Cardiogenic shock, etc. Blonder

Question 1

Cardiogenic shock- importance

Answer 1

This is BIG trouble!
Cardiogenic Shock requires the highest level of care available in your hospital system, including nursing, CV technicians, Anesthesiologists, Cardiovascular Surgeons and Clinical Cardiologists.

Question 2

Most cases of CS

Answer 2

Most cases are the result of Acute MI. Some with mechanical tissue disruption producing a VSD or Acute Severe Mitral Regurgitation.

Fewer cases are chronic CHF that decompensate and “spirals” down with hypotension decreasing CO thus decreasing BP, urine output, coma, death.

Question 3

cardiogenic shock defn

Answer 3

Inadequate tissue perfusion due to cardiac dysfunction.
It is the combination of Hypotension and Pulmonary Edema.
Patient is wet and hypoperfused (cool)

Question 4

CS secondary to AMI

Answer 4

CS complicates 6% of acute MI’s.

Most are STMI, but some are NSTMI, especially in people with prior MI. MI’s “add-up”

Question 5

CS mortality

Answer 5

Mortality used to be 90%
Now it is lower 48% (2004)
This is because of faster treatment with IABP and direct PCI (stenting).

Question 6

CS Predictors of Mortality:

Answer 6

Advancing age
Prior MI
Shock physical findings
Oliguria

Symptom onset to reperfusion time also determines benefit and lower mortality.
less than 2 hours 6% mortality rate.
Up to 12 hours.

Question 7

CS Coronary anatomy

Answer 7

Most patients have severe and extensive CAD
Triple vessel disease
Left Main disease

Question 8

CS echo predictors

Answer 8

lower EF and MR severity

Question 9

CS meds

Answer 9

Meds
ASA, Heparin, IIb,IIIa, Inhibitors
Avoid BB
Drips: Dopamine, Dobutamine, Norepinephrine, Milrinone

Question 10

things to keep an eye on in CS

Answer 10

Hemodynamic monitoring
Volume 
Ventilator
IABP- the Adrian Kantrowitz MD story
LVAD-Left Ventricular Assist Device

Question 11

treating CS

Answer 11

PCI is preferred over Fibrinolytics and has better outcomes.
I usually have the patient intubated on a Vent in the cath lab.
Often it is very helpful to have an Anesthesiologist in the cath lab

Question 12

when does CS need to be treated by emergent surgery?

Answer 12

If the patient has Acute Severe MR or a VSD it needs to be treated by emergent surgery.

Question 13

Shock from end stage CHF- treatment

Answer 13

This may be treated with an LVAD (Left Ventricular Assist Device), as a bridge to transplant or as a destination treatment

Question 14

PAD

Answer 14

Atherothrombotic (Atherosclerosis) of the Lower Extremity Arteries

May be either progressive arterial narrowing or arterial-arterial embolization of atherothrombotic debris

Question 15

pad symptoms due to?

Answer 15

an imbalance of supply (arterial) and demand (muscles), similar to angina

Question 16

PAD Risk Factors-ACC Guidelines

Answer 16

1. Age >70
2. Age 50-69 with a history of smoking or DM
3. Leg symptoms of intermitant claudication, from Latin for “Limp”, or rest pain
4. Abnormal LE pulse exam
5. Known atherothrombosis of other sites

Question 17

Some things we see with PAD

Answer 17

Advances with age, so with the ageing population it is increasing
Always ask about LE pain upon walking, in your H&P. May be Buttocks, hips, calf or foot.
Leriche Syndrome triad of intermitant claudication, absent or diminshed femoral pulses and erectile dysfunction

Question 18

Blue Toes Syndrome

Answer 18

-due to peripheral embolization of atherthrombotic material from proximal atheroma, often from the aorta

Question 19

PAD Clinical Presentations:

Answer 19

1. Asymptomatic 20-50%
2. Atypical Leg Pain 40-50%
3. Classic Claudication 10-35%
4. Threatened Limb 1-2%

Question 20

The presence of PAD is a risk factors for

Answer 20

other vessels having atherothrombotic disease, including Carotid (stroke), Coronary (ACS, etc), Renal (CKI, Hypertension Renovascular)

Question 21

Asymptomatic PAD

Answer 21

Diagnosed by screening:
PE with careful palpation of pulses to include Femoral, Popliteal, DP and PT (LE)
Brachial, radial, ulnar in the UE
Bruits, skin color and temperature, presence of skin ulcers and wounds

Question 22

PAD Exam

Answer 22

should be supine after 15 minutes of rest, allowing the patient to “warm up” if it is cold outside
Use Doppler for more accurate assement when necessary

Question 23

Critical PE component for PAD

Answer 23

ABI is critical.
The Ankle-Brachial Index is the Systolic BP in the arm (highest UE) compared to the Ankle SBP, ie 1.0 would be equal pressures in A/B systolic pressures
Correlation is general with ABI and symptoms:
Claudication: 0.4-0.9
Rest Pain: 0.2-0.4
Tissue Loss: 0.0-0.4

ABI less than 0.90 with no or mild/moderate symptoms has a high degree of sensitivity for PAD

Question 24

Buerger Test

Answer 24

Patient supine, elevate foot (25 cm) drain venous blood, then make foot dependant, it should take less than 20 seconds for foot to refill, more time indicates severe PAD

Question 25

ABI and exercise testing - PAD

Answer 25

Exercise testing will show a drop of the ABI by 0.2 in patients with significant PAD, who have normal ABIs at rest.
The exercise test will also demonstrate the time to claudication, how will this help your patient?

Question 26

Gangrene and PAD

Answer 26

1. Dry-hard dry texture, distal toes and fingers, clear demarcation between viable and black necrotic tissue. This is common.
2. Wet-moist appearance, gross swelling, blistering. Less common and indicative of an emergeny.

Question 27

Ulceration and non-healing wounds are signs of

Answer 27

severe rest ischemia. Always think PAD when assessing LE wounds so you don’t miss the diagnosis.

Question 28

PAD and neuro exam

Answer 28

A Neurologic exam of the LE’s is essential to rule out Peripheral Neuropathy.

Remember “Fleas and Lice”, many of the patients with PAD have DM and PN.