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: ½ 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 • Cardiogenic
– Hemorrhage – Decompensated CHF
– Aortic dissection – Acute coronary
– Anemia syndrome
• Obstructive – Dysrhythmia
• Bradycardia
– Aortic valve stenosis
• Tachycardia
• Fibrillation
• Distributive – Valvular regurgitation
– Sepsis – Myocarditis,
– Thyrotoxicosis – Cardiomyopathy
– Shunt syndromes – 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 Preload
•Anemia

Cardiogenic
•CHF
•ACS Inotropy
Shock
•Dysrhythmia
•Valve Dz
•Cardiac MAP = (SV x HR) x SVR
tamponade
Afterload
Distributive
•Sepsis
•Thyrotoxicosis Hypovolemic Cardiogenic Distributive Obstructive
•Shunt syndromes Low CVP High CVP Low CVP Low CVP
Low CO Low CO HIgh CO Low CO
Obstructive
•Aortic valve stenosis High SVR High SVR Low SVR +/- SVR
 Shock: ACLS approach
Quadrad 1: Primary BLS Quadrad 4:
– A, B, C’s – Temperature , HR, BP,
– Defibrillation Respirations
Quadrad 2: Secondary BLS Quadrad 5:
– A, B, C’s – Tank (volume)
– Diagnosis – Tank (resistance)
Quadrad 3: – Pump (inotropy)
– Oxygen, IV, Monitor, – Rate
Fluids
 Acute shock

Volume Pump Resistance Rate

Fluids? Bradycardia?
Transfusion? Tachycardia?
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) <750 750–1500 1500–2000 >2000

Blood loss (%) <15% 15–30% 30–40% >40%
Pulse rate (beats/min) <100 >100 >120 >140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate (breaths/min) 14–20 20–30 30–40 >35
Urine output (ml/hour) >30 20–30 5–15 Negligible
Mental status Normal Anxious Confused Lethargic
 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 • Volume restoration
– AMPLE H&P – IV crystalloid
• Allergies • Saline
• Medications • Ringer’s lactate
• Past illnesses /Pregnancy – Transfusion
• Last meal • If no response to 2 Liters
• Events / Environment of crystalloid
– What happened? • If Class III hemorrhage
When? Where?
• 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? Pump Problem? Rate Problem?

Administer Tachycardia?
Actions
•Fluids
•Oxygen (& intubation?)
•Transfuions? Blood pressure?
•Nitroglycerin SL
•Cause-specific Bradycardia?
•Furosemide
interventions
•Morphine
•Vasopressors (?)

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

 Preload
In conclusion…
• Systematic approach (ABC’s, 5 quadrads)
• 4 classes Inotropy
– Hypovolemic
– Cardiogenic
– Obstructive Afterload
– Distributive
• 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!