Sandbox/00007
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]
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 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
| |||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||
Cardiogenic shock suspected | Proceed to shock resident survival guide | ||||||||||||||||||||||
Immediate management (click for details)
❑ Intubation with mechanical ventilation ❑ ± Norepinephrine 0.5–1.0 μg/min IV infusion | |||||||||||||||||||||||
Immediate Workup
❑ Lactate ❑ Hold antihypertensive medications | |||||||||||||||||||||||
Cardiogenic shock confirmed (click for details on criteria) | |||||||||||||||||||||||
Hemodynamic Optimization (click for details) | |||||||||||||||||||||||
Preload
❑ Goal: PCWP 15–18 mm Hg ❑ ± Correct pulmonary congestion
| |||||||||||||||||||||||
Afterload
❑ Goal: MAP >60 mm Hg, SVR 800–1200 dyn·s·cm−5
| |||||||||||||||||||||||
Immediate goals for oxygenation and perfusion
❑ 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 | |||||||||||||||||||||||
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 | |||||||||||||||||||||||
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.
- Dosage and Administration
- Mix 1 ampule (4 mg) of norepinephrine in 250 mL of D5W or D5NS. Avoid dilution in normal saline alone.
- Initial dose: 0.5–1.0 μg/min IV infusion; titrate to raise blood pressure (up to 30–40 μg/min).
- Contraindications
- Norepinephrine should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed.
- Norepinephrine should also not be given to patients with mesenteric or peripheral vascular thrombosis unless it is necessary as a life-saving procedure.
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).
Hemodynamic Optimization [Return to FIRE]
- Preload: the goal is to maintain a PCWP of 15–18 mm Hg and to correct pulmonary congestion[7][8][9][10]
-
- Radiologic manifestations of pulmonary congestion reflect the extent of elevation in wedge pressure:
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
- Hypersensitivity to morphine sulfate is one of the contraindications to its use.
- Morphine should not be used in convulsive states, such as those occurring in status epilepticus, tetanus, and strychnine poisoning.
- Morphine is also contraindicated in the following conditions: respiratory insufficiency or depression; bronchial asthma; heart failure secondary to chronic lung disease; cardiac arrhythmias; increased intracranial or cerebrospinal pressure; head injuries; brain tumor; acute alcoholism; and delirium tremens.
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:[14]
- 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.
- Do not administer normal saline in the presence of pulmonary edema.
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 4.2 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 1616690003.
- ↑ Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter
|month=
ignored (help) - ↑ 6.0 6.1 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) - ↑ 7.0 7.1 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) - ↑ 8.0 8.1 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) - ↑ 9.0 9.1 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) - ↑ 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) - ↑ "FUROSEMIDE INJECTION [AMERICAN REGENT, INC.]".
- ↑ "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) - ↑ 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)