Cardiogenic shock

Question 1

Which part of A-E does it affect?

Answer 1

Circulation

Question 2

Breathing

Answer 2

Look for signs of respiratory distress, use of accessory muscles, cyanosis

Auscultate lungs paying attention to bases – crackles and wheeze à pulmonary oedema

Feel for symmetrical chest expansion, tracheal deviation and percuss lung fields

O2 sats, RR – if hypoxic – sit the patient up and put on 15L O2 via NRB

ABG and CXR (signs of heart failure and specifically pulmonary oedema)
- CXR: ABCDEF
- Alveolar oedema, Kerley B lines, Cardiomegaly, Upper lobe diversion, bilateral pleural effusions, fluid in horizontal fissure

Management
1. Sit the patient up
2. Oxygen 15 L via NRB mask - aim 94%
3. Furosemide 40-80 mg
-If already on diuretic, consider giving higher dose than what they are already on, Further doses as required
- If very unstable may use a low dose on cardio advice, then increase once BP improves
4. IV 1.25-5 mg Morphine (venodilator so will increase pre load and help with breathing)
5. GTN - if SBP > 90

Escalate

1. Nitrates infusion (with senior opinion)
2. CPAP (be wary of hypotention, only in Type 1 RF)
3. Intra-aortic ballon pump (if cardiogenic shock)
4. Intubation and ventilation

Question 3

Circulation

Answer 3

Look for scars on chest, raised JVP
- ↑ JVP , Pitting ankle or sacral oedema, Tender smooth hepatomegaly, ascites

Auscultate heart sounds, any murmus?
S3 gallop rhythm - filling against a stiffened ventricle

Feel for CRT, character of pulse, sacral and pedal oedema

HR, BP

IV access and bloods – FBC, LFTs, U&Es, CRP, troponin, BNP, cholesterol, HbA1c

ECG and bedside echo if possible

If BP not low consider GTN infusion

USE NEY YORK HEART ASSOCIATION CLASSIFICATION

Question 4

Management of shock

Answer 4

1. Oxygen: Titrate to maintain arterial saturations of 94-98%
2. Diamorphine 1.25 mg - 5 mg for pain and anxiety
3. Investigations and close monitoring
4. Optimise filling pressure with clinical assessment of pulse, BP, JVP/ CVP

IF underfilled -> Give a plasma expander 100mL every 15min IV (MAP 70mmHg)

IF OVERfilled or norma -> B agonist inotropes, dobutamine 2.5-10 micrograms/kg/min IV

Second line: PD3 inhibitors (milrinone)

Third line: noradernaline (a agonist/ pressors)