326 Cardiogenic Shock and Pulmo Edema Flashcards
Most common etiology of Cardiogenic shock
Severe LV dysfunction
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 (?)
Cardiac index <2.2 L/min/m2
<90 Systolic BP
PCP >18 mmHg
Shock is more common with STEMI than with NSTEMI. True or False.
True. Kaya peborit ni bossing.
Patient profile of CS
Old, female, with prior MI, diabetes, anterior MI, extensive CAD
When does shock occur in patients with MI?
1/4 on admission
1/4 within 6h onset
1/4 within 1st day
1/4 etc
A potent vasconstrictor and inotropic stimulant useful for patients with CS. Used as FIRST LINE, associated with fewer adverse effects.
Norepinephrine (2 to 4ug/min)
Max dose 15 ug/min
Dopamine has varying hemodynamic effects based on dose, what are these doses?
< 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
A synthetic sympathomimetic amin with Positive inotropic and minimal chronotropic activity at low doses, moderate chronotropic at higher doses.
Dobutamine
10ug/kg/min
Diagnosis: Acute pulmonary edema, BP >100 mmHg, what do you give? (Aside from furo, morphine, o2, nitroglycerin)
ACE inhibitor (Captopril 6.25mg)
Figure 326-2 pg. 1761
Diagnosis: Acute pulmonary edema, BP <100 mmHg, with signs and symptoms of shock, what pressors do you give?
Norepinephrine or Dopamine
Figure 326-2 pg. 1761
Diagnosis: Low output Cardiogenic shock, BP >100 mmHg, what wil you give?
Nitroglycerin 10 to 20ug/min IV
Figure 326-2 pg. 1761
Diagnosis: Low output Cardiogenic shock, BP 70 to 100mHg, no signs of shock, what pressor?
Dobutamine 2 to 20 ug/kg per minute
Figure 326-2 pg. 1761
Diagnosis: low output cardiogenic shock, BP <100 mmHg with signs of shock
Norepinephrine or Dopamine
Figure 326-2 pg. 1761
Trial that demonstrated that lives were saved with early revascularization with PCI or CABG compared with medical therapy.
SHOCK Trial.
Features of RV shock
Absence of pulmonary congestion, high right atrial pressure, RV dilatation and dysfunction; mildly depressed LV function, RCA occlusion
Management of RV shock
Fluids
Treatment for Acute severe MR due to papillary muscle dysfunction
Surgery
Case: Sudden loss of pulse, bp and consciousness but sinus rhtym on ECG (PEA) due to cardiac tamponade. Impression?
Free wall rupture
May occur during 1st week of symptoms, increases with age.
Tx: Surgical
Benefits of Mechanical ventilation with PEEP
1) decreases both preload and afterload
2) redistributes lung water from intraalveolar toextraalveolar space
3) increases lung volume
Diuretic of choice that rapidly reduces PRELOAD, venodilators
Loop diurectics
Primarily act as venodilators but also has coronary vasodilating effect; first line therapy for acute pulmonary edema
Nitrates.
Transient venodilator, reduces preload while relieving dyspnea and anxiety
Morphine 2-4 mg IV boluses
Reduce both afterload and preload, recommended for HPN patients, reduces mortality rates
ACE inhibitors
Potent vasodilator with diuretic properties, effective in cardiogenic pulmonary edema; reserved for refractory patients
Nesiritide
Inodilators stimulate myocardial contractility while promoting peripheral and pulmonary vasodilation.
Indicated in patients with cardiopulmonary edema and severe LV dysfunction
Milrinone
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
Digoxin
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.
ECMO.
May develop after removal of longstanding pleural space air or fluid.
Symptoms: hypotension, oliguria
Reexpansion pulmonary edema
Treatment for Reexpansion edema:
Intravascular volume repletion with Oxygenation
CONTRAINDICATED: Diuretics and preload reduction
Treatment for high-altitude pulmonary edema
Dexamethasone, CCBs, B adrenergic agonists
Descent from altitude, bedrest, O2, inhaled NO, nifedipine
