270.4 📌 章末速蚘

270.4.0.0.1 Cardiogenic Shock
  • Definition: inadequate CO + hypoperfusion despite adequate volume
  • BP < 90, CI < 1.8-2.2, PCWP > 15-18
  • End-organ hypoperfusion
270.4.0.0.2 Etiology
  • AMI (75-80%) + mechanical complications (papillary rupture, VSR, free wall rupture)
  • ADHF, cardiomyopathy, myocarditis, valvular, arrhythmia, tamponade, massive PE
270.4.0.0.3 SCAI Classification
  • A (at risk) → B (pre-shock) → C (classic) → D (deteriorating) → E (extremis)
270.4.0.0.4 Initial Management
  1. Recognition + SCAI staging
  2. Echocardiogram + coronary angiography (AMI)
  3. Inotrope (dobutamine) + vasopressor (norepinephrine)
  4. MCS if refractory
  5. Shock team consultation
270.4.0.0.5 Mechanical Circulatory Support
  • IABP: limited evidence (IABP-SHOCK II); less used
  • Impella: catheter-based LV pump; improved with DanGER-SHOCK 2024
  • VA-ECMO: full cardiopulmonary support; refractory shock + biventricular failure
  • ECPELLA: ECMO + Impella for severe biventricular
  • BiPella: biventricular Impella
270.4.0.0.6 AMI + Cardiogenic Shock
  • Primary PCI + culprit-only initially (CULPRIT-SHOCK)
  • Mechanical complications: emergent surgery
  • MCS bridging
270.4.0.0.7 Right Ventricular MI
  • Inferior MI + V4R
  • Fluid resuscitation + avoid NTG/morphine
  • Inotrope if RV failure
270.4.0.0.8 Key Trials
  • IABP-SHOCK II: no benefit IABP
  • CULPRIT-SHOCK: culprit-only PCI
  • DanGER-SHOCK 2024: Impella improves mortality
  • SOAP II: norepinephrine vs dopamine (less arrhythmia, similar mortality)
270.4.0.0.9 Shock Teams (2024)
  • Multidisciplinary, earlier MCS, improved outcomes
270.4.0.0.10 Outcomes
  • 40-50% mortality
  • Improving with modern therapy + shock teams + MCS
270.4.0.0.11 盧醫垫 hint
  • Cardiogenic shock = TIME-CRITICAL (door-to-support time)
  • AMI + shock: emergency PCI + Impella consideration
  • Norepinephrine first-line vasopressor; dobutamine first-line inotrope
  • Mechanical complications post-MI: emergent surgery
  • RV MI: fluids + avoid vasodilators
  • Shock team activation for high-acuity cases
  • VA-ECMO: consider LV decompression (Impella combo)