Cardiogenic shock: Difference between revisions
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#Small Fluid challenge | #Small Fluid challenge | ||
#Increase inotropy | #Increase inotropy | ||
##Titrate to clinical effect | |||
##*Dobutamine or Milrinone: | |||
###Use milrinone if pt is on BB | |||
###CaCl 1gm | |||
####Give if pt is hypocalcemic | |||
#Achieve MAP >65 | #Achieve MAP >65 | ||
Revision as of 03:42, 8 November 2013
Background
- Leading cause of death in pts w/ MI who reach the hospital alive
Work-Up
- Labs
- Troponin
- Lactate
- CBC
- Chem
- BNP
- <100 may rule-out cardiogenic shock
- ECG
- CXR
- TTE
Etiology
- Myocardial infarction
- Pump failure
- Mechanical complications
- Acute MR (papillary muscle rupture)
- VSD
- Free-wall rupture
- RV infarction
- Decreased forward flow
- Sepsis
- Rate-related
- Bradycardia
- Tachycardia
- Myocarditis
- Myocardial contusion
- Cardiomyopathy
- Mechanical obstruction to forward flow
- AS
- HOCM
- Mitral stenosis
- Pericardial
- LV regurgitation
- Chordal rupture
- Aortic insufficiency
DDX
- MI
- PE
- COPD exacerbation
- Peri/myocarditis
- Aortic dissection
- Pericardial tamponade
- Acute valvular insufficiency
- Sepsis
- Hemorrhage
- Toxins/drugs of abuse
Treatment
- General
- Intubation
- Decreases O2 demand BUT may worsen preload
- Intubation
- Coronary perfusion
- Small Fluid challenge
- Increase inotropy
- Titrate to clinical effect
- Dobutamine or Milrinone:
- Use milrinone if pt is on BB
- CaCl 1gm
- Give if pt is hypocalcemic
- Titrate to clinical effect
- Achieve MAP >65
Pressors
| Pressor | Initial Dose | Max Dose | Cardiac Effect | BP Effect | Arrhythmias | Special Notes | |
|---|---|---|---|---|---|---|---|
| Dobutamine | 2.5mcg/kg/min | 10-40 mcg/kg/min | mainly inotrope (ß1) | alpha effect minimal | Some HR(ß1) increase. Also Increase SA and AV node fx | Debut Research 1979[1] Isoproterenol has most Β2 vasodilatory and Β1 HR effects | |
| Dopamine | 2mcg/kg/min | 20-50 mcg/kg/min | β1 and NorEpi release | α effects if > 20mcg/kg/min | Arrhythmogenic from β1 effects | More adverse events when used in shock compared to Norepi[2] | |
| Norepinephrine | 8-12mcg/min | 30 mcg/min | β1 direct effect | β1 and α1,2 effects | Less arrhythmias than Dopamine[2] | Increases MAP, coronary perfusion pressure, little β2 effects. | |
| Milrinone | 50mcg/kg x 10 min | 0.375-75mcg/kg/min | Direct influx of Ca2+ channels | Smooth muscle vasodilator | PDE Inhibitor which increases Ca2+ uptake by sarcolemma. No venodilatory activity | ||
| Phenylephrine | 100-180mcg/min then 40-60mcg/min | 0.4-9 mcg/kg/min | Alpha agonist | Long half life | |||
| Vasopressin | Fixed Dose | 0.4 U/min | unknown | increases via ADH peptide | should not be titrated due to ischemic effects |
- Transfusion
- Consider if Hb < 10
- Specific
- Mitral Regurg
- Need to increase forward flow
- Dobutamine (contractility)
- Nitroprusside (afterload reduction)
- Need to increase forward flow
- MI
- PCI or thrombolysis
- Tox
- Reverse CCB, BB, or dig toxicity
- Mitral Regurg
See Also
Source
Tintinalli EMCrit Podcast 10