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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>'''[[{{PAGENAME}}#Immediate management|<span style="color: #FFFFFF;">Immediate management ''(click for details)''</span>]]'''</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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| ❑ ± [[Normal saline|<span style="color: #FFFFFF;">Normal saline</span>]] IV bolus 100–200 mL
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| ❑ ± [[Norepinephine|<span style="color: #FFFFFF;">Norepinephrine</span>]] IV infusion 0.1–2.0 μg/kg/min
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| ❑ ± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg IV push slowly (in 1–5 min)
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| ❑ Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</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</span>]] >90%–92%
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| ❑ [[CVP|<span style="color: #FFFFFF;">CVP</span>]] 8–12 mm Hg
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| ❑ [[MAP|<span style="color: #FFFFFF;">MAP</span>]] >60 mm Hg
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| ❑ [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 14–18 mm Hg
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| ❑ [[cardiac index|<span style="color: #FFFFFF;">CI</span>]] >2.2 L/min/m2
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| ❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2</span>]] >60%
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| ❑ [[SCVO2|<span style="color: #FFFFFF;">SCVO2</span>]] >70%
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| ❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin</span>]] >7–9 g/dL
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]] <2.2 mM/L
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| ❑ [[urine output|<span style="color: #FFFFFF;">Urine output</span>]] >0.5 mL/kg/h
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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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|
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| ==Do's==
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|
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| ====''Diagnostic criteria''====
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|
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| * ''Criteria for bedside diagnosis''<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><ref name="Hollenberg-1999">{{Cite journal | last1 = Hollenberg | first1 = SM. | last2 = Kavinsky | first2 = CJ. | last3 = Parrillo | first3 = JE. | title = Cardiogenic shock. | journal = Ann Intern Med | volume = 131 | issue = 1 | pages = 47-59 | month = Jul | year = 1999 | doi = | PMID = 10391815 }}</ref><ref name="Goldberg-1991">{{Cite journal | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref>
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| :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]] <90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
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| :* Evidence of [[hypoperfusion|tissue hypoperfusion]] (such as [[oliguria]], [[cyanosis]], [[cool extremities]], and [[Altered mental status|altered mental status]])
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| :* Presence of [[myocardial]] dysfunction after exclusion or correction of non-[[myocardial]] factors contributing to [[hypoperfusion|tissue hypoperfusion]] (such as [[hypovolemia]], [[hypoxia]], and [[acidosis]])
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| * ''Criteria based on hemodynamic parameters''<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><ref name="Goldberg-1991">{{Cite journal | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref><ref name="Forrester-1976">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref>
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| :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]] <90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
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| :* Depressed [[cardiac index]] (<1.8 L/min/m<sup>2</sup> of [[body surface area|BSA]] without support or <2.0–2.2 L/min/m<sup>2</sup> of [[body surface area|BSA]] with support) in the presence of an elevated [[PCWP|wedge pressure]] (>15 mm Hg).
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| <!--
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| :* Adequate filling pressure (left ventricular end-diastolic pressure >18 mm Hg or right ventricular end-diastolic pressure >10–15 mm Hg)
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| :* Elevated [[arteriovenous oxygen difference]] (>5.5 mL/dL)
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| -->
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| ====''Immediate management''====
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|
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| * Ventilatory support is crucial for maintenance of adequate oxygenation and usually requires [[intubation]] with [[mechanical ventilation]].
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|
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| * [[intravenous therapy|IV]] bolus [[normal saline]] should be waived in the presence of [[pulmonary edema]].
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|
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| * '''[[Norepinephrine]]'''
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| :* ''Dosage and Administration''
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| ::* Mix 1 ampule (4 mg) of [[norepinephrine]] in 250 mL of [[Intravenous sugar solution|D5W]] or [[Intravenous sugar solution|D5NS]]. Avoid dilution in [[normal saline]] alone.
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| ::* [[IV|IV infusion]] 0.5–1.0 μg/min; titrated to raise [[blood pressure]] (up to 30–40 μg/min).
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| ::* Do not administer in same IV line as alkaline solutions.
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| :* ''Indications''
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| ::* For severe [[cardiogenic shock]] and [[hemodynamic|hemodynamically]] significant hypotension ([[SBP]] <70 mm Hg) with a low [[systemic vascular resistance]].
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| ::* This is an agent of last resort for management of [[ischemic heart disease]] and [[shock]].
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| ==Don'ts==
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|
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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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