เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

196 rrtrirriainqmfiugru

nrtrfi 3 uao,:d'tutl::noltolor:tit crystalloids fitdrl'ufixlil Dextrose

mosnVL

Ringer's acetate 130 77
solution 10s 2S

Dsi 0.45% NaCl 513 lactate
3% NaCl 109 28

acerare

ctJ

.1. Normal Saline

2. Ringer's lactate solution
3. Ringeas acetate solution

Nolzmal saline (O.9% NaCl, NSS)

riuar:ririifirildniul, niiqnlunr: resuscitate {ilrudoglunrrvfion fi osmolarity 1nd

rdt.tnitt plasma 6arvirnltl soa mosmol/L rloolfi normat saline 1,000 r:4. tdrvtr.trtaontfraaoh

o:rfirLloqjlu extracellular "pu"" tdorltndr:rirdfi osmotarity tndrdutn"l plasma o;lritniau

r.jrutdroonqrn cell membrane 6,ttflu semipermeable membrane tfia normal saline 1,000 tJn.

n:;lrufrr'tu extracellular space 6':a{tu intravascular space tvirfii '/o tdoteln'h extracellular
space tflu intravascular space ttitli:.t-lo ttn;tflu interstitial space tvitn-ll 3lo ri'triuriiotfi satine

1,000 lJR. 6{oqj'lu intravascular space tvirn'l 250 tJa, ltn:a?l interstilial space wirn"l 750 la.
los::urnr

nr:lfi saline arllrrnrfirnr:rirlunnoertfioo (inlravascular fluid) ldrxa t51 rrsi$dan'l:

:;'t,t a{u

1. votume overtoad Lfioernflr:tricr:riT frr€reurfiu}J lunruvfifir-hu'I fi concurrent loss

fi?a continuous leakage *fit
2. Hypernatremia lfio'taln saline fi rua t sq mEq/L 'lulru:fi plasma fi Na 135-145

mEq/L

3. Hyperchloremic metabolic acidosis (normal anion gap metabolic acidosis) fntfio
mnnr:tri saline rfludrururlnlunll resuscitate nllsdrJ-ntfiertuaru:fifl1rtrornr:Inu:trddu

Flr.rid Therapy @fltun€ nfififty 197

iudr rfinelnnr:'lfi satine rflunr:lfi chraride fifi 'rruillnn.i{u prasma uffri.r,,rfl1ufr'o,Jn.u

inur anion gap 1firfluiln6 6.rrir1fi serum Hcq- nio{rdurtreyrr.rriruafiuru.jr sarine rflu

ar:rirvrtfinrurflun:nrrfinflou 6,:lir'hi serum Hco3- nqn.r un;nr:lfi sarine rflunr:'lfi chroride

Tnun:,r i.:rirtrirfin normal anion gap metabolic acioosis ri'.lriuriayrltnr?r metaboric acidosis

n1 114'\:n15 resuscitation t'rntno metabolic acidosis 6-:fiotrirnr:dtu,rru anion gap .hrflu

wide anion gap riorflu normar anion gap urnrflu wide anion gap dawrorrwr dod'lulnqi

fntflu lactic acidosis {rJruo:ri*rfi r6on}J dr.rrf,o #iodruilaruri.,rlri6 (poor rissue perfusion) fir

tflu normar gap finrfioornnr:lfi sarine i1 'rurJln rnlrifiorrn4du.J firirlfirno wide anion gap

u:ro ri dr s fi r a'nurury r.:n 6rinr or {:Jr lTo o c dr'u

Anion gap = Na' - (Cl- + HCO,-)

Ringer's lactate solution (RLS)

irfucr:ririifiuuldl n'r: resuscitate niurfisrfii normar sarine osmorarity lndrdurnlr

ptasma 6o 273 mosmoyl rdotfi nLS rfiryrtrnonrfion 1,000 rJn. qsodlufineorfioot:: rru

eso ro. losfitmnrnrdurdurniun,:}1 normar sarine d'.rnhoimudrofiu nr:}i Rrs arrr:nrfil

:.Jirrnror:rir'lunoaordaerldrSr udfidanr::;{.:o''td

1. vorume overroao rfiorlrnnrr'lfiornirdrfrourfiu}J 'lutru:d61ru1*fi concunent ross
Yio continuous leakage lld'r

2. Lacric acidosis Tnurarr:?u{:-htT:nor'l ruto.,rtrnn.r:lfi nr-s tu{rhufi}irflu1:nsr".:J

lactate lu Rrs r;gnuJduurflu Hco3- lnuarcurr'rr rfirtfi ns tu{:-rrgl:nri'u irrnrtrlrjour:n

r duu ractate rflu nco,- 16 q'rrfiorflu racric acidosis (type B) liu d.:tu{r-hu6'rrrud.rulrq'

filgfi lactic acidosis (type e; odufir

3. Hyperkatemia rfio*re.tn RLS fi tc + meqll {i,:do,lfinrury*t-o::{r'lu{:Jrudincrrv
1iloan utofiuurTririr potassium lurfiooqr rdu rhabdomyorysis, hemorysis. tumor rysis syndrome
tn:r:oredr'hirfio hyperkatemia :uur,,rld

4. Hypercatcemia rfiarlrn BLS fi ca,' 3 mEq/L tu{rJrtfifiuurfti so.rnr:rfio

hypercalcemia tdu malignancy fitfioltn squamous cell carcinoma, granulomatous disease
arofin hypercalcemiald a-rueulunr:fnur hypercarcemia usuislriarur:nlfi crystaloids r;lnyl

atulduonornnrrli normal saline rl,rTrg isotonic crystalloids (RLS, Ringer's acetate solution) fi

calcium tulnr:fi saline hifi cabium

Ringer's acetate solution

rfl u or:rirvr"fi fl ilt$lu n1 ? resuscitate niuro'flrniu normal satine fi osmolarity 'lndr6u,lrYl
ptasma 6a 273 mosmol/L rfiolfi ningefs acetate solution rfiTr$roontdoq 1,000 l.to. tyot.i

198 rrrrirriainqnfrunrl

turnaorrfion ::r.t1fu 250 a.Ioufilfiqnoniutdurriunr:li saline o".tel"raBurudr.ldu nr:lfi Ringer's
acetate sotution d.trJlrnrfi ?rrlrunrrdrlunnaorfionldrfr oT ur:ntdtufiilruT:nfi'!1d rl'r:r;
acetate fioglu Ringer's tactate solution lYu Crl'r:or fruutflu HCq- !im.:tu ptasma lnu}j
dalorrlan'r-rlunrlil6flurdurdurdun'trl,?i Ringer's lactate solution airufiaer:r:r"l6u1 niu16ur

li:.rnr:'tfi ninger's lactate solution

16lr{ianiu.jrfir{rJrurnn hypovotemic shock e1nn1:rfiurAon filnfi0{'16 isotonic crystalloids

tunt: resuscitate dol'ld isotonic crystalloids g-+ rvir?o.tr6oofirfiul:J {rJrtrim:og'lunm;

normovotemia rftdm1mu.ir6:-tr0fi concurrent toss y3o continuous plasma leakage uiolri
fllXriual:l diadann':rrfir r.rtrdil?mrunmtfid1rfltfi1fi11?ru'lsl'ltJ organ perfusion rfludrn'ru

1il16,irrflu'ir6o.r1fi crystalloids g-+ tvirrlo'nl?rrrufi rfi urfronrnrolil

mnh crystaltoids ilrmndul
'1. Hypotonic sotutlon lrjri'rlr'ld resuscilation {:hudaglunn#on tdo,:orn ilrru

ar:rirfiaqjtunoao16oo (intravascutar votume) rioun'jrnr:lfi isotonic colloids finoirurdr':fiu

iiror:r r: n niur ruldn',rd

1) NSS/2 (0.45% Nacl) rfiotrir{rl:J 1,000 n. tda,lq.no.]:tf. NSS/2 1.000 n.
::nordru NSS 500 !n. Ltfl3 water 500 a.'lu6i?ufl4.1 NSS 5OO iln. eYoilu intravascular
space Mrfiu '/o fioMrfii 125 a. dxu water 500 xn. fi osmolarity rvirnlquti i.:n::lrun"rrln

fluid comparlment tfio intravascular space fintln:;c1u6'xLYiTd! t/,, tat fluid compartment
6'',triu *at"r 500 iln. A,,togjtu intravascular space r rflit/,, trirfi:: 41,67 n lfio:uflu saline
ida{lu intravascular space rrirrfu tzs tn. d'lrfu nr:}i t tsslz 1,000 n. ila{'lu intravascular
soace rYilfilJ t66.OZ ln, 10u :;lrru

2) 5% dextrose in water (5% oW) rituor:ririifi osmolarity zsz mosmot/L tdo'lfi
rir'bJ t.ooo r.ra. rirnro dextrose l;qn rtafflfilrJri.tfi n 6.ltu6o osmolarity lndrdu.:4ud n'oriu
{.ln::lru1n fluid compartment d":furiia intravascular space finr:n:votln'lwirril 1/', ta.:
ftuid compartment o''.'rrlurfiatrfi 5% DW i'tLdiilarj'lu intravascular space lvi1fill '/r, to,t 1.000

n, Mlfl"tl 83.g3 n. lau ritJlrL

3) 5% dextrose in o.45o/o Nacl (5% D/NSS/2) rdotfirdrlillunnontfion 1,000 la.
rirnrn d"*tro." o:gn'ldtrn fi{uafiorfiu,r NSS/2 1,000 n. d,:c:n::eruf,xlumnaotdan tvirrftl

166.67 fl. f6u$;rrru a"': r4r a 6u a{r':fiu

2. Hypertonic sotution diaulfiturrlnfifin lfirtri s7. ruacr d.rfid1d1unr:ufi'hn'nv
symptomatic euvolemic hyponatremia rirulunl:riurtfi resusciiate nrT ;6onrfu bjrf ufrfiuil

rfia{ernuicr:rh 3% Nacl lufi osmolarity qln'irlu plasma fiqio drtfifrluvnoq!fion

(inrravascutar votumel rfilduldmnn'jrnr:lfi isotonic crystalloids fierru rrsiiliilrrufrfitrndu

Fluid Therapv tflnTuni nfrfiMS I99

hnaao16oqdu il1?rnfliu interstitiar space lrfl; intravascurar compartment {irtunr.:;6on
r.lul-nfinr:trorir'lu interstitial space ttflv intracelurar compartment i'rrdru d.,lflunr:inurfi

lrinndatotrlnuriRi:ivrur

m?rhil?cmr coiloids

or:ri, rJ:;rnr coltoids fifisltdlunn:6an lduri

1. Gelatin
2. Starch
3. Dextran
4. Albumin

nr, rrfi 4 uflolaitu:l:ynolso0 coloids filfrtlrtrrJfil-fi

l{arn€ Ilextran Ge|3tin Starches Albumin
fro/o
200000 200,000
albumin

IVW (dalton) 40,000 30,000 35.000 30,000

INa (mmoli L) 154 154 154 tc4 130-160 130-160

'"',_l-_ I - 5' < 2.s | .2.t

9d. < o.o4 ozs I os
!":r4-T *,-'olct- 154 I
I-.* 1s4 l!4
reo roo f reo-.'oo

HCO3- -_ tl-"-n I
I
,r, '*3 ilpH 5.0j0.5 7.410 t ga td-os
i
9..11nr 300 I 1103 JIU I .CUU
I s.o+l.s I s.o+t.s

|308 I soa

nr:trtor:rirtfio coloids ttfiirevdr"hillirt.luri.rtuvn0a 16on (intravascurar vcrume) Lfir

l"urSrnir crystaltoids fiei.': uoififiilofir.rrduora'ru r;nr: fjt co oids rn :vlnflc;fiirn{r,r l6u,r

sialildii'le;ir{nilrnriourfi t.r'ln udr udrfi nro.l coloids

1. Anaphylactic/ anaphylactoid reaction rfio{qt narrrirrl:: tnn colloids rfl1lfl.]r
il:clnrIil:'r'u d,rriJuor:*rjon:Jnol rdotrirdilrliuil,tnru6{aladoltirfionr:ur{'[d,

2. Renat toxicity arerirtfirno acute kidney iniury

3. coagulopathy/ prateret dysfunction 6rore tflurfiu'rerr fiorJn6qrnnr:nt1evtt,:rio,r
nr:rJfr :JG yionilfi rfi n or nr:nr.: n &rin 6 o rd o noon

200 rrtdrrinl n q ordug'ru

Gelatin

1. Haemaccet 6o\re:lqf,a!rfirJa.jrrloCrrvoonriou (otiguria) fiiolri yiafinrrvdd,rroil

trirfio nyperkalemia rialri rdo,:crn Haemaccel lflu colloids dfi potassium

2. celofusine tflu isotonic colloids iif,ur:n1{16"1u{ilr41:nd'u 1:n1n riou{r"':rjoonriu

adrrl:fiqufido.rficrtr:vrio::i.rlunr:'lfi 3rfioternfino{r',r rfilt'[d ::nr:oi'rfinrirru{rodu

3. Getifundot riu isotonic cottoids dfi bicarbonate n1r'hi'lul1iil'rrutllno'red{fi1fio

metabolic alkalosis

Stat€hes

luidlauri hydroxylethyl starches (HES) fio{ z;rJrrn 6o oX Hes lrnY 10% HES ttfl
fiarrdrrrdu,tdrpiufio coagutopathy ?o\:fl{tJ'l6an'mLfig renal toxicity
ururutJfim colloids fifi

ritninhrnnnnonr 6o Votuven dt16oriuirritrtrfioflodl.tt6u,tlJo,,lr;llnr:ttf td'rtott6ootunv

qlndr,J lfia.rrialnnnn.r atir.rl:frorlrrdauhlrl{'lurJilrru 'ln o1o}lu anaphylactoid reaction ld

xlndu

nirru:rir:loTiutunl:fnE'l severe sepsis tloY septic shock nltJ Sepsis Campaign

cuidetine 2012lriuusrfrtri1fior:rirfi!flu hydroxyelhyl starches tdotornfinnfir.l16u.t'lu rvl6u1o.1

renal toxicity 6onr: rfi n osmotic nephrosis odr.:fi riudrnr4

Dextrcn

fi 2 ;:Ju!:J 6a dextran-4o lla: dextran-7o riulriTntd'lu dengue hemorrhagic fever

(DHD iifinlis{onirlldrulu{r-hardn unrtdtunr:oiodttunnrn::rrnrsfinfnur{ia'i'rdrlfiviscosity
ragfiaonno'3 rir'lfirdanfinr:lnnddu 6ndr.:r6urfrrriudofia acute kidnev injury d,:tfirnrnnr:
nnnlnoulo.r dextran tu renal tubule uan?1ndti.f a1?tmXa llft'l1 Aoilnfiyr.tnr:U6,tdrtOl6OO

nfiruri! von Willebrand disease dltflunmlrfi o:Jn6nr'lrio,rrJfi:i6nrr

Albumin

fi e ;rJurudfiulli'lun1{n6fin 60 syo albumin ra:', 25yo albumin lousrtltnfiloT :ri'r

rdrm'lurnaorfioold ts-re un. oio t nirtat albumin Tou ::uTru dldtol atbumin dfindngru

yr1,iffAfinflf!f,r.{u 6o nn,rvri large volume paracentesis ta,t ascites Tou'lfi 6-8 nfiJrlon albumin

sia t fifr:1or ascites fiuqr:\d uonerndEi'lore'tli1u{:hudrflu spontaneous bacterial peritonitis

(sep) Tnunrrlfi atuumin rir'lilonram:nri'lrflus*rla{ sBP flnfl{ ddfiir'n:rnr:o{t:{ lu'r!14

nnn{ fidnI1ufl'Nn6fin6n :cnr:vdlla{n1dd albumin 6o ldtunr:inurnrrY hepatorenal
nlsyndrome nllfnu"t severe sepsis tlnv septic shock
Sepsis Campaign Guideline 2012

ruu ;d'r'hiaannoudtfl u al bumin

flrrid Therapv nn?uni lfifrtty 2Ol

n't:'Ifi atbumin turjirrnrrrn amlirlfinruriulnfiorirld rdollrn:Jifiiurtonnl:Lu{

(anaphylactic/ anaphytactoid reaction) t-tonalnd?:o'r carcium orem'rn.r'td rda{qrnfl'lfi carcium

fi{lril atbumtn (bound form) rfirzsu 6,rrir}h:d'u ionized catcium noa{

nr:fionarrlr crystailoids n6o coltoids'lunm;fian

s'rn Cochrane meta-anatysis fl n,s. 2008' ll-jrlrifintuunnrirorYulurdoro'n:rnruta.r
nr:irior:ritr:J::rn cvstafioids ttni coloids uoncrnflrinl'jr co oios n-rlqrir'1fi{:Jrufia-n:r

:aerdinrilfionir cottoids ::mr6u nr:1fi crysta oids is coloids o',,rrfu6o clunr:inur

(state of art) odr.:ndo'lunr::-nrrfi:hunrild at-,,rriu6.,lfi{a uuyrjrrir'trfl fl1rr6on crystaloids yio

colloios d',rd

1. at:16on crystattoids riou colloids rdo,rornfiilrudaejlunrryfiondru'lnryo:finr:

tlrnriryrn ftuid compartment d*rnr:hi crysialtoids 6[.ril1inullflnlro.rrit']14n ftuid comiartmenr

Iddn'j1 colloids uanlrnd crysta oids :tnrgnn.jr co oids tusru;fia-n:rstrulrirrmnDir-rfiu

e. nr:rfiont$ colloids 't dlu'rrnronlfi'jrtfr crystattoids }Ivirter*dr6,tcl1rtr coloids

rrnlfificr:ru'rlrno'nuru;lr,:nfifin frdr6"ryn'a visceral organ edema Totrotrt; pulmonary edema

ltay intestinal edema iitfiacrnnr:i']6mro,:norfl'J1uanlaaa rfioo (ptasma teakage) !!av intestinal

edema oro tflu6i.:firi.rronirnt:riilri cottoids odl,rl:fisru n'nli coloids lu putmonary edema

orcrirlfirfio pulmonary edema trndulouronr:fir particle ro.r co oid"llaglu tung parenchyma

d':rfu6,:omfinT r:.r.irrflufia,rldrn1o.:rirurru'lo'lu{r-han{rdrrnfi putmonary edema 1uu:l r?o

firldrnCooti':uurulooqjudr fi r{artfi coItoids d?unl.nrry -e::tt

e, {rhufifirir serum atbumin dr bjlfirj,:.jrq:fioo'ld coloids ro:.ral:l ldororn{r-1.:td

fi hypoatbuminemia hjl'rrflu'jrq;fior:lrr (edema) r1n:ru nju lu{r-hurv r5.'::; r trl.r ufr

iu:J:srruarurrlillil {rhtrn{riiufi serum atbumin sri urin:rodr.:nrsfiqyy.r!.j.tfirhu cachexia
d'.:rfudr{nranrld6on 6.rnr:r6oncr:rir:J:: rnr crystaloids dau rdo.rornr-nfinr:rrnridu

interstitial compartment unt intracellular compartment iT dru {rJrufifiril serum albumin n'1
fifi visceral organ edema arorfian'lfi cottoidstun'n resuscitateldrfxn'l, {ftaiifi serum albumin

:Jnfilrriau

q. nr:l6on'1fi cottoids fiatdrfir:fi.: ndr,rr6u.r 3:JtJn'l? 6o n'r:ufi (anaphylactic/

anaphylactoid reactton) adr,iL6u.:0i01fi rrncHagio:yulnr:u6.:m"rao.t16ooraua loufiorfiqr:ru't
'lr{:jrufiT:ndr#fi aan::ytusianr:fie't:ru.rld cottoids ySobj

202 nrdrriolnqmdugru

rang1Td1{6it

j. David C. McGe6, M.D.. and Michael K Gould, M.D. Prewnting Complications of Cenud Venous Cathetsization. N

Engl J M€d Volume 3481123-33. March 20.2003.

2. Vincent Jl, Weil llH, Fluid challenge revisited Crit Care Med 2m6l333-7-
3. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev 2008 Jan 23:(1):C0001319
4. Ellender TJ. The Use of Vasopressors and lnotropes in ths Emergency Medical Treatment of Shock. Emerg Med Clin

North Am - 01 -AUG-200826{3):75S-86, iK

S. Winters ME. Monitoring the Criticatly lll Emergency Department Patient. Emerg Med Clin North Am - 01-AUG-2008;

26(3):741-57, ix.

6 Ramsay J. Noninvasii/e Technologies for Tissue FBrfusion. Aneslhesiol Clin - 01-DEC-2006;24(4):763-75.

7. Reinhart K Monitoring 02 transport and tissue oxygenation in critically ill patient. In: Rsinhart K, Eyrich K (eds).

Clinical aspecb of 02 transport and tissue oxygenation. Berlin: Springer: 198S. pp. 195-211.

g. catenacci MH. severe S€psis and septic shock: lmproving outcomes in the Emergency Departmont - Emerg Med

Clin North Am - 01-AUG-2008;26(3):603-23' vii

9. flivels E. lmproving Outcomes for Severe Sepsis and Septic Shock Tools for Early ldentification of At-Risk Patients

and Treatment Protocol lmplementation. Crit CaIe Clin - July 2008;24(3 Suppl)J -47
.10. Rivers E.. Nguyen 8., Havstad S.. et al. Earjy goal-dir€ct€d therapy in the treatment ot sslere sepsis and septic

shock N Engl J Med 345. 1368-n- 2001.

L2

Vasoactive Drugs

wnTwri gFtfrtxg

Vasoactive drug
!fluarfildlunrrrsirnrrrir*um,:riilc unrrd Rrr drufirulormsnrdonlnufinnlnnrr

oonqmf,inn o ilrvnr: f,o

1. PoEitive inotropic effect rfluqnf#rir1finrrfiun-?ao,,ru-r1c (cardiac contractitity) 6r*u
2. Fositive chronotropic *tecr rfluq#drirlfio"nrrnrrrdum,:n-rlc greart ratel rfiudu
3. vasopressor ettect rfluqnddrirtfiarttdunruto.:noon rdaod.ru:Jaru (systemic

vascular resistance, Svnt rfilniu rirlfi aftertoad rfrldu
arlr?unur#fiqnf, positive inotropic drug .fi inotropes rrnttlunurdfi vasopressor effect

'11 vasopressor

vasoactive orug dtfijou'lunrrJfr:Jh fi + d'r 6o

.1 Dopamine

2. Dobutamino
3. Norepinephrine
4. Epinephrine

Dopamine
n'noanqnf,

1. Low dose dopamine lurarurdtf 1-s Fig/kg/min lou rvtrcu aonqnCn:t{u

dopaminergic receptor riu finrnn",r$hooorfiondhjro{ul sptanchnic o€an nururir rirlfi qatemic

204 rrtrirfninqnfiu5rrl

nr1{d 1 udo{qvrf,ta.: vasoactrve orug iildiloulurrtilfrffi

F6c6ptor +++ itt +++ + +++

Dopamine

(depend on dose)

Dobutamine+++++r-l-
Norepinephrine++++++-

Epinephrine

Phenylephrine +++

znrrad los.tnr:t iurtfitrtls{asonule{o nfl1flqinr:'lmn r5uurfrao (hemodynamics)

Drugs

Dopamine 0

0+

++ +

Dobutamine

Norepinephrine > 0.1

Epinephrine > 0.05

[':1trur ri'lrnlrurnalea'r dopamine fiuflunrj':t uglkg/min luttrin:n't:r arqfiql [onoir.:]Yu 'hifi,: rirhirfirsurfi

n'rr;fiqvrf dopam,ne/gic effect triu slrndrunar,t l:fiqndn::{'u beta-receptor rriu rra:luroqt n:fiqvrf

n::qu alpha-receptor rriu

vascutar resistance nofin !fluflnlil'lfinx1tJ6'u1flfinand,Irfinfiou uonqrndnr:'lfi dopamine zuto

n'rrir'lrir]nnrr;oon6du orjrrl:fisrun1r'ld dopamine tururoni bJfindnXrurrtnfiflnorirorlu
ircur:nflo,rniunr:rfiolsrrrut6flt.l oiu 'lriRrrr:nooa"otrnt: ont6on (renal replacement lherapy)

rav'hionon:rnru

2. Moderate dose dopamine ll-t'tou1fi1d6o s-to pg/kgr/min lou :;illru oonqTrfn:;{u

beta receptor roiuJoErrav'Jrv beta-t rirlfid'n:rnrr ldul a':rir'le rErit*u 6an't't posilive chronotropic
effect un;ri{finr:fi:-rn-rto,rri'rhddu t?un'jr positive inotropic effect ldatornqud pcsitive

chronotropic effect ttn:qflf, positive inotropic effect li'illi heart rate LLni stroke volume ttil.t
du o'.rrirtfi artro"uTafi qrfill*u liiatfi dopamine fit moderate dose rrdr qvri'1unr:n::du
dopaminergic receptor ovrtul n-':usuo'tr,llirrloor'lYoonnao\:

Vasoactive Drttss [oniuni nfrfrnJn 2Os

3. High dose dopamine flu1aflldlffia 10-20 prgr/kg/min lou:J:crJrru oonqilf,n:yq'u

r;atpha receptor lauto atpha-i rriu vrh'hinr:flosi'r1o.rfiaon [6oadxu nluurijildu q'rrflunr:

nrrcl svn (systemic vascutar resistancel rirhimruoiuTnfinrfiildu rdoli dopamine fi.,r nign

dose ud'l qvrftunr:n::du beta receptor tr-.:n,,,:orj l-.,rt-{v{r'jrfirhufi tachycaroia ua;1rinlqnf,
'lunr:nr:{u dopaminergic receptor 6,ovrrirfl dFn?:aonoea\t

arir,:l:fimrr flurafllq0\r dopamine luudo:dr.lorelillfinrv{u receptor'lnloaralrr;
tlr:c.ttd o'l:J rdu n1?ifi dopamine flu'ur 4 pg/kg/min orent:6!'ldfl',r dopaminergic receptor
LLnt beta receptor uionr:'tfi dopamine'lururn 9 pg/kg/mln oronrv{ulirf.: beta receptor

LLng alDha receotor

nl5flnU'lUelUUeViU?1,Y.linlvfltA{ dopamine n[Un1ll-nu1 shock ll5:$yltl'l\tT nqfl\t Yl\t

tfi a.,nrnnrutda.rrionr:tfi o tachyarrythmia

ax.tx diJfiuna\r m (concentration)
fier lniu urlunrrrrdrdurir.:1 nYu n-.:d

1t. nrtrdriu v'1:1 'runxrujr dopamine 1 *rn. 'lum"rrirnsnlu n. d'rsr"r?irn:nrfl

orerflu NSS fiio 5% DW fild fintfiilnrnifrlrida,:qhfiou"r rnfn

2. n'nrrirduatn'ir t:t fiauldnruriutu e:t. +:t Inrnrrrtrtrdu 2:1 fi 1un?r 'i'r

Idopamine 2 Nn. tun"lrirnymu n. d.:or"rrirnynruo'rl rflu ttss nia s% ow fr"td r"ntdlu

n:ridfioon'r:irrierdr (restrict vorume;

rdarfisurirdinrrinsr nr:riru:l3ururlo.ru1fi'ldn"xdra;d'ruit'fi lrierr:r6flu 1 :1. 2: j v5o

4:1 rfla.iq'ln?ylri :rrzurour ua;:Jiil1fl?drliiei-t rtiu nr:lfrElujr dopamine 200 mg in NSS

100 mL I ud/min rnn'jrfie;tf tu'lr dopamine (2:1) 8 ud/min

lurnurfild

1-20 Ug/kg/min

Dobutamine

n1:ooflflYt!

Dobutamine oonqnd'1"un',rnrr{u beta receptor f.r o"tu-t rtnc beta-2 n',:ounqrf,

n::{u beta-t tt""nqrf positive inotropic effect tJlnn'j1 positive chronotropic eflect liltli

nrfi:rd'?io\tfdq (cardiac contractitity) 6du l':rhi stroke votume rfildu lulzu:fi heart rate
r$ildulrilrn lurirr{:ruororfirrduilrnldl c',rrnlr:dl:uhrrtdlu{rJruiirfiu ischemic heart disease
rfio.rernnr:'iifir'lcrfiur5rlu{ilrunajrd yri'Ifi aiastotic fitling time Rnn,J d1lfi coronary artery

blood flow Rfin,tTo![a "lclfionf irirdfl': left ventricle d':u coronarv arterv blood ftow fililt7r
right ventricle lrinon,: llfi'jr diastolic filling time e:dunafin1rl

206 rtrdtSo?nqndu5ru

Dobutamine oonqfl fn::qil beta-2 receptor t*tlirlfi rfiondll rduondrrtrdorurud'r

(muscular artery) d,rrunlfi SVR (systemic vascular resistance) nofln 6.:rirtfinrrrd'ulofislsir

nolurir n:n udsio 't cardiac contractility r; lrAtJtiutda.,totn afterload aoo,t ilridfi contractility

#n*u ri.,,:nrabinlla"ulofinrdrduludrwn'.:lourtrlildrorrrd'ulofindra{lrirruvrirtfld oooutamine

rflutjrru:n rda,:crnfrtfinrrl.touTafinnnn.:ernqud vasodilatation rrsifidaan liululr',,t:rud

nrrtloulafinnno.: 1ntfra{qrn cardiac contractilitylri6oEi'1.1il1n orqlfi dobutamine rflun"rrr:n.ld

nl tiriuto.'ts1 (concentration)

fi ulrmiu ur'lunrrrrdrturirrl fi'u d,td

t- nlur{r.rdu 1:l rmgn?f i't dobutamine 1 n.lun"rdrn;nru 1 ln. dtn"':rirn;aru

arcrflu tlss uia s% ow fr^ld n"n1#1un:fifi'hida.mirYqrirlrnrin

z. nrurdldug,lnjr t :t fiul'ldnmltdltdl z:t. 4:1 lorunrut{r{u 2:1 vrrun':ruir
dobulamine z rn. 'luoi"rvrio:n1a 1 l.Ifl. {i{ri'rrilncnruorqrflu t'tss fiio 5% DW fild ffli'fitu

n:rfi d do.rnr:cirioutt lrestrict vol umel

rfioriuuvr"rd.Jnrrfnur nr:rflflutli rrutaaurfitfifr'rrirnvnrufitfi'kiar:riuu 1 :1 , 2:1 r4io
4:1 rfjfl.rcln?rl v:rrlrturqurrrnv il'rn:frufioi': rdu ar:r6uu'jr dobutamjne 200 mg in NSS
100 mL 8 ud/min mnn'irdl:t{uuir dobutamine (2:1) 8 ud/min

Norepinephrine (Noradrenaline)

!n1f,oon6l

Norepinephrine aanqrfn:;{u atpha-1 receptor l9ruFr:'J :r.Ififinon t6ondru:Jnrunofi'r

rflun'r:rvrt*r svn filfi aftertoad rfiudu 6rvr'rlfiartd'uTnfinrfi#rlu Tnud neart rate $ildulri

r.rrn arerirtri cardjac output nnn.':ldornnT:d afterload rfimr*utu{:hudfi cardiac contractility

t1n 6aflrn1

nerlt:iliuto.rrm {concentration)
fiu rniuul'r'lunrtrrdrfiu +:soo. 4:2s0, 8:250

nTlrrdlr{u 4:500 fi run?1 'ir norepinephrine + rn. lu Sof OW SOO rn.

nrrnrfir{u 4:2so fl?o e:zso t4r'1u{r-lrtrfida,rnr:q'rdodr (restrict votume) aruld*:f,u
didlfidrnfu peripherat vein 6a +:s00 oroor..rlnrtd 4:2s0 16 eirunrurfildudc,rn'jrdnr:1fi
ti'rvr1,,r central vein rdofl a,rriu vasoconstriction dluu:,:

ar:rirdrflud'rrirn;nrufia+fluar:n;orudfi d.rtro"" Mrutu rfia,,rr, nfirNfl lu satine c:

rfionr:nnn:nau

rdofiuurirdrnr:inrr or:rfiuu irrruroasrdtdd'rdrn:orrfil'fihiarl6u! 4:s00.4:250
yia 8:zs0 rdo{erne;lriyr:rmurerur ttns:-l3rrn:d rrfiq?t t:iu nr:r{uuir norepinephrine 4 mg

Vasoacti\,€ Drugs nn?un{ nfrf,LtJg 207

in 5% DW 250 mL 8 ud/min rJ1nn.j1fi?yriuu'jl norepinephrine (4:250) 8 udlmin

rrnnu,rdtf
,!u1n 1-50 trrg/min l5a 0.1-1.0 pg/kgr/min
ianr:tvi.r
t- nr:ld norepinephrine lu{fiudfiflqnr peripherat vascutar disease riofifinrurdu.r

oionr:rfior peripherat vascular disease do.:tdn'rant r:fin:cr-*r ldo,:qrnorelil'lfirfio limb ischemia

t6

z. nt:'h norepinephrine do,::yrio:yiolriuroanuon (leakl rnaq16oo rdo{ornlirllilfin
isch€mia uav gangr.n. ld

pi t utat digitar gangrcne ifinctnntt dip norepinephrine aetatiufru al00 dqtninutntJn

1nn1n pe phenl vein

Epinephrine (Adrenaline)

nlroEnq t

Epinephrine aanqvrf,dann receptor 6o alpha receptor l!flJ beta recepror
'1. Alpha recepror Tnuranr! atpha-1 rirtfiynoo r6ond.lu nruynd'r rirtrfi svn rfirdu
rirlfi nr r ur'uTn fi n rfiln*u

2. Beta-receptorl9tunlroonrlflf0io beta-1 filfifis] positive inotropic gffect rr0y oositive

chronic elfect d.:nnlfi cardiac contractility !!ny heart rate r5rfi'u n.rtfi cardiac outout rfiudu

rirlfinrrrn"ulofin $ildu[ncnrroanqrnf,do o"t"-z receptor rirlfirnooa rarun-? (broncho-
dilatation) 6{rfluurfidrilrinur anaphytactic shock

208 rrurhrininqndugru

Fr11sJtfil|fir.lfl o\tu1 (concentration)

fiur.rrniurur'lunrrrt{tJfiu 1 :10 u 'lufi{ adrenaline 1 ln. lun'rdrnsnlu 10 tJfl lnuq?

drn:aruarorfu saline tio s%DW fi"ld

rurosrdl:il
0.05- 1,0 Fykg/m in'lurroJfr :r'fi orlsil rfi u mgrtr r

nttrJi:Jfl vasoactive drugs

rfialqtn vasoactive drug fir,':du fi nall life toduuru 1-2 urfi uro;r{r{ steady stat d
3-5 half life d',rriunTnjil vasoactive drug 6.:nr::Jiuurrln s-t o urfi

n,tafianld vasoactive orugs lufionil?clnndt"l
riouficr:nl, lfi vasoaciive orugs fio.tlfinr:inutwrttqlat6on:Jrvrnvrriul rclo nr:lti

vasoactive drug uritfi utodr.:t6uiririrtfi {:Lru'loniinrrnn*u
1. Hypovolemic snock lnuvf,nlrifiii'ldtat vasoactive drugs
2. cardiogenic shoct 'lusruvfinludulofinu"ln"roEj nr:r6on1d dopamine 1nn'l'llJ

ri'u1ofinn"'u.nn niu systolic ep eirnir z0 ut. :au otltdan norepinepnrine ld (selected case)

nrnnmlo'ulofinduufir ordd dobutamine tdo niil cardiac contractility lrin?:'t$ dobutamine
rfiusr-ru:nlutru:itfio cardiogenic shock untluttnlun:rfidFnjrnrr;6onrfiuc1n cardiac contrac-

tility iiurin.rodrtrnn lun;lrjfivrrtrfr on6u

3. obstructive snock nr:lfiflr:rirriou rlrfinri'n5'ru'l.l right ventricle ildr161il6 n:nifi

nrr*rfi'ulafintitntro{ firr:mld dopamine trnnmld'uTnfinntu'tn niu systolic BP n'rnir z0

rtl.t.rl:or arlrfion norepinephrine'ld (selected casel firnertn-ulnfiordurrfir atold dobutamine

4. seotic shock nr:'tficr:rirriou dr1fiar:rirrfiutuaud':nrud'uTofiorti.rlridu ambi
dopamine uio norepinephrine ndnnr:6ot6on norepinephrine rioutgla rlurrdfitofiril orc
r6on dopamine tu{:Jrufifi:)qrr cardiac contractility rra;1rifinrrrl rfru,otion11tfin tachyarrythmia
'lun:rfidhinorcuo,,:sionrt'lfi norepinephrine uio dopamine rrdr'hificr:nntd epinephrine d'tu
dobutamine lu septic shock o:16ontssiorda resuscitaie16 mean arterial pressure rrdr lnuii
cvP {.r l!fl: hematocrit ldrrnn'jrviorvirniu eo% !td'r uri Scvo, riaun'jr zo%

5- Endocrinologic shockl6ud adrenal crisis !m: thyroid strom nrdfigr:rirrtn:hinr:
insuournurr,,lao{lr.ru nio'hiurdruf,u:aud'lu thyroid strom firnrrln"ulnfinu"loiroqj fior:rur
tfi norepinephrine

6. Anaphylactic shock t6on adrenaline rioutnla (drug of choice) lfiotlrnnr:inur

fio,rnr:qvrifiin:;{u alpha receptor LLns beta receptor

\iasoacrive Drugs nn-tunf nfrftmg 209

fnr1{fi q.fl q,! nllfi ontd vasoactives drug lu6anrh: rnmoir,rl

Anaphylactic shock Epinephrine. 1 mL ol 1:10,000 Norepinephrine inlused at

solution (100 g). can be given as 0.1-1 !-ig/kg/min (0.5-30 Fg/g/min)
a slow lV push. then as a 0.02

pg/kg/min infusion (5-15 F€/min)

Cardiogenic shock, inJusedSBP <70, norepinephrine Amrinone, O.7S mg/kg loading
left ventricular
at 0.1-1 $g/kg/min (0.5-30 Fg/min) dose. then 5-.10 pg/kg/min (not
SBP 70-90. dopamine infused
recommended post-Ml)

at 15 Fg/kg/min t\,titrinone.50 pg/kg toading
SBP >90, dobutamine infused dose. then 5-10 pg/kg/min (not

at 2-20 l"[g/kg/min recommended post-Ml)

shockCardiogenic Dobutamine infused at S Fg/kg/min phenylephrine infused at

0.1-1pulmonary embolism Norepinephrine infused at 10-20 pglkg/min

Ug!4(g/min Dopamine intused at 5-15 U€/kg/
min as a temporizing adjunct
Hemorrhagicshock Volumeresuscitation
Norpinephrine inlused at
Neurogenic shock Dopamine infused at 5- 15 0.1-1 pg/kg/min
Fg/kg/min Phenylephrine infused at
10-20 U.g/kglmin
Septic shock Norepinephrine infused at Dopamine infused at 5-15
pg/kg/min (alternative agent)
0.1-1 lrglkg/min Epinephrine infused at 0.02
Dobutamine infused at Fg/kg/min (second choice)
5 ltgikglmin (for improve
tissue perfusion)

Norepinephrine infused at 0.1-1 Phenylephrine infused at
W/kgimin 10-20 Fg/kg/min
Glucagon given as a s-mg lV
bolus, then as a 1-5 mg/h
infusion (beta blocker overdose)
Calcium salts: calcium
gluconate, 0.6 ml,/kg bolus.
then a 0.6-1.5 mukgy'h infusion
Insulin started at 0.1 uniwkgr'h M
and titrated to a goal of 1 unit/kg/
h (beta blocker overdose)

210 rrtdrtininqnftugru

7. Neurogenic shock t6on dopamine riou ldotorn neurogenic snoct rilufianfrrfio
qtnnrtrir.ltuto,l:yu lJ6nvl sympathetic rjnvido.: 6.:dr'hifi vasodilatation tlflc heart rate d'l

6odo{rdonurdfinvrd u".opr"""or, ttnt positive chfonotropic effect tttdfirvrn neart rate tir'ht

'td norepinephrine

na1aM4

1. lu refractory shock fr lfintrnor lflugi1'f i E1atfiofl adrenaline tunr:inurld
z. lunr.:rrtrJfr:i6 ft:-hu:rfl fitorqtfiodonlfiernvarua1tvq ldu fitJru septic shock
rfiasirul:l:va; ncrnfit arqfi cardiogenic shock 1'ln myocardial suppres.sion factor ?1nfll:
donnr.,r 1r"diato4 tu septic snoct rialu{:hu thyroid storm fififlrytr caroiomyopathy aln

nr?r hyperthyroidism oqjrdl d,rorlfi cardiogenic shock i'rrdruld nrtdrru dcvt6ontd vasoactive
orug" (i'xlofudua{fr'rri'nuru:vrrrnfifinrfluta'n'jrn'rrv6onrot{:-hu rniutflufisflr.rtcr

Vasoactive drugs calculation

6'rodrsd r fi:Jrutrin so fiTnnill fio'rnr:'hi dopamine concentration t:1 firflsurourtYirfi'! 3

ug/kg.zmin fiotlfi dopamine d trrd/min
Dopamine 3 pg/kg/min = 3 x 50 Fg /min ({ilrufifn so filonil1

= 3 x 50 mg/min (1 mg = 1.qgg ra1

1 ,000

= 3 x 50 x 60 mg/hr (1 hr = 60 min)

1.000

Dopamine 1:1 fi 1un?l 'il dopamine t mg'lu ltSS t mL

o,:riu dopamine 3 x 50 x 60 mg/hr 6ttvirrfi dopamine 3 x 50 x 60

1,000 1.000

darfinrioirl: urlnrv ':uorn muhr rflu pozmin 'ldatir.il:

elnl mL = 60 Fd
-v
d',Jlil] 1 muhr = 60 Ucyhr

= 60 ttcl/min

OU

= 1 lrdlmin

Vasoactive Drugs nn?unf nfifiwg 217

9t''n# dopamine 3 x 50 x 60 m[./hr = B x50x60 lrcumin

'I ,000 1,000

= I Pd/min

f,tfioo orip dopamine [d']n"rJ 9 pdlmin

n-'rori1{fi e fl:Jrunrin so filnniu fiornr:lfi dopamine concentration 2:1 firusurnulyirdr i0

U€/kg/min do.,t'hl dopamine fi pO/min

Dopamine 10 Ug/kg/min ='10 x S0 pr,g /min (drhunrin SO fiTnniry
= 10 x 50 mg/min (1 mg = 1.000 pg)

1,000

= 10 x 50 x 60 mg/hr (1 hr = 60 min)

1.000

Dopamine 2:1 fi!1un?1 .j1 dopamine 2 mg lu NSS t mL

-zd1fliu dopamine 10 x 50 x 60 mg/hr 6.:rrirriu dopamine 10 x S0 x 60 mUhr

1 ,000 1,000 x 2

1 mUhr 1 pld/min

nhiu dopamine 1!. jq " j9.m, = 10 x 50 x 60 Fc min
1.000 x 2
1,000 x 2

= 15 ltd/min
i.rfio.,t drip dopamine rrirfiu 1s uo/min

ficr:rurqrn z si'radr{fir.1du o:fl .irst'lrn1 60/1,000 rfludln.lfi {irfrfia otroo riun.l

i.rldsn:nhurruur rfi u polmin n-,rd

md/min = 0j Jqllg) * dose (pg/kg/min)

100 x conc_

drdarnrturlar vasoactive drugs e1n po/min rflu F.g/kg/min tfirirnr:drtdr.tclnr:

a1il1rnri1u1illdn"nd

dose (Fg/kg/min) = pd/min x 100 x conc.
6 x BW (kg)

212 rrtri'rrioinqndnrgru

flrfio.rnrrn"rurrudolil'irtun:nidr.tfuurlSirfinv t po l;'tdurrfhdud ugnymin t#vl'1lnr:

rururir pd/min rvirflu t n'r"b rvlfi

=dose (pg/kg/min) 100 x conc.

6 x BW (kg)

tftorir'rfi o {ilrarfn so filnnir da,,rnr:'lfi nor€pinephrine (4:250) nu'lq pglmin fio,r'Ifi

norepinephrine d pd/min

ruvrurir fln{n:

Pd/min = 6 x BW (kg) x dose (Fg/kg/min)

in 16u1 1 ggy'min 100 x conc.

uueir BW (kg) x dose (Fg/kglmin) dru 1 ua:uuurir conc dtu

4/250

fi\t1.11-l

ud/min = 6 x BW (kg) x dose (pglkg/min)

pd/min 100 x conc.

6x1

100 x (4/250)

= 3.75 prd/min

6tfiar drip norepinephrine tvirn-:.r 3.75 pd/min fitdat drip norepinephrine oti'l'11i0u 4

ucumin

'lun:riiddo,rnrl:lduu vasoactive drugs 9'1fl pcUmin lfiu pglmin f,T il1rnf{dn-.ld

Fg/min = pd/min x 100x conc.

D^

irodr'rd I ffJrunrin so filnnix fiornr: drip adrenaline (1:10) 1tl'ttr 1 mgy'hr fio,ttfi adrenaline

d ud/min

1 mg/hr = 1.000 Fg/hr
= 1.000/ 60 pgy'min

rruri1'luqfir

trrd/min = 6 x BW (kg) x dose (Fg/kg/min)

100 x conc,

\rasoacdve Drugs lon?uni gfrfttl3 213

pd/min = 6 x (1,000/60)

100 x (1/10)

= 10 lrcVmin

6':da'r drip adrenaline ryi.triu 10 Fd/min

!1s$rq lu:rud orip adrenatine 1 mg/trr tuftJrunrin so filanfi.r

= (1,000/50)/ 60 trg/kglmin
= 0.33 Ug/kg/min

fiarirrd s {rhunrin so fitnnfir dornr drip adrenatine (r:10) n 'iq 2 mg/hr fiot'lfi adrenatine

fi pd/min

2 mg/hr = 2x1,000 Fgy'hr
= 2x1,000/ 60 pgy'min
!! ud1'hf,6:

lrdlmin = 6 x BW (kg) x dose (F€/kg/min)
Ud/min
1 00 x conc,

= 6 x (2x1.000/60)
100 x (1/10I

= 20 ucUmin

ilfio,: orip adrenatine rfln":J 20 p{d/min

qrr 'lur 'a[2u:ruii orip adrenatine z mg/hr lufiilruyrin so filnnll

= (2x 1,000/ 50)/ 60 Fg/kg/min

= 0.66 pglkg/min

lun:rfita-rnr:1# aorenatine frfin1:doutflu mgr/hr aru:neiurruirfiot drip u1 adrenatine
!n F(y-.min n-\tuE

pd/mln = 10 x dose (mg/trr)

fln? 5\rxr{R'lunr?rit ?ruur vasoactive drugs findrurf,r,,:fiu nrltrndrUldn-uu1n$j}J
vasodilator'tddru niu nitroglycerine, nitroprusside

nrrfino,,r{:.1':ul6n nT?fifl u,tccqlfl d?u6?1 rdtdufiuqnrhoornflr,rd Taufi1n{.rnrru
ndotfiltruru po/min wirn"utfru? Fgn(g/min

214 rrttiriainqnfiugru

6'radrrd o {r-lrulfinurin s frlnniil fioonr: drip dopamine 1fi16'iruru trrd/min tvirfi'r-ro"ruru
tlg/kg/min e;datzuc dopamine adr.tl:

l',rnqnr = 6 x BW (kg) x dose (trg/kg/min)

pd/min 100 x conc,

rdorirvuntfi pld/min rvirrildruxu pgy'kg/min 6.:tor pd/min ttr:f,rnr:nnoon".:f,otdr.l

1 = 6 x BW (kg)

100 x conc.

Conc. =9r rLtg)

100

n'rriu i{flgrJ dopamine ts mg ludrriro:o1u 100 mL triu rrndo.tnr: drip dopamine

tfil{ s ug/Lglrin fi1tr'rrod'idloufldu dopamine t e mg tu6'rrirn:fl'ltl 100 mL LLfl! drip

dopamine d'tu rate 3 ud/min

[ond1ld1.'6\t

1- David C, Mccee, M.D.. and i,4ichael K. Gould, M.D. Preventing Complications of Central Venous Catheterization. N

Engl J M6d Volume 348:1123-33, March 20,2003.

2. Vincent Jl. Weil MH. Fluid challenge revisited. Crit Care Med 20061333-7.
3. Colloid solutions lor lluid resuscitation. Cochrane Database Syst Rev 2008 Jan 23:(1):C00013'19.
4. Ellender TJ. The Use ol Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Em€rg Med Clin

North Am - 01 AUG-2008:26(3):759-86. ix.

5. Winters ME. Monitoring the Critically lll Emergency Departmert l%tient. Emerg M€d Clin North Am - 01-AUG-2008;

2613): 741-57, i/-

6. Ramsay J. Noninvasive Technologies for Tissue Perfusion. Anesthesiol Clin - 01-DEC-2m624(4):763-75.
7. Reinhart K. Monitoring O: transport and tissue orygenation in critically ill patient. In: Reinhart K, Eyrich K (eds).

qClinical aspects ol transport and tissue oxygenation. Beriin: Springer: 1S89. pp. 195-211.
L Catenacci MH. Severe Sepsis and Septic Shock; lmproving Outcomes in the Emergsncy Department - Emerg Med

Clin North Am - 01 AUG-2008:26(3):603-23, vii.

L Rivers E, lmproving Outcomes for Severe Sepsis and Septic Shock: Tools for Early ldentfiication of AfHisk Patients

and Treatment Protocol lmplementation. Crit Care Clin - July 2008:24(3 Suppl)l-47.

10. Rivers E., Nguyen B-, Havstad S.. et al. Eady goaldirected therapy in the treatment of s€vere sepsis and septic
shooK N Engl J Med 345. 136€-77. 2001,

r3

Tissue Perfusion

nniun€ gfifimg

n",rfi'ldnnjrrrrnaufiuufir'jlnrrc6anr rufi,lnrrcfi16ooltlds,rrda r6adrurlnrtirjro (poor
tlssue perfusion) d''rriulunr:fnuT nrr;6anriu itdo.,rfir:lrnmulunr:rirtfi tissue perfusion n6

drfl 'lrinr:vro'lqrrdsr"r rn11o.: systoric brood pressure vio mean arteriar pressrre Lvi'ruru
nr:!::rfiu tissue perfusion tuur,rofif,n lfir,irnrah;rfiur4ri'tern resuscitate euld' mean

arterial pressure lldt rrnu"'r resuscitate ri'l-kjld mean arterial pressure ri.,rkjdo.,rvrinr: :yrfiu

tissue perfusion [ :r: tissue perfusion rflunrt :; rfiunasronSnr:-[vnriaur6oolu:yri''lennro

(microcircularion) lurruvfinr:r"o mean arteriar pressure rflunr: :vrfiulrnflrdnfnr:lrariuu

tfioertu:vFr-L nrn (macrocirculation) Tvt.lunlTlfiorluurdosrtu:yorir microcircuration q; lfl!

:Jnn"ldfio,rfinr:lna riaulu:;6'l macrocircutarion a{lurnnrdrJn6riou drur:nrirnr: :;rfiuldd'ld
1. Urine output rflunr::J::rfiu splanchnic circutation lou:J::rfiul3urruflna1rsriu

n./nn./rlJ. Ioutorbnr:firlnorlyoonrurnnir 0.s rJfl./nn./r . adr,r'l:finrrt firr,rnrr;fiflnntr;
oonrrnn'jr 0.5 rJfl./nn./rlr. urihj'Lfirj.ruan'lrf,:-ha:rarfufi rissue perfusion orilurnrud:Jno'fi

drdtpFa nrrflirorroturdaoa',r (hyp€rglycemia) uanorndti.,rruldlu chronic renat tubutoinrers tial
disease. posfobstructive uropathy, diabetes insipidus, hypercalcemia rfludu

2. Level of consciousness rilunr:il:yrfiu::d'lnrtrifinni fi.lri.suonfi{rjiiltrurfiogtfi
'hJ raru.Jailo.J (cerebrar perfusion) arjr'r'l:fisrrl:v 6'rnrril5finn''rkjarqdrrr'lf:J:y rfiu tissue

pertusion lfflufirhavr"fiorrnq6udvihhi:voilomlSfrnnraern,ruonrfifioqrnnrr:6on rdu metaboric
encephalopathy. post cardiac arrest. status epileoticus tflufiu

216 rerruhrininqndugru

3. Bowel ileus tflunr:rl:lrfi splanchnic circutation tdo,rlrntirtfioe rdu"rr"r6uortr:

u*.r1il6 ccrfio bowet iteus du lt roru'r:oo':rqir,lnruldlnu.iru uono'tndti,:orcnornnrflrirEji,:fi

vr:'r{on 6{orc ! bowel ileusldd?u odr,il:finunr::J:c tfiu bowel iteus hin'rlr:ndllr!:vtfiu

tissue perfusion ld yrnfil:nturjotfioofr rflunrttqTougtlo njtr intestinal perforatian, intestinal

infection/ inflammation, severe electrolyte imbalance

4. capillary retilling test lourri'n'hjldnr'::J:: lfiu tissue perfusion trrirflunr: ::rfiu

afterload (systemic vascular resislance, svn) orjr\r'hfrnu capillary refilling test fl'llJ'llfldltJ'l
:vtfiu tissue per{usion'lfitu to* cardiac output shock (hypodynamic shock) riounr:inur
6liu11rfiu flufla,tn.5ing'1.j1 capittary refilling tlme rfrduuio'lrj fir capillary refilling time [5x

duuan':'jr tissue perfusion 6jf,u drulu high cardiac output shock (hyperdynamic strocq lri
nrrur:n"l$ capillary refilling test tl:;tfiu tissue perfusion 1d rn:r:rrrf ir{ilruoqitunm; shock

n1r9r5'rc capillary retilling test fildflar.lnfi

Microcirculation monitoring

gul, :nrni. d 2 i7!$l

1. Global circulalion tflunr:r"n microcirculation toa:rl niu nt:lfi venous o*ygen

saturation, serum lactale

2. Regional microcirculation tflunr:r"o microcirculation tavlr:fi ttiu nr:lfi gastric

tonometry, sublingual capnography

tuvn.'raftfin fiu Td serum lactate. venous oxygen saturation tunr: :;tfiu tissue

perfusion

Lactate
rfrorta{finr:vr rtLU }ifi'taanBLct-t (anaerobic respiration) qcf,fl'luli161flloutdn"unau

ro{ glycolysis Mrriu lnunraii'lrftYuqofi'ru (end product) a;ld lactate d,l'lfi n":nlutfiur 2 ATP

ru16u:.rrfiE1urirnr:oarufrnT a1nunr:firEJhttr!'ldoonfirct.t (aerobic respiration) ilt,rcvldiln"l,l'lu

36-g8 ATP lfiu'ld'irnr:vratqullt anaerobic Ifild,:.1'tutioun'irnrlvluteLtul aerobic orit,tl.ltfl

drzun'lfinrrvrtr'le rlutl anaerobic lfi lactate doqvrflu metabolic acidosis Touq:tflutttl! wide

anion gap

nrlfir'rrr:olj lactate lurfion n1t]r':nueur t:tfiu tissue perfusion ld lourirfig.:n'ir z

mmo/L ritron'ir:ct-trl microcirculalion firfioel:lrdu.ilrittnu,:l'ia (poor tissue perfusion) odr,tl:

finr nfinrtcflu tactate tu16oer lrild:-i{!anirq;fio':rfio?'1fl'!:uu microcircutation fifiiqrrtoua}J
rvr:'r:ololfinqrndrrnqduir^l 1drfi orln poor tissue pertusion fild

Tissue Perfusion nniuni nfrfitay 277

n1fr{ii 1 ltfln,Jd'i! q?o,r lactic acidosis

Hypoperfusion Associated with acquired disease

. Cardiogenic shock . Hepatic lailure
. Hypovolemic shock . Hematoliogic malignancy (tymphoid disorder)
. Septic shock . Thiamine deticiency
. Regional ex. Mesenteric ischemia
Associate with drugs and toxin
Hypoxia
.lvletformin
r Carbon monoxiade poisoning
. Severe anemia . Cyanide
. Other cause of severe hypoxemia
.lsoniazid

r Nitroprusside
. Nuclosides analogue lor HIV

Associate with inborn error metabolism

Venous saturation

Venous oxygenation riunr::J::rfiud-t venous saturation'lurooorfionrdrrioufi 16aooh
usuovgnrir}lv,/onfi oo drnr:nml svq rflunral::rfiurdaodni,roonrnrnrtr'lo nioriunir oxygen
delivery un:l:;rfiurdardodrurjara'lunr:riroan6reu'liltd rSoGan'ir tissue oxygen consumption

nr:lfi d{snrodr venous oxygenation saturation iildrflulh:eh arm:noi,lntr d z i6

1. ScvO, (saturated central venous oxygenation) Orrur:n rfrl6'.:odr.lr6ao'tdl.rnntrqa
t6ooqrnrdut6oonh'lvddrunnrr (central vein) nrlr:nrffrn-rarjrtrdonldq'rn suDerior vena cava
ttiB inferior vena cava flld m-rrrrJ$i6d-uJ1:on1?o scvor lnuoorfianl,rfl cenlrar venous carheter
fiioernnrfl venous cutdown rjr'lildtn:te arterial blood gas

2. MvO, (mixed venous oxygen saturationl t?out.lriruriun,h SvO, rflutfioofrr,ro:l
n"u:vrirt superior vena cava !!flg inferior vena cava tt6'l Toatfiror-rotir.rtfiooqln pulmonary
artery iitfiar'ld putmonary artery catheter Touon16onllnfiru distal lumen d1"l

uonotnfiri.,rarlr:nnt?o Scvo, r?a Mvo, lnunr:ld fiberoptic catheter rdrl fi central
vein lt5o putmonary artery rfiaindt Scvo, fl?a Mvo, .[ds]non rrar

ilcq"rrfifiruaodadr Scvo, u3o Mvo, fi 2 flqdu ldrtri
1. oxygen detivery d.lnrlr:nn'rurrul6qrn

Oxygen delivery = oyvgen content x cardiac oulput x 10
= ((1_34 x Hb x O, sat) + (0.003i x paO,)) x cardiac output x 10

218 rlnirriainqnfrugrl
lulrisr'r:r n-?rflt 1.34 arrrtruiid,lu 1.36 il64 t-sg 6.:6airriun'11! unnd'l'rnu

rFnriou

ovrfiuld'jr flm"udr6'qfifinrnn'u oxygen delivery 6o hemoglobin, oxygen saturation
L!flv cardiac output d?uri1 eaq e:lrifinrnoioril oxygen delivery ,Jlnlin

2. Tissue oxygen consumption tflunrl ,:!onjr lda riiaeirurlnrufll 'llod'loofl6tqul

'ld'ld*:rnriau rfi fl ,o'ln

barail Sd||E

t'ttli ua a,t oxygen saturation'lu 6anun,t uav Gaati'fludauoiN T sa,tiNnta'lunltv nB

n?'lildilflrfxcn'jr.rn'r SvO, ttavdr ScvO,

nrrr.rdr.rfiuf,:vn'jr.rrir svo, ua:dr scvo, rdoudr$'ufiau lnudufl:LomtJllnndll?a'1
oxygen delivery $n! tissue oxygen consumption lunm:oiro1 d.rrrqnoi, oriuoonhJlunuilnfi

runvnufirflul:n uonmnda--rdurYuJ?urrur6ondurir{rT{corn coronary sinus !!ns Thabesian

vein dtdurilil::Ruinrutunr:vth.:rulo.:vr'lo tunu:lnfi d'no.t Scvo, q:firdr :vmru 26.8%

'I irsuc Pcr{usion nn1unf nfifirvg 2L9

{isoirn'fi svo, dsfieirrlrvlru ze.+% trriodrnlrfinurirrjn6do;ujduuurjn,rl drvraff.lf,ninl:

lnnriaurfionkia'rfi l;fi(hemodynamic insrabirity) lufirJ, uiifrornr:n,:fi rdr scvo, uo; Svo"

rirtnd'rfiurriu {rletfrfinm:r''rlod:lrrnr theart faiture) eyfiFi't ScVq g\:n.jl SvO" f,r-haiiodll
nrrcfon o;firir Scvo. drn.jr Svo,

lunulnfi rdandadlu inferior vena cava rrfi iMruoancrou (oxygen content) rJ1nn.i1

rda':crnlnrfluor"urcfi'ld'i! cardiac outprn rJ'ln Ieifin1r'ldoonfiroufiou n-.niurijarfiud'.rorjr{r6oocrn

inferior vena cava i'r'lfiriilnru oxygen saturation o.rnirrdaadrfiurl,in superior vena cava
nr''rrYu{uril{ilrufia{lun, rz6on rfionfi'h.Jrorurairrrv'lutiarrioo (sptanchnic circutation) uoc
riaqdbi r6'uodlnaon.'r d',rrfurlSlroroon6mu'lu inferior vena cava noo.rrfior iulrfiuun-rr6on

firfiurlrn superior vena cava finr:frnurvnrunr:frnurfirarauvrnrrrnrfiuf,ra,r svo, rra;

rirscvo,urifi urirri.olrifi nrrudrriudnturjri'o

nr:rirrit SvO, unv ScvO, lrrJ:vanftfrtunr.rnifin

I Svo, ufly Scvo" cr\n'irrir:Jn6 rfinldernor lvrrGialild
.l) Oxygen delivery nont lduri nnc6n (hemogtobin flna{) ntx; arteriat hypoxemia

(oxygen saturation lutfionnonol lrn:ntrtfi cardiac output non{
2) Tissue oxygen consumption rlrnlsu niu nn;ldg.: d'n *u

Svo, rlfl r Scvo, 4.rn'lrdr!n6 rfi oildornarlymcio'ltd

1) Orygen delivery lrndulduri nrrcdffiqr6asun.,l rnfiu (potycythemia) uacnr.t:d
cardiac output trnniu'lurr,:n6fineiru'lvr!rfinlrnnr.t: cardiac output lrntr*u
firvrild'lu distributive shock

2) Tissue oxygen consumption oftfl.J niu nrr; sepsis (tdo.ternfi microvascular

shunt), cyanide poisoning, carbomonoxide poisoning. liver disease. arteriovenous

malformation. intracardiac left to right shunt rfludu

nrdlril Svo2 uf, s scvo2 illrhssndl#tunr,rn6finil,.lil:lqn61iln1rn uninul

fltJru severe sepsis uog septic shock'n
Tnrrlnfi {:hufroqjtunrr: sepsis nia septic shock etfid1 SvO, LLay Scvq fig,:n.lrra'r

nft rfjolernfinr:drlrutalri'rtulndu lnign cardiac output) rJ::nalrYl tissue oxygen
consumption flfin{ River rrn:nruc 161irnr:finurlu{r-lru septic shock Tou}itnr:dnrnlulio,l
qnriu lfi early goat directed rherapy r:lisurfiuunuoirfi1ild prorocol Toflfirirm ra,!a.,rnrr
intr6s inrr:;oil central venous pressure odfi B-t2ll.rj:ovr ltSolvirril to-ts tl.rih; inut

::o'ra':rro'ufafinradu 1re"n arteriat pressure. Vne) l4g.,rn.Jr 6s !rJ. :or ua:imfl:sdu

scvo, '1fi4':n'iriauac zo Tnflfi'rdr Scvq oirn.i'rfalav zo tvirirnr:inurri,:d

220 rern-rhrjoinqndugrl

t. fir:;d'uiir.r,lnnivrriaun'jrtaun: 30 lfifi1r?il{fi packed red cell

z. rir:ldr central venous pr.rrrr" al'r tfifio'r:rur}in'r:ril rdainu1l:n'u central venous
8-rzpressure tfiaqj.::r.jrl
. :syr (10-15 nr.rhl tu{frufififlrpnrrJanfinrJnfi ldrniafliru

yrtr'lo nionruri'u'luriorrio.rAr da-:inut central venous pressure lfiq-rn'ir a-tZ ll.r-6ovr

g. riio::d'u6rr1nnil rrnc central venous pressure aflurnruddrnr'rr:fl $fi1 fi1rYfi'u

ScvO, tioriaun.jrSoud; 70 fia1: 'rlfi doOutamine tfrorfij n1:fillfixflo.llh'le (cardiac contractiliM

nn,l:;iflD't x'i't {rjrudld early goal directed therapv daT'rr:ndr1fifioril'Mll1uno{
fl'r:inr{dn,U'lurxal 6 $';Iil.r f,'llr'l?rlflel0-n?1el'luiuf,:-lrtln{rri'.:nrilxldiotla; te nr:6nurd

riurflunrrdnurddrdqdn:;{ulfifinr:niruouururrinurlu{ rrsevere sepsis u;o septic shock

loflfio,rdrnr:inur{:-Jra'lu::r;rirrr:ndfia.:gnrf,u rialuro{:jru riouil{:Jruluno{:-hutrin

supplemental orEgen t' end tacheal

intubatbn and tDechanical venlilation

!t6 nnd <to rrfira

Trans{Gion of red cells

unul hematoicrit >3o%

u{u0rn 1'" UflAi Early goal directed therapy ptotocol

srRs systemic inflammatoly /esponse syndrome' CVP cmtral venous pressure, MAP

mean arterial prcssure, ScvO2 central venous oxygen satutation

Iissue Perfusion nn?uni QfifiraS 22L

lunr:r.l:slfiu microcirculation yia tissue perfusion riu firrflulilIfinr: t;rfiu Scvo,

e.lr-r{'lrJril tactare tevet r1fi uurulllunr:rJ:urftunruuruu4fifi e

%in. ASilation,
T€mp #

I'tcro-Clrcubbry
deraryan€rt

Afisr 2 hrs :
lacbte decrease > 20,1

uttugfrfi z uda'tntaJtandnt rllaufr Ectate i.t*riu Scvo,

flflJ
vgrj{.[runr:niirirecd6'oununrf;lnurn:irnr-:ufirufilg;dnridoourlurfuioror:qnntnriuiuyuiatrrftiurord'{lc:rvGflrvrr'r:o'lial oumnrdt;ru'rrl:fnluffrroou:ddar..l:1fialrnrluf
tafirvoiUr;fi rfin't fl'tul;xu (multiorgan faiture) [[d;d1x'nnaadn:tnr:r5lufiinlal{ilruo.ild

222 rrrni,rioinqndunru

lsnfi?dN6it

1. David C. Mccee, M.D.. and l\,lichael K. Gould. lVl.D, Preventing Complications of CentralVenous Catheterization. N

Engl J Med Volume 3481123-33, irarch 20,2003

2. Vincent Jl, W6il MH, Fluid challenge revisited. Cit Care Med 2006i1333-7
3. Colloid solutions for nuid resuscitation. Cochrane Database Sys't Rev 2008 Jan 23:(1):CD001319
4. Ell€nder TJ. The Use of Vasopressors and Inotropss in the Emergency Medical Treatrnent of Shock Em€rg Med Clin

North Am - 01-AUG-2m826{3):759-86, ix

5. Wintets ME. Moniloring the Critically lll Emeqency Departrnent Patient. Emerg Med Clin North Am - 01-AUG-2008:

26€l:741-57. ix.

6. Ramsay J. Noninvasive Technologies for Tissue Perfusion. Anesthesiol Clin - 01-DEC-2006:24(4):763-75.
7. Reinhart K. Monitoring O, transport and tissue oxygenation in critically ill patienl. ln: Heinhart K. Eyrich K (€ds).

Clinicat aspecb of O, transpon and tissue oxygenation, Beriin: Springer: 1989. pp 195-211

8. Catenacci MH. SeverE Sepsis and Septic Shock lmproving Outcomes in the Emergency Department - Emcrg l\4ed

Clin North Am - 01 -AUG-2008;26[3):603-23, vii.

g. Rivers E, lmproving Outcomes for Severe Sepsis and Septic Shock:Tools for Early ldentification ofAt-Risk hients

and Treatment Protocol lmplementation. Crit Care Clin - July 2008;24(3 Suppl)|1-47.

'10. Bivers E., Nguyen 8., Havstad S., et al. Early goal{irected therapy in the treatment of se\ere sepsis and septic
shock N Engl J MBd 345. 1368-772m1.

Cardiogenic Shock

qinrt naoagi

cardiogenic shock fio nt;firclulaariuulnfiorirlrulrirfiu,0norio{crnnrtfi rTrro,t
ndrlrdori'elon's:Jn6 flourfr}Jrurufi'rrrunirf,nfru) rir'h{nruri'ulofinnh uacaiurydr.rr ,!0.*t
'ir'lnruldftlrfianlrirfiurua 'lunruvntnrudutirre nrudhalrruniGndru fleft ventricurar end

diastolic pressure. LVEDP) glduun;finrrrrirdTJrlon (acute pulmonary edema) iudtur
n'r'rr cardiogenic snocr ddrulnqjuunrlud,:nr:rfi nntynfirl rdari'rlolrs6aqodr,,:

rduura'u fiarfunrr;qnriufiffo.rldfunrrfnnrsdr{rdrdru rdoomnnr.:rdiio-n:rnr:rilufiinqrun

rui'jroddfilnr:inurrdrfrsn nrudrloluornr4uo:rurioi:lnrr iinrlrdrf,rylunr:fiqr:rur

16oni6nr:5nurd *urvaluri{:Jruuriovmu

Incidence and outcome

loruntrlJnrnn'nrrgrgrfiunrnirmuto,:ndtr dorirtcro,: rrun?rfiad.rurfiun.j'rioua; +0 es

n:r1finr:fi:-rfirrarrrunir6adtufio nfi' rroctfinnrr; cardiogenic {dshock et.txJ druh{vru

nrmtdln'nrfionrrcndrurdofil?rror6ooori.xr6uuudl (acute myocardiat infarction, AMI) ns,t
1tiio ST-segment elevation myocardial infarction (STEMI) rlRc non-ST-segment elevation
myocardial inJarction (NSTEMD ernda4mornrrilns{ur;ucrfllytla"nnnr:rfio cardiogenic
stroct ld:J:yITrut0uay 6-10 nrulur:uvrrnr go iurrntd.:rfis acute STEMtk lunrwd4rJru
NsrEMr lnrRl'tr cardiogenic shockld:Jrmrutouns 2.s4 mslridrntcu :nfiaudr:rfiantrrfr
steut nio nsreur d'rufia-nrrnrrtf,ufilngl rdurfiurrlu lrJrrlrrulouny 65-70 nru'lu so ,ru1

otirdrfinrl :fio4nrrn rv rrnrrfla rlinrnu.j.ruurlimolo'nrrnr:rfiuiiiqlul:\nru.lu1n

224 rrtr.irtTninqnfiugru

rfiooornnT: cardiogenic shock oaR\tF!1 6i'louluriro t o f,dr'iru r oln!?Y lruiouflY 60.3 'lu
fl n.a. tggs rfluioua; az.g lufl q.a.20046 rildororflunaorn{rhuldirnr:inurdruii earlv
reperfusion therapy loutalrlnl:dr primary percutaneous coronary intervention (PCl) xrln
duerntafln; 81,5'tufl a.ff. t99s rflufasn; 74.4 tufl o.FI. 2004 truvddnrrnr:mrtcrnnnld

luvri:J ro 16 u u-t6 o'jro{tu: : nir q': lrnu

on:rnr:tfin cardiogenic shock fio-.l acute myocardial infarction tta;o"n:rnr:tfiufiisl
ro.rnrr:d'.:ndm $nnllilunrrrsfi t

rn1,ncd uorrta"'orr'tn1tLfin cardiogenic shock ud't acute myocardial inJarction ttnJoslllnlltfiu

6imarnrrvotnairr

Goldberg RJ3 1991 4.762

G U STO-|' SS31 41 ,O21 7.zVo North Am. lsrael. Aus, NZ
North Am, Europe, Aus
GUSTO- b1 1996 12,084 4.2% 63% STEIII I
73o/o (4.092)

NSTEMI

(7.991)

200sCREATE-ECLAT 20.201 6.5% 6A% STEMI China.
8.6%
NRMf 2005 293.633 47.9% STElVll
4.4o/o
coMMn+ 200s 45,852 5.O% 680/o STEMI China
ffio/D (overall)
3.9%
72Vo Metoptolol

L Placebo i
I

f,1lilqna{ cardiogenic shock

nrr:firiucrtrqnd'nlo.'tnr:tfin cardiogenic shock 'lduri nrr;ndrllrdorir'lotrntdoq
rfiurlqd'u louranr; sreMt {i.rfndur{u6'rYrnr:ary rfitrrronfirr rdari'ttqlrnn'jriauav 40 to,,:

:.Ji:.rrrunfiurdoto,rnusrir6ndru'uonerndnrrcnfirilrdar.rr'lctror6otrrflrrl'rii'u'iirirbirfionmr

rurrndoul€,rnnro.rnunirfindrr (mechanical complications of AMD lduri nrr;duri'dqlililio
*ratlrtlulr:r16ulnniu (acute severe mitral regurgitation) nrr;nni{rYutruflit6nit (ventricular

septal rupture) n1?r f.t[lun;r6nir (ventricular {ree wall rupture) ungnl']glfiacri.l'iu1io{lda
rirrir'le (caroiac lamponade) fl 'lulrndltliLnanl'li cardiogenic srrocr'tdrdurfu

Cardiogenic Shock dinri rra1ffii 225

rda,oornd rurfi uriouny z0-29 rviru"udiinrrl cardiogenic shock ns,,iusi.lrnf,u rd{u
T:rnurt.lrayo".,,:rfina'tn't?ro\r acute Mt6 {r-hud':ul4irfinnrrt6onnrunn-.lil'lfluT:,,rnurlro
n-.,:r.rsunr:fnurlriaurii'4rhu1dfulr,:adrr6,,raro lfluRr lrq'lfirfiornrr: cardiogenic shock'ld crn
:tutrunrtdnut coMMlf (the clopidogrel and metoprolol in myocardial infarction trial) B4.'r
6nurHnnr:fnurfirlxu acute STEMT druru 4s,ase:ru r:J?u!rfiflu:;r.jrn{1fil{fu metoprotol

luro s finfinirvrrwnoordoorfrln ts urfioun:u ts finhnil.r fin'',rcrnfutfiiurl:;n'ruulriunc
200 flnnnn5l nu0o??uu9e0a0of1nflixx{{Yfrdto0out.ai[ituluuTLL ?r..:ytrUu'r]r:Jrnrn fti5aalfrliujurrrxnnr,t 28 i'1t r nn"ttnan'i f<li\l!f0iefe1u1ujfrly't1n4ofnl0nruu.?i1r

amtlnlt16rur'tafl0,tfilllxull{f3lo. {nqrJ . '1LrJrrnndl'rn-u (.iuaufly 7.7 o[un{1. fr+r[od metoprotot rfruuni!5oufft

z.a 'lun6i nr:.lnu e=o.oo1 urirfiafior:ru'rtu:run;16uovrl.ir fiil.lufrlfifiu.r metoprotot fid'et:l
nt:rfin cardiogenic shock 4,:n'irn{lirnlfifiarynonodr,rfiu-urf'rdq ltatrn: s rfiu!n't.r Soun:

3.9. P < 0.001)

nrr:ntrrfio nFrocnfiurdor'rlourrrfindfimu.rruirarl.r:orfionll; cardiogenic shock
lduri acute apicat battooning syndromee ii.,:fi:r u.rru'lurvrnrf,.rr-ur,rln:.1:;e'rrFau (post-

menopausat women; drJrurinfiornr:rSuuriron uo:r,ro!rfida!:.trJfru:finunrufinrJn6ro.lndu

lv{flrrirhulr ST-segment elevation uanotndd.rorlr:no:tcltu:tg'r cardiac enzyme rntldu
ldr6nriou firnn'irioua; zo tald rufir:o'u troponin T nio t X.rfinrJnfi ua;rrnn.jriauo; 40
aardrhufi::riu cr-Me a,la'oiln6l {iltun{lflutarirnr:n:myoaaGaofnT:uricvlriunr:qn

sium{ aaotfiootrdodrdo (no significant obstructive coronary artery diseasel rinn:1lnr:n:ro
nr:rir.lrutalr,l'rlefia,,rsirtdruqv uirnfirlrdori'r'lel?r?fu aoex clfinlrrcrrur:nlunrrfirn-rooo,l
truvfindrlrdolurirrrulndfi'r.rdur{'l'lclrJflinri,0fr.rruldd nrlr tett ventricurogram o.rnnlrnr.rr
d'lutnia.rndurfiara;fiaunrufiowlonrzli fluoroscope 6turn-nr*ru:RdruqrJn:nil-rilar6.rfi

do 6un6ndamfj.r'j1 takotsubo cardiomyopathy lurloliurdodrl:ndrfincrnnrrllfinrJnfilu::dr-r
microcirculation tatrdurdaolnt:u'ti orn:rurru{:-hl acute apicat ba ooning syndrome e'ru:u

256 rrr r1l,jrrfion'r'l; cardiogenic shock ldfi.,riarjfl! 4.2

ils16fl5:eru1

urd16rrnsrdo'jr nr:rfin cardiogenic shock fior nrolrnnr:qryrfifl rnnfir ldoto,l

rrun?16adrEJI.Jrnn'j'r5oan: +0 zo,rqhu'run6'rlrdonv{yln lri.irecrflun1:n1uro.0nfir rdaaEir.l
rdarlra'uvriolriun'ufi riofinrrnruro,:ndlro{ ln'lriouo:rfionr:orrro.,:nfirllrdorfir.rdu6ntunrr

na'o udfia ncrn:ru{rurr.: uriiytur' vruir nr:lfiondurdorir'hmruornnr:nrordaoourfr}J{
R11s cardiogenic shock tiu firi'nsilcdriun'jr extension of infarction rfluoirutfiqj noimdofi
nr:rfinnfirrrf,orirloqru $lilrlnrrurau1 rirrudrnurnn acute myocardiar infarction 16r ili,r
o6rrrernnrurd1,tnr:rfin acute myocardial infarction luntru:n Tou raurvurnrfionl:nlura\t

ndrurdan"T 'lcitldftlrdanrrnfioaqrdon left anterior descending coronary artery (tAD) d-:rflu
rdur6onn.rfi'u.rnd'urdari'rto'lurirrzunir.rn'ir rduriandu ovrirtfifinr:fiud'rra.rrirtolou:uann,,r

226 rrtrirrininqmfiugru

d.lrrnlfirtrlcpfinInfinld'lu:Jimruriasn.:nirt6r dr.rnrm:rirnr: iudr1nufinr:nt;{u::uu
:J:yorvrd'nluri6 (sympathetic stimulation) nrafinrurfio finrrfir.rd':latrnantfionoirurlnru tfio
trirca':Jnrriloulafin.[rinontrrn rfiu}l lu:rnr:16urn'un-':lqfiatrfiur5rdu dr'lfi::uvrrartirrrirtr

anlueY? (diastotic filling time) #un'r oor.rn'tfinr,loiutnr:duqnnr:etnlud'rto,'ttrunitFafiru

llveoel goduouarctflqnrr;frvirtJ:Joa (acute pulmonary eoema) duld nr: fuoYrcr'ondrrd,:

fiorfi!eiondrrrdafiT 'ir rdo.,:ernrijorirhrdurfrtsuua:da,,rrortu;tt:.ldrumrudru!fl1i1 (systemic
vascutar resistance, svnl dg,,lrlui.rfinl do{nlroon0tquniln*uluuu:d:JiurruoonfinufilJrdu.l

ndrilrdorr'rtc (myocardial oxygen supply) nnr-unontrfio{ernfin't:oorYutatrtaau16ooTnl:uri

6,rdrrunlfirirrnnoond'urdorirtrdarqr6oofiu!itrrun{'r.rlnndueulfinnl'rc cardiogenic shock
gr..l
flu tuflfla

dryiuncoordood rfinnr:qnn'u (infarct-related artery) eud1lildn1?: cardiogenic shock

:rriudrulnqirflu teft anterior descending artery [ lruiauflt 39.5 fi,,r a6.t1 :o.lmm6a rignt

coronary artery (RCA) [5ouns 37.1 n'r 43.8] circumflex artery (LCX) 15olnl a.s fit l+.41 tett
main coronary artery (LM) 15oan: z.z fit o.o1 rrn: bypass graft occlusion liouni 2.0 fi': 2.2]

m1r ti1 o"ro'o

crnnr:finursoo shock trialll nu'hfi{thu cardiogenic shock .iru':uundiiarudrunru
la.:rnonr6anei'rurlaraofrn'jrfin?rc:tfru (syslemic vascular resistance; sVR < 1.357 dyne/

sec/cmt1 nerfildfiarn::{unr:vnn'ruo,,traontdaolu:rurnot ttffr (high dose vasopressors) rrnJ

{:Lran{ldsirutuo,:fiornrtllopt*ltatnl'tv systemic inflammatory response syndrome (SIRS)
nfirufrlrr:'tufirJrun11: septic snocx" fiair6"rgti.rvw'jr{dra cardiogenic snoct dfi SvR sl"rq;fi

ri'srirnrsfi ao iu g.rn'lr{:-hudfi svR a''r''

fi ndngruirnllvnr:fi svR o'r"rlu{rh u cardiogenic shock rjrrr tfi oornnr:rn.na,t

inflammatory mediators niu tumor necrosis factor-d, infedeukn-1. interleukin-o [LflJ C-reactive

protein qrn mad'ndurdorirhdld:luaun:ruqtnnt:rltn 16ao nsolutir,,rriauua;na'ddi:inr:turu

vnoorfioneurfiq reperfusion tatndrrldoritrruor''.rnajre nr: cytokines lvrirdn::{uraultf

inducible nitric oxide (No) synthase (iNoS) thlfi:J?xr1 ro.r No 'lulfionrvitrr*uorjrtrrn dtno

tfi svR nno.rlrnqrdnr:tsriiflnao rfiooaor No ril':ndrr uonlrnd:;ra"'r t',to fiq.,:duti.,raresirarn

'lfinrrnorfi'rla.rnfirurdononufinnrr: myocardial stunning du16 alndoXolurloliu nr:rfinnmv

cardiogenic shock o',: liunnirrniu:;r'jrt n1?qrurfiu?Jo{rJlnndtr rdov"r'lcqudr'lfierrrraur:n

tunrri:Jsr'rrlorfxhun:rlirrrurfiaoiioonernlir'lqnna.r drrunirnr:var,:ro,r inftammatory mediators

d.:nn'lfiartrri'ulnfinsrin.rodr{uln 0fiooern tow svR} drrniufi stns un;fi.:lirtfi:vulnnriuu

lofiodrrrar Iqurorr;nfir:r rdar,t'rlofildfiL 16oanna': turru;fiqnnr:{u}ilir,rrurrnr*u o'.:rfio

extension of infarction duf,un,rv multiple organs dysfunction syndrome 1uOoS1 rrn:r6lu
'a^o

x?n
A ., (rrDrun-al]ll 1)
trvrs{o

Cardiogenic Shock qini uotrog! 227

AculE myqcardiel inLrction t_

r--I Inflamnatorycytokihes LBft ysntricular dys{un ction

.N--o_p-f-o_d--u- clion t_ _l

gRS

i-_r_--! ..._ l'-__-l:| |...-L. otv .--L. ou-l.pu-.l.-
u^€c-t€pas-eor8fuysstgiomntc |
catdiec

ct sz2 Lftninirr,2

;L_'\Vdg-A_eb|c!s'tsr9-oeo-.drds:1cieillaa1.Slt,aal-_rtqi-'oR_4-n_|Il lI|,--._l-__nI.n_I.nc-c_crrt.re8r.evayas-s-ee..SS-H_y'VR_-R..I_-I.. ---.. .ft.G-o1-r.e.n,.li.d.n..--.l- t-- -l'Pulmonarv edema

SBp <90 mmHo I

'\.. -.. -.. -.. -..-..-..J.-..-..-.---,1

Low coronary pefusion +HypoI€mia

l,'"T:*11,,'rt

tillilugni aTJnniafuinu.dd.ra-rysann1?c caz;iiogenic dlock

n1t?u?ou
nr?a"ffail{rhuog'lunrrv cardiogenic shock riofirhufi dnuil:6'.:Oall#

1. n?1ilo'uTnfinn'1 (SBp < 90 mmHg) riurrnrodr.rrlou 30 ilrfi fllodanlfiu,r vasopressors
rfi'orfirt:yri'u sep'lfirtinn'jT fiioniT nlJ 9o mmHg lu{rl.tudfiornr.:unlornrlrfin.rno,cnrl! acute
myocardial infarction flouronr;{rhan{finrtrfinrjnfi:rorndulvtflrrtrhdn sr segment elevation)

2. o-nrruyra.r'lcuulilarlauTnfisilrjrfi a.lno (poor tissue perfusion) rriu :Jorufi o nra

rrhrfru ndrfiyrlrlt:Jaruuau nrurrldlrid'nrou flflonlr;oanfiouo{ (urine output < go mvhr)

rrl:;rrn : fi n"u n Ycfi o n al

3, n1lfod1n'1lrr!duurrilnmornnntoninrrluarluu1nfin (hemodynamic pafameterc)
rfirldrilnm; cardiogenic shock'u ldrrfi {d1 cardiac index < 2.2 lJmin/m2, rir pulmonary capillary
wedge pressure [PCWP] z 15 mmHg iofin"ncrusra.: putmonary edema ?1nfl1?B??9d'1.,:n1u

t?o n1r cir ur",,r 61fl rr,Jsn

228 lrtfrfninqmfiuSru

fl1i:flIt1

o"rn u16fl;tivtultts.lnl:tfio cardiogenic shock 6inHnlfifia?'1 fio'in1:oan8[au'!o'J

myocardium dti,':fi6ina{rfim'ulurruviinmrd'ulnfiarrir rir'lrtrdaouovoonitoutdrqi mvocardium

ldaonr drrunlfir?rrnrndrurdorirlllro16oorfirt*u (extension of infarction) r'fiotqofiin::uru
n1?d'{n6j1? fl 'r?inuln'txc cardiogenic snocr 1fi16Hn66',1 ::na!fi 'lu'ru

1. n'r:fnurtdotduudolfinre;nasrosrinr:'l nri uuTnfin r{r{nlqn (stabilizing life-

threatening hemodynamic condiiion)

2. nr:fnrr tfi aanrunr:qcn'uto.t tfiurdaolnT:uri (early reperf usion therapy)
3, n'r:5nur r$jaflo.:nlunrr tfinn firl rdari'rlolrer 16oodh (secondary prevention of

cardiovascular event)

tulrnrrudesrlonsjrrfilnr:inurtu::uvSnqn rfiadru6inno':{il'lu cardiogenic shock

rflundn

t. nrrinr*rujo.rfiurCs1#nt:uerrcefrn:lnarluu1afinrfrr{alqe (stabilizing life-threa-

tening hemodynamic conditionl
vd,rrfiornrrv acute myocardial infarction {:.hlfiIanroiio:fio1n'lrttn:a'1fl'l:ttf,o\tna,l

n1?r cardiogenic shockld x1nfin1r{ry tdultn'uo'tndurdorir'to nuslirFn6ru rnniriaual 40
Tiaarcfiocrnnrr;ul:ndoutilnn niu acute mitral regurgitation lourovrr;1u{rhufifinr:qol

6'uro.'rrnoa16oa right coronary artery tfiaterntnaorfionoonrirrtdu.lndrr.rrda postero-medial
papittary muscte uon"'tnd{tltuut.lmu 1nl rallrl{:Jrurrar{.:dfierrrrri'u1afiotg,: orqrrnn'ir

i60 tLnctfigR']1: acute myocardial in{arction rflun*.:ru:n oretfiglRrrv cardiogenic shock

rfiorlrnfinr:vwqto.,rndrl.ttdolSrrnruri.JrYulo.trnusri16fl (ventricular septal rupture) vissre lfio

nr:iiro.,,:aniirrusrir6nfiru (left ventricular free wall rupture) fltd nllctr :ndouri.lnodlndlld

nr:ldi:.riioduori'r.::rn uSrlnuorfunr:n:lcnntulfiuro:rlaurir'lc (echocardiography) tfioi?1n
rfl unrr :fr da,r nrrnr:inurlofl nr:!.ir oYoo rir.'rir rdru

dr 5:inmc cardiogenic shock fi tfinlrnnr:fi!n"1rto,1trustitFnsluoon{ rYnfintt; acute
putmonary edema dudra lunr{u{rhudfinr:r,roar:rirtunnao r6aoodrtqurt:.t1 nlilfinr:

lnB10{u

t.t nrtinnrrfiarfirrsduoonf nu'lurfiaa lnunrrlfiooniucu :rtJfi.'lnr:'ldviori, Evrula
(endotracheal intubation) lla;rirufilu'ledlurnBa.:rirunru"le (mechanical ventilator) tu{rJrffi
finr?:nr:iruhfi n4R1 (respiralory failure)

rdo,rlrn'lunm: cardiogenic shocr {rJrufnfinrtrd'u1nfiqn"T nr:lfiurdnsarrtJniu
Tafin tiamguruiloaqtfi00 niu morphine, nitroglycerine, nitroprusside niotrrrTlilnnrr; arc

drtfinrr; afirRqinr:lvnrlfluInfinfiqiln6ilrnduld {.rnr::;fio::irnr:tdurndud'lunr:insr

n'r r : rir vir ilrJ a cl

Cardiogenic Shock aiaf nangi 229

r.z nrrimnlf, aJ:rutrrt nmf,nimrl ariuulaiio (hemodynamic management)

illnadludnruddfia't.uJt{io nldd putmonary arrery catheter fi rJ::Iutrilun.r:

ounfitjrunrr: cardiogenic srroct< rfialfiirrnrurrn;aiur;dl,r.1 ldfiL rfion unyoonfireu arfiu.:

rtpruduyasnnl?o-\Jtu

1.el Preload adiustment ylnd rtfi pulmonary capillary wedge pressure (pCWp)
fioun'ir t s mmHg nrr'lfinr:inrrlnflnr:1finr:fr l{ynoerrfion rdarfir pcwp tfiatilutirt

18-20 mmHg

1.2.2 Increase perfusion pressure rfiolfior"ur;rn'rt1 lotutattryrirtcrro;oxra.,t'ld
irr6aolu:Jtrrrudflarfiu,r 6.'re'1rflud'orrfrrnlloi'uTnfintfi arfiu*rJqEJorduu.r'[un6ir vasopressor
tu!finn fi{u

1) Dopamine y1n l3rirl'luluror]ou (rl?sxlfu 2-5 mcg/kglmin) l:oonqn6r.jru

beta-adrenergic receptors tfil "troke volume !!ny cardiac output :rryr".rrfir renal blood flow
nhu dopamine receprors 8-10 mcg/
orir,rl:finrilyrnfi:-hrfintud'ulnfisroir nr:1{ur'luzuro

kg/min {ituro:oonqndoi'ru apnu-"drenergic receptors urndursjr.r svn ua:r,rilfi systoric brood

pressure (SBP) rfi g.:du rihymulo\: SBp n?rod :vrJ.lru 90-100 mmHg

crrr:orfir svR u2f)f;NsoBrepplinder,prhnrintuetrfui ::rdrilfriuq'ujrfona:n:{qunfb,oeit,a,u-ad"rtepnne"-rugiOc rreenceerpgtiocrsrercfietlp:rtfoinrsria6u,,r

i.rfiaranirldn:'rnr:rdura:rir'hlritrn d,,laratfifitonrgrfio arrhythmia n;rn.ir dopamine n-lrfu

nTnfio.,ilr4 dopamine 'luturcrg,r lrrnn'ir ts mcg/kg/min) 6lo:srm:nrfjr sBp ht$otfiu.ild
nr:cyr duu rrlfiar norepinephrine rdolornfi:ru{ru'ir dJrun.tryinqnfild:"uur dopamine fi
onlrduiino.0nirnrjffildiltr norepinephrine uoilrildi:.rur dopaminel' ltaan; ++.s rfiuun-l

36.9)

1,2.3 Increase cardiac output yrnnrlrrOtfrl SBp oUlrnn'ir g0 mmHg rrd'r

oreriilbiur dobutamine luuuro e-s mcg/kg/min uny:Jfu rfiltruroulyn 5-i0 ud yt:dur

rrTrneirrour:orfi cardiac output ldffiuodred uncorqrfr rnrr o*uTnfi nld q1nfia?,ornr:rfi

cardiac output riura.r atir. :fimrru dobutamine hjf,lrJr:nuijlerrrro'uTnfimld:.rrnu-n t.lilrfiu 10-
15 mmHg) uone, nd dobutamine a-,rarlnn pcwp 16',r6ndou"

1.2.4 combine therapy 1o u rotr viu nrridfi pcwp o.,rdr rnilnirrd'uTafi n n'r arq
fiqr:{ur'lfiur nitroprusside rdano preload ro.,:urun?lfindru lurru;16lrrTu dooamine ?:ri?u

rfir cardiac output rrflvinHli&ri'u sBp lilbinirfiill rlnnrriln''ulnffneiouir{d{0l?fiq'r:rul

'lti nitroprusside irrnir dobutamin" d.:l;arrrrnrdr cardiac outout lrfl:an pcwp ldfin.i1's

r.s rmlfqrlnrniriru'lunrr inmsnonrgnS.rnbre riuulflfin (mechanicat circularory

assist devicesl

qrJn:nifildrYuadrurvrinnruluicliu fio intra-aortic ba oon counterputsation,n (tABp)

230 r'mir:jainqndunrl

L"*jlor:::.,1.1." shock _ l
t_

Syslolic BP Systolic BP

70J00 mmHg |I 70100 mmHg

Ng signstsym ptotn s of sflocl | ''!T1"-{T:.:i"111

, Dobutamine I Dopamine Norepinsphrine
5- 15 mca/kg/min lV 0.5-30 mcg,/min lV
t' .l2-20 mcqiko/min lv

2uuugfrii udntuutnuntt6on'16 vasopressors ufrJ inotropes'lfitnutvrivsnttvzs,lilil'ra d@u Rn

nnnnf,11d1n6'Jfr n)

dr:J::nordrudrudrd'rg z dru 6o intra-aortic balloon r!fl;d?uLLtl{ft'l!q eirr'rilrinfinsr

Iruunridnu'trrfiufi rfl utfifiun{1?rn!onflTd1{a{fi rt'1fl m1 1

2. n.trinrrrtfi af,a'lsnltqnn-una{rdurFsalnlrur? (early reperfusion therapy}

nr:fln'run'r?qo6' lo'r aoert6oqJnl:uriadrrlrorfrfiqn rvirfrwrirld 6a uflunr::"nnrron

dfiil::fin6nrvrla,lnl?: cardiogenic shock iitfioornnrxvnfiillf,flliil?flrntfiantiuu du crn

rl11u,t'tll1o{ shock triall5 d'rrirnr:6nurril5trr tfiuu nnr:insr{ cardiogenic shock <i'rulu

302 rludxuiE early reperfusion therapy [thurufidra tsz l']u lnuiaflnc 54,6 16i!n1rd1
pTcA llny3oufl; B7.s 1d:"un1:1i'r CABG] niuiBnl:hinrrfnt' nun1:t$srtflurn"n ldruru{:Jru
150 r1s dilun6irrfld:*r-,ora:arldrrfioniaunv 63.0 'lunrunn-r{rJrunrjlftdiunr:nh ect 5or
ar 14,0 un:16iun1rvrh cABc toun; tI.s1 uru'lr{:Jrufilr{finrtinurdrsi6 early reperfusion
rherapy o;fid'n:rnr:rfisiind'rn'jrtfjonarr.irul:J o 16ou 15oun; s0.3 tfiuln"l 63.1. P=0.024
uanrrnriu{rl'rudldirL earty reperfusion therapy tisfion:rnr:r6fl6in1u::tt;umst'rn'jrdru"
fioun; a.a dafl rfisln"riauay 14.3 dofl. P=0.031

tuihlfuarrnr unrril:nr-r'loto.'roriga uinr rru;rjr'lfitdnr:fnurttltt early reperfusion
tnerapy drnir{rJrufrfi cardiogenic shock n1u'lu go ri'JruravatrfionrrvnfiTrtdan-rtearq

rfioo ldarlra"urfio ST-segment elevation n5oiofiulv,lfltn"rlofio nfiru-u left bundle branch

brock dfialqlilrnu zs fl ua:fio'rnr:lr\rjrfiu ta d'drt"

Cardiogcnic Shock aiaf naragi 231

rT nfio4atuflrlliuil!fi{lhu cardiogenic shock dtfiit,nr:r-nuluuu earty reperfusion
therapy rnunr:n:r pct usufidn:rnr::ao6inlndr6a.rn-u{dldiunr:fnurTounr:vrh cnec,' r1'lil

:rdrr 30 iuu:nra"rrfio acure t'tt liauo: ss.6 rfiwn"u s2.4. p= 0.861 uo;tudrr t flu:n [ioao;

sr.g rfitrr-rni:-r 46-g, p= 0.711 ns.:de:rrfiudio:cuvurrfilildr.rfiu ;toua; z rn'ai rfiu:lnirl fouay
9.3 rdoil. p=0.511 a-{1iun'rrficrrrurr6onl6 reperfusion i,rduriuim:ruqrruna,r uuyffi'trinr:

inr+run;nrrrlvrrvormarfi ru'luurn'oc:ru Toug'd:ruusrirlfifior:rurfr cABc 1 fi xur!1 ?lu

firjrafrfirT116on'ruto.:rfiu16ao reft main coronary artery riafir,rar6anlwatrdurfianlnT:rri
rt': s rdu unvlu:rufifia,raird'oufillnrr;fi'urirlql rinr-rr6u!1rd'u ruri,rrYurta.orrurrirfiar:o r?a
nfi'rrrunirFndruy:q rfl udu

drrfi{rhlc,rorl 1> zs ij1 fuu:i'doryfle1n shock viat,u o;kjofiauunr:inuru:.r:t early
reperfusion ttrerapy tu{{rorr rroiorn{o4nzo': NRMI flr.jrn1?dr revascularization fl1 rrfl

nna"n:rnr:rfiu6inra'o{r-hrgrarqdfif,n'ric cardiogenic shockldr?iuriue nr:sl-ofiulelfinr:inur
urifirl'lunairii6rd'a.rfie r:rur rflumu1 l:.1 rirdrtunitln'lu!firl'r:drjxo{6rn1?;lotfi:-rrurfluna'n

s. nr:fnrndu#fitleunr1fiir..
ftJru cardiogenic shock ?1n acute Mr nr:ldiuurdrurnfiolfiae (aspirin niourtun{r

theinopyridine) urnobr'ulurfion lnaranr:urlunsjr statin ua:rnd'.rornldiunr:fnurlnunr:
rufi.harrvonm'ulo.lrdurfioo1nT:uri :rrr",lvlnfironinr. mrisuTofinto.rd rund'rLrdr{aloolou
hjfiarfi',rnr:'lfiur vasopressors rrdr{rJrunr:ldiuurlunq'r beta-nocker [rR: AcEr (angiotensin-

converting enzyme inhibitors) ifl ARB (angiotensin-receptor blockers)

f,flJ

fir'r: cardiogenic shock tilufl,t?!ltr:ndoufidrn''cyrrn: tfluolfiqya'nlo.0n.r:tdEj6ifi1a,l

{rJru acute Mt rrnourrolfi nr:ifiqdusdr,1:rorituot 16onl6nr:insrdrr r;a loure?n;n1t

'lfinr:inr+rurr earry repertusion therapy e!f[1rJ']rnriru6infi:Jruli nr:trin.rrinur rfiorJilclqa
ro.r anroninr:lnoriruTnfiorro.:{riru'lfilfifl,ivlofinrr q'1lfluad1,r r nlu nr:fn ur fl:Jr tr lfiio'hi
orrr:n oi,: n"r firlr u rdrfi nr:inurln u n1:fl"1 pc I nio cnge ri altl

tonar:drr6'r
I Antman EM. sr-elevation myocardial infarctjon: management. In: zipes Dp. ed. Braunwald's heart disease.

l'A textbook of cardiovascular medicine edition. Elsevier saundeE. USA. 2OO5:1167_226.

2. Alonso DB. Scheidt S, Fost M, Ki ip T' Pathophysiology of Cardiogenic Shock Ouantitication of Myocardial

Necrosis, Clinical. Fathologic and Eleclrocardiographic Co'elations. Circulation 1923;49;588_96.

3. Goldberg RJ' Gore JM. Alpert JS, et al. Cardiogenic shock after acute myocardial inlarction: incidence and mortality

from a community-wide peEpective. 1975 to 1988. N Engl J Med 'lgg1.,g21:1117_n.

232 rrtdrr.iainqmdugru

4. Holmes DR, Berger PB, Hochman JS, et al. Cardiogenic shock in patients with acute ischemic syrldromes with and

without ST-segment elevation. Circulation 19991100:2067-73

5. The GUSTO lnvestigators. An international randomized trial comparing four thrombolytic strategies for acute myo-

cardial infarction. N Engl J Med 1993;329:673 82

6. Babaev A. Frededck PD, Pasta D.J. et al. Trends in management and outcomes of patients with acute myocardial

infarction complicated by cardiogenic shock JAMA 2005;294:448-54.

7. The CFEATE-ECLA Trial Group. Effect of glucose insulin-potassium infusion on mortality in patients with acute ST-

s€gment etevation myocardial inlarction: the CREATE-ECLA Randomized Controlled Trial. JAMA 2005293:'137-46.

8. Chen ZM. pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patienls with acute myocardial

infarction: randomized placebocontrolled trial. Lancet 2005;366:1622-32

g. Gianni lvl, Dentali F. Grandi AM, et al. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic

review. EuroDean Heart Joumal 2006i27t1523 9.

10. Zeymer U, Vogt A Zahn R, et al. Predictors of in-hospital mortality in 1333 patients with acute myocardial infarction
complicated by cardiogenic shock treat8d with primary percutaneous coronary intervention (PCl) Results of the
primary pcl registry of the Arbertsgemeinschaft Leitende Kardiologische KEnkenhausarzte (ALKlq. European Heart
Joumal 2004i25,322-8.

1'1. Menon V. Slater JN, White HD. et al. Acute myocardial infarction complicated bysystemic hypoperlusion without
hypotension: report of the SHOCK trial registry. Am J i.4ed 2000:108:374-80

'12. Kohsaka S. lvlenon V, Lange lvl, et al. High incidence of sepsis complicating cardiogenic shock follovting acute
myocardial infarction. Circulation 2001104{suppl ll)ll'483. Abstract.

'13. Kohsaka S, Menon V, Lowe AM, et al. Systemic inflammatory response syndrome after acute myocardial inlarction
complicated by cardiogenic shock Arch Intern Med 2005:165:1643-50.

14. Hochman JS. Cardiogenic shock complicating acute myocardial infarction. Expanding the paradigm. Circulation

2003:107:2998-3002.

15. Hochman JS. Sleeper LA Webb JG, et al. Early revascularizalion in acute myocardial infarction complicated by
cardiogenic shock. N Engl J [4ed 1999;341:625-34.

16. Mann HJ, Nolan PE. Update on the management of cardiogenic shock. Curr Opin Crit Care 2006;12:431-6.

'17. Sakr Y. Feinhart K, Vincent JL, et al. Does dopamine administration in shock influeflce outcome? Besults of the
Sepsis Occurence in Acutely lll Patients (SOAP) Study. Crii Care Med 2006:34:589-97.

18. Aleander RW, Pratt CM, Ryan TJ, Roberts R. ST-s€gmenFele\€tion myooardial infarction: clinical presentalion.
diagnostic evaluation and medical management. Inr Fuster V, ed. Hurst's the heart 11u edition. McGraw-Hill. USA.
2004:1277 350.

1s. Trost JC, David Hillis L lfllra Aortic Balloon Counterpulsation. Am J Cardiol 2006:9139'l-8.

20. Sanborn TA Sleeper LA Bates EH. et al. lmpact of thrombolysis. intra-aortic balloon pump counterpuisation, and
their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial
Registry. SHould we emergently revasculadze Occlud€d Coronaries for cadiogenic shocK? J Am coll Cardiol

2000:36:1123-9.

21. Chen EW_ Canto JG. Parson LS. et al. Relation Between Hospital Intra-Aortic Balloon Counterpulsation Volume and
Mortality in Acute Myocardial lnlarction Complicated by Cardiogenic Shock Circulation 2003J08:951-7.

22. Hochman JS, Sleeper LA, Webb JG, et al. Early Revascularization and Long-term Survival in Cardiogenic Shock

Complicating Acute Myocardial Inf arction. JAMA 20061295:2511 -5

Cardiogenic Shock frieri notad 233

23. Antman EM, Anbs DT, Armstrons PW et at. ACC/AHA guidelines forthe management of patients with ST-etevation
myocardial infarction. A report of the American Coll€ge of Cardiology/American Heart Assoclation Task Force on
Prac,tice Guidelines (Committee to Revise the 1999 Guidelines for the Management ol Patients With /€ute Myocar-
dial Infarction). Circulation 2004; 1 10:82-292.

24. White HD, Assmann SF, Sanborn TA, et al. Comparison of percutaneous coronary interv€ntion and coronary artery
bypass gratting after acute myocardial infarction complicated by cardiogenic shock. Results from the should we
em€rgently revasculadze occluded corcnaries for cardiogenic shock (SHOCK) trial. Circulation 20051'121992-2001.

25- Dzavik v, sleeper LA, Picard MH, et al, outcome of patienb aged >75 years in the shoutd we emergenfly

revascularize Occluded Coronaries in cardiogenic shocK (SHOCK) trial: Do eldedy patients with acute myocardial

intarclion complicated by cardiogenic shock re€pond differently to emergert revascularization? Am Heart J

2005;149:1 1 28-34.

234

15

EKG: Cardiac Arrhythmias

6lXnu nafaa

{ilr udlfi ir nrrinur'lu1o6 g (l nten sive care un it, t cu l riu airuvri'r rfl u{4mr q ri o {rJru
dfinrufiorlnfiro.ll:nu''r'loo{ rfir drrfi':.rnr:r!dturr:Jartot:v:.t:.t'lvntiuulnfin rialfinrrrudl.r
fieylflernrl;nr:lirtruto,rrirhftnr]n6t*utntaglulodgldluflclfunr:n:rcfioer nr:t duur a.l
ro.rndulvifltirlqlu1adr riiunr:n:re6onrrrrm:g'tuodr'tnfitta,tnt:inur{rh unrr:inqm

n-rriuuurd{rJ4r*fi.nulula6s6.rfinrudrrfludovdattfinr:irioari rrncdofiutctfrnr:inurrfrauu

aru fi n:Jn6roradublM rri'r'iolfr odr.rqnda'r
lvrnrr dqvn6j'r'rfi'rnrr finrlnfirla.snAulr''lfirrirlrdrl'lfiriailu1adg :rln'tortuqlra:i6

nr:binr:guainurlunt:qnrdu1nud.,: tr! louqrzo rrrjodnuru:ntufinrJnfito'r Ecc rflu e

:J:;rnvrlrd1 rfioa;Frrn'hnr:drnlrrdrlo n-.rd

i. nrr n fi nln6n o'te'.Jvr c [[n rdntrnr: rdlgo'rri-r'h lfi trri

nrr:rir'lq rdurSrfi nrrJnG (tacnycardia) ldrrri

- Sinus lachycardia
- Atrial tachycardia
- Supraventricular tachycardia (AVNRT. AVRT)
- Atrial tlutter. atrial fibrillation
- Ventricular tachycardia, ventricular fibrillalion

nrr;rirltrfiudrfi erJn6 (bradycardia) ldrrri

- Sinus bradycardia

- 1o deqree AV block

EKG: Cardiac AlThl'thmias aiafi nawgj 235

- 2'o degree AV block
- 3d degree AV block

2. n?1rJfi0:JnAflsondulyfiltirtodt uootnrtyndrr rdarirlurretra'oo (myocardiat ische-

mia or infarction)

3. 6?1 fto n6ra rdtn nianmcdu1 irtlr:idriaululafip

errufiqlnfrroon6ulv'lfltl'rlomu{o 2. un;do 3. tfifinglelnrunrrr rio,r EKG, non

cardiac arrhythmia

a?rrtfi nrjnAga{,ifu nrvuacan:rnr:dugo.rfl rlc

nnlnnr:rfionrufin n6to$',,ry.r:uo:do:rn.r:rduraorir"le (cardiac arrhythmiasl rY.rtfin

3rdu6rua;rdudrfto nfi aur:nrfinmnnnlnrn-n ::nr:', d'tua

1. nr:rfiotarufio nn'lo,rc-.,ifir; unyo'o:rnr:rfiulorfitecrn[rr6i,:rir rfioF]6u1ffirr.i'rtl
d'rl1uf6 r,rs,rmno{trnu,r n6 uo;sl'rrryil.tfifioiln6 (normat and abnormat imputse

generation)

2. rfiocrnnrufta nfisa.inr:frn:vrrollflrturirle (abnormat impulse conductionl

ni3. rfioernnru finrlnfivrs,,rAagfiodr (combination of impulse generation and

conduction simultaneous abnormalilies)

lmpulse initiation

6anr:rfionrrn::fiulrrrly,ifirtumndySoneirrrnri'firirrrutarirlruudrturirla a1flo'r.rl

r:Jduu ula,rro,:dnfh^lfir:;n'ir.r fir rrfld (depotarization of the ce membrane) LLfiluri

n:voruaanllsiuiardorirrrufiT .:rdtrolqunr:uJduurr nsorerurirrdnrih,lflroi.rndmrfiaornfinr:
tn6iouto',: ion current airurda{lrrnd (celt membrane)

o:rrfinr:rfio arrhythmia 1'lnnRln imputse initiation fi'fl.l 1?flurj,:ldrfu 2 nnuru: fio
n1'lY automaticity ttn; triggered activity

Automaticity

efruiunolndti,rolrr:nuritldrfiu normal automaticity ttflJ abnormal automaricity

1. Normal automaticity
'lduri nr:rfionr:n:;{uvn.,rl'lflrraorradndurdorir'lcTouo-nTun$iiudurdorijorirb

fifiqruollsfirnrdriun'ir pacemaker cefisldrrri rdsreiolurinru node rlflr tatent pacemaker
"tnus
areas cittl r:iu nsjr.r lradrrrdrutulorFlisr noirrrnd'lu atrioventricular (AV) node uasn6j

ttnri'lu His-Purkinje sysrem

236 r'nrthrioinqndug'ru

nt:d pacemaker cells fl'ltJllntfig spontaneous action potential ldrfu rdo.rl'rnrtnd
q'.:neirrfinrrtlrlfiuutL a\:1a.lnx'ltJrir.rdnfitotrdo{lrtnd (cell membrane) 1u::tl: diastole
ldrot rigniT diastolic depolarization lnufid':crntfio action potential gd? pacemaker cell ot
rtr{nrrv depotarization ?un't1 n'1{n'ntita.:rdarlr.rrtndieir rnfisn ::tJrru -60 fi{ -zo fiofiLnd
nd,lnmfuovfinr:rndoudaal Na llnnlu aneiutdoqxrtndrdrqinru'turtaddr'Ififin net inward
current du tdanrulurrads:aurl:;1urn rfildurir'lfinrrr.rrdrrdndlalanir rtndnoo,loutirlnfi

ta'rrrrrjr threshold porential (TP) c; tfinnrrrndoufilo.: Ca'. rdr{rtadTouij'lu L-type calcium
channels rirltitfio spontaneous action potential duludqn

lqulix'hlnelilfi?Jalnt:tfio sponianeous action potential tl0.i sinus node pacemaker

cetts r: rflud'rdrruoo''flir1n1:tfitrtJolil"r1q doecrfrviodrduo{n"lflodann"n 3 ilrcfllr (gild 1)
-t

tl.t1.l

1. Maximum diastolic potentiar dolaurt'rtJfirirl:;tr.lfll -60 fin6hn6' fi1nfidln11$J
dft dnSlilfu 1ldil1*u cvdrtfi o'er:rnr:rfi o action potential dln,l

Threshold poteniial fi"rnfiti'rfl,J evlno action potential ld$1an

J. Slope ol phase 4 depolarization tl'Ifl slope flllflofl.t1o.l membrane potential ii
n r1r"i'u n;iildu rvtfin action potentiat lfirirdu

tgtli tttowtt*nJduuutJa,,#nilv'lfltida(umaitw6a spontaneous action potential aflJ pace-

maker cell 6tutj,t&u 4 1zuvn1vntJ1a6l #'tnnzvriv membrane potential 1ud'l,t phase 4 of

depolarization frnttix{uatil,tsiatda,tctn tvutn -ao fiadI'tad lnaximum diastolic poten-

tiatl ounfiri,tfrri1|J,lnnil threshold potential (TP)

nt{dnr:uldsuuijo.,rsofi vuurj:vdtvta'nlui6 (auronomic nervous sysrem) rh1fi lf, 0nr:

njduuurlnratjr.r'lnadr{nut,rdarlcdsf.r 3 uncdl'lfio-q:rnrlduto$i'r'lculduurr n.:l lnfln'r:
n:i{ur0,l::!u :;dtvrtntr6rnr tn6n (parasympathetic stimulationl rirlfirfionr:n6t',olo,l

acetytchotine draalti maximum diastolic potential firirr.nndu (rfluar.rilrndu)Inueirunr:n:l{u
muscarinic receptors u0nl1ndti.tfilfin'l1lJt'ulo\: diastolic depolarization flnnn d.rnrn'lfio'srfl

nrlduro,ofrhann.: tu r{fi:{dl nrrn:;{urv:.ttL!:;fi1Y1fi 'ttrfin (sympathetic stimulation)

rirlfifinr:n4".:no,r norepinephrine frilnru:J:ccrra"or1uffi{i'rl:n::{u B, receptor drlrtnrrldu

EKG: Cardiac Arrhydlmias ainfi na,sa1! 237

'uo{ diastotic deporarizarion rfilniu dranlfidrnlnl:rduro{v-xte 6rdu rfi.odnr:da-n:1n1rrdu
lorrirlotunrr:rJnfignrirnuolnu sinus node riu rfiorlrnnejlmnd"luuirrruo-,rndncrmrnrfin
spontaneous action potentiat ldlSrn.j.rndurnd'lulirrn-rdu1 lo,llorniar AV-node trR: His-
Purkinje system qr:Jnl!i"! 6unttndfiarrr:nLfio spontaneous action potential 'lusir ttvur6ur

'jt latent (subsidiary) pacemakers

2. Abnormal automaticity

rfiqcrnfinr1 r duurr:-ln,ln'ftor.ln6to\t cel membrane potentiat drrl'ldlunrr:fi'

rirlefinrufin:Jnfi niu nr:finrr: myocardiat ischemia nio'tdfiturlrrrfin ntrlrfinnr:n::{u
tatndurdori'rloloua'n1ur.r'fi d',rnrrlw'orJn6o-rnnirraronufi pacemaker area liondurdadru
oAu.i l|a.lv2nt?na\too

drrfillzodndrurdorirlefi.ililiiy,r:iursroiur uny nunir6oqs'hiarrJr:nriolfirfio spon-
taneous action potentiat1d uri'jrqylilldiilnrrn:;fiuTntn:yruolv,lflrdai.,:rjru lcrn pacemaker

cetts rflurrnrurufinril usirfiotoiifinrun'o:Jnfilfiodu crdr'hi::d'!nl rdr,:d'ndgorfttmndnn

n,r (finx1rJ rflun!rioua,:y o:fiTanrornfi diastolic depotarization -ldun;rirtfirfiafi abnormal
automaticity (ttntfin spontaneous action potential nru:fi resting membrane potenlial oUlu

::d'u nn'saortndrfioriul lvr?un'jrrflu normal automaiicity usifirfinrrrJrfuaurjaunir::d'1
ilnn'riourfi n spontaneous action potenlial l: ioirfi abnormal automaticity)

cr nnr:6lnurfi druuryu'ir fi nr:rofr ous o,,rloo ou!,irufi r maduorun:::.r,unr:drdsr{oo

drnr:lfin abnormal automaticity rtju nr:n::fiullnvnr:u-rrf,Jra,:n:;rLo K ajruftrttad Ca"-
dependent activation r0{ inward current ,Rs pacemaker cunent rflufiu atit.:1:finru'lu

ihliuti,ilrjnr*n:no6!rfl nalnnr:rfi n abnormal automaticity'ldodr,rorl:ni

Triggered activity
fi onr:tfi nnr:n::{u}^lflrsrtrvdrcrnrfi o action potentiat'ludrr after depolarization

Tnulurjr,,rrrorn'rnoi'nfinr:rRdouror ion o'rc1 oiruoni,:rrndnijo'hinrrrqir.rslnridfi.r mn{nri'r rdr

{nt;arqndnnir rrnturjrrr':ara-rnairrfinr:rfjlsiuga{nmild.xqndiiftrmn6ourfiu threshotd

fiq:or r:nrfio action porentiat du'ld tlrlnr:d',,rndrrorrr:n urJ.,rldrflu z tio stlJdrorlorfi

rnet action potentiat 6o (::Jfi z)

1. Early after depolarization (EADS)
2. Delay after depolarization (DADS)

Early after depolarization (EADS)
fianr:rfio action potential 6nnifiu::u:duta.rnr:fin repolarization n1ufin-{ action

potential n*lriou nr:rfio EADS dorqrfinludr,i plateau ran repolarization fiio'lu ohase 3 ro{

238 r:trirriotnqnfiugru

Threshold
potential

-60mv Resting
memDrane
potential

zpld uaat pnase oit,t1 zot action potentia dw ,ttfiu 4 phases unfiantznzz{u'lfitfia action

potentiaf nni,s\udtt phase 3 afln repolarization 681fiu EADS ntnfrnnntz{ufi phase 4 Gan

DADS

repotarization pnase fild drulnrln"nrfio enDS dn{lrtndla{ F'urkinje libers rrnn'jrl?trru6u

tt1o,rn6'rurdor'rle lnao-n:rnr:tfio triggered rhythm dun-l:rn-lta.I membrane potential s

drfis EAos lounrn enos rfinlutir.: plateau phase fla\t repolarization o;fidn:rtSrlrnn'jr
triggered action potential drfin'iutu phase 3 ttei EADS lu plateau phase dlvfi stow upstroke
rrn;frIonrodcvfi,: threshold fiarn'jrnr:tfin rnos lu pnase 3 fito:fi upstroke ufrttncor r:n
n::{umad'da{n'o1illdirun'jr vrttdnruunnoirwo.r action potental 6-{n6i'r?rfioorntuirru;fifi

E"cDS til plateau phase BrCu inward L-type Ca'?-current lutrurn" enos 'lutir'ofiutro.r phase 3

ot repolarization tYu ordu inward Na+ current ttnc L-type Ca!*cunent iori't'tfi action poteniial
fi upstroke r5rrrnvfi trign amplitude eudlllltoro'ttuv threshold.ld

f,'lrll4flE{ elOS fio.rd
n'r:fidnfln1:lduro.rrie'hdr rirtrttir,: repolarizatjon urdu finrrilrdfl.,iiie:tfio triggered

action potential gfio eeOS mndu lbradycardia-induce tachycardia)

- nr:fi::6'r.flvr uvrsrfiuil'luor:fr:cvir,ltro6onnt rvrirlfin'r:rirmuton Na*-Kt Dumo

snon d1tfi outward cunent lftfidrudr6'41un1? repolarizaton Roon f{fid?'l repolarization

umuruo*u rvltilonrarfi o eaos

- nmlfierrjn6trttiuon::urtodr.r d.:niadanr:fr.:'ru1o,J ion channel loutorrv K

channet (tK) d,,rd,,rna'1fi outward current rfiodulddrar uSonr:tfrlnr:d'r,t1ueo,,t Na channet fi,,:

dorun'lfifi inwarc current tfirtlru {i.rrY.:oatn'rrvd.:toS ririr.t repolarization urrurudu d,,tr:tfiu

ldqrn surface ecc frnmcfirTiin'h prolonged QT interval fi:Jruiifinm:d',:ndrrdfinrutdutd
csrfiufiinncviuli'us'Ifl ventricular anhythmia tJlnn'j'ta n6

EKG: Cardiac Arhlrhmias qin{ now;.i 239

Delay after depolarization (DADS)

6ont:rfinn'l,ut:Jn'flutr!n.,r?o,: membrane potential qlnnlTtfir.rdurou car. tulgadtio

ntul sarcoprasmic reticurum 6.Jayrfifiur rlfirfianr:rnfiousr-rro,:n::rro1 fl'rrdr6irtaii (transrent

inward current) nruud.rnr:duoovia rflam:duqnla{R'lrv repotarization (udsornlfin action

potential rdx) mnnr:r:Jduuu mnrrlldr.:dndri',lnrirrlrncurfiu:;o threshotd fioyorm:nn:ydu

}itfio action potentiat duld udnrnlriilrnilsfic;lricrrr:nrrfiuru.rlfirfionr:n:;{uro.rsndld

lorurtrlilnrr:frvrhlfi cardiac cycte tength dua.: lnioo'n:.rn.r:rfiutocr''llq rirdu; Toulorr;nr:

n:yduro,:::ul ryf,rt6|JIlrrufin c;vthtfinr:n:sfiulfiu::q'l threshold rrflsrfiq adion potential

.[djrfldu
fiioore rfierernnr:fi short RR intervat Q1n action porentiat d'rriaurnjr fiarllr:nni'fiirfin

triggered action potentiat tfiq onoS ldjrudurtiuniu

er nrqdn'r'lfi fi n Dlos fi n"rd

- Digitatis toxicity fiiJxw"lfi5uul cardiac gtycoside arcfi Na- o;o nrulurrad'niudu

rY'rdrfiotrrnurn-tnsirrrirri': t't*-x pump fift':rrnd rfia::n-r intracerutar Na. q.,rii*u rtndo:ri:.1

Na. oonlofl unnr:Jfiuuf! ca'. rir"h4:ca"il intraceflurar ca'. rfirldu nalnnr:n;iu ca" nruturrad
dsitrciilfi cardiac conrractiriry 6du uoiturru;16urfiufi6ir rn?iltfirfio onos srrrJnnlnn-''1n6jrr

dr..:du

- firi, ufifinrrn:vduro.,r:;ulr ::flryrdnludGfitrrrrtnhn uialdi,uururwfior fquronr:

u'flunritr catecholamines e;duai rifinr:r$il ca'- lurtodloloirunr,,:nr:n::{utor p+eceptors

lltJ1rafln

- rjr!'t,Jrfiodft'1fi action potentiat duration urrurudu rtlu quinidine lirlfifinrra;ol

flo\, intracellular Ca'- utn:d,rp,intfirfio DADS \ilutru

airyfinrrrfiq nfirLarnr:drn:: uo}iflr (abnormat impulse conductionl firfluarnrqtol

cardiac anhythmia riorrie tachycardia !!n3 bradycardia rfurzldnrirrfiiludrufirfrurdornir

urfici:i ureo,,tn'n!fig arrhythmia n.rdardoloiall

Tachycardias'u

rdorlflrJrufinduh!fltr''rlefioiln6rfinr''r1ordu6.: (rnnn.j1 i00 nitriourfi) fi-rfiarr'lrtr
nrunirnqrflufirou6onllfin arrhythmia fufiflnn::yrusio::u!1 a liiuu1nfistfiSolrj yrnul'jr
nt:tfin tachycardia doHo}i::d'lnrrun"uTninoirmua:findngru.ir cardiac output lrirfiuu'ra
uian'nrr;rirhrra rhndu nr:'hinr:fnllRl?! tachycardia uruodr,ud.rcitu drniu anhythmia fi
lrid'rorn 6udo::uulranrisulnfin or:ldf!nr':n:rqndu'lv{flrfi'':1e 12 reads udrrirnr:ricr:ru.l
g drtnnuru; un:dot'lrnr:rdurra{fir'leodr{n; 16un rdo,lqrnorcfid.]uriru'lunr:ifiearj unyifinr:

fnurFa ururrJuunifild'ir rachvcardia riufio-or:rnr:rfiuorirreranialri ufly eRS comprex
ntrtn'jtln6y?o'lri (eRS comptex #nir,:nir 1 20 msec 6a.jrnir.lfio:Jn61

240 rrnirrioinqndugru
filnrlrj'jl QRS complex ttfi! (narrow QRS complex tachycardia) nl1llixhtfiulE?

rfurirl:aqj'lunrjlfrtiun'jr supraventricular tachycardia {i',rurnfio\rr:n15lfiurlo',tli1'todri'lrflx0
(regular nanow QRS complex tachycardia) n?riinfinnlx:d',1dolJd lauri sinus tachycardia,

atrlal tachycardia atrjoventricular nodal reentrant iachycardia (AVNRT). atrioventricular reentrant

tachycardia !!n: atrial flutter with 2 to 1 conduction vrnxl'jridur:nr:rdulriarirto o (inegular

narrow eFS complex tachycardia) o1qlflu atrial fibrillation (AF) fi€a multifocal alrial tachycardia

(MAl fi ld 6.,rfi :rB ac r6unn-{d
Narrow QRS complex

fl'rrJ'rrfrrLunli?1: rrflu z n{illqi1 6o regular rate narrow QRS complex tachycardia

(tild 3) tta; irregular rate narrow QRS complex tachycardia Jnufi:ruavr6aorn-.rd

7ld s uaot tachycardia xfrnoi 1 nfiuutfiuuattufuttuito't QRs comptex !,flt P wave un1fr 1

ufiat{ntruz shott P?'.tong RP (sinus tachycardia or atriat tachycardia). uatfi 2 utw long
P+-short RP f,f, np-intervat iunh ao fisiiutfi atzNRT > evan. uati 3 ufian tong PR-

short RP ifl ap-interva a11ni1 80 fiadiutfi 6vnT > AvNRn uazuoti 4 rf,nt regutar

narrow QFS comphx fteiwu P wave

EKGI Cardiac Arhvthmias a{afi naoaei 241

Regular narrow QRS complex tachycardia

1. Sinus tachycardia

riunrryfio'n:rnr:rfiuro.rri?lqr5rn.ir too ni.:rn'ourfi lnari'rLlinlillSrn.ir zoo n*.1

piaurfi rfintaurds.leln SA node gnn::{ulfioir.r etectricat impulse (p wavel l5rrlu fl-nuru;la.t
t.Ecc ?cvrrJ p wave fififlrfluurn qn"rfrt1 'tu teads
unr AVF d.:rj,ruon.lrfi1on"r rfifi?.ln SA

node uacfi P wave rjrurriou eRS comprex 4nra"'dnrfi pR interval rvirn'u luo:lririounir ao
fin6iurfr a'n:rnr:rfiurto-r#rteore 6rn*uiliodro, dnrunr:n:yfiulo.::rrr:J::orrdnlur-n'

n'r't: sinus tachycardia drflud,,ryrvnr:rdularrirldnuldriaadqo'lu{rhun'niril

nr:inurlu"lo6g 6orflunr:nauouo.,natirtnrun'odn.rr:nrrlfio nn'dr.r1 niu nrrflldo.: nr:6orda

fi :u u:.: ntuo'utnfi nn"r ntyfi oncrn atnqc'ro1 nr:dr.,rru ru'n n fi s o.::v:.ruoi alliri o rdu

thyrotoxicosis un;nr:ldurlr.,rtfin rdu dopamine, amphetamine, antahistamine LLn: atroDine
n1t1fllj1: 2lfvin1ttne]J']fl1lltnytau4lUd'w]ntygtqi.l ?Ls]a1[rlq sinus tachycardi-a tLnCyrJfiUlafrAle

vr"'r'hia'sr:r nr: rdul o,rrir"le r5rdu lrin'lilfiur'lun{r p-blocker, catcium-channet blocker n6a

amiodarone rfir.:rdafio,:nr:nod'n:rnr:rfiuroo#r'lc'lunrrsd rfla,rernoredltfifilJ.:rfinlr:n'u

tflfioml L0

2. Atrial tachycardia

lfl supraventricutar rachycardia frfi0'n:rnr:rfiuto.,rrtr'loag'lurir.,t tso 6o zso ni,,r

eiaurfi tour'iJo'rtrrnr:rfia p wave r5rn'jr sinus tachycardia udlrjrfrrri.r atriat flutter o1efl

fi nv otoct<'irrdrflld fibirfifiau oRs fid'nmrsrLian'rrota yrnnirior:nnr iuuufiu:Jfi! ecc

arlllirriourfin tachycardia p wave rlo.t atrial tachycardia figrJdr.,rhjrnfiol p wave a1n SA

nooe Id

orrlfio:JnGrfiodrfiaornnr:d3ro el€ctricat imputse orn rdordo'luro lniurJlirrruiu

uan SA node nll:darrr:nyr drorunylrifiaiunrturiofi ru Tntrralrr;nnfio-n:rr5rhi rn usi

fi'rnr'fiJ atrial tachycardia dT rJrTx AV block 'lfi:vr"urr; digitatis intoxication 6lar:nruJ:;i6
uriidrl':ufirJ:ynruuoyndn rdu.:nr:ld oigitatis 1u{ilrunr;a-rnrilr

nr:inn1: nr:lfi p-bbcrer amjrunodn:rnr:rdura.,rri'rto1fi nrnlrioroloua,,rriaur

tunvg.tfluirq;rfluarrnq'hirfin iachycardia induced cardiomyopatny rfluda:-i,rdifirirnr:fnur

drui6 radiof requency ablation

3. Atrial llutter

l nvir tachycard ai d fi ri'nsru: narrow eRS comp lex ufl ;fi 1-rturt n t.:tdu al'i rcla

:tloufish:rr5'ua,l QRS comptex 1ru 140-150 eri{siourfi (2:1) nio too niln'ourfi (g,t)'ifi

urarrtd.ttnn'hfin'nuaur saw toorh p wave niaLilooranr:odrl6.t'lu tead r.t?cdrcttflnd.]{
a1n atrial tachycardia fifidq:rnr:rfin p wave ilrJ.tru tso-zso ni,'lriaurfi rfioicrnlu atriat
ttutter t:'lrilruirn' isoetectric line losrfiu basetine fla{ ECG t;fionrnr;rfrufiurdou t;:1fi +t lu

242 r':rdrrlotnqndugrl

rruyd atriat tachycardia dfi,r ufiorfid'nlr5rldfi,: zso n$.:riaurfi evthcrrl:ntfiu isoelectric
rine ld

nm:dtfiocrnnr:fi re-entry loop nrulu rlgnt atrium lhlfitfin flutler P wave filfid'n:r
rirrioudrtn,,:d :J:vrrlru 300 (250-350) niroiourfi dtlouviililo;crxr:nnr:{ulfitfio oRS complex
Ifi'luh'nurur 2:1 i0 3:1 block tda':crnqruol:ifi delay electrical conduction fl0{ AV node vlx
atrial llufierld ou'lu{rhudfinrr;ndlrrdav-r'lqtrgr16oo, n1?Y congestive heart failure, cardio-

myopathy. pulmonary embolism ttav myocarditis tfludu

nrrinul: nfirlnfi,rrYr atrial {ilrillation tt'rcv'ldn6irrdolil fia'nfier:rurlnuvJr1:J6o rrn

{r-hufinm;nnnrnninrilfinrluur6oolrintdvrn arrhytnmia tfiod nr:lfinrrinurdeu synchronized
cardioversion drmuro so-tso.t udrrn{il?ufi nqrosrSnr:lvariuut6ootfifl.lvto fltttt:nfier:rut
lfiurrdoaoo'm:rnr:rdura':r.t'rle16 orqrdant# B-blocker, calcium channel blockers [diltiazem
uia verapamil) ttoJ digitalis

-*"+---1-L-+--"-1t=^r.* e

I ll '-

--,-,*t

ll-;u-*,,-----.t-*L-^1.-u- *-'*,*t-rj*1*i ". I" i. -

'liit'r'

.--{*'r--+,-**1ar*1,-*.^!*r.r*-;,*--.r*,*i*-f*r r*1--r*

gli I nmuuuanondul f,trtelqsa,t{ ta atriat fluner ratfin tachycardialnafr{nnnu\l fltcitu

AV node titiu 2 :1, n1n6hn nuni,tldiunnantzit'nuga't AV node (adenosine 12 mg iv

push) wud6fln11i1lvtfl1ii'tu AV node lfrrtauat zJtzxta s :1-4 :1) i';lli6uanw vflan atriai
nutter taiu

EKG: Cardiac Arh)'thmias diati ns1agi 243
4. Paroxysmal supraventricular tachycardia (pSWl

rfludo 6unTnil:rrJfla{R1?: narrow eRS comptex, regular rate tachycardia vr.lfint.n

re-entry loop d{il:cnaudrurdorf,orirludrular atrium. ventricre r!o! AV node nr:orrflo

3arrhythmia dnfldr:fi a.rfi otf,rh:no:L ?3n.t: 6io

t. firrlr6un::uc'lv{flrrir'hrrnnir 1 rduyrr$ic'rr:nrirnruoldflrldri.,r antesrade

LLn: retrograde

z. rr',r lfiuldfltfueydo,rfin0rorl-fim'rorYuluuinrul5rrarnr:r6uyn,lro,rn:;*o1l,lflr
(rate of conductionl un:rtu; rrnr'[un.r:fiun-rydrrirnr: uoldfi.rrrd.r {refractorv

oeriod)

3. nr:fi premature beat ?slfl n"?nz:{u1firfio psw r*u
Atrioventricular nodal reentrant tachycardia (AVNRT)

rfi oor n nr:ii nv noce fi nlo rdofi rfl uvrrnjr nr r uoldfl rdfi q ruauifi oirr niu 6o
1. Stow pathway 6,lrirnrvuallJfl roirua,:u'rlddr (stow conductionl udidrrnrtunr:

frud'rfu 1st'o.t refractory peroid)
2. Fast pathway {iflirn:yuc}iflr1drir 6ast conduction) udfi retractory period fl1.)

JL=lJj'^

fllfi a.t usa,t dow pathway ual fast pathway fj,tfiunalnluntfin evnar

244 rrtrirfainqnfrugru

'lunt:rln6riion:yrr6il1'hnrilueln atrium tirei AV node udr rvtfiumrtirurYl z rdu
flr.:o-.,Jn6i.tr uririo{ern fast pathway fl't r5ndrnlJ ttfllilfl1'[dLSlniritOrrr:nn:v{u His Purkinje

fiber ldd0u n::{u'lfirfio QRS complex tundrltdoto't nuqi16n tulnlyrdurrTufrdouvrrtdul]

n'r:J dow pathway (retrograde conduction) {ilc:}Jluril anlegrade conduction fia'lmnu

slow pathway lnu'lulirrnrn''tneirrli'ro{turirt refractory period o'.,thjnur:nd1nr;ttfiIilfl1

nfuriu'bld tttiv'lntfin premature electrical activity qlnlolniul ludrtfi fast pathway tito{
'lutirr refractory period n:v[f,}{fl1i,tfl,J 1rl'ltl slow pathway tdon'o nrurr'lc:fia nd'udunlx

fast pathway d,lduqo':;w refractory period l!fix ttn;1:fi1tJ1lnnl;{u stow patnway 16dn
nitnd.':rfin un:tdo'tern re-entry circuit o{nrltu nv nooe n''t#u reirograde P wave o'.:oqi
lnfiri'u ons comptex (EirultniJrirfiu 8o msec)

Atrioventricular reentrant tachycardia (AVRT)

nrr:dords AV node tLar accessory pathway frtdal:;fi'jl.l alrium ttnt ventricle fl'l

rirtruta.r Av-ring:JnG impulse orntotstiu evtilu AV node fl.ll]lo'l:l His-Purkinje system tfio

QRS complex lulfu;d elecrrical impulse 1l'\td?ufl'ltJtnd'ln:: lldijl accessory pathway'ld
drorrr:nn:;{unfirt.lrdorruni16nritrru:al1 accessory pathway ld tflern"nuruvdGun delta

*uu" dr rfrorfio psw n:lufl1d'ihevi,,tfl\rn1 AV node n:v{utruotirfin rrn:fisunnillsullo-.1
ralsriu Tquiilu accessory pathway rioufil;n::{u nv node rrflv His-Purkinie system dnnfi

x,,rern'.0n6i1?d{1t P wave fifiarrtorunnil P wave lnfi 1olfifinr{luautu lead ll.lll LLn; aVF nitr
rdurfirfrurttr AVNRT adlnlrfinurdotlrnlu AVRT riu retrograde P wave tfinltnnr:n::fiu
rorn;u loflnrcrrd1liflriinjru accessory pathway d,:oqjuan nv nooe o-':tfi p wave i.:tfiel?*udr

fri't P wave tu nvruRf lounrr}J P wave 9;tJ'1u1 fid,l QRS complex (R-P interval > 80 msec)

loufr}Jvru AVNRT oun'i1 AVRT lau r:rlruiasn: oo lto.l Psw rfioorn nvruRt tu

rru:fi nvRt rfluo'r mqr..J:lltrruSaan: 30 1to{ PSvt arirol:finru arrhythmia fr,raoltf,ofnrfin

mlndtnr:fi oremature atrial contraction fi{e;rr'l:J'ld afl'lunre:fifinr:tfinnrrrn"ulutatsriul

niu tu{rJradfinrrt congestive heart failure, acute myocardial infarction uia nr:dntalta't

nF- 1 ruAol-t.l1L? a t!uof' ilJt''l'l[1 LLlU9lU
1450

rminrr: rijormnnalnnr:rfin reentry r,olrYo nvruRr uat AVBT liudo{orda AV node

rj',niunr:tfiurrionr:n::{u::r.rr.r:J:;n'rila'sflufihiifiHnnnnt:vth,trura.'t AV node 6.:finntunr:
fiqg reentrant circufi vY.': u:-t:-t AVNRT tln; AVBT

TourtrlJvrn{rJrufiraeraninrdtariuu16ooaqjturnrud'rJn6 o:tillnunr:rttrurrtfir
parasympathetic siimulation nju nr:ft Valsalva maneuver Yionlldl carolid sinus massage
rnrnlrjldruafier:rurttittt adenosine dficfiqnftll8.'tnr:rir.lruto.t AV node lurir.ttrorful lou

EKG: Cardiac Arrhlrhmias qia{ naoagi 245

}iurrurn o finfinfi.r dootirmrqrSrlln noo!60nrhnu161fid uflyDnild?urjrrnfia6nodr,,r:ror5r

dnrjr:rrru to fiofifrn: vrnti.rlrildnrnour:nrfr rurnurrflu 12 n'n6nirJ lfi uonorndriucur:n
rfionldr,tunq'r beta-blocker vio catcium channet btocker lduri verapamit nio oiltiazem Id

ltjuriuusi ldororn:yEJ: lror'lunr:aonqrdrarurarrurunjr adenosine

nhniufir-hadn'lrr.rri'ulofinoiurn vioflnflraqinrrliloriuu16ooLirfiu.,rna nr:riorrrur
lfinr:fnrgrlounrrh electrical cardioversion drand.roru ::rJ1ru 100-.1s0 J lounrr"lfiur sedative

drugs rrnJu't analgesic drugs rtriftJruriouti.l cardioversion

o: lfiuldirfl:Jrudfio'n:rn.:rdula,ofi'.11q rfrsfio regutar rate. narrow eFS comptex
tachycardia fur'i6nrrinur ttnvnrrsrotif,ua{danrt:-nsrunnsirrniu d,lfiiun-rjtriounyflrrnswo,:
arr1lfiorlnfiriu nr:nurur 'lfinr:ifiqdurunsfozo.r tachycardia louordundulvJflrrirlcn6uirfio

tachycardia louroln:n1:8"nuru: p wave unJ pR-interval tar:Orlr:nrirulunr:ificduld 1fl
fi e1 Tnafinnnnr:o",ld

1. 11u'tu'ttJtJo\r111 P wave rra;fiq1lrul pR-interval lost'dtOrlr:nfr tnn rfiu p wave

'ld1u teao rr, u, avF unz v1 lnnltrir pR-intervar #un'ir Rp-intervat r.riofi p wave ritrri'r
QRS complex (short PR-long nR1 arirouunr:ificdunT: sinus tachycardia ria atrial

tachycardia lrnn'itnttv paroxysmal supraventricular tachycardia ?1n AVNRT nia nvnr d,r

rinfi abnormar P wave n.|rJrn",,r eBS comprex u3ofi pR-intervd umn'j't Rp-intervd (long pR-

short RP)

z. rirrfinq'l short pR-tong np d.lulrnlflu sinus tachycardia atiri'l:frsrr nrrfiertrur
6lnpru;ro.r P wave 'irunnsireain sinus p wave riohj vrnrrnlltt:Jduuu o,nat: drtttn:
fifirr':aor P wave l:icrn sinus p wave orilcqunr:irilda atriar tachycardia rYrdnr:fiqr:rur

a"n:rnr:rduzarrir'lqun;dr,taralooff eu :rrnslih{udu1 iidrrcir.rtfirfin tachycardia i?rrd?u

S. nq'r.r tong PR-short pR fiarinnu abnormal p wavefnstoutv retrograde p wave stltJ

rn'r QRs comptex fi'tnfl!'j,t Rp-intervat #un.ir eo fiafiiurfi arilcuunr:ifiodg AVNRT d1fii!

fii Rp-intervat trtn'jr B0 finfiiurfi tachycardia riuure;rfioern nvRt

+. urn'lrjrr.l p wave t3afi e wave lt:no{lu eRS comptex rfindnuruvfiritn.j.t pseudo
S wave ria pseudo R wave eiruludfinrfioorn paroxysmat tachycardia tfin nvruRr

s. rilnfifiilrufiiio'n:rr5rsa,,i eRS comptex :rrrru tso niooioiurii nr:f.nnno'nrnry

tarndu'hiflrn"r'lq'irfi isoerectric tine niohi ?r1n1rli1il'n'nuauvrflu:arrrinndrut{ur60u (saw

tooth appearance) ar:iinfionrr: atrial flutter nr:triurdfiqvrd'nont,:yirerulo,r AV node 1ilu
'lfirfiun"nuuvro.r aviar frutter .ldd'aroudu 1pd
+1 uoilrjnur:nruous\: arrhythmia rfiorfld i,r

n'lr'ltdrunr'r :yrio::i.r'lu.:rufio.,rdurfiariru'lunr:ifi du rdrfu