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Cardiogene shock

1. Oorzaken

 

= falen van de hartpomp
 
- AMI:
- 7 à 15% gaat in shock
- of linkerventrikel (> 40% necrose) of rechter ventrikel
- ruptuur van papillaire spieren en of ventrikelwand
- myocarditis
- cardiomyopathie
- hartkleplijden
- ritmestoornissen
- toxiciteit
- Beta blokkers
- calciumantagonisten

- Adriamycine?

Anamnese

- algemeen
- ischaemische retrosternale pijn
- angst
- cyanose
- bleekheid
- zweten
- afkoeling
- uitsluiten van andere vormen van shock
- hypovolemisch
- anafylactisch

- septische shock

 

Lichamelijk onderzoek

- vitale parameters
- Ademhaling: dyspnee, tachypnee
- Pols: tachycardie, zwakke pols
- bloeddruk: systolisch (BD S < 90 mmHG)
        diastolisch: indien laag, denk aan ondervulling of vasodilatatie.
                Indien hoog, denk aan cardiogene shockz
- zijn de halsvenen opgezet?
- indien ja: overvulling?  congestief hartfalen? tensie pneumothorax? Harttamponade? (constrictieve pericarditis of retrograde aortadissectie?)
- Meten van de centraal veneuse druk: > 15 cm H2O suggereert tamponade.  Kan ook bij hypovolemie.
- Auscultatie:
- longen: < VAG bij tensie pneumothorax en of longoedeem
    reutels
- Hart:
- indien < harttonen? Denk aan harttamponade (constrictieve pericarditis, retrograde aortadissectie) of aan tensie pneumothorax. 
- systolisch geruis aan de hartpunt
- systolische klik: ruptuur chordae tendinae
- gallopritme: S3: ernstige myocarddysfunctie, S4 bij AMI in 80% hoorbaar.
- Abdomen: epigastrische pijn, nausea en braken

- urineflow: < 20 ml/u

 

Lab

- CBC
- electrolieten
- hartenzymen

ECG

beeld van AMI op ECG

 

Echocardio

- ventrikel akinetisch
- klepdysfunctie
- ruptuur septum, papillairspier en of ventrikelwand

 

3. DD

- mogelijke oorzaken van obstructieve shock
- cardiogeen:
- acuut myocardlijden (myocarditis, cardiomyopathie, rechter ventrikelinfarct
- acuut kleplijden: ischaemie, endocarditis
- harttamponade: constrictieve pericarditis, retrograde aortadissectie
- septale ruptuur
- pulmonaal:
- longembolen (luchtembool?)
- tensie pneumothorax
- Medicatie:
- beta blokkers
- calciumantagonisten
- adriamycine
- andere vormen van shock
- hypovolemische shock
- anafylactische shock
- septische shock (koude septiscje shock, oesofagale ruptuur)
- Addison crisis

 

 

Eerste opvang

- ABC
- IV-lijn
- O2 100%
- ALS
- monitoring
- intubatie (crush inductie)
- dringend consult cardioloog, owv kans op snelle revascularisatie.  Dit is het allerbelangrijkste voor overleving.

 

Specifieke therapie

- Myocardischaemie
- Aspirine
- Heparine
- Bij hypotensie geen cedocard, diuretica of betablokkers
- bloeddruk voldoende hoog houden met dobutamine.  Bij rechterventrikelinfarct geen Dopamine geven omdat dit de longweerstand verhoogt.
- Harttamponade:
- eerste opvang: best 2 IV-lijnen, voldoende vocht IV, bij instabiele patient een pericardiocentese, evtl een spoedthoracotomie met pericardiotomie indien de patient onvoldoende stabiel is na pericardiocentese en vochttoediening.  Ook uit te voeren bij hartstilstand door tamponade bij penentrerend trauma.
- plaatsen van een voorlopige pericarddrain
- specifieke therapie:
- indien een bacteriele pericarditis: start antibiotica: tegen welke kiemen? gramnegatieven, staphylococcus aureus en anaeroben. Soms is heelkunde nodig (partiele resectie van het pericard)
- indien een uremische pericarddeffusie: indicatie voor urgente dialyse
- NSAID: bij het Dressler syndroom (enkele weken na AMI) of na radiotherapie
- Bij penetrerend thoraxtrauma: dringend plannen van thoracotomie
- bij aortadissectie: dringend plannen van operatie
- tensiepneumothorax:
- onmiddellijke naaldthoracotomie
- erna een thoraxdrain
- longembolen
- anticoagulatie:
- IV Heparine: geef een bolus van 80 U/kg (volwassenen) of 75U/kg (pediatrie).  Nadien continu infuus van 18U/kg (volwassenen) of 20U/kg (pediatrie).  Dosage aanpassen aan PTT tussen 90 en 200.
- LMWH: Fraxiparine
- Marcoumar: dosering: 3-2-1 co/d en direct erna INR meten. Titreren tot INR = 2-3  Later opstarten
- Thrombolyse:
- indicaties: bij stabiele patient indien uitzetting rechter hart te zien is op echocardio.  Bij onstabiele patient
- steeds associeren met Heparine en Aspirine
- Thrombolytica:
- Tirofiban (Aggrastat): eerste 30 min 0,4mg/kg/min.  Dan 48 tot 108 uren 0,1microgram/kg/min.  Bestaat in flacons van 12,5mg/50ml of prefabinfuus van 12,5mg/250ml
- Abciximab (Reopro): Bolus van 0,25mg/kg.  1 amp is 10mg
- embolectomie: heelkundig of locale thrombolyse via catheter.
- op termijn filter in de Vena Cava Inferior
- Longoedeem:
- is de patient hypotens (BDS < 90 mmHg)?
- Neen: Nitraten (SL of IV), Morfine, Diuretica (tegenindicaties hypotensie, niet- cardiogene oorzaak, nierdialysepatient)
- ja: geef geen nitraten, morfine en diuretica, wel inotropica zoals Dobutamine, Dopamine of Milrinone (Corotrope)
- positieve druk beademing:
- CPAP: niet bij risico op AMI
- intubatie: PEEP van 5-10 cm H20, Tidal volume12-15 ml/kg om atelectase te voorkomen.  Initieel 100% O2, mar afbouwen zo mogelijk.
- indien nierdialysepatient:
- snelle dialyse. 
- Zo niet mogelijk geef Nitroglycerine IV of ACE-inhibitoren: Enalapril (Renitec) 1,25mg IV over 5 min en elke 6u te herhalen zo nodig.  Of geef Captopril (Capoten) 25-50mg/d PO
- best geen diuretica
- Intoxicatie:

- cave recidief longoedeem 1e 3 dagen

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