Management of a patient with a cardiogenic shock

1. Cardiogenic shock
Presented by
Rashmimala Pradhan
Associate Prof.
SNC SOA DTU

2. Cardiogenic shock
• Syndrome of inadequate tissue perfusion
associated with normal circulating BV, and low
cardiac output.
• Symptoms: dyspnoea, poor exercise
tolerance, confusion, sweating, PND.
• Signs: tachycardia, cold skin, high JVP, added
heart sounds, engorged liver, peripheral
oedema.

3. ASSESSMENT
Assess for:
– Blunt trauma to the chest
– Cardiac tamponade
– Cardiac dysrhythmias
Core Skills Treat for Shock 28
– Myocardial infarction
– Cardiac contusion

4. CONT…
Assess for
– Tachycardia
– Muffled heart sounds
– Engorged neck veins with hypotension
– Dyspnea
– Edema in feet and ankles

5. Etiologies
Mechanical complications of MI:
– Papillary Muscle Rupture!!!!
– Ventricular aneurysm
– Ventricular septal Rupture
• Other causes:
– Cardiomyopathies
– tamponade
– tension pneumothorax
– arrhythmias
– valve disease

6. Pathophysiology
Impaired pumping ability of LV leads to…
• Decreased stroke volume leads to…..
• Decreased CO leads to …..
• Decreased BP leads to…..
• Compensatory mechanism which may lead to
…
• Decreased tissue perfusion !!!!

7. Impaired pumping ability of LV leads to…
Inadequate systolic emptying leads to ...
Left ventricular filling pressures (preload) leads
to...
Left atrial pressures leads to ….
Pulmonary capillary pressure leads to …
Pulmonary interstitial & intra alveolar edema
!!!!

8. CLINICAL FEATURES
Abnormal heart sounds
• Murmurs
• Pathologic S3
• Pathologic S4

9. Pericardial tamponade
– muffled heart tones, elevated neck veins
• Tension pneumothorax
– JVD, tracheal deviation, decreased or absent
unilateral breath sounds, and chest
hyperresonance on affected side

10. MANAGEMENT
Goal of management :
• Treat Reversible Causes
• Protect ischemic myocardium
• Improve tissue perfusion
• Optimizing pump by:
– Increasing myocardial O2 delivery
– Maximizing CO
– Decreasing LV workload (Afterload)

11. COLLABORATIVE MANAGEMENT
Limiting/reducing myocardial damage during
Myocardial Infarction:
• Increased pumping action & decrease workload
of the heart
– Inotropic agents
– Vasoactive drugs
– Intra-aortic balloon pump
– Cautious administration of fluids
– Transplantation
• Consider thrombolytics, angioplasty in specific cases

12. OPTIMIZING PUMP FUNCTION:
– Pulmonary artery monitoring is a necessity !!
– Aggressive airway management: Mechanical
Ventilation
– Judicious fluid management
– Vasoactive agents
• Dobutamine
• Dopamine

13. OPTIMIZING PUMP FUNCTION (CONT)
– Morphine as needed (Decreases preload,
anxiety)
– Cautious use of diuretics in CHF
– Vasodilators as needed for afterload reduction
– Short acting beta blocker, esmolol, for
refractory tachycardia

14. Therapy of low Stroke Volume
• Drugs to move point back down curve: e.g..
GTN(nitro glycerin), diuretics, head-up posture
• Drugs to improve contractility: I.v.
inotropes, amrinone, ACE inhibitors
• Drugs to prevent fluid retention: ACE
inhibitors, diuretics.

15. Dopamine
• Dopamine receptor activation at low doses-
”splanchnic dilation” (2-5 mcg/kg/min)
• Beta receptor activation-increase cardiac
output (5-10 mcg/kg/min)
• Alpha receptor activation-vasoconstriction
(>10 mcg/kg/min)

16. Dobutamine
• primarily a beta 1-receptor agonist (cardiac
stimulation), but it also has mild beta 2 effects
(vasodilation)
• causes a dose-dependent increase in stroke
volume
• decrease in cardiac filling pressures
• an alkaline pH inactivates catecholamines such as
dobutamine
• Dose 2-20 mcg/kg/min

17. Dobutamine
Dobutamine is the preferred inotropic agent for
the acute management of low output states due
to systolic heart failure. Because dobutamine
does not usually raise the arterial blood
pressure, it is not indicated as monotherapy
in patients with cardiogenic shock.

18. Norepinephrine
• Alpha-receptor agonist that promotes
widespread vasoconstriction
• administration of any vasoconstrictor agent
carries a risk of hypoperfusion and ischemia
involving any tissue bed or vital organ
• Dose 8-12 mcg/min

19. ?

20. THANK YOU