenic shock
Causes
Acute coronary syndrome Myocarditis Acute valve disease Pulmonary embolism Pericardial tamponade Dysrhythmia
Bradycardia Tachycardia

Killip stages
I. No heart failure, no signs of decompensation II. Heart failure, rales, S3 gallop, pulmonary venous hypertension III. Severe heart failure, frank pulmonary edema, rales throughout lung fields IV. Cardiogenic shock, hypotension (SBP <90mmHg), peripheral vasoconstriction with as oliguria, cyanosis and diaphoresis

Cardiogenic shock: physiology

Reduced inotropy Reduced stroke volume Reduced cardiac output Left-sided heart failure
Increased PAOP, pulmonary edema

Right-sided heart failure

Peripheral edema

MAP = (SV x HR) x SVR

Heart failure syndromes

Forward HF
Weakness, confusion, low BP Vasodilation, fluid replacement, inotropic support

LV intropy, SV, CO, PAOP

Heart failure syndromes

Left-backward HF
DOE, pulmonary edema, BP normal or high Vasodilation, diuretics, bronchodilators (?), respiratory support (?)

LV intropy, SV, CO, PAOP

Heart failure syndromes

Right backward HF
Peripheral edema, dyspnea, and ascites Diuretics for fluid overload Fluids for RV infarction

RV intropy, +/- PAOP

PA catheterization?
PAC not needed to dx heart failure or shock
PAC may help differentiate cardiogenic vs non-cardiogenic shock

PCOP gives inaccurate estimation of LVEDP if:

Valvular disease such as MS or AR Ventricular shunting Stiff left ventricle

PAC only recommended in unstable patients not responding to standard interventions

Acute shock, hypotension, pulmonary edema

Oxygen, IV, Monitor

Pulmonary Edema?

Volume Problem?
Administer Fluids Transfuions? Cause-specific interventions Vasopressors (?)

Pump Problem?

Rate Problem?

Actions Oxygen (& intubation?) Nitroglycerin SL Furosemide Morphine

Tachycardia? Blood pressure? Bradycardia?

SBP < 70, shock

SBP 70-100, shock

SBP 70-100, no shock

SBP > 100

Norepinephrine

Dopamine

Dobutamine

Nitroglycerin OR Nitroprusside

Adapted from: ALCS Resource Text. Dallas, TX: American Heart Association, 2008.

Distributive shock
High-output heart failure
CO unable to match systemic demand
Thyrotoxicosis Anemia

Hypotensive heart failure

MAP & peripheral perfusion
Shunt syndromes Septic shock

May also have venous return and preload

MAP = (SV x HR) x SVR

Obstructive Shock
Resistance to cardiac outflow
afterload, but SVR and MAP

MAP = (SV x HR) x SVR

Obstructive Shock
Aortic stenosis
Angina, DOE, exertional syncope SEM initially, softens w/ progressive stenosis Diagnosis suspected on exam, ECG, CXR Echo vital for definitive diagnosis

Management
Avoid reductions in MAP (avoid hypotension) Correction requires surgery
MAP = (SV x HR) x SVR

In conclusion
Systematic approach (ABCs, 5 quadrads) 4 classes
Hypovolemic Cardiogenic Obstructive Distributive

Preload

Inotropy

Afterload

MAP = (SV x HR) x SVR Continual assessment of ABCs

Resources
Executive summary of the guidelines on the diagnosis and treatment of acute heart failure. Eur Heart J. 2005 Feb;26(4):384. (http://eurheartj.oxfordjournals.org/cgi/content/full/26/4/384) Rogers J. Cardiovascular Physiology. Updates in Anaesthesia. 1999 (Issue 10): 1-4. (http://www.nda.ox.ac.uk/wfsa/html/u10/u1002_01.htm) (accessed 8 December 2008) ALCS Resource Text. Dallas, TX: American Heart Association, 2008. Gutierrez G, Reines HD, Wulf-Gutierrez ME. Clinical review: hemorrhagic shock. Crit Care. 2004 Oct;8(5):373-81. Epub 2004 Apr 2. PMID: 15469601 Committee on Trauma. Advanced Trauma Life Support Manual. Chicago. American College of Surgeons, 1997: 103 112. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol. 2006 Aug 1;48(3):e1-148. (http://content.onlinejacc.org/cgi/content/full/48/3/e1)

THANKS!