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2
EKG
3
Phone a friend
a. Call your attending
b. Call the cardiologist
c. Call the cardiothoracic surgeon
d. Call your mother
4
Hemodynamic Parameters
Systemic Vascular Resistance (SVR)
Cardiac Output (CO)
Mixed Venous Oxygen Saturation (SvO2)
Pulmonary Capillary Wedge Pressure (PCWP)
Central Venous Pressure (CVP)
Normal Values
PATIENT PRESENTATION
Source: Andrew Lenneman, MD. Cardiogenic Shock. Medscape Reference February 2011
CARDIOGENIC SHOCK — IDENTIFICATION
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CARDIOGENIC SHOCK — IDENTIFICATION
1. Systemic Hypotension
systolic arterial pressure < 80 mmHg
2. Persistent Hypotension
at least 30 minutes
3. Reduced Systolic Cardiac Function
Cardiac index < 1.8 x m²/min
4. Tissue Hypoperfusion
Oliguria, cold extremities, confusion
5. Increased Left Ventricular Filling
Pulmonary capillary wedge pressure > 18 mmHg
Etiologies
Acute myocardial Other conditions complicating large
MIs
infarction/ischemia Hemorrhage
LV failure Infection
Excess negative inotropic or
VSR vasodilator medications
Papillary muscle/chordal Prior valvular heart disease
Hyperglycemia/ketoacidosis
rupture- severe MR Post-cardiac arrest
Ventricular free wall Post-cardiotomy
rupture with subacute Refractory sustained
tamponade tachyarrhythmias
Acute fulminant myocarditis
End-stage
cardiomyopathyHypertrophic
cardiomyopathy with severe outflow
obstruction
Aortic dissection with aortic
insufficiency or tamponade
Pulmonary embolu
Severe valvular heart disease -
Critical aortic or mitral stenosis,
Acute severe aortic or MR
Pathophysiology
Cardiogenic Shock
Clinical Findings
Physical Exam: elevated JVP, +S3, rales,
oliguria, acute pulmonary edema
Dopamine
<2 renal vascular dilation
<2-10 +chronotropic/inotropic (beta effects)
>10 vasoconstriction (alpha effects)
20
IABP is a temporizing measure
Augments coronary blood flow in diastole
P=0.04
Points
70-year-old, 60 kg female
Age 37
from the US with a history
Systolic B/P 49
of hypertension, no prior Weight 17
PCTA, diagnosed with HR 17
acute anterior MI. On Diastolic B/P 5
admission, HR=123, Killip Class 9
B/P=112/70 and a few MI Location 8
PATIENT CONDITION WHEN SHE LEFT THE CATH LAB AFTER SUCCESSFUL STENTING OF LAD
HR=105,
B/P=102/65
Few crackles in
lungs when she
left CCL
CARDIOGENIC SHOCK — CASE STUDY
NOW LET’S TAKE A LOOK AT THIS PATIENT 4 HOURS LATER IN THE CCU
BP 80/40, HR – 135
Skin cool and clammy; becoming agitated
Saturating 90% on 2L per N/C
Crackles more prominent
Short of breath with minimal activity
Pulses weak and thready
Has not urinated since admission
12 Lead EKG shows no changes
3/2/2010 V
CARDIOGENIC SHOCK — CASE STUDY
INTERVENTIONS
2D Echo at bedside
No mechanical complications i.e. VSD or MR
Shows wall motion abnormality
100% non-rebreather oxygen mask
Fluid bolus 250cc NS
Dopamine 10 mcg/kg/min
Dobutrex 5 mcg/kg/min
Lasix 40 mg IV
Foley catheter placed
Swan-Ganz Catheter inserted at bedside
CARDIOGENIC SHOCK — CASE STUDY
Considering intubation
Dopamine increased to 20
mcg/kg/min
Dobutrex 10 mcg/kg/min
Bumex (diuretic) 4 mg IV
given
Preparing patient for
IABP placement
3/2/2010 V
CARDIOGENIC SHOCK — TREATMENT
KEY TO TREATMENT
How it works
Balloon inflates at onset of diastole
in aortic pressure
Benefits
Increases coronary artery perfusion
How it works
Balloon deflates just prior to systolic ejection
(before aortic valve opens)
Results in a rapid decrease in aortic pressure
Benefits
Decreases afterload
Decreases cardiac workload
Increases cardiac output