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| <div style="width: 1px; height: 1px; background-color: #999999; position: fixed; top: 10px; left: 10px"></div>
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| <div style="width: 90%; -webkit-user-select: none;">
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| {| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0";
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| ! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align=center| {{fontcolor|#2B3B44|Cardiogenic Shock<BR>Resident Survival Guide}}
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Overview|Overview]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Causes|Causes]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Do's|Do's]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
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| |}
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| __NOTOC__
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| {{CMG}}; {{AE}} [[User:Ahmed Zaghw|Ahmed Zaghw, MBChB.]] [mailto:ahmedzaghw@wikidoc.org]
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| ==Overview==
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| The clinical definition of [[cardiogenic shock]] includes decreased [[cardiac output]] with evidence of tissue [[hypoxia]] in the presence of adequate intravascular volume.<ref name="Califf-1994">{{Cite journal | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref>
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| ==Causes==
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| ===Life Threatening Causes===
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| Cardiogenic shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.
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| ===Common Causes===
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| :* ''Arrhythmic''
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| ::* [[Atrioventricular block]]
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| ::* [[Sinoatrial block]]
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| ::* [[Supraventricular tachycardia]]
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| ::* [[Ventricular tachycardia]]
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| :* ''Mechanical''
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| ::* [[Mitral regurgitation|Acute mitral regurgitation]] ([[papillary muscle rupture]], [[chordae tendinae]] [[rupture]])
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| ::* [[Myocardial rupture|Free wall rupture]]
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| ::* [[Hypertrophic cardiomyopathy]]
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| ::* [[Left ventricle|Obstruction to left ventricular filling]] ([[mitral stenosis]], [[left atrial myxoma]])
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| ::* [[Left ventricular outflow tract obstruction|Obstruction to left ventricular outflow tract]] ([[aortic stenosis]], [[hypertrophic obstructive cardiomyopathy]])
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| ::* [[Ventricular septal defect]]
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| :* ''Myopathic''
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| ::* [[Cardiomyopathy]]
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| ::* [[Myocardial contusion]]
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| ::* [[Myocardial infarction]]
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| ::* [[Myocarditis]]
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| ::* [[Myxedema coma]]
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| ::* [[ischemia|Postischemic]] [[myocardial stunning]]
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| ::* [[Sepsis|Septic myocardial depression]]
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| :* ''Pharmacologic''
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| ::* [[Anthracycline]]s
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| ::* [[Calcium channel blockers]]
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| ''Click '''[[Cardiogenic shock causes|here]]''' for the complete list of causes.''
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|
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| ==FIRE: Focused Initial Rapid Evaluation==
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
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| <span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
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| <span style="font-size: 85%;">
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| '''Abbreviations''':
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| CBC, complete blood count;
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| CI, cardiac index;
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| CK-MB, creatine kinase MB isoform;
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| CVP, central venous pressure;
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| DC, differential count;
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| ICU, intensive care unit;
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| INR, international normalized ratio;
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| LFT, liver function test;
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| MAP, mean arterial pressure;
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| MVO2, mixed venous oxygen saturation;
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| PCWP, pulmonary capillary wedge pressure;
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| PT, prothrombin time;
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| PTT, partial prothrombin time;
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| SaO2, arterial oxygen saturation;
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| SBP, systolic blood pressure;
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| SCVO2, central venous oxygen saturation;
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| SMA-7, sequential multiple analysis-7.
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| </span>
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| {{Family tree/start}}
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| {{Family tree|boxstyle=width: 400px; text-align: left; font-size: 90%; padding: 0px;| | | | | A01 | | | |A01=<div style="padding: 15px;"><BIG>'''Does the patient have cardinal findings that increase the pretest probability of cardiogenic shock?'''</BIG>
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| ❑ Evidence of hypoperfusion
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| : ❑ [[Altered mental status|<span style="color: #000000;">Altered mental status</span>]]
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| : ❑ [[Cool extremities|<span style="color: #000000;">Cool extremities</span>]]
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| : ❑ [[Cyanosis|<span style="color: #000000;">Cyanosis</span>]]
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| : ❑ [[Oliguria|<span style="color: #000000;">Oliguria</span>]]
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| : ❑ Sustained hypotension
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| :: ❑ [[SBP|<span style="color: #000000;">SBP</span>]] <90 mm Hg for ≥30 min ''or''
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| :: ❑ [[MAP|<span style="color: #000000;">MAP</span>]] ↓ >30 mm Hg below baseline for ≥30 min
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| ❑ Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%;| |,|-|-|-|^|-|-|-|.| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A02 | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>YES</BIG></div>|A03=<div style="text-align: center; background: #FA8072; color: #F8F8FF; font-weight: bold; padding: 15px;"><BIG>NO</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | |!| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A04 | | | | | | A05 |A04=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic <br> shock <br> suspected</BIG></div>
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| |A05=<div style="text-align: center; background: #FA8072; color: #FFFFFF; padding: 15px; font-weight: bold;"><BIG>'''Proceed to <br> [[shock resident survival guide|<span style="color: #FFFFFF;">shock resident survival guide</span>]] <br> to identify and correct the cause'''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A06 | | | | | | | | |A06=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate management'''</BIG>
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| ❑ [[Intubation|<span style="color: #FFFFFF;">Intubation</span>]] with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]
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| ❑ ± IV bolus [[Normal saline|<span style="color: #FFFFFF;">normal saline</span>]] 100–200 mL
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| ❑ ± [[Norepinephine|<span style="color: #FFFFFF;">Norepinephrine</span>]] 0.1–2.0 μg/kg/min
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| ❑ ± Control pain and/or anxiety
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| : ❑ [[Morphine sulphate|<span style="color: #FFFFFF;">Morphine sulphate</span>]]
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| : ❑ [[Fentanyl|<span style="color: #FFFFFF;">Fentanyl</span>]]
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| ❑ [[Cardiology|<span style="color: #FFFFFF;">Cardiology consultation</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Workup'''</BIG>
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| ❑ [[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
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| ❑ [[Pulse oximeter|<span style="color: #FFFFFF;">Pulse oximeter</span>]]
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| ❑ [[Arterial blood gas|<span style="color: #FFFFFF;">Arterial blood gas</span>]]
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| ❑ [[Central venous catheter|<span style="color: #FFFFFF;">Central venous catheter</span>]]
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| ❑ [[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]]
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| ❑ [[CBC|<span style="color: #FFFFFF;">CBC</span>]]/[[Differential blood count (patient information)|<span style="color: #FFFFFF;">DC</span>]]/[[Basic metabolic panel|<span style="color: #FFFFFF;">SMA-7</span>]]/[[LFT|<span style="color: #FFFFFF;">LFT</span>]]/[[PT|<span style="color: #FFFFFF;">PT</span>]]/[[PTT|<span style="color: #FFFFFF;">PTT</span>]]/[[INR|<span style="color: #FFFFFF;">INR</span>]]
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| ❑ [[Troponin|<span style="color: #FFFFFF;">Troponin</span>]], [[CK-MB|<span style="color: #FFFFFF;">CK-MB</span>]]
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]]
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| ❑ [[CXR|<span style="color: #FFFFFF;">Chest radiograph</span>]]
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| ❑ [[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]
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| ❑ [[Foley catheter|<span style="color: #FFFFFF;">Foley catheter</span>]]
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| ❑ [[ICU|<span style="color: #FFFFFF;">ICU admission</span>]]
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A08 | | | | | | | | |A08=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate goals'''</BIG>
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| ❑ [[SaO2|<span style="color: #FFFFFF;">SaO2 >90%–92%</span>]]
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| ❑ [[CVP|<span style="color: #FFFFFF;">CVP 8–12 mm Hg</span>]]
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| ❑ [[MAP|<span style="color: #FFFFFF;">MAP >60 mm Hg</span>]]
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| ❑ [[PCWP|<span style="color: #FFFFFF;">PCWP 14–18 mm Hg</span>]]
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| ❑ [[cardiac index|<span style="color: #FFFFFF;">CI >2.2 L/min/m2</span>]]
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| ❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2 >60%</span>]]
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| ❑ [[SCVO2|<span style="color: #FFFFFF;">SCVO2 >70%</span>]]
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| ❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin >7–9 g/dL</span>]]
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate <2.2 mM/L</span>]]
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| ❑ [[urine output|<span style="color: #FFFFFF;">Urine output >0.5 mL/kg/h</span>]]
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| ❑ ± Correct [[arrhythmia|<span style="color: #FFFFFF;">arrhythmia</span>]]
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| ❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A09 | | | | | | | | |A09=<div style="text-align: center; background: #FA8072; color: #FFFFFF; font-weight: bold; padding: 15px;"><BIG>Proceed to <br> [[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]] <br> below</BIG></div>}}
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| {{Family tree/end}}
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| ==Complete Diagnostic Approach==
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| ==Treatment==
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| ==Do's==
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| * ''Initial Management''
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| :* Ventilatory support is crucial for maintenance of adequate oxygenation and usually requires intubation with mechanical ventilation.
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| :* Optimization of [[hemodynamic|hemodynamic status]] may be initially achieved by judicious administration of [[diuretic]]s, [[vasopressor]]s, [[vasodilator]]s, [[inotrope]]s, and/or [[intravenous fluid]]s.
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| :* [[intravenous therapy|IV]] bolus [[normal saline]] should be waived in the presence of [[pulmonary edema]].
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| :* End point of fluid therapy may be defined as a [[central venous pressure|central venous pressure (CVP)]] of a few [[mmHg|millimeters of mercury (mmHg)]] above the baseline to prevent fluid overload.<ref name="Dellinger-2013">{{Cite journal | last1 = Dellinger | first1 = RP. | last2 = Levy | first2 = MM. | last3 = Rhodes | first3 = A. | last4 = Annane | first4 = D. | last5 = Gerlach | first5 = H. | last6 = Opal | first6 = SM. | last7 = Sevransky | first7 = JE. | last8 = Sprung | first8 = CL. | last9 = Douglas | first9 = IS. | title = Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. | journal = Crit Care Med | volume = 41 | issue = 2 | pages = 580-637 | month = Feb | year = 2013 | doi = 10.1097/CCM.0b013e31827e83af | PMID = 23353941 }}</ref>
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| ==Don'ts==
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| * Do not test [[orthostatic hypotension]] in [[hypotension|hypotensive]] patients.
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| * Do not rely solely on [[oxygen saturation|SpO2]] readings from [[pulse oximeter]]. [[Oxygen saturation|SaO2]] from [[Arterial blood gas|blood gas analysis]] provides more precise status of [[oxygenation|oxygenation]].
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| * Do not administer low-dose [[dopamine]] (<5 μg/kg/min) to preserve [[renal function]] in patients with [[shock]].
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| ==References==
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| {{reflist|2}}
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| [[Category:Disease]]
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| [[Category:Pulmonology]]
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| [[Category:Emergency medicine]]
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| [[Category:Medicine]]
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| [[Category:Resident survival guide]]
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