Sandbox/00007: Difference between revisions
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A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="Robin-2006">{{Cite journal | last1 = Robin | first1 = E. | last2 = Costecalde | first2 = M. | last3 = Lebuffe | first3 = G. | last4 = Vallet | first4 = B. | title = Clinical relevance of data from the pulmonary artery catheter. | journal = Crit Care | volume = 10 Suppl 3 | issue = | pages = S3 | month = | year = 2006 | doi = 10.1186/cc4830 | PMID = 17164015 }}</ref> | A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="Robin-2006">{{Cite journal | last1 = Robin | first1 = E. | last2 = Costecalde | first2 = M. | last3 = Lebuffe | first3 = G. | last4 = Vallet | first4 = B. | title = Clinical relevance of data from the pulmonary artery catheter. | journal = Crit Care | volume = 10 Suppl 3 | issue = | pages = S3 | month = | year = 2006 | doi = 10.1186/cc4830 | PMID = 17164015 }}</ref> | ||
<span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span> | <span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span> | ||
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SaO2, arterial oxygen saturation; | SaO2, arterial oxygen saturation; | ||
SBP, systolic blood pressure; | SBP, systolic blood pressure; | ||
ScvO2, central venous oxygen saturation; | |||
SMA-7, sequential multiple analysis-7. | SMA-7, sequential multiple analysis-7. | ||
</span> | </span> | ||
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❑ Evidence of hypoperfusion | ❑ Evidence of hypoperfusion | ||
: ❑ [[Altered mental status|<span style="color: #000000;">Altered mental status</span>]] | : ❑ [[Altered mental status|<span style="color: #000000;">Altered mental status</span>]] | ||
: ❑ [[ | : ❑ [[Cold extremities|<span style="color: #000000;">Cold extremities</span>]] | ||
: ❑ [[Cyanosis|<span style="color: #000000;">Cyanosis</span>]] | : ❑ [[Cyanosis|<span style="color: #000000;">Cyanosis</span>]] | ||
: ❑ [[Oliguria|<span style="color: #000000;">Oliguria</span>]] | : ❑ [[Oliguria|<span style="color: #000000;">Oliguria</span>]] | ||
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❑ [[Intubation|<span style="color: #FFFFFF;">Intubation</span>]] with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]] | ❑ [[Intubation|<span style="color: #FFFFFF;">Intubation</span>]] with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]] | ||
❑ ± [[Norepinephrine|<span style="color: #FFFFFF;">Norepinephrine</span>]] IV infusion 0.1–2.0 μg/kg/min</div>}} | |||
❑ ± [[Norepinephrine|<span style="color: #FFFFFF;">Norepinephrine</span>]] IV infusion 0.1–2.0 μg/kg/min | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | ||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Workup'''</BIG> | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate Workup'''</BIG> | ||
❑ [[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]] | ❑ [[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]] | ||
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❑ [[ICU|<span style="color: #FFFFFF;">ICU admission</span>]] | ❑ [[ICU|<span style="color: #FFFFFF;">ICU admission</span>]] | ||
❑ [[Cardiology|<span style="color: #FFFFFF;">Cardiology consultation</span>]] | |||
❑ Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</span>]] | |||
</div>}} | </div>}} | ||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | ||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A08 | | | | | | | | |A08=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>''' | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A08 | | | | | | | | |A08=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: preload'''</BIG> | ||
❑ [[ | ❑ '''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 14–18 mm Hg''' | ||
: ❑ ↑ [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] by [[Normal saline|<span style="color: #FFFFFF;">normal saline</span>]] IV bolus 100–200 mL | |||
: ❑ ↓ [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] by [[Furosemide|<span style="color: #FFFFFF;">furosemide</span>]] slow IV injection (over 1–2 min) | |||
: ❑ ± Correct [[{{PAGENAME}}#Immediate management|<span style="color: #FFFFFF;"> pulmonary congestion '''''(click for details)'''''</span>]] | |||
: ❑ ± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg slow IV injection (over 1–5 min) | |||
</div>}} | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A09 | | | | | | | | |A09=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: afterload'''</BIG> | |||
❑ '''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] >60 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>''' | |||
: ❑ If ↑ MAP & ↑ SVR: wean [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasodilator|<span style="color: #FFFFFF;">vasodilators</span>]] | |||
: ❑ If ↓ MAP & ↑ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] + [[inotrope|<span style="color: #FFFFFF;">inotropes</span>]] | |||
: ❑ If ↓ MAP & ↓ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasopressin|<span style="color: #FFFFFF;">vasopressin</span>]] | |||
</div>}} | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A10 | | | | | | | | |A10=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: cardiac index'''</BIG> | |||
❑ '''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] >2.2 L/min/m<sup>2</sup>''' | |||
: ❑ ± [[Dobutamine|<span style="color: #FFFFFF;">Dobutamine</span>]] | |||
❑ [[ | : ❑ ± [[Milrinone|<span style="color: #FFFFFF;">Milrinone</span>]] | ||
❑ [[ | : ❑ ± [[IABP|<span style="color: #FFFFFF;">IABP</span>]], [[VAD|<span style="color: #FFFFFF;">VAD</span>]], or [[ECMO|<span style="color: #FFFFFF;">ECMO</span>]] if refractory</div>}} | ||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A11 | | | | | | | | |A11=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate goals'''</BIG> | |||
❑ [[ | ❑ [[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] >90%–92% | ||
❑ [[ | ❑ [[CVP|<span style="color: #FFFFFF;">CVP</span>]] 8–12 mm Hg | ||
❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2</span>]] >60% | ❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2</span>]] >60% | ||
❑ [[SCVO2|<span style="color: #FFFFFF;"> | ❑ [[SCVO2|<span style="color: #FFFFFF;">ScvO2</span>]] >70% | ||
❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin</span>]] >7–9 g/dL | ❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin</span>]] >7–9 g/dL | ||
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❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}} | ❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}} | ||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | ||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A12 |-| A13 | | | | | |A12=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Immediate management|<span style="color: #FFFFFF;">ACS likely? ''(click for details)''</span>]]'''</BIG> | ||
❑ [[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)</span>]] | |||
❑ Symptoms of myocaridal ischemia | |||
❑ New significant ECG findings of myocardial ischemia | |||
</div> | |||
|A13=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 16px;"><BIG><BIG>'''YES, then manage as <br> UA/STEMI <br> and proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></BIG> | |||
</div>}} | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}} | |||
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A14 | | | | | | | | |A14=<div style="text-align: center; background: #FA8072; color: #FFFFFF; font-weight: bold; padding: 15px;"><BIG>No, then proceed to <br> [[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]]</BIG></div>}} | |||
{{Family tree/end}} | {{Family tree/end}} | ||
==Acute Ischemia Pathway== | |||
<!--return to top--> | |||
==Complete Diagnostic Approach== | ==Complete Diagnostic Approach== |
Revision as of 05:41, 21 April 2014
Cardiogenic Shock Resident Survival Guide |
---|
Overview |
Causes |
FIRE |
Diagnosis |
Treatment |
Do's |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, MBChB. [2]
Overview
The clinical definition of cardiogenic shock includes decreased cardiac output with evidence of tissue hypoxia in the presence of adequate intravascular volume.[1]
Causes
Life Threatening Causes
Cardiogenic shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.
Common Causes
- Arrhythmic
- Mechanical
- Acute mitral regurgitation (papillary muscle rupture, chordae tendinae rupture)
- Free wall rupture
- Hypertrophic cardiomyopathy
- Obstruction to left ventricular filling (mitral stenosis, left atrial myxoma)
- Obstruction to left ventricular outflow tract (aortic stenosis, hypertrophic obstructive cardiomyopathy)
- Ventricular septal defect
- Myopathic
- Pharmacologic
Click here for the complete list of causes.
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2]
Boxes in the salmon color signify that an urgent management is needed.
Abbreviations: CBC, complete blood count; CI, cardiac index; CK-MB, creatine kinase MB isoform; CVP, central venous pressure; DC, differential count; ICU, intensive care unit; INR, international normalized ratio; LFT, liver function test; MAP, mean arterial pressure; MVO2, mixed venous oxygen saturation; PCWP, pulmonary capillary wedge pressure; PT, prothrombin time; PTT, partial prothrombin time; SaO2, arterial oxygen saturation; SBP, systolic blood pressure; ScvO2, central venous oxygen saturation; SMA-7, sequential multiple analysis-7.
Does the patient have cardinal findings that increase the pretest probability of cardiogenic shock?
❑ Evidence of hypoperfusion
| |||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||
Cardiogenic shock suspected | |||||||||||||||||||||||
Immediate management (click for details)
❑ Intubation with mechanical ventilation ❑ ± Norepinephrine IV infusion 0.1–2.0 μg/kg/min | |||||||||||||||||||||||
Immediate Workup
❑ Lactate ❑ Hold antihypertensive medications | |||||||||||||||||||||||
Hemodynamic optimization: preload
❑ Goal: PCWP 14–18 mm Hg
| |||||||||||||||||||||||
Hemodynamic optimization: afterload
❑ Goal: MAP >60 mm Hg, SVR 800–1200 dyn·s·cm−5
| |||||||||||||||||||||||
Immediate goals
❑ SaO2 >90%–92% ❑ CVP 8–12 mm Hg ❑ MVO2 >60% ❑ ScvO2 >70% ❑ Hemoglobin >7–9 g/dL ❑ Lactate <2.2 mM/L ❑ Urine output >0.5 mL/kg/h ❑ ± Correct arrhythmia ❑ ± Correct electrolyte disturbance | |||||||||||||||||||||||
ACS likely? (click for details)
❑ Positive cardiac biomarkers (cTnT, cTnI, or CK-MB) ❑ Symptoms of myocaridal ischemia ❑ New significant ECG findings of myocardial ischemia | |||||||||||||||||||||||
No, then proceed to complete diagnostic approach | |||||||||||||||||||||||
Acute Ischemia Pathway
Complete Diagnostic Approach
Treatment
Do's
Diagnostic criteria
- Sustained hypotension (SBP <90 mm Hg or MAP 30 mm Hg below baseline in preexisting hypertension for at least 30 minutes)
- Evidence of tissue hypoperfusion (such as oliguria, cyanosis, cool extremities, and altered mental status)
- Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion (such as hypovolemia, hypoxia, and acidosis)
- Sustained hypotension (SBP <90 mm Hg or MAP 30 mm Hg below baseline in preexisting hypertension for at least 30 minutes)
- Depressed cardiac index (<1.8 L/min/m2 of BSA without support or <2.0–2.2 L/min/m2 of BSA with support) in the presence of an elevated wedge pressure (>15 mm Hg).
Immediate management
- Ventilatory support is crucial for maintenance of adequate oxygenation and usually requires intubation with mechanical ventilation.
- IV bolus normal saline should be waived in the presence of pulmonary edema.
- Dosage and Administration
- Mix 1 ampule (4 mg) of norepinephrine in 250 mL of D5W or D5NS. Avoid dilution in normal saline alone.
- IV infusion 0.5–1.0 μg/min; titrated to raise blood pressure (up to 30–40 μg/min).
- Indications
- Blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions).
- Adjunct in the treatment of cardiac arrest and profound hypotension.
- Precautions
- Dosage and Administration
- Slow IV injection 2–4 mg (over 1–5 minutes) every 5–30 minutes as needed.
- Indications
- Relief of severe pain as in severe injuries or in severe chronic pain associated with terminal cancer after all non-narcotic analgesics have failed.
- Relief of chest discomfort that is unresponsive to nitrates in STEMI (Class I, LOE C) and unstable angina or NSTEMI (Class IIa, LOE C).
- Management of dyspnea associated with acute left ventricular failure and pulmonary edema to relieve anxiety and reduce preload.
- Preoperative sedation to facilitate anesthesia induction and reduce anesthetic dosage.
- Precautions
- May cause respiratory depression
- May exacerbate hypotension in volume-depleted patients.
Don'ts
- Do not test orthostatic hypotension in hypotensive patients.
- Do not rely solely on SpO2 readings from pulse oximeter. SaO2 from blood gas analysis provides more precise status of oxygenation.
- Do not administer low-dose dopamine (<5 μg/kg/min) to preserve renal function in patients with shock.
References
- ↑ 1.0 1.1 1.2 Califf, RM.; Bengtson, JR. (1994). "Cardiogenic shock". N Engl J Med. 330 (24): 1724–30. doi:10.1056/NEJM199406163302406. PMID 8190135. Unknown parameter
|month=
ignored (help) - ↑ Robin, E.; Costecalde, M.; Lebuffe, G.; Vallet, B. (2006). "Clinical relevance of data from the pulmonary artery catheter". Crit Care. 10 Suppl 3: S3. doi:10.1186/cc4830. PMID 17164015.
- ↑ Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter
|month=
ignored (help) - ↑ 4.0 4.1 Goldberg, RJ.; Gore, JM.; Alpert, JS.; Osganian, V.; de Groot, J.; Bade, J.; Chen, Z.; Frid, D.; Dalen, JE. (1991). "Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988". N Engl J Med. 325 (16): 1117–22. doi:10.1056/NEJM199110173251601. PMID 1891019. Unknown parameter
|month=
ignored (help) - ↑ Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts)". N Engl J Med. 295 (24): 1356–62. doi:10.1056/NEJM197612092952406. PMID 790191. Unknown parameter
|month=
ignored (help) - ↑ Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts)". N Engl J Med. 295 (25): 1404–13. doi:10.1056/NEJM197612162952505. PMID 790194. Unknown parameter
|month=
ignored (help) - ↑ Reynolds, HR.; Hochman, JS. (2008). "Cardiogenic shock: current concepts and improving outcomes". Circulation. 117 (5): 686–97. doi:10.1161/CIRCULATIONAHA.106.613596. PMID 18250279. Unknown parameter
|month=
ignored (help) - ↑ "NOREPINEPHRINE BITARTRATE INJECTION".
- ↑ 9.0 9.1 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 1616690003.
- ↑ "MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE".
- ↑ O'Connor, RE.; Brady, W.; Brooks, SC.; Diercks, D.; Egan, J.; Ghaemmaghami, C.; Menon, V.; O'Neil, BJ.; Travers, AH. (2010). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028. PMID 20956226. Unknown parameter
|month=
ignored (help)