Definition:
I.C.C.
Clinical syndrome in which the heart is incapable to ensure adequate blood flow, usefull for the metabolic necessities of the body the heart can not excessively limit the venous
Physiopathology.: myocardic failure=> CO (cardiac output) consequences: downstream of heart - A.P oxygenation failure of the tissues upstream of the heart The heart can not get blood flow (output) - pulmonary - venous systemic venous congestion (stasis) visceral (pulm., liver, kidney, so on) peripheral (edema)
the CO decrease attracts: cardiac modifications elongation hypertrophy sweating dilatation of myocardic fibers tachicardy discharge of catecholamines T.A. min. activation of the renin-angiotensin-aldosterone Retention of Na+ and H2O oliguria edemas
Etiology finishing stage in affections: C.C.M. especially with a large shunt L-D Infectious miocarditis, endocarditis , Rheumatic fever
Rhythm disturbances (AF, AFl, complete block, paroxistic atrial tachycardia) iatrogenic: liquid overloading, Adriamycin, ventriculotomy
extracardiac
severe anemia, septicemy, pulmonary diseases thyrotoxicosis, colagenoses storage and neuromuscular disease
Mechanism
increased filling pressure Interstitial edema Bronchiolar edema alveolar edema respiratory effort transport of O2
4. Volume overloading:
precordial activity noises Mechanism Chamber dilatation Keep the inotropic status ventricular filling
5. Pressure overloading:
noises breathes Mechanism postload compliance poststenotic turbulence
6. Adaptative modifications:
tachicardy paleness Mechanism neuronal response 1 - adrenergic activity 1 and angiotensin response vasoconstriction
7. Other modifications:
Decreased urinary debit urinar Deficient body weight curve sweating
Left C.C.F Right C.C.F Global C.C.F manifestations - pulmonary manifestations - cardiac - periferic - visceral - cardiac
In infant and small child triad: tachipnea ( pulmonary stasis) hepatomegaly ( hepatic stasis) tachicardy (cardiomegaly)
Treatment Eliminate the precipitant causes - correct the malformations - control of tachidisritmia - correct anemia
Objectives of C.C.F. treatment: contractile performance effort of the heart overloading of volume
I.
-
general measurements
repause in bed physical activities => metabolic needs in big child, adolescent O2 in those hypoxic Fenobarbital consume of O2 peripheral 3-5 mg/kg/day in 1-2 doses PO or IM
phenomena of cardiac right failure and congestive edema from CCF Diuretics excessive volume load of the heart Divided into: loop diuretics thiazides antagonists of aldosteron
Loop diuretics
Furosemid - 1 mg/kg/dose I.V./I.M. at 8-12h - After a few days follows the therapy P.O. 25 mg/kg/day, in 2-3 doses
Henle loop Inhibates the active reabsorption of cations of Cl and passive reabsorption of Na ions and water
Thiazides
Clorotiazid
20-40 mg/kg/day
Hidroclorotiazid
2-5 mg/kg/day PO
Antagonists of aldosteron
Spironolacton
Weak diuretic effect It is used in association with other pp 1-2 mg/kg/day PO, in 2 doses The action starts after 2-3 days Limits the losses of K
III. Improve heart contractility inotropic agents Digital - Fundamental agent used in treatment of -
CCF in children force of ventricular contraction Used for fast digitization 0,03 mg/kg in infants, up to 0,05 mg/kg/24-48 hours (0,04 pt. Lanatozid) as dose of attack (fast saturation) 1phial of 2 ml = 0,5 mg is dissolved in 24 ml sol. glucose 10-20-33%
If it is administered. I.M., it will not be diluted and the dose calculated is administered I.V., then at 8 h interval/at 12 h interval When signs of efficiency appear ( tachipnea, hepatomegaly) we change with D for maintenance: - 1/3 from Datac (in new born = 1/6) If we pass to administration of PO of digoxin, the dose will increase with 30% (absorbtion 70%) For children there are preparations of digoxin: Phial of 20 ml ( 1 ml = 0,5 mg = 50 pic.) compr. of 0,25 mg.
Rules: Infants and small children are more sensitive at toxic effects of the digitalicelor Will be correctly monitored - temperature - vomiting - Na+, K+ hypopotasemia enhances the digital toxicity Do NOT administrate calcium in the same time
III. Improve heart contractility inotropic agents simpatomimetic - Use din acute states Izoproterenol - inotrop, cronotrop - pulmonary and peripheral vasodilatator - D: 0,001-0,1 g/kg/min - Side effects.: tachicardia, aritmia Dopamin natural cathecolamin - precursor of NE
Dopamin
In small doses - 2-5 g/kg/min produces renal vascular vasodilation Medium doses - 10-20 g/kg/min - effect -adrenergic, increase the inotropic stimulation of the heart Big doses- effect -adrenergic, which determine vasoconstriction and limit the increase of cardiac debit
Dobutamin
simpatomimetic agent stimulates 1-2 and -receptor adrenergic Primary effect of of cardiac debit and myocardic contractility (positive inotrop ) It starts with a dos eof 5 g/kg/min Up to 20 g/kg/min
Milrinone
Inhibits the action of fosfodiesterasis upon adenozid monosphate ciclic, AMPc Increases intracellular AMPc and contractility Administered in bolus 50 g/kg, hen it is continued with 0,25-0,75 g/kg/min
resistance) Peripheral vasodilatators In consequence cardiac debit vene capacity a patului vascular sistemic and volume of filling => venous congestion reduction Nitroprusiat de sodiu (acute treatment) It is started with small doses, of 0,5-1 g/kg/min Increased up to 3-4-10 g/kg/min
postload reduction
Prazosin 0,01-0,05 mg/kg/dose, p.o. Captopril 0,1-0,5 mg/kg/dose, p.o. at 8-12 h in infant/new born 6,25-12,5 mg/dose, p.o. at 8-12 h in adolescents maximum 50-75 mg/day
Postload reduction
Nutrition in ICC
increased metabolic requests, they need more than 100 200 kcal/kg/day with minimum necessities of salt and liquids Na 2 3 mEq/kg/day intake of 7 12 mEq/l sol First, start with 130 140 kcal/kg/day. Intolerance to liquids manifests through body weight growth, more than 30 g/day with hepatomegaly and dispnea Treatment of iron anemia max 15 mg/day to prevent anemia, because any decrease of hemoglobin leads to a peripheral decrease of O2 intake
COLLAPSE (SHOCK)
Collapse static notion
- semiologic - shows a circulation insufficiency shock dynamic notion - physiopathological in practice is mistaken with Definition: clinical state with systemic perfusion inadequate for the body metabolic necessities
The shock - Unspecific acute syndrome: Deficient tissue perfusion - common factor to all types of shock sympatic tonus endocrin and metabolic modifications - unspecific Reaction of response to: traumatism arsuri hemorrhages (syndrome and a symptom, disease, separated entity)
Tissue perfusion stagnant hypoxia metabolic acidosis It is not equal with hypoTA or hypovolemia It is not always with D.C. (in infections it can be n./, and tissue needs) the arterial pH is not always Variable peripheral resistance (although not always means vasodilatation) Organic lesions - general, difuse: - Shocking lung, shocking kidney and so on self-maintenance intervention (feed-back +)
Essential factors in treatment: time (precoceus treatment) ensure the right volemia
physiopathology:
Physiopathology classification
colapse of relaxation - vagal excitation colapse of centralization circulant mass - infant, small child- centralization, adrenergic tonus (decreasedvolemia according with Scorp) colapse paralitic vasomotor paralysis: severe infectious diseases, sfinishing stage in the other 2 forms
1) hipovolemic
mass
clinico-etiologic classification
shock- through circular
5) septic
EPA, massive pulmonary embolia endocrin, metabolic disease anevrism disecant by aorta exogen intoxications
Hipovolemic shock
circulant mass
a. haemorragic (different haemorages) b. anhidremic (dehydration, burns)
osm , pe seama glicemiei > after haemorrage) - the report of compart. plasmatic/interstitial-1:3 - adm. of 3-4 x > liquids than the lost blood Crystalloid solutions admin. Go in the intracellular space, after filling , filtration and diuresis appear Appreciate the balance restoration - after 24 h of perfusion (Ht, Hb, and so on) The same with the plasma substituents (Dextranii -hyperosmolar besides crystalloid solutions (thus, the intracellular space and kidney suffer)
cardiogen shock pericarditis miocarditis rhythm disorders hyperpotasemia Obstructive MCC After surgeries on cord deschis
D.C. depends of: Hemodinamic modifications *preload, preload = blood supply to the heart *afterload, postload =peripheral resistance
resistance VS debit determined by peripheral resistance Myocardium contractility (inotropia) Cardiac frequency (! Pay attention to disritmii) Blood viscosity => - D.C. -tissue hypoperfusion - stagnant hypoxia
The aim of hemodynamic therapeutic modifications: Increase of DC Combat tissue hypoperfusion Increase the intake of O2 (prevent hypoxia)
Pathogenic aspects
Phases of hipovolemic shock Peripheral vasoconstriction
The whole capillary unit - arteriola - venula - pre and postcapillar sphincter
lactacidemia
relaxes the precapillar sphincter (not the
postcapillar)
Stase in the whole capillary system, venous st. Increases the capillary permeability plasma vessel leaves TA , blood viscousity - - -> disseminated intravascular coagulation (DIC)
The phases of the shock toxico-septic vasodilatation kinin ( tissue peptides) Under the action of endotoxins ( warm shock) peripheral resistance DC is n or cellular insufficiency of O2 caption arterial
vasoconstriction
Symptomatology
cardinal symptoms (major) pulse alteration of big vessels(carotid, femural) TAs < 60 mmHg Cold, pale, cyanotic extremities, recolor time > 3 sec. Intrarectal temperature 10C than skin (centralization) Stop the diuresis Consciousness disorders
agitation, sleepiness, tiredness, coma
Other symptomes: - Weak tissue perfusion (deficiency of O2; glucose) Signs of toxicity: tachicardy tachipnea sweating Sensation of cold Cold, sticky skin Increased sensitivity
hypotension - tardive sign
Lab diagnosis
Treatment - emergency
15 minutes severe forms 60 minutes the mild forms about 30 minutes anaphylaxis shock administration of adrenalin therapeutic order in any other form : V = ABC - ventilation P = perfusion C = heart (suport the function of pumping) M = medicines
ABC
A airway airway assessment open,
patent B breath breath assessment + oxigen (100%), intubation and ventilation when needed C circulation improvement
General measurements:
Position with decliv head covering with a blanket (heat) Release the respiratory ways Administration of oxigen (aerotherapy) ventilation (when needed)
perfusion- pathogenetic treatment, the base of the treatment 1. blood -10-20 ml/body kg , repetable - only in hemorrhagic shock -hardly accessible - transmits viral hepatitis, HIV 2. Plasm -10-20 ml/body kg , repetable - inaccessibility disadvantage - risk of infections transmission idem 3. coloidal substituent of plasma - 10-20 ml/body kg corp repetable
Groups of substituents Dextran- plasmaexpander Dextran 70, 40 Macrodex Rheo-macrodex gelatin Products Marisang, Plasmagel, Haemacel 4. Human Albumin (sol. 5-10%) - 10-20 ml/body kg - There is no risk to transmit the infection - It expands SEC very well (1g retains 18 g liquid)
5. Crystaloid solutions ~ izotonic ~ Composition more similar to blood - SF - sol. Ringer - sol. Starter, and so on ~ 20-30 ml/ body kg, repeated 1-2 times ~ Associations between crystaloids, plasma, substituents, even artificial blood
Practical rules: In phial/syringe any other medicine is forbidden The liquid chosen has < import. Than quantity As fast as possible - in bolus 10 ml/kg plasma, albumin, substituents of plasma or 20 ml/kg sol. crystaloids, repeteated as long is necessary successful perfusion = PVC with 5 cmc H2O (n = 4-8, PVC max. in child: 12 cmc H2O) agressive therapy, liquid, with atb and which support the heart, prevent the irreversible phase of the shock essential factors: - time , volemia
5 10
10 20 0,1 - 2 5 - 20 0,1 septic cardiogenic Shock resistant to liquid resuscitation cardiogenic Arrhythmia Ventricular arrythmia ischemic extremities
agonist
1 redus
CRS insufficiency
supraglotic obstruction (epiglotitis, dyphteric croup) glotic obstruction (strange body, Congenital malformation, acute lesions) subglotic obstruction (LTB, bacterial tracheita ) CRI insufficiency Crysis of asthma or bronchilitis pCO2 > 55 mmHg = respiratory failure
Metabolic collapse
intoxication
alcohol aspirin CO ethilen glicol
Diabetic Cetoacidosis Hepatic and renal insufficiency Inborn errors of metabolism Alteration signs of vital functions Corect acidosis (HCO3 1-2 mEq/kg)