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| {| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0";
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| ! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align=center| {{fontcolor|#2B3B44|Cardiogenic Shock<BR>Resident Survival Guide}}
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Overview|Overview]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Causes|Causes]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Do's|Do's]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
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| |}
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| __NOTOC__
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| {{CMG}}; {{AE}} [[User:Ahmed Zaghw|Ahmed Zaghw, MBChB.]] [mailto:ahmedzaghw@wikidoc.org]
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| ==Overview==
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|
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| The clinical definition of [[cardiogenic shock]] includes decreased [[cardiac output]] with evidence of tissue [[hypoxia]] in the presence of adequate intravascular volume.<ref name="Califf-1994">{{Cite journal | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref>
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| ==Causes==
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| ===Life Threatening Causes===
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| Cardiogenic shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.
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| ===Common Causes===
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| :* ''Arrhythmic''
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| ::* [[Atrioventricular block]]
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| ::* [[Sinoatrial block]]
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| ::* [[Supraventricular tachycardia]]
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| ::* [[Ventricular tachycardia]]
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| :* ''Mechanical''
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| ::* [[Mitral regurgitation|Acute mitral regurgitation]] ([[papillary muscle rupture]], [[chordae tendinae]] [[rupture]])
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| ::* [[Myocardial rupture|Free wall rupture]]
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| ::* [[Hypertrophic cardiomyopathy]]
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| ::* [[Left ventricle|Obstruction to left ventricular filling]] ([[mitral stenosis]], [[left atrial myxoma]])
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| ::* [[Left ventricular outflow tract obstruction|Obstruction to left ventricular outflow tract]] ([[aortic stenosis]], [[hypertrophic obstructive cardiomyopathy]])
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| ::* [[Ventricular septal defect]]
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| :* ''Myopathic''
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| ::* [[Cardiomyopathy]]
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| ::* [[Myocardial contusion]]
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| ::* [[Myocardial infarction]]
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| ::* [[Myocarditis]]
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| ::* [[Myxedema coma]]
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| ::* [[ischemia|Postischemic]] [[myocardial stunning]]
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| ::* [[Sepsis|Septic myocardial depression]]
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| :* ''Pharmacologic''
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| ::* [[Anthracycline]]s
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| ::* [[Calcium channel blockers]]
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|
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| ''Click '''[[Cardiogenic shock causes|here]]''' for the complete list of causes.''
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|
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| ==FIRE: Focused Initial Rapid Evaluation==
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="Robin-2006">{{Cite journal | last1 = Robin | first1 = E. | last2 = Costecalde | first2 = M. | last3 = Lebuffe | first3 = G. | last4 = Vallet | first4 = B. | title = Clinical relevance of data from the pulmonary artery catheter. | journal = Crit Care | volume = 10 Suppl 3 | issue = | pages = S3 | month = | year = 2006 | doi = 10.1186/cc4830 | PMID = 17164015 }}</ref>
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| <span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span>
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| <span style="font-size: 85%;">
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| '''Abbreviations''':
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| CBC, complete blood count;
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| CI, cardiac index;
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| CK-MB, creatine kinase MB isoform;
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| CVP, central venous pressure;
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| DC, differential count;
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| ICU, intensive care unit;
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| INR, international normalized ratio;
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| LFT, liver function test;
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| MAP, mean arterial pressure;
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| MVO2, mixed venous oxygen saturation;
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| PCWP, pulmonary capillary wedge pressure;
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| PT, prothrombin time;
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| PTT, partial prothrombin time;
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| SaO2, arterial oxygen saturation;
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| SBP, systolic blood pressure;
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| ScvO2, central venous oxygen saturation;
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| SMA-7, sequential multiple analysis-7.
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| </span>
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| {{Family tree/start}}
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| {{Family tree|boxstyle=width: 400px; text-align: left; font-size: 90%; padding: 0px;| | | | | A01 | | | |A01=<div style="padding: 15px;"><BIG>'''Does the patient have cardinal findings that increase the pretest probability of [[cardiogenic shock|<span style="color: #000000;">cardiogenic shock</span>]]?'''</BIG>
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| ❑ Evidence of end-organ [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]
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| : ❑ [[Altered mental status|<span style="color: #000000;">Altered mental status</span>]]
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| : ❑ [[Cold extremities|<span style="color: #000000;">Cold extremities</span>]]
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| : ❑ [[Cyanosis|<span style="color: #000000;">Cyanosis</span>]]
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| : ❑ [[Oliguria|<span style="color: #000000;">Oliguria</span>]] ([[urine output|<span style="color: #000000;">urine output</span>]] <0.5 mL/kg/h)
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| : ❑ Sustained [[hypotension|<span style="color: #000000;">hypotension</span>]]
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| :: ❑ [[SBP|<span style="color: #000000;">SBP</span>]] <90 mm Hg for ≥30 min ''or''
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| :: ❑ [[MAP|<span style="color: #000000;">MAP</span>]] ↓ >30 mm Hg below baseline for ≥30 min
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|
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| ❑ Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%;| |,|-|-|-|^|-|-|-|.| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A02 | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>YES</BIG></div>|A03=<div style="text-align: center; background: #FA8072; color: #F8F8FF; font-weight: bold; padding: 15px;"><BIG>NO</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | |!| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072| A04 | | | | | | A05 |A04=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic shock suspected</BIG></div>
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| |A05=<div style="text-align: center; background: #FA8072; color: #FFFFFF; padding: 15px; font-weight: bold;"><BIG>'''Proceed to <br> [[shock resident survival guide|<span style="color: #FFFFFF;">shock resident survival guide</span>]]'''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A06 | | | | | | | | |A06=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate management [[{{PAGENAME}}#Immediate management [Return to FIRE]|<span style="color: #FFFFFF;">''(click for details)''</span>]]'''</BIG>
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| ❑ [[Intubation|<span style="color: #FFFFFF;">Intubation</span>]] with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]
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| ❑ ± [[Norepinephrine|<span style="color: #FFFFFF;">Norepinephrine</span>]]
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| :❑ Initial dose: 0.5–1.0 μg/min [[IV|<span style="color: #FFFFFF;">IV infusion</span>]]
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|
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| :❑ Titrate to maintain [[SBP|<span style="color: #FFFFFF;">SBP</span>]] at ≥90 mm Hg (up to 40 μg/min)</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate Workup'''</BIG>
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| ❑ [[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
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| ❑ [[Pulse oximeter|<span style="color: #FFFFFF;">Pulse oximeter</span>]]
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| ❑ [[Arterial blood gas|<span style="color: #FFFFFF;">Arterial blood gas</span>]]
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| ❑ [[Central venous catheter|<span style="color: #FFFFFF;">Central venous catheter</span>]]
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| ❑ [[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]]
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| ❑ [[CBC|<span style="color: #FFFFFF;">CBC</span>]]/[[Differential blood count (patient information)|<span style="color: #FFFFFF;">DC</span>]]/[[Basic metabolic panel|<span style="color: #FFFFFF;">SMA-7</span>]]/[[LFT|<span style="color: #FFFFFF;">LFT</span>]]/[[PT|<span style="color: #FFFFFF;">PT</span>]]/[[PTT|<span style="color: #FFFFFF;">PTT</span>]]/[[INR|<span style="color: #FFFFFF;">INR</span>]]
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| ❑ [[Troponin|<span style="color: #FFFFFF;">Cardiac troponins</span>]], [[CK-MB|<span style="color: #FFFFFF;">CK-MB</span>]]
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| ❑ [[Brain natriuretic peptide|<span style="color: #FFFFFF;">BNP</span>]], [[Brain natriuretic peptide|<span style="color: #FFFFFF;">NT-proBNP</span>]]
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]]
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| ❑ [[CXR|<span style="color: #FFFFFF;">Chest radiograph</span>]]
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| ❑ [[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]
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| ❑ [[Foley catheter|<span style="color: #FFFFFF;">Foley catheter</span>]]
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| ❑ [[ICU|<span style="color: #FFFFFF;">ICU admission</span>]]
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| ❑ [[Cardiology|<span style="color: #FFFFFF;">Cardiology consultation</span>]]
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| ❑ Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</span>]]
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A08 | | | | | | | | |A08=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic shock confirmed</BIG> <br> ''[[{{PAGENAME}}#Criteria for Cardiogenic Shock [Return to FIRE]|<span style="color: #FFFFFF;">(click for details on criteria)</span>]]''</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A09 | | | | | | | | |A09=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic Optimization''' '''''[[{{PAGENAME}}#Hemodynamic Optimization [Return to FIRE]|<span style="color: #FFFFFF;">(click for details)</span>]]'''''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A10 | | | | | | | | |A10=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''Preload'''''</BIG>
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| ❑ '''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 15–18 mm Hg'''
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| ❑ '''± Correct [[pulmonary congestion|<span style="color: #FFFFFF;">pulmonary congestion</span>]]'''
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| : ❑ ↑ [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] by [[Normal saline|<span style="color: #FFFFFF;">normal saline</span>]] 100–200 mL IV bolus
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|
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| : ❑ ↓ [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] by [[Furosemide|<span style="color: #FFFFFF;">furosemide</span>]] 40 mg slow IV injection
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|
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| : ❑ ± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg slow IV injection
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A11 | | | | | | | | |A11=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''Afterload'''''</BIG>
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| ❑ '''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] >60 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>'''
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| : ❑ If ↑ MAP & ↑ SVR: wean [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasodilator|<span style="color: #FFFFFF;">vasodilators</span>]]
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|
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| : ❑ If ↓ MAP & ↑ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] + [[inotrope|<span style="color: #FFFFFF;">inotropes</span>]]
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| : ❑ If ↓ MAP & ↓ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasopressin|<span style="color: #FFFFFF;">vasopressin</span>]]
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A12 | | | | | | | | |A12=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''Cardiac Index'''''</BIG>
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| ❑ '''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] >2.2 L/min/m<sup>2</sup>'''
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| : ❑ ± [[Dobutamine|<span style="color: #FFFFFF;">Dobutamine</span>]]
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| : ❑ ± [[Milrinone|<span style="color: #FFFFFF;">Milrinone</span>]]
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| : ❑ ± [[IABP|<span style="color: #FFFFFF;">IABP</span>]], [[VAD|<span style="color: #FFFFFF;">VAD</span>]], or [[ECMO|<span style="color: #FFFFFF;">ECMO</span>]] if refractory</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A13 | | | | | | | | |A13=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate goals for oxygenation and perfusion'''</BIG>
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| ❑ [[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] >90%–92%
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| ❑ [[CVP|<span style="color: #FFFFFF;">CVP</span>]] 8–12 mm Hg
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| ❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2</span>]] >60%
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| ❑ [[SCVO2|<span style="color: #FFFFFF;">ScvO2</span>]] >70%
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| ❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin</span>]] >7–9 g/dL
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]] <2.2 mM/L
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| ❑ [[urine output|<span style="color: #FFFFFF;">Urine output</span>]] >0.5 mL/kg/h
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| ❑ ± Correct [[arrhythmia|<span style="color: #FFFFFF;">arrhythmia</span>]]
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| ❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072;| A14 |-| A15 | | | | | |A14=<div style="background: #FA8072; color: #F8F8FF; padding: 16px;">'''Acute myocardial infarction likely?''' [[{{PAGENAME}}#Criteria for Acute Myocardial Infarction [Return to FIRE]|<span style="color: #FFFFFF;">'''''(click for details)'''''</span>]]
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| ❑ [[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)</span>]]
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| ❑ Symptoms of myocaridal ischemia
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| ❑ New significant ECG findings of myocardial ischemia
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|
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| </div>
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| |A15=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 20px;"><BIG>'''YES, then manage as <br> UA/NSTEMI <br> and proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A14 | | | | | | | | |A14=<div style="text-align: center; background: #FA8072; color: #FFFFFF; font-weight: bold; padding: 15px;"><BIG>No, then proceed to <br> [[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]]</BIG></div>}}
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| {{Family tree/end}}
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| ==Acute Ischemia Pathway==
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| ==Complete Diagnostic Approach==
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| ==Treatment==
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| ==Do's==
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|
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| ====''Immediate management'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>====
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|
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| * [[Mechanical ventilation|Ventilatory support]] is crucial for maintenance of adequate [[oxygenation]] and usually requires [[intubation]] with [[mechanical ventilation]].
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| * [[Norepinephrine]]<ref name="NOREPINEPHRINE BITARTRATE INJECTION">{{Cite web | last = | first = | title = NOREPINEPHRINE BITARTRATE INJECTION | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3352c7d0-e621-46ed-9a54-e4a9583cde10 | publisher = | date = | accessdate = }}</ref><ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref>
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| :* ''Dosage and Administration''
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| ::* Mix 1 ampule (4 mg) of [[norepinephrine]] in 250 mL of [[Intravenous sugar solution|D5W]] or [[Intravenous sugar solution|D5NS]]. Avoid dilution in [[normal saline]] alone.
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| ::* Initial dose: 0.5–1.0 μg/min [[IV|IV infusion]]; titrate to maintain [[SBP]] at above 90 mm Hg (up to 30–40 μg/min).
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| <!--
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| :* ''Indications''
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| ::* [[Blood pressure]] control in certain acute [[hypotensive]] states (e.g., [[pheochromocytoma|pheochromocytomectomy]], [[sympathectomy]], [[poliomyelitis]], [[spinal anesthesia]], [[myocardial infarction]], [[septicemia]], [[transfusion|blood transfusion]], and [[drug reaction]]s).
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| ::* Adjunct in the treatment of [[cardiac arrest]] and profound [[hypotension]].
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| -->
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| :* ''Contraindications''
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| ::* [[Norepinephrine]] should not be given to patients who are [[hypotensive]] from [[hypovolemia|blood volume deficits]] except as an emergency measure to maintain [[coronary]] and [[cerebral]] artery [[perfusion]] until blood volume replacement therapy can be completed.
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| ::* [[Norepinephrine]] should also not be given to patients with [[mesentery|mesenteric]] or peripheral vascular [[thrombosis]] unless it is necessary as a life-saving procedure.
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|
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| ====''Criteria for Cardiogenic Shock'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>====
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|
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| * ''Clinical Criteria''<ref name="Califf-1994">{{Cite journal | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref><ref name="Hollenberg-1999">{{Cite journal | last1 = Hollenberg | first1 = SM. | last2 = Kavinsky | first2 = CJ. | last3 = Parrillo | first3 = JE. | title = Cardiogenic shock. | journal = Ann Intern Med | volume = 131 | issue = 1 | pages = 47-59 | month = Jul | year = 1999 | doi = | PMID = 10391815 }}</ref><ref name="Goldberg-1991">{{Cite journal | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref>
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|
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| :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]] <90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
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| :* Evidence of [[hypoperfusion|tissue hypoperfusion]] (such as [[oliguria]], [[cyanosis]], [[cool extremities]], and [[Altered mental status|altered mental status]])
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| :* Presence of [[myocardial]] dysfunction after exclusion or correction of non-[[myocardial]] factors contributing to [[hypoperfusion|tissue hypoperfusion]] (such as [[hypovolemia]], [[hypoxia]], and [[acidosis]])
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|
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| * ''Hemodynamic Criteria''<ref name="Califf-1994">{{Cite journal | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref><ref name="Goldberg-1991">{{Cite journal | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref><ref name="Forrester-1976">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref>
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|
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| :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]] <90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
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| :* Depressed [[cardiac index]] (<1.8 L/min/m<sup>2</sup> of [[body surface area|BSA]] without support or <2.0–2.2 L/min/m<sup>2</sup> of [[body surface area|BSA]] with support) in the presence of an elevated [[PCWP|wedge pressure]] (>15 mm Hg).
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| <!--
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| :* Adequate filling pressure (left ventricular end-diastolic pressure >18 mm Hg or right ventricular end-diastolic pressure >10–15 mm Hg)
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| :* Elevated [[arteriovenous oxygen difference]] (>5.5 mL/dL)
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| -->
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|
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| ====''Hemodynamic Optimization'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>====
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|
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| * ''Preload'': the goal is to maintain a PCWP of 15–18 mm Hg and to correct [[pulmonary congestion]]<ref name="Forrester-1976">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref><ref name="Crexells-1973">{{Cite journal | last1 = Crexells | first1 = C. | last2 = Chatterjee | first2 = K. | last3 = Forrester | first3 = JS. | last4 = Dikshit | first4 = K. | last5 = Swan | first5 = HJ. | title = Optimal level of filling pressure in the left side of the heart in acute myocardial infarction. | journal = N Engl J Med | volume = 289 | issue = 24 | pages = 1263-6 | month = Dec | year = 1973 | doi = 10.1056/NEJM197312132892401 | PMID = 4749545 }}</ref>
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| :* [[Pulmonary congestion]]
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| ::* Radiologic manifestations of [[pulmonary congestion]] reflect the extent of elevation in [[PCWP|wedge pressure]]:
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| {| style="border: 2px solid #DCDCDC; font-size: 80%;" align=center
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| | align="center" style="background: #DCDCDC; width: 100px;"| '''PCWP (mm Hg)'''
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| | align="center" style="background: #DCDCDC; width: 200px;" | '''Phase of Pulmonary Congestion'''
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| | align="center" style="background: #DCDCDC; width: 500px;" | '''Findings on Chest Radiograph'''
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| |-
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | 18–20
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | Onset of pulmonary congestion
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| | style="padding: 0 5px; background: #F5F5F5;" align=left | Redistribution of pulmonary flow to the upper lobes ("cephalization") and Kerley lines
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| |-
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | 20–25
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | Moderate congestion
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| | style="padding: 0 5px; background: #F5F5F5;" align=left | Diminished clarity of the borders of medium-sized pulmonary vessels ("perihilar haze")
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| |-
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | 25–30
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | Severe congestion
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| | style="padding: 0 5px; background: #F5F5F5;" align=left | Radiolucent grapelike clusters surrounded by radiodense fluid ("periacinar rosette")
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| |-
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | >30
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| | style="padding: 0 5px; background: #F5F5F5;" align=center | Onset of pulmonary edema
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| | style="padding: 0 5px; background: #F5F5F5;" align=left | Coalescence of periacinar rosettes resulting in "Bat's wing" opacities
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| |}
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|
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| :* [[Furosemide]]<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="FUROSEMIDE injection">{{Cite web | last = | first = | title = FUROSEMIDE INJECTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=2d6a6ff9-3f12-4a6e-bba3-3f85fd54ffac | publisher = | date = | accessdate = }}</ref>
| |
| ::* ''Dosage and Administration''
| |
| :::* For [[pulmonary edema|acute pulmonary edema]], the initial dose is 40 mg injected slowly intravenously (over 1 to 2 minutes).
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| :::* If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).
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| ::* ''Contraindications''
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| :::* [[Anuria]]
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| :::* [[Hypersensitivity]] to [[furosemide]]
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|
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| :* [[Morphine]]<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="MORPHINE SULFATE INJECTION">{{Cite web | last = | first = | title = MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=cadc3fdb-8edc-44cd-aaea-89e68aaf9a04 | publisher = | date = | accessdate = }}</ref><ref name="O'Connor-2010">{{Cite journal | last1 = O'Connor | first1 = RE. | last2 = Brady | first2 = W. | last3 = Brooks | first3 = SC. | last4 = Diercks | first4 = D. | last5 = Egan | first5 = J. | last6 = Ghaemmaghami | first6 = C. | last7 = Menon | first7 = V. | last8 = O'Neil | first8 = BJ. | last9 = Travers | first9 = AH. | title = Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S787-817 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.971028 | PMID = 20956226 }}</ref>
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| ::* ''Dosage and Administration''
| |
| :::* Slow [[IV|IV injection]] 2–4 mg (over 1–5 minutes) every 5–30 minutes as needed.
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| <!--
| |
| ::* ''Indications''
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| :::* Relief of severe [[pain]] as in severe [[injuries]] or in severe [[chronic pain]] associated with terminal [[cancer]] after all non-[[narcotic]] [[analgesic]]s have failed.
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| :::* Relief of [[chest discomfort]] that is unresponsive to [[nitrate]]s in [[STEMI]] [[ACC AHA guidelines classification scheme|(Class I, LOE C)]] and [[unstable angina]] or [[NSTEMI]] [[ACC AHA guidelines classification scheme|(Class IIa, LOE C)]].
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| :::* Management of [[dyspnea]] associated with [[heart failure|acute left ventricular failure]] and [[pulmonary edema]] to relieve [[anxiety]] and reduce [[preload]].
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| :::* Preoperative [[sedation]] to facilitate [[anesthesia]] induction and reduce [[anesthetic]] dosage.
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| -->
| |
| ::* ''Contraindications''
| |
| :::* [[Hypersensitivity]] to [[morphine sulfate]] is one of the contraindications to its use.
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| :::* [[Morphine]] should not be used in [[convulsion|convulsive states]], such as those occurring in [[status epilepticus]], [[tetanus]], and [[strychnine]] poisoning.
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| ::* [[Morphine]] is also contraindicated in the following conditions: [[respiratory insufficiency|respiratory insufficiency or depression]]; [[bronchial asthma]]; [[heart failure]] secondary to [[COPD|chronic lung disease]]; [[cardiac arrhythmia]]s; increased [[ICP|intracranial or cerebrospinal pressure]]; [[head injury|head injuries]]; [[brain tumor]]; acute [[alcoholism]]; and [[delirium tremens]].
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| <!--
| |
| ::* ''Precautions''
| |
| :::* May cause [[Hypoventilation|respiratory depression]]
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| :::* May exacerbate [[hypotension]] in [[hypovolemia|volume-depleted]] patients.
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| -->
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|
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|
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|
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|
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|
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| <!--
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|
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| * [[Nitroprusside]]<ref name="Chatterjee-1973">{{Cite journal | last1 = Chatterjee | first1 = K. | last2 = Parmley | first2 = WW. | last3 = Ganz | first3 = W. | last4 = Forrester | first4 = J. | last5 = Walinsky | first5 = P. | last6 = Crexells | first6 = C. | last7 = Swan | first7 = HJ. | title = Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction. | journal = Circulation | volume = 48 | issue = 6 | pages = 1183-93 | month = Dec | year = 1973 | doi = | PMID = 4762476 }}</ref>
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| :* Initial dose: 16 μg/min
| |
| :* Adjust the infusion rate to maintain a [[PCWP]] of 15–18 mm Hg without causing a marked decrease in [[arterial pressure]].
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|
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| -->
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|
| |
| ====''Criteria for Acute Myocardial Infarction'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>====
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|
| |
| * Detection of a rise and/or fall of [[cardiac biomarker]] values (preferably [[cardiac troponin]]) with at least one value above the 99th percentile upper reference limit and '''with''' at least one of the following:<ref name="Thygesen-2012">{{Cite journal | last1 = Thygesen | first1 = K. | last2 = Alpert | first2 = JS. | last3 = Jaffe | first3 = AS. | last4 = Simoons | first4 = ML. | last5 = Chaitman | first5 = BR. | last6 = White | first6 = HD. | last7 = Thygesen | first7 = K. | last8 = Alpert | first8 = JS. | last9 = White | first9 = HD. | title = Third universal definition of myocardial infarction. | journal = J Am Coll Cardiol | volume = 60 | issue = 16 | pages = 1581-98 | month = Oct | year = 2012 | doi = 10.1016/j.jacc.2012.08.001 | PMID = 22958960 }}</ref>
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|
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| :* Symptoms of [[ischemia]]
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| :* New or presumably new significant [[ST-segment]]–[[T wave]] (ST–T) changes or new [[LBBB|left bundle branch block (LBBB)]].
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| :* Development of [[Pathologic Q Waves|pathological Q waves]] in the [[ECG]].
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| :* Imaging evidence of new loss of viable [[myocardium]] or new region wall motion abnormality.
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| :* Identification of an intracoronary [[thrombus]] by [[angiography]] or [[autopsy]].
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|
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| ==Don'ts==
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|
| |
| * Do not test [[orthostatic hypotension]] in [[hypotension|hypotensive]] patients.
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| * Do not rely solely on [[oxygen saturation|SpO2]] readings from [[pulse oximeter]]. [[Oxygen saturation|SaO2]] from [[Arterial blood gas|blood gas analysis]] provides more precise status of [[oxygenation|oxygenation]].
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| * Do not administer low-dose [[dopamine]] (<5 μg/kg/min) to preserve [[renal function]] in patients with [[shock]].
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|
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| * Do not administer [[normal saline]] in the presence of [[pulmonary edema]].
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|
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| ==References==
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|
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| {{reflist|2}}
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|
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| [[Category:Disease]]
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| [[Category:Pulmonology]]
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| [[Category:Emergency medicine]]
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| [[Category:Medicine]]
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| [[Category:Resident survival guide]]
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