Der Internist
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The preclinical diagnosis of shock is still based on the patient's history, the physical examination, the injury pattern and a few hemodynamic parameters available in the emergency set-up. The clinical picture is characterised by hypotension and tachycardia, tachypnoe and dyspnoea as well as cerebral impairment. Results from recent clinical trials indicate, that a adapted and specific therapeutic approach for the various shock forms is necessary. ⋯ In all other forms of shock the treatment approach can and should be more aggressive in order to improve microvascular perfusion as early as possible. Besides adequate fluid resuscitation in a combination of crystalloid and colloid solutions catecholamines and-under specific circumstances-also vasopressin should be used. Of utmost importance in the pre-clinical management of patients in shock is the optimal selection of the centre that the patient is referred to in order to establish the fastest and best possible definite treatment for the patient.
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Documented mortality from myocardial infarction (MI) has significantly decreased from around 30% in the 1960s to 6-7% currently, following the introduction of intensive care treatment, thrombolysis, effective antithrombotic therapy and coronary angioplasty. However, the approximate mortality of 70-80% of patients with cardiogenic shock following acute MI has hardly improved despite the introduction of modern treatment strategies. ⋯ Prompt coronary revascularisation by "facilitated" or "adjunctive" percutaneous coronary intervention (PCI), is currently considered the best method to reduce the high mortality in these patients. Facilitated PCI includes administration of glycoproteine receptor antagonists, mechanical circulation support strategies, such as, intraaortic balloon counterpulsation and potentially prehospital thrombolysis.
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Review Comparative Study
[New therapeutic approaches in the treatment of shock: hypertonic hyperoncotic solutions and vasopressin].
The extreme disturbance of hemodynamics in shock leads to a minimized oxygen delivery to several vital organs. If this state is not rapidly lifted, a multi-organ-failure can occur. In addition to the removal of the underlying causes, for example, bleeding or septic focus, measures must be started to stabilize hemodynamics. ⋯ It has been shown that the infusion of vasopressin contributes to stabilization of hemodynamics in septic shock, in lower, as well as in higher concentrations. On the other hand vasopressin worsens splanchnic perfusion. Therefore the routine use of vasopressin in the treatment of sepsis can not be recommended.
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Randomized Controlled Trial Multicenter Study Clinical Trial
[Atorvastatin for primary prevention of cardiovascular events. ASCOT-LLA Study].
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Patients in circulatory shock are being treated in emergency as well as in intensive care units. Despite different resources in personnel and technical equipment in both areas, patient management has to follow standardized protocols. Diagnosis of shock has to be based upon objective parameters (lactate, pH, standard bicarbonate, arterial blood pressure, central venous pressure, cardiac output). ⋯ Target values are: mean arterial blood pressure >80 mmHg, central venous pressure >6 mmHg, hemoglobin >8.0 g/dl, cardiac index >3.5 l/min/m(2). New concepts for optimization of hemodynamics and hematocrit, cortisone, intraaortic balloon counterpulsation, mechanical ventilation with low tidal volumes, and intensive insulin therapy are discussed. However, as shock reversal is dependent on its reason, clarification and treatment of the shock causing event has to be performed with highest priority.