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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]
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.
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
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YES | NO | ||||||||||||||||||||||
Cardiogenic shock suspected | |||||||||||||||||||||||
Immediate management
❑ Intubation with mechanical ventilation ❑ ± IV bolus normal saline 100–200 mL ❑ ± Norepinephrine 0.1–2.0 μg/kg/min ❑ ± Control pain and/or anxiety
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Workup
❑ Lactate | |||||||||||||||||||||||
Immediate goals
❑ ± Correct arrhythmia ❑ ± Correct electrolyte disturbance | |||||||||||||||||||||||
Complete Diagnostic Approach
Treatment
Do's
- Initial Management
- Ventilatory support is crucial for maintenance of adequate oxygenation and usually requires intubation with mechanical ventilation.
- Optimization of hemodynamic status may be initially achieved by judicious administration of diuretics, vasopressors, vasodilators, inotropes, and/or intravenous fluids.
- IV bolus normal saline should be waived in the presence of pulmonary edema.
- End point of fluid therapy may be defined as a central venous pressure (CVP) of a few millimeters of mercury (mmHg) above the baseline to prevent fluid overload.[2]
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
- ↑ 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) - ↑ 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)