Week 4 - Cardiogenic Shock

Question 1

what is cardiogenic shock?

Answer 1

• occurs when the hearts pumping ability is compromised to the point at which it cannot maintain cardiac output and adequate tissue perfusion
• HEARTS ABILITY TO CONTRACT AND TO PUMP BLOOD IS IMPAIRED LEADING TO DECREASED CO

Question 2

COMMON CAUSES FOR

CARDIOGENIC SHOCK

Answer 2

• Myocardial Infarction (most common)
• Arrhythmias
• Cardiomyopathies
• Severe Hypoxemia
• Acidosis
• Cardiac Surgery
• Valvular Issues

HINT: ‘MACSAC V’

Question 3

_____________ is the most common

cause of cardiogenic shock

Answer 3

Myocardial Infarction

Question 4

OVERALL GOALS R/T MEDICAL

MANAGEMENT OF PT

W/CARDIOGENIC SHOCK

Answer 4

• Limit further damage to the myocardium and preserve healthy tissue
• Improve cardiac output
• Identify underlying cause and correct it

Question 5

Name three (3) types of Colloids

Answer 5

Albumin (Naturally Occurring) Dextran , Hetastarch (synthetics)

Question 6

How does albumin help with shock?

Answer 6

• Albumin is a large molecule
• Water is attracted to the large molecule

If we give a patient Albumin then we are able to HOLD onto fluid in the vascular space.

Question 7

Albumin is a naturally occurring colloid.

What are the two SYNTHETIC colloids?

Answer 7

• Dextran
• Hetastarch

Question 8

Do you need two nurses to administer Albumin?

Answer 8

No. Even though ALBUMIN is a “blood product” it does not go through all the same checks as other blood products do.

• you do NOT need two nurses for administration, and
• you do NOT need any special tubing or filter tubing for administration.

IMPORTANT TO NOTE: ^{Patients that often refuse “blood products” (ie, Jehovahs Witness) WILL refuse Albumin because the albumin is synthesized out from blood that is donated}

Question 9

Colloids can affect platelet adhesion causing//

Answer 9

causing our patients an increased risk of bleeding

Question 10

(True / False)

Colloids ^{<strong>(Albumin, dextran, Hetastarch)</strong>} reduce platelet

adhesiveness and is associated with reductions is blood coagulation.

Answer 10

TRUE

• We should be monitoring the clients:^{(values listed below are the normal lab values)}
  
  • PT 10-15 seconds
  • INR 1 - 1.2 seconds
  • Platelets 150,000 - 400,000 /mm³
  • aPTT < 35 sec

Question 11

True / False Primary medications for cardiogenic shock consist mostly of DILATORS and INOTROPES?

Answer 11

TRUE

Question 12

In cardiogenic shock–should we stimulate the BETA receptors?

Answer 12

NO–because this will end up making the heart work harder than it needs to

Question 13

Why are DILATORS good for pts with Cardiogenic shock–

Answer 13

It dilates leaving less work load on the heart

Question 14

if cardiogenic shock patient is BRADYCARDIC we might need _________ and/or a __________

Answer 14

ATROPINE PACEMAKER

Question 15

>

Medical Management of

Cardiogenic Shock

Answer 15

• Supplement the hearts own functioning w/ meds/devices
• Control Chest Pain
• Fluid Management
  
  • Be conservative ^{(dont want to overload their heart)}
• Diuretics
  
  • ^{may be needed to get rid of excess volume so heart can function better}
• Colloids
  
  • Albumin ^{<strong>(naturally occurring colloid)</strong>}
  • Dextran ^(synthetic)
  • Hetastarch ^(synthetic)
• VASOACTIVE MEDS
  
  • Primarly given:
    
    • DILATORS
    • INOTROPES ^{(Dobutamine—strictly there to strengthen the contraction but doesnt increase heart rate)}
  • ^{(in extreme cases vasoconstriction is necessary to maintain MAP)}
• CONTROLLING/SUPPORTING HEART RATE/RHYTHM
  
  • ​If Bardycardic- ^{use ATROPINE and possibly a pacemaker}
• ASSISTIVE DEVICES
  
  • IABP
  • LVAD
  • ECMO
• LABS
  
  • _{Brain Natriuretic Peptide} ^(BNP)
    
    • >100 pg/mL^{(can be indicative of heart failure)}
  • _{Creatinine Kinase} ^(CK)
    
    • > 200 U/L ^{(indicative of muscle damage)}
  • _Troponin
    
    • > 0.4 ng/mL
• EKG
• ECHO (u/s of heart)

Question 16

Important Labs / Diagnostics to check (Cardiogenic Shock)

Answer 16

NORMAL BNP <100 pg/mL **Labs will be ELEVATED NORMAL CK 22 - 198 U/L **Labs will be ELEVATED NORMAL TROPONIN 0 - 0.4 ng/mL **Labs will be ELEVATED **ECHOCARDIOGRAM **EKG

Question 17

medications that act directly on the smooth muscle, relaxing arterioles and veins

Answer 17

vasodilators

Question 18

How to Vasodilators affect the heart

Answer 18

• acts directly on the smooth muscle, relaxing both arterioles and veins
  
  • RESULTS In…..decreased O₂ demands of the heart
    
    • ^{Decreased PRELOAD}
    • ^{Decreased AFTERLOAD}
• • ^{<strong>Examples: </strong> Nitroglycerin, Nitroprusside}

Question 19

Nursing management of Cardiogenic Shock

Answer 19

• Recognition of S/S
  
  • Poor perfusion? Cyanosis? Chest pains? Arrhythmias?
• Monitoring hemodynamic status
  
  • CVP- make sure pt isnt overloaded with fluid
  • Pulmonary Artery Catheter
  • Vasodilators can lead to rebound tachycardia and increases O₂ demands of the heart
• Administering fluids and medications
  
  • Closely watch for fluid overload
  • Complications of vasoactives
• Management of Assistive Devices

Question 20

(TRUE / FALSE) Pulmonary Artery Catheter sits in the PA and measures the pressures in the lungs and left side of the heart and measures cardiac output

Answer 20

TRUE

Question 21

Reasons for a Pulmonary Artery Catheter

Answer 21

1) Early detection/treatment of life threatening conditions of the heart and lung
2) Evaluation of clients immediate response to treatment
3) Evaluation of the effectiveness of Central Venous function

Question 22

Assistive devices (3) sometimes

used in the management of

Cardiogenic Shock

Answer 22

Intra-Aortic Balloon Pump (IABP)

Left Ventricular Assist Device

Extracorporeal membrane oxygenation

Question 23

What does the IABP do?

^{Intra-Aortic Balloon Pump}

Answer 23

• Mechanical device used to:
  
  • Increase myocardial oxygen perfusion
  • Increase cardiac output

Placed through femoral artery via sheath

filled with helium

sits distal to left subclavian artery

^{<em><u>INFLATES on diastole to IMPROVE LV Volume and perfuse coronary arteries</u></em>}

^{DEFLATES on systole to pull blood out of LV (via vacuum effect)–decreased afterload}

Question 24

Complications of IABP

Answer 24

• Lower Extremity Compromise
  
  • Ischemia
  • Compartment Syndrome —-_{Pain, Pallor, Pulse, Paresthesia, Paralysis}
  • Infection
  • Aortic Dissection (tear in Aorta)
  • Device Malfunction

Question 25

Indications for IABP

Answer 25

• Cardiogenic Shock- ^{b/c it supports functioning of the heart}
• Post-Op cardiac surgery- ^{as temporary/supportive measure}
• Cardiac^{<em> (mechanical)</em>} defects
  
  • Mitral Valve Regurgitation
  • septal perforation

Question 26

Circulatory DEVICE that is used

to partially (or completely) replace

the function of a failing heart

Answer 26

Left Ventricular Assist Device (LVAD)

Question 27

What is a LVAD

Answer 27

Left Ventricular Assist Device (LVAD)

–it is used to partially or completely replace the function of a failing heart

Question 28

How long can you use a LVAD?

Answer 28

• SHORT TERM:
  
  • ^{following a MI or heart surgery to prevent / treat cardiogenic shock}
• LONG TERM:
  
  • ^{used with severe Heart Failure (EF 5 - 10%)}
  • ^{often used as a bridge to transplant}

Question 29

What is ECMO

Answer 29

• Extracorporeal Membrane Oxygenation –advanced life support technique –provides long term breathing / heart support *blood is taken outside the body-oxygenate, warmed, CO2 removed, then pumped back into the body

Question 30

Types (2) of set-up for the ECMO

Answer 30

VENO-ARTERIAL (vein to artery) —Primarily cardiac failure w/ respiratory support VENO-VENOUS (Vein to Vein) —Primarily for Respiratory failure (ARDS)

Question 31

CARIOGENIC SHOCK (RIGHT SIDED)

^{<em><strong>FLUIDS</strong>…?? </em>}

^{<em><strong>First-Line Agent(s):… Second-Line Agent(s)…??</strong></em>}

Answer 31

1) FLUID:

Crystalloid (20 mL / kg)

2) 1st line tx:

Vasopressors directed at cause of right heart failure

Dopamine (with signs of shock)-^{<em>increased rate and contractility</em>}

Dobutamine (w/o signs of shock)-^{<em><strong>increased contractility</strong></em>}

3) 2nd line tx:

additional Vasopressors PRN

Dopamine -^{<em>increased rate and contractility</em>}

Epinephrine^{<em><strong>-increased rate and contractility</strong></em>}

Milrinone (severe CHF or RV infarct)

Question 32

CARIOGENIC SHOCK (LEFT - SIDED) FLUIDS…?? First-Line Agent(s):… Second-Line Agent(s)…??

Answer 32

1) FLUID:

IV fluids as appropriate-^{use caution with CHF}

2) 1st line tx:

Dobutamine (w/o signs of shock)-^{increased contractilit}

Norepinephrine (with signs of shock)- ^{initiates vasoconstriction}

3) 2nd line tx:

Dobutamine and Norepinephrine

Epinephrine-^{<strong>increased rate and contractility</strong>}

Milrinone ^{<em><strong>(severe CHF or RV infarct)</strong></em>}

Question 33

LVAD

Left Ventricular

Assist Device

Answer 33

Question 34

HEALTH PROMOTION / DISEASE PREVENTION

^{“what education would you provide to assist the patient on}

^{how to reduce the risk of cardiogenic shock?”}

Answer 34

• Educate client on how they can reduce their RISK for MYOCARDIAL INFARCTION (MI)
  
  • Exercise
  • diet
  • stress reduction
  • smoking cessation