Cardiogenic shock

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. Fluid challenge
  • 2. Increase inotropy
    • Titrate to CO (e.g. warm extremities)
    • Dobutamine or Milrinone
      • Use milrinone if pt is on BB
    • CaCl 1gm
      • Give if pt is hypocalcemic
  • 3. Achieve MAP >65
    • Pressors
      • Norepi or dopamine
• 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

• Shock
• Ultrasound in Shock and Hypotension

Source

Tintinalli

EMCrit Podcast 10