Sandbox/00007
Cardiogenic shock Resident Survival Guide |
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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]
Diagnositic Criteria
Criteria for bedside diagnosis[1][2][3]
- Sustained hypotension (systolic blood pressure <80–90 mm Hg or mean arterial pressure 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)
Criteria based on hemodynamic parameters[1][3][4][5][6]
- Sustained hypotension (systolic blood pressure <80–90 mm Hg or mean arterial pressure 30 mm Hg below baseline in preexisting hypertension for at least 30 minutes)
- Depressed cardiac index (<1.8 L/min/m2 of body surface area without support or <2.0–2.2 L/min/m2 of body surface area with support) in the presence of an elevated pulmonary capillary wedge pressure (>15 mm Hg).
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)
- Cardiac tamponade
- 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.
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?
❑ Arterial hypotension ❑ Evidence of tissue hypoperfusion ❑ Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion | |||||||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||||||
Ventilate—Infuse—Pump (VIP) ❑ Oxygen ± mechanical ventilation ❑ Normal saline 300–500 mL over 20–30 min ❑ ± Norepinephrine 0.1–2.0 μg/kg/min | Consider other causes (eg, chronic hypotension, syncope) | ||||||||||||||||||||||||||||||||||
Immediate Goals | |||||||||||||||||||||||||||||||||||
Identify the cause | |||||||||||||||||||||||||||||||||||
NO, then proceed to complete diagnostic approach below | |||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
History |
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Laboratory Findings |
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ECG Findings |
Radiographic Findings |
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Hemodynamic Profiles and Echocardiography Findings | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Treatment
Do's
- Initial Management
- Resuscitation should be initiated while investigation is ongoing. Correct the cause of shock immediately once it is identified.
- The VIP (Ventilate-Infuse-Pump) approach is useful for ensuring an orderly sequence of therapeutic-diagnostic maneuvers.[8]
- Ventilate
- Endotracheal intubation should be performed in patients with severe dyspnea, hypoxemia, or persistent or worsening acidemia (pH <7.30).
- Infuse
- A central venous catheter should be placed for the infusion of fluids and vasoactive agents and to guide fluid therapy.
- A pulmonary artery catheter should be inserted for monitoring of blood pressure and blood sampling unless shock is rapidly reversed. (Indications)
- An infusion of 300–500 ml of crystalloid fluid is usually administered during a period of 20–30 minutes.
- End point of fluid therapy can be defined as a central venous pressure (CVP) of a few millimeters of mercury (mmHg) above the baseline to prevent fluid overload.[9]
- Pump
- Vasopressors are indicated in hypotension that is severe or refractory to fluid challenge.
- Norepinephrine (0.1–2.0 μg/kg/min IV) is the first choice of vasopressor, while epinephrine (0.1–0.5 μg/kg/min IV) is reserved for severe hypotension as the second-line agent.
- Isoproterenol (0.5–5.0 μg/min IV) should be limited to the treatment of hypotensive patients with severe bradycardia.
- Adjunctive vasopressin (0.01–0.04 U/min IV) to norepinephrine should be considered only in hyperdynamic phase of distributive shock.
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) - ↑ Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 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) - ↑ Vincent, JL.; De Backer, D. (2013). "Circulatory shock". N Engl J Med. 369 (18): 1726–34. doi:10.1056/NEJMra1208943. PMID 24171518. Unknown parameter
|month=
ignored (help) - ↑ Weil, MH.; Shubin, H. (1969). "The VIP approach to the bedside management of shock". JAMA. 207 (2): 337–40. PMID 5818156. Unknown parameter
|month=
ignored (help) - ↑ Dellinger, RP.; Levy, MM.; Rhodes, A.; Annane, D.; Gerlach, H.; Opal, SM.; Sevransky, JE.; Sprung, CL.; Douglas, IS. (2013). "Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012". Crit Care Med. 41 (2): 580–637. doi:10.1097/CCM.0b013e31827e83af. PMID 23353941. Unknown parameter
|month=
ignored (help)