Cardiogenic shock FFM

Question 1

Cardiogenic shock FFM

Definition of Cardiogenic Shock

Answer 1

Acute state of decompensated cardiac output resulting in inadequate tissue perfusion despite adequate circulating volume. “Pump failure”. MCC myocardial infarction

Question 2

Cardiogenic shock FFM

ASAP:

Answer 2

ASAP: ABCs, 2 LB IVs, O2, monitor/EKG, VS, pCXR, POCUS

Question 3

Cardiogenic shock FFM

Hx/exam:

Answer 3

Hx/exam: SOB, CP, SAMPLE hx, mental status, JVD, murmurs, crackles, edema, perfusion, hypotension (or at least compared to their normal BP)

Question 4

Cardiogenic shock FFM

Labs:

Answer 4

Labs: CBC, BUN/Cr, lytes, gluc, CK/MB/Trop, BNP, coags

Question 5

Cardiogenic shock FFM

DDx:

Answer 5

DDx: RV infarct, large LV infarct, acute valvular insufciency, wall rupture, papillary muscle rupture, tamponade, TAD, myocarditis

Question 6

Cardiogenic shock FFM

Tx:
If suspecting infarct …

Answer 6

If suspecting infarct …
stat Cards consult for cath/ IABP/ECMO
ASA and Heparin after CXR reviewed. Do not give BB
If no cath lab or contraindications consider thrombolytics

Question 7

Cardiogenic shock FFM

Tx:
If Thoracic Aortic Dissection:

Answer 7

If TAD … stat CT surgery consult
Oxygenation/pulm edema:
Can trial BIPAP but may not tolerate well
Early intubation
Challenging due to hypotension, hypoxia and acidosis. Need to maximize pre-intubation hemodynamics (small bolus, push dose pressors,
preoxygenation, oxygenation during intubation. Etomidate may be best choice for induction

Question 8

Cardiogenic shock FFM

Tx:
If ↓BP / shock …

Answer 8

If ↓BP / shock …
250-500ml IVF bolus: eval response (need to be cautious). Consider especially if dehydrated or RV infarction
>90 Consider dobutamine or milrinone (if patient on BB)
< 90 Consider NE. Can add on dobutamine
Optimize electrolytes (especially Ca) and H/H (higher threshold for transfusion, 10)

Question 9

Cardiogenic shock FFM

Dobutamine (inotrope) action and use:

Answer 9

Dobutamine (inotrope): increases contractility, consider if ≥ 90 without signs of overt shock or organ dysfunction. Avoid as single agent if BP < 90 due to vasodilatory
potential. Will need a vasoconstrictor

Question 10

Cardiogenic shock FFM

Milrinone action and use in cardiogenic shock:

Answer 10

Milrinone: selective phosphodiesterase inhibitor. Can be substituted for the catecholamine if dobutamine is ineffective (patients on BB)

Question 11

Cardiogenic shock FFM

Calcium (inotrope) dose in cardiogenic shock:

Answer 11

Calcium (inotrope): 1 gm CaCL

Question 12

Cardiogenic shock FFM

Dopamine (vasopressor) action in cardiogenic shock:

Answer 12

Dopamine (vasopressor): may increase cardiac work by increasing HR and increase LV end-diastolic pressure by B agonist effect. May have more beneficial effect if
combined with inotrope

Question 13

Cardiogenic shock FFM

Norepinephrine( Vasopressor) action in cardiogenic shock:

Answer 13

Norepinephrine( Vasopressor): When used with dobutamine may have more of a peripheral vasoconstriction effect than dopamine. If BP < 70 prefered over dobutamine
due to antithrombotic effect. RCT study in 2010 showed NE superior to dopamine in patients with cardiogenic shock.

Question 14

Cardiogenic shock FFM

Epinephrine (vasopressor) action in cardiogenic shock.

Answer 14

Epinephrine (vasopressor): alternative to norepi/dobutamine when dobutamine not available. Associated with increase acidosis, tachycardia, dysrhythmias