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]
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
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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 | |||||||||||||||||||||||
Cardiogenic shock confirmed (click for details) | |||||||||||||||||||||||
Hemodynamic optimization: preload
❑ Goal: PCWP 14–18 mm Hg
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Hemodynamic optimization: afterload
❑ Goal: MAP >60 mm Hg, SVR 800–1200 dyn·s·cm−5
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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
Immediate management [Return to FIRE]
- 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.
Criteria for Cardiogenic Shock [Return to FIRE]
- 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).
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:[12]
- Symptoms of ischemia
- New or presumably new significant ST-segment–T wave (ST–T) changes or new left bundle branch block (LBBB).
- Development of pathological Q waves in the ECG.
- Imaging evidence of new loss of viable myocardium or new region wall motion abnormality.
- Identification of an intracoronary thrombus by angiography or autopsy.
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.
- ↑ "NOREPINEPHRINE BITARTRATE INJECTION".
- ↑ 4.0 4.1 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) - ↑ Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter
|month=
ignored (help) - ↑ 8.0 8.1 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) - ↑ 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)