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 is decreased cardiac output with evidence of tissue hypoperfusion in the presence of adequate intravascular volume. Hemodynamic criteria include sustained hypotension (systolic blood pressure <90 mm Hg for at least 30 minutes) and a reduced cardiac index (<2.2 L/min/m2) in the presence of elevated pulmonary capillary wedge pressure (>15 mm Hg).[1][2]
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
- 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 shock?
❑ Arterial hypotension ❑ Signs of 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.[4]
- 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.[5]
- 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
- ↑ 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) - ↑ 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)