Nursing Case Study for Cardiogenic Shock
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Outline
Betty is a 71-yr-old woman with a history of high blood pressure, diabetes, and acute myocardial infarction 2 years ago. She has complained of chest pain with nausea and fatigue at her nursing home and, per protocol, an EKG was done in the ambulance on her way to the local ER. The ER provider interprets the EKG as having significant ST-segment elevation in the anterior leads and he mentions Q waves as well.
The nurse should initiate what protocol with this information? Why?
- A STEMI (ST elevated myocardial infarction) alert should be called. This alert is a systematic way to let staff (varies from facility to facility but often includes ER, cardiac cath lab staff with on-call cardiac interventionist, respiratory therapy, and administrative support) know to get ready for the patient. Since “time is tissue,” the patient should be taken into the cardiac catheterization lab ASAP. The faster percutaneous coronary intervention (PCI) is done, the better chance the team has of restoring blood flow (and therefore oxygen) to the patient’s heart.
What signs and symptoms did Betty have that caused the staff of the nursing home to call 911?
- Nausea and fatigue are sometimes missed symptoms of an MI in females (who are more likely to have different symptoms than their male counterparts like nausea, jaw pain, fatigue, pain between the shoulders). Chest pain is not the singular symptom of a heart attack. Sometimes, neuropathy in diabetics can cause them to present differently, as well. Plus, DM puts them at higher risk (and, in this case, so does hypertension).
Vital signs as follows prior to the patient being taken to the cath lab:
BP 80/50 mmHg SpO2 91% on 2 L NC
HR 111 bpm with frequent PVCs on monitor
RR 32 bpm at rest
Temp 37°C
She also complains of “having trouble breathing” and has a look of fear and worry on her face. She is placed on the portable monitor to go to the cath lab and the nurse notices that the cardiac rhythm is very fast, approx. 180 bpm. There appear to be no P waves anymore and the QRS is very wide. The monitor alarms loudly and Betty’s eyes are now closed.
How does the nurse interpret this rhythm? What should she do first?
- This is ventricular tachycardia (called “sustained” if it lasts) and she should check for a pulse. High-quality CPR should be started if there is no pulse. Check for a pulse no longer than 10 seconds in a CENTRAL location (like carotid, femoral). Rapid defibrillation is also necessary for no pulse.
The ACLS team begins resuscitation of Betty, and she does not appear to be breathing either. The ER provider initiates rapid sequence intubation, and an endotracheal tube is placed. Respiratory therapy brings a ventilator to assist with the patient’s respirations. She is taken to the cath lab.
What does the nurse think the cardiac catheterization will show?
- During the cath, the interventionist will inject dye into Betty’s coronary blood vessels to look for blockages. The nurse should anticipate major arteries being blocked (aka occluded) which is what is causing the STEMI. Along with this, the cath can provide a look at the other structures of the heart. This intervention can provide measurements indicating ejection fraction aka EF (normal about 70%, low meaning the heart is not pumping effectively or heart failure) so the nurse should be on the lookout for low EF.
Betty’s family waits in the ER because they are requesting, she be sent to a larger hospital for open-heart surgery. The patient will come back to the ER instead of being admitted to the small ICU. The cath lab calls with a report and confirms the nurse’s suspicions of blocked coronary arteries and she has an EF of only 15% indicating heart failure.
Are there devices to help Betty’s heart ineffective pumping (similar to the ventilator to help her breathe)?
- Yes, an intra-aortic balloon pump (IABP) may help with coronary perfusion. It can be placed in the cath lab but requires specially trained staff to manage. They may also opt for a ventricular assist device (VAD) like the Impella pump. These pumps can support the patient’s pumping problems.
Betty’s urinary catheter reveals scant, dark urine. Her extremities are cool to the touch. She is sedated for the ventilator support but when sedation is paused for assessment, she does not wake up at all.
What signs of shock is Betty exhibiting? What other clues does the nurse have indicating this could be cardiogenic shock?
- Low urine output indicates poor perfusion to the kidneys. Less than 30 ml/hr of urine is indicative of end-organ tissue perfusion issues. “The “classic” patient with cardiogenic shock has severe systemic hypotension, signs of systemic hypoperfusion (e.g., cool extremities, oliguria, and/or alteration in mental status), and respiratory distress due to pulmonary congestion.” Low ejection fraction (EF).
Her family asks why she is not being transferred right away.
How can the nurse best explain the situation to the family?
- Betty is very critically ill at the moment. She must be carefully monitored for hemodynamic changes, and it may be harmful to move her to another facility at this time due to her unstable condition.
Another staff member interrupts the nurse during her discussion with the family to say that Betty’s MAP is only 50.
How does the nurse interpret this number? How is it calculated?
- MAP is mean arterial pressure and is a better indicator of peripheral perfusion than blood pressure alone. It is calculated automatically by blood pressure machines and other monitoring devices. However, to calculate manually (which may be beneficial if you take a manual BP) it is SBP + 2(DBP)/3. A MAP of 60 mm/Hg is usually the desired parameter to maintain because this amount is at the low end/minimum to perfuse organs (including the brain, kidneys, bowel, etc.)
What type of medication might the nurse request from the provider or ask about starting?
- “Adrenergic agents, such as phenylephrine, dopamine, and dobutamine, are the most commonly used vasopressor and inotropic drugs in critically ill patients”
- Dobutamine — Dobutamine (Dobutrex) is not a vasopressor but rather is an inodilator that causes vasodilation. Dobutamine’s predominant beta-1 adrenergic receptor effect increases inotropy and chronotropy and reduces left ventricular filling pressure. In patients with heart failure, this results in a reduction in cardiac sympathetic activity [29]. However, minimal alpha- and beta-2 adrenergic receptor effects result in overall vasodilation, complemented by reflex vasodilation to the increased CO. The net effect is increased CO, with decreased SVR with or without a small reduction in blood pressure.
- Dobutamine is most frequently used in severe, medically refractory heart failure and cardiogenic shock
The nurse prepares to call in a report to a larger facility to transfer Betty. The family asks what to expect “from all of this.”
How can the nurse explain the course of treatment to the family?
- This patient will need ventilation and perfusion support as determined by her medical team. They may notice many different medications as well as the machines. Each patient will be managed individually. Frequent testing of her labs and continuous monitoring of her respiratory and cardiac status are to be expected.
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Transcript
Hey everyone. My name is Abby. We’re going to go through a case study regarding cardiogenic shock. Let’s get started. In this scenario, Betty is a 71-year-old woman with a history of high blood pressure, diabetes and two years ago, she had an MI. She has complained of chest pain with nausea and fatigue at her nursing home and per protocol, an EKG was performed in the ambulance on the way to her local ER. The ER provider interprets the EKG as having significant ST Elevation in the anterior leads. He also mentions Q waves. Now, let’s take a look at critical thinking checks number one and number two below.
Great job. The vital signs were taken in the cath lab. Let’s take a look at them:
Her blood pressure was 80 over 50. She had a heart rate of 111 beats per minute, but she was also having some ectopy with pre-ventricular contractions. Her respiratory rate was 32 breaths per minute at rest and her temperature, 37 degrees Celsius on two liters nasal cannula. She was saturating at 91%. She also complains of having trouble breathing. She has a look of fear and worry on her face. She’s placed on the portable monitor to go to the cath lab and the nurse notices that the cardiac rhythm is very fast, approximately 180 beats per minute. It’s very tachy. There appear to be no P waves anymore and the QRS complex is very wide. The monitor alarms loudly and Betty’s eyes are now closed. Now that we have these results, let’s take a look at critical thinking check number three below.
Excellent. The ACLS team begins resuscitation of Betty, and she does not appear to be breathing. The ER provider initiates rapid sequence intubation and an endotracheal tube is placed. Respiratory therapy brings a ventilator to assist with the patient’s respirations. She’s taken back to the cath lab. Now that we have this information, let’s take a look at critical thinking check number four below.
Wonderful job. Betty’s family has been waiting in the ER because they’re requesting that she be sent to a larger hospital for open heart surgery. The patient will come back to the ER instead of being admitted to the small ICU, the cath lab calls with a report and confirms the nurse’s suspicion of blocked coronary arteries. And she has an ejection for action of only 15% indicating heart failure. Now that we know this, let’s take a look at critical thinking. Check number five below.
Well done. Betty’s urinary catheter reveals scant, dark urine. Her extremities are cool to the touch. She is sedated for ventilator support, but when sedation is paused, she doesn’t wake up at all. Now that we know this information, let’s take a look at critical thinking check number six.
Great work. Her family asks why she’s not being transferred right away. Let’s take a look at critical thinking check number seven below and see what’s up.
Nicely done. Another staff member interrupts the nurse during her discussion with the family to let the nurse know that Betty’s map is only 50. Now that we have this information, let’s take a look at critical thinking checks number eight and number nine below.
Well done, the nurse prepares to call in a report to a larger facility to transfer Betty. The family asks what to expect from all of this. We know that families like to ask questions. Now that we have this, let’s take a look at critical thinking check number 10 below.
Great job you guys, that wraps up the case study on cardiogenic shock. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you all,now go out and be your best self today and as always, happy nursing!
References:
Clinical manifestations and diagnosis of cardiogenic shock in acute myocardial infarction
Author:Alex Reyentovich, MD, updated Jan, 2020, Overview of the acute management of ST-elevation myocardial infarction
Authors:Guy S Reeder, MDHarold L Kennedy, MD, MPH updated Mar, 2021; Use of vasopressors and inotropes
Author:Scott Manaker, MD, PhD updated Nov, 2021
https://www.ahajournals.org/doi/full/10.1161/JAHA.119.011991
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