Management Of Cardiogenic Shock Flashcards
What is cardiogenic shock
This is a life threatening emergency in which the heart cannot pump enough blood to meet the body’s needs.
It is commonly associated with severe left ventricular (LV) dysfunction causing pulmonary congestion, systemic hypoperfusion, circulatory failure and clinical and biochemical evidence of tissue hypoxia.
List the aetiology of cardiogenic shock
ACUTE STEMI
Extensive infarction
Anterior MI
Multivessel CAD
MECHANICAL COMPLICATIONS
Severe MR
Ventricular Septal Rupture
Free wall rupture
Acute Cardiac tamponade
Severe LV or RV dysfunction
Acute decompensated HF
List the risk factors for cardiogenic shock
• Older age
• Female
• Anterior MI
• Hypertension
• Diabetes mellitus
• Multivessel coronary artery disease
• Previous MI
• Acute decompensated HF
List the clinical features of cardiogenic shock
• Severe hypotension (SBP <80 mm Hg) > 30 minutes or MAP that is 30mmHg lower than baseline
• Severe reduction of cardiac index (<1.8 L/min/m2 without support or <2 - 2.2 L/min per m2 with support and adequate or elevated filling pressures)
• Oliguria
• Altered mental status
• Cold, clammy extremities
• Palor
• Cyanosis
• Jaundice
• Peripheral edema may be present in the setting of fluid overload
• Respirartory distress with pulmonary vascular congestion +/- rales
• Peripheral pulses (faint,thready, rapid, irregular).
• Jugular venous distension
• Diminished heart sounds, S3 or S4, may be present, murmurs (valvular disorders /insufficiency)
Which investigations are important in cardiogenic shock?
• Complete blood Count
• Metabolic and electrolyte panel,
• Coagulation profile,
• Arterial blood gas+ Lactate
• Lactate
• Brain natriuretic peptide
• Cardiac enzyme assay
• Chest x-ray
• Serial ECG, Echo
• Coronary angiography
How would you manage a case of cardiogenic shock?
This is a medical emergency and must be managed as such.
1) Quick history to ascertain etiology and risk factors
2) Early restoration of coronary blood is the most important intervention and is the standard therapy for patients with cardiogenic shock due to myocardial infarction
3) Admit in Cardiac ICU/HDU: Mechanical ventilation may be required
MEDICAL MANAGEMENT
1) Intravenous Fluid therapy
- Plasma/volume expanders i.e 0.9%
Saline and ringers Lactate (avoid in
overload).
- Place central Line for optimal fluid
resuscitation and monitoring of
central venous pressure.
- Urethral catheter for optimal urine
output monitoring
- Arterial line placement where
available provides continuous blood
pressure monitoring
2) Inotropic Support
- Dobutamine (beta-1 and beta-2
agonist activity) improves
myocardial contractility, lower left
ventricular end-diastolic pressure,
and increases cardiac output.
- Milrinone Helps reduce left
ventricular filling pressures.
- Dopamine Positive inotropic
effect but may worsen PCWP. Also
predisposes to arrythmia
- Diuretic therapy Loop diuretics
reduce plasma volume overload
and oedema with an increase in
peripheral vascular resistance.
- Antiplatelet therapy Mortality
reduction in patients with ACS
- Fibrinolytics therapy For
patients who are unsuitable for
either percutaneous coronary
intervention or coronary artery
bypass graft.
NB:- Norepinephrine not used as 1st line. Causes tachycardia and increases myocardial oxygen demand.
REPERFUSION
- Percutaneous coronary intervention for pxs with acute STEMI and NSTEM as aetiology
- Coronary artery bypass graft for px with significant left main coronary artery dx, Multivessel dx/ three vessel dx and those with mechanical complications of MI
MECHANICAL ASSIST DEVICE
- Intra-aortic ballon pump (IABP)
- Left ventricular assist device (LVAD)
- Percutaneous left atrial-to-femoral arterial ventricular assist device (TandemHeart).
- Percutaneous cardiopulmonary bypass support + extracorporeal membrane oxygenator (ECMO).
What are the complications of cardiogenic shock?
• Dysrhythmias
• Cardiac arrest
• Renal failure
• Ventricular aneurysm
• Stroke
• Thromboembolism
• Death
