326 Cardiogenic Shock and Pulmo Edema

Question 1

Most common etiology of Cardiogenic shock

Answer 1

Severe LV dysfunction

Question 2

Cardiogenic Shock (CS) characterized by systemic hypoperfusion due to severe depression of cardiac index (?) and sustained arterial hypotension (?) despite an elevated filling pressure PCP (?)

What are the values (?)

Answer 2

Cardiac index <2.2 L/min/m2
<90 Systolic BP
PCP >18 mmHg

Question 3

Shock is more common with STEMI than with NSTEMI. True or False.

Answer 3

True. Kaya peborit ni bossing.

Question 4

Patient profile of CS

Answer 4

Old, female, with prior MI, diabetes, anterior MI, extensive CAD

Question 5

When does shock occur in patients with MI?

Answer 5

1/4 on admission
1/4 within 6h onset
1/4 within 1st day
1/4 etc

Question 6

A potent vasconstrictor and inotropic stimulant useful for patients with CS. Used as FIRST LINE, associated with fewer adverse effects.

Answer 6

Norepinephrine (2 to 4ug/min)

Max dose 15 ug/min

Question 7

Dopamine has varying hemodynamic effects based on dose, what are these doses?

Answer 7

< 2ug/kg : Dilates renal vascular bed

2-10 ug/kg/min : chronotropic and inotropic (B adrenergic stimulation

Higher doses: a adrenergic stimulation, vasoconstriction

Max 20-50 ug/kg/min

Question 8

A synthetic sympathomimetic amin with Positive inotropic and minimal chronotropic activity at low doses, moderate chronotropic at higher doses.

Answer 8

Dobutamine

10ug/kg/min

Question 9

Diagnosis: Acute pulmonary edema, BP >100 mmHg, what do you give? (Aside from furo, morphine, o2, nitroglycerin)

Answer 9

ACE inhibitor (Captopril 6.25mg)

Figure 326-2 pg. 1761

Question 10

Diagnosis: Acute pulmonary edema, BP <100 mmHg, with signs and symptoms of shock, what pressors do you give?

Answer 10

Norepinephrine or Dopamine

Figure 326-2 pg. 1761

Question 11

Diagnosis: Low output Cardiogenic shock, BP >100 mmHg, what wil you give?

Answer 11

Nitroglycerin 10 to 20ug/min IV

Figure 326-2 pg. 1761

Question 12

Diagnosis: Low output Cardiogenic shock, BP 70 to 100mHg, no signs of shock, what pressor?

Answer 12

Dobutamine 2 to 20 ug/kg per minute

Figure 326-2 pg. 1761

Question 13

Diagnosis: low output cardiogenic shock, BP <100 mmHg with signs of shock

Answer 13

Norepinephrine or Dopamine

Figure 326-2 pg. 1761

Question 14

Trial that demonstrated that lives were saved with early revascularization with PCI or CABG compared with medical therapy.

Answer 14

SHOCK Trial.

Question 15

Features of RV shock

Answer 15

Absence of pulmonary congestion, high right atrial pressure, RV dilatation and dysfunction; mildly depressed LV function, RCA occlusion

Question 16

Management of RV shock

Answer 16

Fluids

Question 17

Treatment for Acute severe MR due to papillary muscle dysfunction

Answer 17

Surgery

Question 18

Case: Sudden loss of pulse, bp and consciousness but sinus rhtym on ECG (PEA) due to cardiac tamponade. Impression?

Answer 18

Free wall rupture
May occur during 1st week of symptoms, increases with age.
Tx: Surgical

Question 19

Benefits of Mechanical ventilation with PEEP

Answer 19

1) decreases both preload and afterload
2) redistributes lung water from intraalveolar toextraalveolar space
3) increases lung volume

Question 20

Diuretic of choice that rapidly reduces PRELOAD, venodilators

Answer 20

Loop diurectics

Question 21

Primarily act as venodilators but also has coronary vasodilating effect; first line therapy for acute pulmonary edema

Answer 21

Nitrates.

Question 22

Transient venodilator, reduces preload while relieving dyspnea and anxiety

Answer 22

Morphine 2-4 mg IV boluses

Question 23

Reduce both afterload and preload, recommended for HPN patients, reduces mortality rates

Answer 23

ACE inhibitors

Question 24

Potent vasodilator with diuretic properties, effective in cardiogenic pulmonary edema; reserved for refractory patients

Answer 24

Nesiritide

Question 25

Inodilators stimulate myocardial contractility while promoting peripheral and pulmonary vasodilation.

Indicated in patients with cardiopulmonary edema and severe LV dysfunction

Answer 25

Milrinone

Question 26

once mainstay because of their inotropic function. may be useful for control of rate with AF or flutter and LV dysfunction; they do not inhibit AV nodal conduction

Answer 26

Digoxin

Question 27

For patients with acute severe non cardiogenic edema with possible reversible cause, this may be used as temporizing supportive measure to achieve adequate gas exchange.

Answer 27

ECMO.

Question 28

May develop after removal of longstanding pleural space air or fluid.

Symptoms: hypotension, oliguria

Answer 28

Reexpansion pulmonary edema

Question 29

Treatment for Reexpansion edema:

Answer 29

Intravascular volume repletion with Oxygenation

CONTRAINDICATED: Diuretics and preload reduction

Question 30

Treatment for high-altitude pulmonary edema

Answer 30

Dexamethasone, CCBs, B adrenergic agonists

Descent from altitude, bedrest, O2, inhaled NO, nifedipine