Sandbox/00008

Revision as of 02:55, 28 April 2014 by Gerald Chi (talk | contribs)
Jump to navigation Jump to search
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]



FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[1]

Boxes in the red 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 end-organ hypoperfusion

❑  Altered mental status
❑  Cold extremities
❑  Cyanosis
❑  Oliguria (urine output <0.5 mL/kg/h)
❑  Sustained hypotension
❑  SBP <90 mm Hg for ≥30 min or
❑  MAP ↓ >30 mm Hg below baseline for ≥30 min
❑  Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiogenic shock suspected
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate workup

❑  CBC/DC/SMA-7/LFT/PT/PTT/INR

❑  Cardiac troponins, CK-MB

❑  BNP, NT-proBNP

❑  Lactate

❑  12-Lead ECG

❑  Chest radiograph

❑  Echocardiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiogenic shock confirmed
(click for details on criteria)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preload (click for details)

❑  Goal: PCWP 15–18 mm Hg, CVP 8–12 cm H2O

❑  Fluid challenge protocol

❑  ± Correct pulmonary congestion

❑  ± Furosemide 40 mg slow IV injection
❑  ± Morphine 2–4 mg slow IV injection
 
 
 
 
 
 
 
 
Afterload (click for details)

❑  Goal: MAP >60 mm Hg, SVR 800–1200 dyn·s·cm−5

❑  If ↑ MAP & ↑ SVR: wean vasopressors ± vasodilators
❑  If ↓ MAP & ↑ SVR: vasopressors + inotropes
❑  If ↓ MAP & ↓ SVR: vasopressors ± vasopressin
 
 
 
 
 
 
 
 
Cardiac index (click for details)

❑  Goal: CI >2.2 L/min/m2

❑  ± Dobutamine
❑  ± Milrinone
❑  ± IABP, VAD, or ECMO if refractory
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate goals

❑  SaO2 >90%–92%

❑  MVO2 >60%

❑  ScvO2 >70%

❑  Urine output >0.5 mL/kg/h

❑  Lactate <2.2 mM/L

❑  Hemoglobin >7–9 g/dL

❑  ± Correct arrhythmia

❑  ± Correct electrolyte disturbance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute myocardial infarction likely? (click for details)

❑  Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)

❑  Symptoms of myocaridal ischemia

❑  New significant ECG findings of myocardial ischemia

 
YES, then manage as
UA/NSTEMI
and proceed to
acute ischemia pathway
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No, then proceed to
complete diagnostic approach
 
 
 
 
 
 
 
 


Do's

Criteria for Cardiogenic Shock [Return to FIRE]

Hemodynamic Optimization

Preload [Return to FIRE]

Fluid Challenge Protocol[9]
  • 1. Type of fluid
  • The choice of crystalloid or colloid solution should be made on the basis of the underlying disease, the nature of fluid deficit, the severity of circulatory failure, the serum albumin concentration, and the risk of bleeding.
  • 2. Rate of infusion
  • Based on the baseline of central venous pressure or pulmonary capillary wedge pressure, a volume of 50, 100, or 200 ml of fluid is administered over a 10-minute interval through a peripheral venous catheter.
  • 3. Clinical end points
  • Fluid challenge with predetermined boluses should be titrated to reach hemodynamic and clinical endpoints.
  • Vasopressors, inotropes, mechanical circulatory assistance, or ECMO may be considered if end-organ hypoperfusion persists despite adequate ventricular filling pressure.
  • 4. Pressure safety limits



  • Dosage and Administration
  • Contraindications
Pulmonary Congestion
PCWP (mm Hg) Phase of Pulmonary Congestion Findings on Chest Radiograph
18–20 Onset of pulmonary congestion Redistribution of pulmonary flow to the upper lobes ("cephalization") and Kerley lines
20–25 Moderate congestion Diminished clarity of the borders of medium-sized pulmonary vessels ("perihilar haze")
25–30 Severe congestion Radiolucent grapelike clusters surrounded by radiodense fluid ("periacinar rosette")
>30 Onset of pulmonary edema Coalescence of periacinar rosettes resulting in "Bat's wing" opacities
  • Dosage and Administration
  • For acute pulmonary edema, the initial dose is 40 mg injected slowly intravenously (over 1 to 2 minutes).
  • If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).
  • Contraindications
  • Dosage and Administration
  • Slow IV injection 2–4 mg (over 1–5 minutes) every 5–30 minutes as needed.
  • Contraindications





Afterload [Return to FIRE]

Cardiac Index [Return to FIRE]

Criteria for Acute Myocardial Infarction [Return to FIRE]

  • Detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin) with at least one value above the 99th percentile upper reference limit and with at least one of the following:[15]



References

  1. 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.
  2. 2.0 2.1 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)
  3. Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter |month= ignored (help)
  4. 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)
  5. 5.0 5.1 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)
  6. 6.0 6.1 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)
  7. 7.0 7.1 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)
  8. Crexells, C.; Chatterjee, K.; Forrester, JS.; Dikshit, K.; Swan, HJ. (1973). "Optimal level of filling pressure in the left side of the heart in acute myocardial infarction". N Engl J Med. 289 (24): 1263–6. doi:10.1056/NEJM197312132892401. PMID 4749545. Unknown parameter |month= ignored (help)
  9. Weil, MH.; Henning, RJ. "New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture". Anesth Analg. 58 (2): 124–32. PMID 571235.
  10. "NOREPINEPHRINE BITARTRATE INJECTION".
  11. 11.0 11.1 11.2 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 1616690003.
  12. "FUROSEMIDE INJECTION [AMERICAN REGENT, INC.]".
  13. "MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE".
  14. 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)
  15. Thygesen, K.; Alpert, JS.; Jaffe, AS.; Simoons, ML.; Chaitman, BR.; White, HD.; Thygesen, K.; Alpert, JS.; White, HD. (2012). "Third universal definition of myocardial infarction". J Am Coll Cardiol. 60 (16): 1581–98. doi:10.1016/j.jacc.2012.08.001. PMID 22958960. Unknown parameter |month= ignored (help)