Cardiogenic Shock

Question 1

Physiologic triad of the classic and most common picture of Cardiogenic shock due to LV infarction

Answer 1

1. Low cardiac index
2. High systemic vascular resistance indices
3. Increase pulmonary capillary wedge pressure

low-high-high
CSP

Question 2

What to check in Echocardiogram in Cardiogenic Shock (8)

Answer 2

1. EF
2. Wall motion abnormality
3. Dilated RV
4. Pericardial Fluid
5. Valvular dysfunction
6. Aortic root <3cm
7. Volume status of IVC
8. Lungs for B line

Question 3

in cardiogenic shock, treatment of hypotension (SBP 90, or MAP <65)

Answer 3

1. If no evidence of pulmonary congestion - fluid boluses of 250-500ml and reassess
2. If pulmonary congestion is present or develops:
   a. If blood pressure is <90 mm Hg, combine dobutamine with dopamine or norepinephrine.
   i. If on β-blockers, administer MILRINONE as inotrope.

b. If blood pressure is <70 mm Hg, administer norepinephrine.

Question 4

Inotropes of choice for patient in cardiogenic shock, treatment of hypotension (SBP 90, or MAP <65) on beta blocker

Answer 4

Milrinone

Question 5

Role of Blood Gas Measurement in Cardiogenic Shock

Answer 5

Blood gas measurements help identify those at risk of acute respira- tory failure/carbon dioxide retention, quantify the presence and severity of acidosis, and determine the contribution of metabolic or respiratory components to acidosis.

Question 6

Signs of TAMPONADE in POCUS

Answer 6

1. Pericardial Effusion - 4chamber view
2. Dilation of IVC
3. Diastolic collapse of the RV with systolic collapse of the RA

Question 7

Best way to monitor hemodynamic status of patients with Cardiogenic Shock

Answer 7

Arterial blood pressure

a. Noninvasive blood pressure measurements may underesti- mate systolic pressure by >30 mm Hg; however, mean arterial pressure varies by only 1 to 2 mm Hg whether central or peripheral.

b. Arterial blood pressure monitoring allows accurate assessment of cardiovascular instability during resuscitation and is particularly useful when giving vasoactive medications.

c. Central venous pressure, an indirect indicator of central blood volume, can aid assessment of global volume status, but isolated values outside extremes to guide resuscitation in critically ill patients are less helpful

Question 8

Definitive intervention for acute ischemia-related cardiogenic shock

Answer 8

EMERGENT REVASCULARIZATION

Question 9

The following are the risk factors for cardiogenic shock, except
a. Previous MI
b. Hypertension
c. Diabetes
d. Elderly

Answer 9

B. Hypertension

RISK FACTORS FOR CARDIOGENIC SHOCK

Elderly
Female

Acute or prior ischemic event assoc with the following
- impaired EF
- Extensive infarct
- proximal LAD coronary artery occlusion
- Anterior MI
- Multivessel CAD

PMH
- Previous MI
- CHF
- Diabetes

Question 10

Inotrope to avoid if patient is on Beta Blocker

Answer 10

Dobutamine
- initial pharmacologic treatment
- 2-µ5km up to 20µkm
Inotrope and potential vasodilator (avoid if SBP <90); lowers blood pressure; give as individual agent as long as systolic blood pressure (SBP) ≥90 mm Hg. Can use with dopamine or norepinephrine. Avoid if on β-blocker.

Question 11

This inotrope is associated with systemic acidosis, tachycardia and dysrhythmia

Answer 11

Epinephrine