Cardiogenic shock (CS) yog qhov teeb meem loj tshaj plaws ntawm myocardial infarction lossis mob hnyav rau lub plawv cov leeg. Nws muaj xws li ib tug ntse inhibition ntawm lub twj tso kua mis muaj nuj nqi ntawm lub myocardium, nrog rau ib tug txo nyob rau hauv cov ntshav siab thiab kev loj hlob ntawm pulmonary hypertension. Qhov no yog theem kawg ntawm qhov kawg ntawm txoj kev loj hlob ntawm sab laug ventricular tsis ua hauj lwm, ib qho kev cuam tshuam loj heev hauv plawv kev ua haujlwm, uas feem ntau inevitably xaus rau tus neeg mob tuag.
hom kab mob
Nyob rau hauv lub pathogenesis ntawm cardiogenic poob siab nyob rau hauv thawj qhov chaw yog inhibition ntawm lub systolic muaj nuj nqi ntawm lub plawv, uas ua rau impoverishment ntawm cov ntshav. Thiab kev txhim kho ntawm qhov teeb meem zoo li no tshwm sim hauv ntau txoj hauv kev. Piv txwv li, nrog cov nyhuv reflex, nrog rau qhov tsis muaj zog ntawm lub plawv cov leeg, nrog rau kev loj hlob ntawm hemodynamically tseem ceeb arrhythmias, los yog nrog kev puas tsuaj rau myocardial. Raws li qhia ua txhaum cai ntawm contractilityPaub qhov txawv xws li kev hloov pauv ntawm cardiogenic poob siab:
- reflex shock cuam tshuam nrog kev txhawb zog, feem ntau mob ntse;
- Muaj tseeb CABG tshwm sim los ntawm kev puas tsuaj rau lub plawv cov leeg hauv myocardial infarction lossis mob myocarditis, plawv tamponade, papillary nqaij rupture, lossis sab laug ventricular valve puas;
- arrhythmic variant ntawm CABG uas txhim kho nrog ventricular fibrillation lossis tachycardia, idioventricular atherosclerosis, transverse block lossis bradysystole hnyav;
- Reactive CABG cuam tshuam nrog ntau yam kab mob plawv, xws li myocardial infarction thiab hemodynamically tseem ceeb arrhythmia.
Kev faib tawm ib txwm rau kev poob siab cardiogenic tau tsim thiab nthuav tawm xyoo 1971 los ntawm Soviet kws kho plawv thiab kws tshaj lij E. I. Chazov. Thiab qhov tseem ceeb ntawm kev kho mob txawv ntawm kev poob siab yog qhov tseem ceeb heev, vim tias nws muab cov ntaub ntawv hais txog qhov tshwm sim rau tus neeg mob. Piv txwv li, kev poob siab reflex muaj qhov kev tuag ntawm 10% thiab nws yooj yim los kho.
Hauv kev poob siab tiag tiag, kev tuag yog li 20-35% hauv thawj 4 teev ntawm qhov pib, thiab 40-60% thaum kho ntxiv rau myocardial infarction. Hauv qhov sib txawv ntawm arrhythmic thiab tsis muaj zog, qhov tshwm sim ntawm kev tuag ntawm tus neeg mob yog 80-100% yog tias nws tsis tuaj yeem nres qhov arrhythmia lossis tshem tawm tsawg kawg ib qho ua rau ua rau mob plawv.
daim duab kho mob
Cardiogenic poob siab yog ib qho mob hnyav tshwm sim los ntawm kev raug mob, ischemic, arrhythmic lossis ua ke puas tsuaj rau myocardium. Nws txhim kho vim muaj kev cuam tshuamyam uas ncaj qha los yog tsis ncaj qha inhibit myocardial contractility. Qhov tshwm sim ntawm qhov kev cuam tshuam no yog qhov txo qis hauv cov ntshav ntim, uas yog thawb tawm los ntawm sab laug ventricle mus rau qhov chaw ib puag ncig, uas ua rau txo qis hauv cov ntshav siab, tsis muaj microcirculation, nce siab hauv cov hlab ntsha pulmonary thiab pulmonary edema.
Hypotension
Kev poob siab ntawm cardiogenic keeb kwm pib nrog kev puas tsuaj ntawm myocardial. Hauv kev tshaj tawm no, qhov tseeb txawv ntawm kev poob siab yog suav tias yog ib qho piv txwv los qhia cov tsos mob thiab cov tsos mob tshwm sim. Nws pib nrog transmural infarct uas muaj ntau tshaj 50% ntawm sab laug ventricular (LV) cov leeg. Qhov no ntawm lub plawv tsis koom nrog hauv kev cog lus, thiab yog li ntawd lub ventricular systole ua haujlwm tsawg. Piv txwv li, feem ntau LV thawb tawm ntau dua 70% ntawm cov ntshav ntim los ntawm nws cov kab noj hniav, tab sis nrog cov necrosis loj, qhov ntim no poob qis dua 15%.
Raws li qhov tshwm sim ntawm qhov poob hauv qhov ntim systolic, lub periphery tau txais cov as-ham thiab oxygen tsawg, thiab tsis muaj cov ntshav tawm ntawm lub voj voog me me. Tom qab ntawd, nyob rau hauv lub voj voog loj, lub siab poob qis vim qhov txo qis systolic ejection feem, thiab hauv lub voj voog pulmonary nws nce ntau. Tawm tsam keeb kwm yav dhau los ntawm kev txhim kho pulmonary edema, kev ua pa ntawm kev ua pa txo qis, cov ntshav tseem tsawg dua nrog cov pa oxygen, thiab tus neeg mob tus mob tsis tu ncua.
Symptoms
Cov duab tsos mob ntawm qhov tseeb cardiogenic poob siab los ntawm myocardial infarction nthuav tawm sai sai thiab yog cov saw ntawm cov xwm txheej, txhua qhovuas, ib tug tom qab lwm yam, aggravates tus neeg mob tus mob. Thaum pib, nyob rau lub sijhawm mob plawv tshaj plaws, tus neeg mob txhawj xeeb txog 20 feeb lossis ntau dua los ntawm kev kub hnyiab lossis nias qhov mob tom qab lub sternum, tom qab ntawd qhov kev xav ntawm qhov tsis muaj cua sai sai, kev puas siab puas ntsws tshwm sim, ntshai kev tuag, panic tsim. Yuav luag tam sim ntawd, daim tawv nqaij yuav moist, hws tshwm rau ntawm lub hauv pliaj, lub ntsej muag tig daj ntseg, xim liab ntawm daim di ncauj yog hloov los ntawm daj ntseg, thiab ces xiav (cyanotic).
Dyspnea thiab acrocyanosis
Qhov chaw ntawm lub cev nyob deb ntawm lub plawv, ko taw, ob txhais ceg thiab ob txhais tes sai sai txias, kis tau cov xim daj ntseg lossis cyanotic, ua tsis taus pa hnyav tshwm sim nrog kev ua pa ntau dua 35-40 ib feeb, lub plawv tus nqi nce, tab sis cov mem tes ntawm cov hlab ntsha peripheral tsis muaj zog heev. Vim qhov nce hauv hypoxia, tus neeg mob qhov mob hnyav zuj zus tuaj, nws tsis tuaj yeem zaum ntawm nws tus kheej, poob ntawm nws sab lossis nraub qaum, neuropsychic excitation ploj mus, lethargy thiab apathy tsim. Nws hais tsis tau, kaw nws lub qhov muag, ua pa hnyav thiab nrawm, tuav nws lub siab.
Pulmonary hypertension
Thaum ua pa vim qhov mob ntsws sai sai tiv thaiv keeb kwm yav dhau los ntawm kev txo qis hauv lub raum cov ntshav ntws thiab pulmonary hypertension, noo noo tshwm sim. Tom qab ntawd ib qho hnoos qhuav tshwm sim, ib qho kev xav ntawm suffocation, tom qab ntawd cov npuas dawb yog hnoos. Cov tsos mob no yog lub teeb liab ntawm kev kub siab hauv cov hlab ntsha pulmonary, vim tias cov ntshav plasma nkag mus rau hauv cov kab noj hniav alveolar, thiab kev sib pauv roj hauv lub ntsws yog txo qis ntxiv. Vim li no, cov ntsiab lus oxygen hauv cov ntshav poob ntau dua, thiab cov tsos mob ntawm cardiogenic poob siabhnyav zuj zus, tus neeg mob tsis teb rau nws hu.
Hemoptysis
Tom qab ntawd, raws li edema nce, erythrocytes nkag mus rau hauv alveoli ntawm lub ntsws vim muaj kev nce ntxiv hauv cov hlab ntsha pulmonary. Tom qab ntawd tus hnoos ntub nrog cov npuas dej dawb yog hloov los ntawm hnoos nrog cov hnoos qeev liab (stained nrog ntshav). Tus neeg mob ua tsis taus pa yog bubbling, zoo li muaj kua ntau hauv nws lub ntsws. Thiab yog tias vim qee yam kev kho mob tsim nyog tsis tau muab rau kev poob siab cardiogenic, tus neeg mob sai sai poob tsis nco qab. Nyob rau tib lub sijhawm, ua tsis taus pa nyuaj siab, thiab ua pa luv yog hloov los ntawm lub xeev ntawm bradypnea, zaus ntawm inhalations thiab exhalations txo mus rau 10-15 ib feeb thiab hauv qab no.
Terminal shock
Ua pa maj mam ua ntiav thiab tom qab ntawd nres tag nrho tom qab kev txhim kho asystole lossis ventricular fibrillation. Tus neeg mob tuag (clinical death). Lub sij hawm los ntawm lub sij hawm ntawm kev loj hlob ntawm lub plawv nres mus rau kev tuag yog luv heev, txawm hais tias nws nyob ntawm txoj kev loj hlob ntawm tuag arrhythmias. Yog tsis muaj arrhythmia, CABG tuaj yeem ua tiav hauv 40-60 feeb, txawm hais tias lub sijhawm no yog nyob ntawm qhov pib ntim ntawm myocardial puas tsuaj. Nrog rau kev loj hlob sai ntawm asystole, ventricular fibrillation, transverse blockade, idioventricular atherosclerosis lossis electromechanical dissociation, nrog rau ventricular tachycardia, kev tuag tuaj yeem tshwm sim sai sai.
Kev ua ntawm lwm tus
Nws yog ib qho tseem ceeb heev ntawm thawj cov tsos mob ntawm lub plawv nres mus nrhiav kev pab kho mob thiab mus pw hauv tsev kho mob tus neeg mob hauvtsev kho mob intensive. Nws muaj peev xwm hais tias nyob rau hauv myocardial infarction lossis cardiogenic poob siab, cov tsos mob yuav tsis raug txhais los ntawm tus neeg mob hauv tsev neeg. Txawm li cas los xij, tus nqi ntawm qhov ua yuam kev ntawm no tsawg tsawg, vim tias kev pab hauv cov xwm txheej no tau muab raws li cov txheej txheem zoo sib xws.
Nws yog ib qho tseem ceeb uas yuav tsum nco ntsoov tias qhov tshwm sim ntawm qhov mob hauv lub plawv ntawm lub siab thiab kub hnyiab nrog ua tsis taus pa luv, mob ua pa tsis ua haujlwm thiab tsis nco qab, txawm tias lwm tus neeg nkag siab qhov ua rau lub hauv paus ntawm cov tsos mob no., yog vim li cas thiaj nrhiav kev pab kho mob xwm txheej ceev. Nws tsis tuaj yeem pab tus neeg mob yam tsis muaj kev mob narcotic, tshuaj cardiotonic, kho oxygen nrog defoamers, nitrates thiab osmotic diuretics. Yog tsis muaj kev kho mob, nws yeej yuav tuag nyob rau hauv ib qho txawv ntawm cov chav kawm ntawm CABG, thaum txoj kev kho raws li tus txheej txheem algorithm nyob rau hauv cov xwm txheej ntawm SMP thiab NICU muab rau tus neeg mob txoj kev muaj sia nyob.
Kev kuaj mob Prehospital
Nyob rau hauv ib qho xwm txheej xws li kev poob siab cardiogenic, kev kuaj mob yog ua raws li kev tshawb pom ntawm myocardial infarction lossis ib qho tseem ceeb uas tuaj yeem ua rau poob qis hauv systolic lub plawv: hemodynamically tseem ceeb arrhythmia, lom nrog cardiotropic tshuaj lom, raug mob thiab tamponade ntawm lub plawv, pulmonary embolism, myocarditis, rupture ntawm papillary cov leeg ntawm sab laug ventricle, kev puas tsuaj ntawm nplooj ntawv ntawm lub mitral los yog aortic valve nyob rau hauv endocarditis. Kev kuaj mob thawj zaug yog ua raws li kev ntsuas tus neeg mob tus mob, txheeb xyuas qhov mob ntawm tus kab mob thiab kev noj qab haus huv, cov ntaub ntawv electrocardiography, ntsuas ntshav siab, pulse oximetry.
Cov kev tshawb fawb no muaj feem cuam tshuam rau theem prehospital thiab sawv cev rau qhov tsawg kawg ntawm kev ntsuas uas yuav qhia meej qhov ua rau poob siab thiab ua etiotropically. Hauv particular, ECG nyob rau hauv 100% ntawm cov neeg mob yuav qhia ib tug hemodynamically tseem ceeb arrhythmia thiab nyob rau hauv 98-100% yuav qhia pom muaj transmural myocardial infarction. Txawm hais tias, nyob rau hauv cov xwm txheej xws li kev poob siab cardiogenic, kev saib xyuas xwm txheej ceev tau muab txawm tias nyob rau theem ntawm kev kuaj mob (kev poob siab ntawm qhov tsis paub meej etiology). Tom qab ntawd, cardiotonic infusion yog tsim, kho cov pa oxygen, kho mob narcotic, kho anticoagulant, hemodynamic unloading ntawm pulmonary ncig yog nqa tawm.
Kev kho mob ceev ceev Prehospital
Yog tsis muaj tshuaj, lub tshuab nqus pa thiab cov tshuaj tua kab mob, nws nyuaj ua txhua yam los pab tus neeg mob. Nyob rau tib lub sijhawm, nws yog qhov nyuaj heev los muab cov lus pom zoo tsis meej thiab tsis xwm yeem rau cov tib neeg uas tsis muaj kev kawm kho mob thiab kev paub txog kev txwv kev noj qab haus huv tseem ceeb. Yog li ntawd, ib qho kev pom zoo tsuas yog nrhiav kev pab kho mob sai sai hauv kev txhim kho myocardial infarction, txhua yam ua pa nyuaj lossis tsis nco qab.
Lub ntsiab tseem ceeb uas txiav txim siab qhov kev mob tshwm sim hauv cardiogenic poob siab yog kev saib xyuas xwm txheej ceev. SMP algorithm xav tias tsim kom muaj kev saib xyuas zoo prehospital. Rau lub hom phiaj no, cov tshuaj thiab cov kev kho mob hauv qab no tau sau tseg:
- kev kho mob cardiotonic ("Dopamine" lossis "Dobutamine");
- oxygen kho 100% oxygen 8-12 litres ib feeb nrogethyl cawv li defoamer;
- tshuaj kho mob nrog "Morphine" lossis neurolepanalgesia "Droperidol" nrog "Fentanyl";
- tshuaj tiv thaiv coagulant nrog "Heparin", "Enoxaparin" lossis "Fragmin" intravenously;
- hemodynamic unloading ntawm cov ntshav siab tshaj 100\60 mmHg (ua luv luv nitrate infusion, osmotic diuretic "Furosemide 40 mg" intravenously);
- arrythmia nyem ("Atropine" lossis transcutaneous pacing rau bradyarrhythmia, "Novocainamide" lossis "Amiodarone" rau tachyarrhythmia, defibrillation);
- resuscitation nyob rau hauv qhov chaw kho mob tuag ntawm tus neeg mob;
- nkag mus rau qhov xwm txheej ceev hauv ICU.
Cov theem qhia nyob rau hauv arrhythmic lossis muaj kev poob siab tsis tshua muaj peev xwm ua tau vim tus neeg mob tuag sai. Tab sis nyob rau hauv cov ntaub ntawv muaj tseeb los yog reactive KSh, lawv tso cai them nyiaj rau kev noj qab haus huv tsis zoo thiab kev khiav tawm. Nyob rau hauv ICU ntawm lub tsev kho mob nyob rau hauv cov ntaub ntawv ntawm lub plawv nres nrog ruaj khov hemodynamics, nws muaj peev xwm ua tau recanalization coronary hlab ntsha thiab restore lub contractility ntawm ib tug tej thaj chaw ntawm cov cuam tshuam myocardium.
Nws yuav tsum to taub tias kev poob siab cardiogenic yog qhov teeb meem loj tshaj plaws ntawm lub plawv nres, hauv kev kho mob uas muaj ntau yam teeb meem tsis tuaj yeem nyob rau theem ua ntej tsev kho mob thiab tsev kho mob. Lub ntsiab ntawm kev kho tshuaj yog los cuam tshuam cov txheej txheem hauv tus neeg mob lub cev. Nyob rau hauv cov ntaub ntawv ntawm kev poob siab heev, nws tsis muaj peev xwm ua haujlwm tau los teb kom txaus rau kev noj cov tshuaj thiab ua kom cov hemodynamics ruaj khov. Hauv qhov xwm txheej no, kev siv nruj ntawm kev saib xyuas xwm txheej ceevtej zaum yuav tsis muaj txiaj ntsig los pab txo kev poob siab thiab cawm tus neeg mob.
