Cardiogenic shock physical examination: Difference between revisions
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{{Cardiogenic shock}} | {{Cardiogenic shock}} | ||
{{CMG}}; {{AE}} {{JS}} | {{CMG}}; {{AE}} {{JS}} {{sali}} | ||
==Overview== | |||
[[Physical examination]] findings in patients with [[cardiogenic shock]] include the following: [[Altered mental status]], [[cyanosis]], cold and clammy skin, mottled extremities [[Peripheral pulses]] are [[faint]], rapid and sometimes irregular if there is an underlying [[arrhythmia]], [[Jugular venous distension]], Diminished heart sounds, S3 or S4, may be present, [[murmurs]] in the presence of valvular disorders such as [[mitral regurgitation]] or [[aortic stenosis]], [[Pulmonary vascular congestion]] may be associated with [[rales]] [[Peripheral edema]] may be present in the setting of [[fluid overload]]. | |||
==Physical Examination== | ==Physical Examination== | ||
=== | *Patients in '''cardiogenic shock complicating acute-MI''', often present to the hospital with signs of end-organ [[hypoperfusion]], such as [[altered mentation]] and [[agitation|agitated]]. The typical [[physical examination]] may include:<ref>{{Cite book | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages = }}</ref> | ||
* [[ | :*'''''Vital Signs''''' | ||
* [[ | ::#New or worsening [[hypotension]] with [[narrow pulse pressure]]. However, due to increased [[SVR]], [[blood pressure]] may be normal | ||
*[[ | ::#[[Tachycardia]] (90-110 beats/min) with a weak [[pulse]] or [[bradycardia]] if in the presence of high-grade [[heart block]] | ||
:*'''''Skin''''' | |||
::#[[Cyanosis]], [[Cool extremities|cool]] and [[clammy skin]] | |||
::#[[Diaphoresis]] | |||
:*'''''Neck''''' | |||
::#Distended [[jugular vein]]s due to increased [[jugular venous pressure]] | |||
:*'''''Heart''''' | |||
::#Soft [[S1|S<sub>1</sub>]] | |||
::#[[S3 gallop|S<sub>3</sub> gallop]] | |||
::#[[Systolic murmurs]] if in the presence of mechanical complications, such as [[mitral regurgitation]] or [[VSR|ventricle septal rupture]]: | |||
:::*''Acute [[mitral regurgitation]]'' - there may be a soft pansystolic [[murmur]] heard best at the [[apex of the heart|apex area]], radiating to the [[axilla]], with no [[thrill]] (may be absent in [[left ventricle]] [[systolic]] function impairment or in increased [[left atrial]] [[pressure]])<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref>{{cite book | last = Braunwald | first = Eugene | title = Braunwald's heart disease : a textbook of cardiovascular medicine | publisher = Saunders | location = Philadelphia | year = 2012 | isbn = 1437703984 }}</ref><ref name="pmid19564568">{{cite journal| author=Stout KK, Verrier ED| title=Acute valvular regurgitation. | journal=Circulation | year= 2009 | volume= 119 | issue= 25 | pages= 3232-41 | pmid=19564568 | doi=10.1161/CIRCULATIONAHA.108.782292 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564568 }} </ref> | |||
:::*''[[VSR|Ventricle Septal Rupture]]'' - there may be a harsh pansystolic [[murmur]], heard best at the lower [[left sternal border]] and with a [[thrill]] in 50% of the cases, however, its absence does not rule out [[VSR]]. This finding in the setting of [[hemodynamic]] compromise following an [[MI]] may be mistaken for acute [[mitral regurgitation]], with which it may occur simultaneously<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref name="pmid7643642">{{cite journal| author=Reeder GS| title=Identification and treatment of complications of myocardial infarction. | journal=Mayo Clin Proc | year= 1995 | volume= 70 | issue= 9 | pages= 880-4 | pmid=7643642 | doi=10.1016/S0025-6196(11)63946-3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7643642 }} </ref><ref>{{cite book | last = Cohn | first = Lawrence | title = Cardiac surgery in the adult | publisher = McGraw-Hill Medical | location = New York | year = 2012 | isbn = 007163312X }}</ref> | |||
:*'''''Lungs''''' | |||
::#[[Tachypnea]] due to [[sympathetic nervous system]] stimulation by [[stretch receptors]] and as compensation for [[metabolic acidosis]] | |||
::#[[Cheyne-Stokes respiration]] | |||
::#[[Respiratory distress]] due to [[pulmonary edema]] from insufficient pumping of the [[heart]], leading to fluid accumulation | |||
::#[[Rales]] on [[auscultation]], commonly in left ventricle failure | |||
:*'''''Genitourinary''''' | |||
::#[[Oliguria]] (usually less than 30 mL/h) due insufficient [[renal]] [[perfusion]] | |||
=== | *In patients with '''cardiogenic shock complicating right ventricle myocardial infarction''', the [[physical examination]] will generally reveal a clear [[lung]] [[auscultation]]. There will often be a so called triad of [[signs]] (with poor [[sensitivity]] for [[diagnosis]]):<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref name="pmid4810018">{{cite journal| author=Cohn JN, Guiha NH, Broder MI, Limas CJ| title=Right ventricular infarction. Clinical and hemodynamic features. | journal=Am J Cardiol | year= 1974 | volume= 33 | issue= 2 | pages= 209-14 | pmid=4810018 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4810018 }} </ref><ref name="pmid6638720">{{cite journal| author=Dell'Italia LJ, Starling MR, O'Rourke RA| title=Physical examination for exclusion of hemodynamically important right ventricular infarction. | journal=Ann Intern Med | year= 1983 | volume= 99 | issue= 5 | pages= 608-11 | pmid=6638720 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6638720 }} </ref> | ||
::#[[Hypotension]] | |||
::#[[Jugular venous distention]] | |||
::#Clear [[lung sounds]] | |||
:''There may also be findings of:''<ref name="pmid10894433">{{cite journal| author=Haji SA, Movahed A| title=Right ventricular infarction--diagnosis and treatment. | journal=Clin Cardiol | year= 2000 | volume= 23 | issue= 7 | pages= 473-82 | pmid=10894433 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10894433 }} </ref> | |||
::#[[Tricuspid regurgitation]] | |||
::#[[Right ventricle]] gallop | |||
::#[[Complete AV block|Atrio-ventricular block]] | |||
::#[[Kussmaul's sign]], often present in [[constrictive pericarditis]] | |||
::#[[Pulsus paradoxus]] with elevation and equalization of [[central venous pressure]], [[pulmonary artery]] [[diastolic]] [[pressure]], [[Pulmonary capillary wedge pressure]] and [[right ventricular]] [[systolic]] [[pressure]] | |||
:''The presence of increased [[JVP]] and [[Kussmaul's sign]] together, is both [[specificity|specific]] and [[sensitivity|sensitive]] for the [[diagnosis]] of [[right ventricle myocardial infarction]].'' | |||
=== | *Patients suffering '''free wall rupture''', the [[physical examination]] may be consistent with the findings in [[cardiac tamponade]] and therefore include:<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref>{{cite book | last = Braunwald | first = Eugene | title = Braunwald's heart disease : a textbook of cardiovascular medicine | publisher = Saunders | location = Philadelphia | year = 2012 | isbn = 1437703984 }}</ref><ref name="pmid19064683">{{cite journal| author=Figueras J, Alcalde O, Barrabés JA, Serra V, Alguersuari J, Cortadellas J et al.| title=Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period. | journal=Circulation | year= 2008 | volume= 118 | issue= 25 | pages= 2783-9 | pmid=19064683 | doi=10.1161/CIRCULATIONAHA.108.776690 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19064683 }} </ref> | ||
:#[[Hypotension]] | |||
:#[[Jugular Venous Distension]] | |||
:#Softened [[heart sounds]] | |||
:#[[Pulsus paradoxus]] | |||
==References== | ==References== | ||
Latest revision as of 18:12, 8 January 2020
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Cardiogenic shock physical examination On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Syed Musadiq Ali M.B.B.S.[3]
Overview
Physical examination findings in patients with cardiogenic shock include the following: Altered mental status, cyanosis, cold and clammy skin, mottled extremities Peripheral pulses are faint, rapid and sometimes irregular if there is an underlying arrhythmia, Jugular venous distension, Diminished heart sounds, S3 or S4, may be present, murmurs in the presence of valvular disorders such as mitral regurgitation or aortic stenosis, Pulmonary vascular congestion may be associated with rales Peripheral edema may be present in the setting of fluid overload.
Physical Examination
- Patients in cardiogenic shock complicating acute-MI, often present to the hospital with signs of end-organ hypoperfusion, such as altered mentation and agitated. The typical physical examination may include:[1]
- Vital Signs
- New or worsening hypotension with narrow pulse pressure. However, due to increased SVR, blood pressure may be normal
- Tachycardia (90-110 beats/min) with a weak pulse or bradycardia if in the presence of high-grade heart block
- Skin
- Neck
- Distended jugular veins due to increased jugular venous pressure
- Heart
- Soft S1
- S3 gallop
- Systolic murmurs if in the presence of mechanical complications, such as mitral regurgitation or ventricle septal rupture:
- Acute mitral regurgitation - there may be a soft pansystolic murmur heard best at the apex area, radiating to the axilla, with no thrill (may be absent in left ventricle systolic function impairment or in increased left atrial pressure)[2][3][4]
- Ventricle Septal Rupture - there may be a harsh pansystolic murmur, heard best at the lower left sternal border and with a thrill in 50% of the cases, however, its absence does not rule out VSR. This finding in the setting of hemodynamic compromise following an MI may be mistaken for acute mitral regurgitation, with which it may occur simultaneously[2][5][6]
- Lungs
- Tachypnea due to sympathetic nervous system stimulation by stretch receptors and as compensation for metabolic acidosis
- Cheyne-Stokes respiration
- Respiratory distress due to pulmonary edema from insufficient pumping of the heart, leading to fluid accumulation
- Rales on auscultation, commonly in left ventricle failure
- Genitourinary
- In patients with cardiogenic shock complicating right ventricle myocardial infarction, the physical examination will generally reveal a clear lung auscultation. There will often be a so called triad of signs (with poor sensitivity for diagnosis):[2][7][8]
- There may also be findings of:[9]
- Tricuspid regurgitation
- Right ventricle gallop
- Atrio-ventricular block
- Kussmaul's sign, often present in constrictive pericarditis
- Pulsus paradoxus with elevation and equalization of central venous pressure, pulmonary artery diastolic pressure, Pulmonary capillary wedge pressure and right ventricular systolic pressure
- The presence of increased JVP and Kussmaul's sign together, is both specific and sensitive for the diagnosis of right ventricle myocardial infarction.
- Patients suffering free wall rupture, the physical examination may be consistent with the findings in cardiac tamponade and therefore include:[2][10][11]
References
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ 2.0 2.1 2.2 2.3 Ng, R.; Yeghiazarians, Y. (2011). "Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies". Journal of Intensive Care Medicine. 28 (3): 151–165. doi:10.1177/0885066611411407. ISSN 0885-0666.
- ↑ Braunwald, Eugene (2012). Braunwald's heart disease : a textbook of cardiovascular medicine. Philadelphia: Saunders. ISBN 1437703984.
- ↑ Stout KK, Verrier ED (2009). "Acute valvular regurgitation". Circulation. 119 (25): 3232–41. doi:10.1161/CIRCULATIONAHA.108.782292. PMID 19564568.
- ↑ Reeder GS (1995). "Identification and treatment of complications of myocardial infarction". Mayo Clin Proc. 70 (9): 880–4. doi:10.1016/S0025-6196(11)63946-3. PMID 7643642.
- ↑ Cohn, Lawrence (2012). Cardiac surgery in the adult. New York: McGraw-Hill Medical. ISBN 007163312X.
- ↑ Cohn JN, Guiha NH, Broder MI, Limas CJ (1974). "Right ventricular infarction. Clinical and hemodynamic features". Am J Cardiol. 33 (2): 209–14. PMID 4810018.
- ↑ Dell'Italia LJ, Starling MR, O'Rourke RA (1983). "Physical examination for exclusion of hemodynamically important right ventricular infarction". Ann Intern Med. 99 (5): 608–11. PMID 6638720.
- ↑ Haji SA, Movahed A (2000). "Right ventricular infarction--diagnosis and treatment". Clin Cardiol. 23 (7): 473–82. PMID 10894433.
- ↑ Braunwald, Eugene (2012). Braunwald's heart disease : a textbook of cardiovascular medicine. Philadelphia: Saunders. ISBN 1437703984.
- ↑ Figueras J, Alcalde O, Barrabés JA, Serra V, Alguersuari J, Cortadellas J; et al. (2008). "Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period". Circulation. 118 (25): 2783–9. doi:10.1161/CIRCULATIONAHA.108.776690. PMID 19064683.