Cardiogenic Shock

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Cardiogenic Shock

Definition/Etiology:

Definition
- Circulatory failure
  - Poor Perfusion = tissue/organ ischemia = Anoxia (Cell DEATH)
  - Fluid Overload = Lung Injury → Edema
- Numerous Types = Cardiac Focus
- Analogy= Circulatory System = The Gas Station
  - Gas Pump = Heart
  - Hose = Vasculature
  - Gasoline = Blood/Volume
  - Vehicle = Tissues
Etiology/Cause
- CAD/MI*
- Acute Valve dysfunction
- Heart Failure
- Dysrhythmias
- Pericarditis = Cardiac Tamponade

Pathophysiology:

Gas Pump Fails – Extreme version of Heart Failure
- Decreased Cardiac Output/Perfusion
  - No Gas from Pump to vehicle
  - Gas Runs backwards
- ↑CVP & Increased Fluid Overload
  - Fluids must go somewhere
    - Backs up to lungs = HF Sx
    - Backs up to tissues and organs
- Compensatory
  - ↑SVR
  - Shunt blood to vital organs
  - Kidney = no perfusion =oliguria

Noticing: Assessment & Recognizing Cues:

Subjective Cues (Typical Cardiac Patient)
- Chest Pain/SOB
- FEEL COLD
Objective Cues (All point to poor perfusion)
- Vitals
  - ↓BP (SBP<90) & Narrow Pulse Pressure
  - ↑HR (Compensation)
    - Hidden by Beta Blockers
  - Pulses ↓
  - Temp = Low
- Hemodynamics – Art Line
  - Central Venous Pressure ↑
    - Amount of blood backing up/not getting pumped through
  - ↑ SVR (Compensation – Shunt Blood back to heart)
  - +JVD/Edema
- Heart & Lung Sounds
  - S3/Murmurs/Muffled Heart Sounds
  - WET! Crackles/Rales
- ↓Tissue/Organ Perfusion
  - Brain
  - Kidneys
  - Extremities

Interpreting: Analyzing & Planning:

Labs
- H/H -hemorrhage
- Troponin -MI
- BNP – HF
- BMP/CMP – Electrolytes
- BUN/Creatinine – Arrhythmias
Diagnostics
- ECG – Electricity
  - Ischemia
  - Alternans
- Echocardiogram – Plumbing
  - Inflammation – Pericarditis
  - Valves
- CXR – Heart Failure
  - Cardiomegaly
  - Pulmonary Edema/Effusion

Responding: Patient Interventions & Taking Action:

ABCs & Treat Cause
- Lifesaving measures
Pharmacological Interventions
- ↓SV (due to ↓ contractility and ↑ SVR)
  - + Inotropes/Dobutamine or Milrinone
    - ↑ Contractility
    - Similar outcomes but Dobutamine is faster
  - Vasopressors/Norepinephrine
    - ↑ Vasoconstriction
    - Generate pressure support
  - Anticoagulants/Thrombolytics
    - if MI/Clot
  - Diuretics -Treats HF but may ↓ BP
Non-Pharmacological Interventions
- IABP – Heart Failure
- PCI: Angioplasty, Stent- (MI/Clot)
- Pericardiocentesis – (Tamponade)
- Cardioversion – Dysrhythmia)
- Open Heart (blown heart valve)
Adjunct Medical Therapy
- Cardiology
- Interventionist/Surgeon

Reflecting: Evaluating Patient Outcomes:

Airway/Breathing
- Sufficient oxygenation is provided
- Pulmonary congestion is decreased
Hemodynamics/Circulation
- iSBP is increased to adequately perfuse tissues and vital organs.
- BP and pulse are within normal limits for the patient.
- Fluid and electrolyte balances are maintained
- Intake and output are balanced

Linchpins (Key Points):

Notice
- Objective/Subjective Cues ↓ Perfusion
Interpret
- Labs/Diagnostic -underlying cause
Respond
- Treating underlying cause
- Hemodynamics
Reflect
- ABCs are supported

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Transcript

References

AACN, and Tonja Hartjes. AACN Core Curriculum for Progressive and Critical Care Nursing. Available from: Pageburstls, (8th Edition). Elsevier Health Sciences (US),[Insert Year of Publication].

4Mathew, R., Di Santo, P., Jung, R. G., Marbach, J. A., Hutson, J., Simard, T., ... & Hibbert, B. (2021). Milrinone as compared with dobutamine in the treatment of cardiogenic shock. New England Journal of Medicine, 385(6), 516-525.

Samsky, M. D., Morrow, D. A., Proudfoot, A. G., Hochman, J. S., Thiele, H., & Rao, S. V. (2021). Cardiogenic shock after acute myocardial infarction: a review. JAMA, 326(18), 1840-1850.

Tehrani, B. N., Truesdell, A. G., Psotka, M. A., Rosner, C., Singh, R., Sinha, S.
S., ... & Batchelor, W. B. (2020). A standardized and comprehensive approach to the management of cardiogenic shock. Heart Failure, 8(11), 879-891.

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