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