Cardiogenic shock

Background

• Leading cause of death in pts w/ MI who reach the hospital alive

Work-Up

• What is the etiology
  • Is this is a rate-cause?
    • Bradycardia - give atropine/pace
    • Tachycardia - Meds/cardioversion
  • Is this a valve problem?
    • Needs surgery
  • Is pt ischemic?
    • Cath
    • Is there RV infarction?
      • Increase preload
  • Is there a cardiomyopathy
    • Medical management
  • Is there tox issue
    • CCB, BB, dig overdose

• 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 contractility
  • Sepsis
  • 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
  • Airway
    • Caution - PPV may worsen preload and CO
  • Blood Pressure
    • Fluid challenge
    • Pressors
      • Sys BP < 70: Dopamine or dopamine + dobutamine
      • Sys BP > 70: Dobutamine or dobutamine + dopamine
        • Dobutamine: 2–5 mcg/kg/min, up to 20mcg/kg/min
          • Has potential vasodilation effect
        • Dopamine: 3–5 mcg/kg/min, up to 50mcg/kg/min
• Specific
  • Mitral Regurg
    • Need to increase forward flow
      • Dobutamine (contractility)
      • Nitroprusside (afterload reduction)
  • MI
    • PCI or thrombolysis

Source

Tintinalli