Cardiogenic shock: Difference between revisions
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****Give if pt is hypocalcemic
****Give if pt is hypocalcemic
#Achieve MAP >65
#Achieve MAP >65
==Pressors==
==Pressors<ref>Charles McKay MD, Harbor-UCLA Medical Center</ref>==


{| class="wikitable"
{| class="wikitable"
|-
|-
! Pressor !! Initial Dose !! Max Dose !! Cardiac Effect !! BP Effect !! Header text !! Header text
! Pressor !! Initial Dose !! Max Dose !! Cardiac Effect !! BP Effect !! Arrhythmias !! Special Notes
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| 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<ref>Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine</ref>
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| Dopamine || Example || Example || Example || Example || Example || Example
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| Norepinephrine || Example || Example || Example || Example || Example || Example
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| Milrinone || 50mcg/kg x 10 min || Example || Example || Example || Example || Example
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| Phenylephrine || 100-180mcg/min then 40-60mcg/min || Example || Example || Example || Example || Example
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| Vasopressin || Fixed Dose || Example || Example || Example || Example || Example
|}
|}


Revision as of 03:03, 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
  • Coronary perfusion
  1. Small Fluid challenge
  2. Increase inotropy
      • Titrate to CO (e.g. warm extremities)
      • Dobutamine or Milrinone - if
        • Use milrinone if pt is on BB
      • CaCl 1gm
        • Give if pt is hypocalcemic
  1. Achieve MAP >65

Pressors[1]

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[2]
Dopamine Example Example Example Example Example Example
Norepinephrine Example Example Example Example Example Example
Milrinone 50mcg/kg x 10 min Example Example Example Example Example
Phenylephrine 100-180mcg/min then 40-60mcg/min Example Example Example Example Example
Vasopressin Fixed Dose Example Example Example Example Example



  • Transfusion
    • Consider if Hb < 10
  • Specific
    • Mitral Regurg
      • Need to increase forward flow
        • Dobutamine (contractility)
        • Nitroprusside (afterload reduction)
    • MI
      • PCI or thrombolysis
    • Tox
      • Reverse CCB, BB, or dig toxicity

See Also

Source

Tintinalli

EMCrit Podcast 10

  1. ↑ Charles McKay MD, Harbor-UCLA Medical Center
  2. ↑ Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
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