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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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| ==Diagnositic Criteria==
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| '''Criteria for bedside diagnosis'''<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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| * Sustained [[hypotension]] ([[systolic blood pressure]] <80–90 mm Hg or [[mean arterial pressure]] 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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| '''Criteria based on hemodynamic parameters'''<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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| * Sustained [[hypotension]] ([[systolic blood pressure]] <80–90 mm Hg or [[mean arterial pressure]] 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]] without support or <2.0–2.2 L/min/m<sup>2</sup> of [[body surface area]] with support) in the presence of an elevated [[PCWP|pulmonary capillary 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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| ==Causes==
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|
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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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|
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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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| ::* [[Cardiac tamponade]]
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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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|
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
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|
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| <span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
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|
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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/start}}
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| {{Family tree|boxstyle=width: 350px; text-align: left; font-size: 90%;| | | | | | | | | A01 | | |A01=<div style="padding: 15px;">'''Does the patient have cardinal findings that increase the pretest probability of shock?'''
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| ❑ '''Arterial hypotension'''
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| : ❑ [[SBP|<span style="color: #000000;">SBP</span>]] <90 mm Hg ''or''
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| : ❑ [[MAP|<span style="color: #000000;">MAP</span>]] <70 mm Hg
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|
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| ❑ '''Signs of hypoperfusion'''
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| : ❑ [[Altered mental status|<span style="color: #000000;">Altered mental status</span>]]
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| : ❑ [[Cool extremities|<span style="color: #000000;">Cold</span>]], [[clammy|<span style="color: #000000;">clammy skin</span>]]
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| : ❑ [[Oliguria|<span style="color: #000000;">Oliguria</span>]]
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| : ❑ [[Metabolic acidosis|<span style="color: #000000;">Metabolic acidosis</span>]]</div>}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | | | | | | | | |!| | }}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | |,|-|-|-|-|-|-|^|-|-|-|-|-|.|}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | A02 | | | | | | | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 5px; font-weight: bold;">YES</div>|A03=<div style="text-align: center; font-weight: bold;">NO</div>}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | |!| | | | | | | | | | | | |!|}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 400px;| | A04 | | | | | | | | | | | | A05 |A04=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
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| '''Ventilate—Infuse—Pump (VIP)'''
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|
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| ❑ [[Oxygen therapy|<span style="color: #FFFFFF;">Oxygen</span>]] ± [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]
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|
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| ❑ [[Normal saline|<span style="color: #FFFFFF;">Normal saline 300–500 mL over 20–30 min</span>]]
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|
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| ❑ ± [[Norepinephine|<span style="color: #FFFFFF;">Norepinephrine 0.1–2.0 μg/kg/min</span>]]</div>
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| |A05=<div style="text-align: center; padding: 15px;">Consider other causes (eg, [[chronic hypotension|<span style="color: #000000;">chronic hypotension</span>]], [[syncope|<span style="color: #000000;">syncope</span>]])</div>}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | |!| }}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 450px;| | A06 |A06=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
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| '''Workup'''
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|
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| ❑ [[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
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|
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| ❑ [[Pulse oximeter|<span style="color: #FFFFFF;">Pulse oximeter</span>]]
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|
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| ❑ [[Arterial blood gas|<span style="color: #FFFFFF;">Arterial blood gas</span>]]
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|
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| ❑ [[Central venous catheter|<span style="color: #FFFFFF;">Central venous catheter</span>]]
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|
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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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|
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| ❑ [[Troponin|<span style="color: #FFFFFF;">Troponin</span>]], [[CK-MB|<span style="color: #FFFFFF;">CK-MB</span>]]
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|
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]]
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|
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| ❑ [[CXR|<span style="color: #FFFFFF;">Chest radiograph</span>]]
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|
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| ❑ [[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]
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|
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| ❑ [[Foley catheter|<span style="color: #FFFFFF;">Foley catheter</span>]]
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|
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| ❑ [[ICU|<span style="color: #FFFFFF;">ICU admission</span>]]
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|
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| ❑ ± [[Transfusion|<span style="color: #FFFFFF;">Transfusion</span>]] '''''([[Transfusion therapy resident survival guide|<span style="color: #FFFFFF;">Indications</span>]])'''''
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|
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| ❑ ± [[Culture|<span style="color: #FFFFFF;">Cultures of blood, urine, etc.</span>]]
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|
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| ❑ ± [[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]] '''''([[Right heart catheterization#Indications|<span style="color: #FFFFFF;">Indications</span>]])'''''
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| </div>}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | |!| }}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | A07 |A07=<div style="text-align: left; background: #FA8072; color: #F8F8FF; padding: 15px;">
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| '''Immediate Goals'''
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|
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| ❑ [[SaO2|<span style="color: #FFFFFF;">SaO2 >90%–92%</span>]]
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|
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| ❑ [[CVP|<span style="color: #FFFFFF;">CVP 8–12 mmHg</span>]]
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|
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| ❑ [[MAP|<span style="color: #FFFFFF;">MAP >65–70 mmHg</span>]]
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|
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| ❑ [[PCWP|<span style="color: #FFFFFF;">PCWP 12–15 mmHg</span>]]
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|
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| ❑ [[cardiac index|<span style="color: #FFFFFF;">CI >2.1 L/min/m2</span>]]
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|
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| ❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2 >60%</span>]]
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|
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| ❑ [[SCVO2|<span style="color: #FFFFFF;">SCVO2 >70%</span>]]
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|
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| ❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin >7–9 g/dL</span>]]
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|
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate <2.2 mM/L</span>]]
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|
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| ❑ [[urine output|<span style="color: #FFFFFF;">Urine output >0.5 mL/kg/h</span>]]
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| </div>}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 250px;| | |!| }}
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| {{Family tree|boxstyle=font-size: 90%; text-align: left; padding: 0; background: #FA8072;| | C00 | | |C00=<div style="background: #FA8072; color: #F8F8FF; padding: 15px; text-align: center">'''Identify the cause'''</div>}}
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| {{Family tree|boxstyle=font-size: 90%; text-align: left;| | |!| | | |}}
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| {{Family tree|boxstyle=padding: 0; font-size: 90%; width: 500px;| | A08 |A08=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 5px;">'''NO''', then proceed to <br>[[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]] below</div>}}
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| {{Family tree/end}}
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|
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| ==Complete Diagnostic Approach==
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|
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| <div style="width: 80%;">
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| {| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
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| |'''History'''
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| |-
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| * ''Review all medications''
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| :* [[Antihypertensives]] can cause significant [[hypotension]], especially in the setting of [[volume depletion]] or [[Diuresis|over-diuresis]].
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| :* [[Anaphylaxis]] should be considered if the patient recently started on a new drug and presented with [[respiratory distress]].
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|
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| * ''Findings suggestive of hypovolemic shock''
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| :* [[Abdominal pain]]
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| :* [[Diarrhea]]
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| :* [[Dry skin|Dry skin, mucosa, axillae]]
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| :* [[Hematemesis]]
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| :* [[Hematochezia]]
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| :* [[Melena]]
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| :* [[Surgery|Postoperative]]
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| :* [[Trauma]]
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| :* [[Vomiting]]
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|
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| * ''Findings suggestive of cardiogenic shock''
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| :* [[Chest pain]]
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| :* [[Dyspnea]]
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| :* [[Palpitations]]
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|
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| * ''Findings suggestive of distributive shock''
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| :* [[Altered mental status]]
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| :* [[Chills]]
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| :* [[Dyspnea]]
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| :* [[Dysuria]]
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| :* [[Fatigue]]
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| :* [[Fever]]
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| :* [[Flushing]]
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| :* [[Headache]]
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| :* [[Hematuria]]
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| :* [[Malaise]]
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| :* [[Myalgias]]
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| :* [[Photophobia]]
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| :* [[Productive cough]]
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| :* [[Rash]]
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| :* [[Tachycardia]]
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| :* [[Tachypnea]]
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| |}
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|
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| {| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
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| | '''Physical Examination'''
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| |-
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| * ''Vital signs''
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| :* ''Temperature''
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| ::* [[Fever]] may suggest [[sepsis]] or [[anaphylactic reaction]] related to [[transfusion|transfusion]].
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| ::* [[Hypothermia]] may be associated with [[sepsis]], [[adrenal crisis]], or [[myxedema]].
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| :* ''Pulse''
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| ::* [[Bradycardia]] or [[tachycardia]] can either be a primary or secondary process.
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| ::* [[Pulsus paradoxus]] may be seen in [[cardiac tamponade]], [[pulmonary embolism]], [[hemorrhagic shock]], or [[tension pneumothorax]].
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| ::* [[Pulsus alternans]] may be seen in [[heart failure]], severe [[aortic insufficiency]], or [[hypovolemic shock]].
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| :* ''Respiration''
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| ::* [[Tachypnea]] commonly occurs in [[pneumothorax]], [[sepsis]], and [[cardiogenic shock]].
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| ::* [[Hypopnea]] may be seen in [[narcotic]] or [[sedative]] [[overdose]].
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| :* ''Blood pressure''
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| ::* Confirm [[hypotension|arterial hypotension]] by checking [[blood pressure]] in both arms manually. [[Arterial line]] may be considered.
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| ::* [[Postural hypotension]] suggests [[volume depletion]] or [[autonomic dysfunction]]. Do not test [[orthostatic hypotension]] in [[hypotension|hypotensive]] patients.
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|
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| * ''Mental status''
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| :* [[Altered mental status]] may indicate inadequate [[perfusion]] to vital organs or use of [[sedative]]s or [[narcotic]]s.
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|
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| * ''Cutaneous''
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| :* [[Volume status#Volume depletion|Decreased skin turgor]] and dry [[mucous membrane]] signify [[dehydration]].
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| :* [[Cool extremities]], [[clammy]] and [[mottled skin]], [[peripheral cyanosis]], and [[capillary refill|delayed capillary refill]] are commonly noted in [[cardiogenic shock]] and [[hypovolemic shock]], whereas warm and moist skin may represent hyperdynamic phase of [[septic shock]].
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| :* [[Burn|Extensive burns]] and [[Trauma|severe trauma]] may be evident on inspection and are associated with significant fluid loss.
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| :* [[Hyperpigmentation]] may be an indicator of [[adrenal crisis]].
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|
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| * ''Neck''
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| :* [[Jugular venous pressure|Elevated jugular venous pressure (JVP)]] correlates with increased [[Preload|left ventricular end diastolic pressure (LVEDP)]] and decreased [[LVEF|left ventricular ejection fraction (LVEF)]]. [[Jugular venous distention]] or [[Jugular venous pressure|elevated JVP]] typically occurs in:
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| ::* [[Heart failure]]
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| ::* [[Tricuspid stenosis]]
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| ::* [[Pulmonary hypertension]]
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| ::* [[Superior vena cava]] [[obstruction]]
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| ::* [[Constrictive pericarditis]]
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| ::* [[Cardiac tamponade]]
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| :* [[Kussmaul's sign]]
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| ::* [[Constrictive pericarditis]]
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| ::* [[Restrictive cardiomyopathy]]
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| ::* [[Tricuspid stenosis]]
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| ::* [[Superior vena cava]] [[obstruction]]
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| ::* [[Right ventricular infarction]]
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| :* [[Abdominojugular reflux]] (a positive [[abdominojugular reflux]] correlates with a [[PCWP]] of 15 mmHg or greater)
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| ::* [[Cardiac tamponade]]
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| ::* [[Constrictive pericarditis]]
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| ::* [[Tricuspid insufficiency]]
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| ::* [[Inferior vena cava]] [[obstruction]]
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| ::* [[Heart failure]] (except for pure backward [[heart failure|left-sided heart failure]])
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|
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| :* [[Jugular venous pressure#JVP waveform|Jugular venous pressure waveform]]
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| ::* [[Jugular venous pressure#Abnormalities in the JVP Waveforms|Blunted y descent]] suggests [[cardiac tamponade]] or [[tricuspid stenosis]].
| |
| ::* [[Jugular venous pressure#Abnormalities in the JVP Waveforms|Steep y descent]] suggests [[constrictive pericarditis]] or severe [[tricuspid insufficiency]].
| |
|
| |
| * ''Cardiovascular''
| |
| :* [[Systolic murmur|Decrescendo early systolic murmur]]
| |
| ::* [[mitral regurgitation|Acute severe mitral regurgitation]]
| |
| :* [[Third heart sound|Third heart sound (S<sub>3</sub>)]]
| |
| ::* [[Heart failure]]
| |
| :* [[Systolic murmur|Pansystolic murmur along lower left sternal border]] with [[thrill|palpable thrill]]
| |
| ::* [[Ventricular septal defect]]
| |
| :* [[Pericardial friction rub]]s
| |
| ::* [[Pericarditis]]
| |
| :* [[muffled heart sounds|Distant, muffled heart sounds]]
| |
| ::* [[Cardiac tamponade]]
| |
|
| |
| * ''Pulmonary''
| |
| :* [[Tracheal deviation]]
| |
| ::* [[Tension pneumothorax]]
| |
| :* [[Stridor]] and [[wheezing]]
| |
| ::* [[Anaphylaxis]]
| |
| ::* [[COPD|Acute exacerbation of chronic obstructive pulmonary disease]]
| |
| :* [[Rales]]
| |
| ::* [[Anaphylaxis]]
| |
| ::* [[Pneumonia]]
| |
| ::* [[Heart failure]]
| |
| :* [[percussion|Chest percussion]] may aid in the diagnosis of [[tension pneumothorax]], [[pleural effusions]], and [[pneumonia]]
| |
|
| |
| * ''Abdominal''
| |
| :* [[Grey Turner's sign]]
| |
| ::* [[Acute pancreatitis]]
| |
| ::* [[Blunt force trauma|Blunt abdominal trauma]]
| |
| ::* [[Retroperitoneal hemorrhage]]
| |
| ::* [[Abdominal aortic aneurysm|Ruptured abdominal aortic aneurysm]]
| |
| ::* [[Ectopic pregnancy|Ruptured ectopic pregnancy]]
| |
|
| |
| :* [[Cullen's sign]]
| |
| ::* [[Acute pancreatitis|Acute pancreatitis]]
| |
| ::* [[Blunt force trauma|Blunt abdominal trauma]]
| |
| ::* [[Abdominal aortic aneurysm|Ruptured abdominal aortic aneurysm]]
| |
| ::* [[ectopic pregnancy|Ruptured ectopic pregnancy]]
| |
| :* [[Hepatomegaly]]
| |
| ::* [[Inferior vena cava]] [[obstruction]]
| |
| ::* [[Heart failure]]
| |
| :* [[Rebound tenderness]] with [[absent bowel sounds]]
| |
| ::* [[Sepsis]] due to [[abdomen|Intraabdominal]] [[infection]]
| |
| ::* [[Ischemic colitis]]
| |
| ::* [[Gastrointestinal hemorrhage]]
| |
| :* [[Mass|Pulsatile mass]]
| |
| ::* [[Abdominal aortic aneurysm]]
| |
|
| |
| * ''Rectal''
| |
| :* [[Hematochezia|Bright red blood]] or [[melena]]
| |
| ::* [[Gastrointestinal hemorrhage]]
| |
| :* Diminished [[sphincter|sphincter tone]]
| |
| ::* [[Spinal cord injury]]
| |
|
| |
| * ''Extremities''
| |
| :* [[Digital clubbing]]
| |
| ::* [[Heart failure]]
| |
| :* [[Edema]]
| |
| ::* [[Heart failure]]
| |
| :* [[Erythema]] at the site of [[intravenous therapy|venous access]]
| |
| ::* [[Catheter|Catheter-associated]] [[infection]]
| |
| :* [[Pelvic girdle pain|Pelvic girdle pain or instability]]
| |
| ::* [[Pelvic fracture]]
| |
|
| |
| * ''Genitals''
| |
| :* Perform a [[pelvic examination]] in women of childbearing age to rule out [[ectopic pregnancy]] or [[pelvic inflammatory disease]].
| |
|
| |
| * ''Neurologic''
| |
| :* [[Agitation]] or [[delirium]]
| |
| ::* Poor [[Cerebral perfusion pressure|cerebral perfusion]]
| |
| :* [[Meningeal signs|Meningeal signs (nuchal rigidity, Brudzinski's sign, and Kernig's sign]]
| |
| ::* [[Meningitis]]
| |
| |}
| |
|
| |
| {| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
| |
| | '''Laboratory Findings'''
| |
| |-
| |
| |
| |
|
| |
| * ''Complete blood count''
| |
| :* In acute [[hemorrhage|blood loss]], [[hemoglobin]] and [[hematocrit]] levels may remain normal until volume repletion.
| |
| :* [[Leukocytosis]] with or without a [[Granulocytosis#Left Shift|left shift of neutrophils]] suggests [[sepsis]].
| |
| :* [[Thrombocytopenia]] with alterations in [[coagulation]] panel indicates [[disseminated intravascular coagulation|disseminated intravascular coagulation (DIC)]], which may be a complication of [[sepsis]].
| |
| * ''Electrolytes''
| |
| :* Decreased [[bicarbonate]] levels may be the primary deficit in [[metabolic acidosis]] or the compensatory change in [[respiratory alkalosis]].
| |
| :* [[Hyperkalemia]] due to transcellular shift is commonly associated with [[metabolic acidosis]].
| |
| * ''Coagulation panel (PT, PTT, INR, etc.)''
| |
| :* Abnormalities in [[coagulation]] panel may be caused by [[disseminated intravascular coagulation|disseminated intravascular coagulation (DIC)]], [[anticoagulation|over-anticoagulation]], or [[hepatic failure]].
| |
| * ''Cardiac markers''
| |
| :* Check [[troponin]] and [[Creatine kinase|CK-MB]] levels when suspecting [[myocardial infarction]].
| |
| :* Elevation in [[cardiac markers]] may be associated with both cardiac and extracardiac etiologies.
| |
| * ''Liver function''
| |
| :* Increased levels of [[conjugated bilirubin]], [[alkaline phosphatase]], and [[aminotransferase|hepatic aminotransferases]] are typically seen in [[ischemic hepatitis|ischemic hepatitis ("shock liver")]] due to [[cardiogenic shock]].
| |
| * ''Renal function''
| |
| :* [[Acute kidney injury|Prerenal azotemia]] and/or [[acute tubular necrosis]] may be associated with conditions of [[hypovolemia]] or reduced [[cardiac output]].
| |
| :* [[Oliguria|Oliguria (urine output <0.5 mL/kg/h)]] is usually evident.
| |
| * ''Lactate''
| |
| :* [[Lactate|Hyperlactatemia]] generally reflects the development of anaerobic metabolism in hypoperfused tissue and/or imparied hepatic clearance.
| |
| :* [[Lactate]] level could decrease within hours with effective therapy.<ref name="Vincent-2013">{{Cite journal | last1 = Vincent | first1 = JL. | last2 = De Backer | first2 = D. | title = Circulatory shock. | journal = N Engl J Med | volume = 369 | issue = 18 | pages = 1726-34 | month = Oct | year = 2013 | doi = 10.1056/NEJMra1208943 | PMID = 24171518 }}</ref>
| |
|
| |
| * ''Arterial blood gas''
| |
| :* [[Lactic acidosis]] may be an indicator of [[hypoperfusion|tissue hypoperfusion]] typically seen in [[septic shock]].
| |
| :* Combined [[acid-base disorders]] are fequently encountered in different stages of shock.
| |
| :* Severe [[acidosis]] could blunt the effectiveness of [[vasopressor]]s and potentiate the development of [[arrhythmia]]s.
| |
| * ''Cultures''
| |
| :* Samples of [[blood culture|blood]], [[urine culture|urine]], and/or [[sputum culture|sputum]] should be sent for culture before administering [[antibiotics]] if [[sepsis]] is concerned.
| |
| * ''Nasogastric aspirate''
| |
| :* A negative [[nasogastric intubation|nasogastric aspirate]] does not rule out [[gastrointestinal hemorrhage|upper gastrointestinal bleeding]].
| |
| * ''Pregnancy test''
| |
| :* A [[pregnancy test]] should be performed on [[hypotension|hypotensive]] women of childbearing age presenting with lower [[abdominal pain]].
| |
| |}
| |
|
| |
| {| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
| |
| |'''ECG Findings'''
| |
| |-
| |
| |
| |
| * [[ST segment elevation]] or [[ST segment depression|depression]], [[Pathologic Q Waves|pathologic Q waves]], [[tented T waves|hyperacute]] or [[T wave inversion|negative T waves]]
| |
| :* [[Myocardial infarction|Myocardial infarction or ischemia]]
| |
| * [[Sinus tachycardia]] with [[S1Q3T3|S1Q3T3 pattern]]
| |
| :* [[pulmonary embolism|Acute pulmonary embolism]]
| |
| * [[Low QRS voltage]] with [[electrical alternans]]
| |
| :* [[Cardiac tamponade]]
| |
| * [[QRS complex|QS deflections]] in [[precordial lead]]s with [[right axis deviation]] and [[low QRS voltage]]
| |
| :* [[Pneumothorax|Pneumothorax]]
| |
| * [[Bradyarrhythmias]] or [[tachyarrhythmias]]
| |
| |}
| |
|
| |
| {| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
| |
| |'''Radiographic Findings'''
| |
| |-
| |
| |
| |
| * ''[[Chest radiograph]]'' may aid in establishing diagnosis in the following conditions:
| |
| :* [[Aortic dissection]]
| |
| :* [[Cardiac tamponade]]
| |
| :* [[Pneumonia]] complicating [[septic shock]]
| |
| :* [[Pulmonary edema]] complicating [[cardiogenic shock]]
| |
| :* [[Tension pneumothorax]]
| |
|
| |
| * ''[[Computed tomography|CT scan]]'' may aid in directing management in the following conditions:
| |
| :* [[Hemorrhage|Occult internal hemorrhage]]
| |
| :* [[Pulmonary embolism]]
| |
| |}
| |
|
| |
| {| class="mw-collapsible mw-collapsed" data-expandtext="Click to Expand" data-collapsetext="Click to Collapse" style="border: 0;"
| |
| |'''Hemodynamic Profiles and Echocardiography Findings'''
| |
| |-
| |
| |
| |
| <table style="border: 2px solid #A8A8A8; width: 100%; font-size: 80%;" align="center">
| |
| <tr>
| |
| <td align="center" style="background: #B0B0B0; width: 55px;"> <b>Type of Shock</b>
| |
| </td>
| |
| <td align="center" style="background: #B0B0B0; width: 55px;"> <b>Etiology</b>
| |
| </td>
| |
| <td align="center" style="background: #B0B0B0; width: 55px;"> <b>CO</b>
| |
| </td>
| |
| <td align="center" style="background: #B0B0B0; width: 55px;"> <b>SVR</b>
| |
| </td>
| |
| <td align="center" style="background: #B0B0B0; width: 55px;"> <b>PCWP</b>
| |
| </td>
| |
| <td align="center" style="background: #B0B0B0; width: 55px;"> <b>CVP</b>
| |
| </td>
| |
| <td align="center" style="background: #B0B0B0; width: 55px;"> <b>SVO2</b>
| |
| </td>
| |
| <td align="center" style="background: #B0B0B0;"> <b>Echocardiographic Findings</b>
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC; width: 80px;" align="center" rowspan="4"> <b>Cardiogenic</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC; width: 20%;"> <b>Acute Ventricular Septal Defect</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" rowspan="3"> Large ventricles with poor contractility
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Acute Mitral Regurgitation</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Myocardial Dysfunction</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>RV Infarction</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> Dilated RV, small LV, abnormal wall motions
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" rowspan="2" align="center"> <b>Obstructive</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> <b>Pulmonary Embolism</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">N — ↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Dilated RV, small LV
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"><b>Cardiac Tamponade</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓ — ↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Pericardial effusion, small ventricles, dilated inferior vena cava
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" rowspan="2" align="center"> <b>Distributive</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Septic Shock</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓ — ↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" rowspan="2"> Normal cardiac chambers with preserved contractility
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;"> <b>Anaphylactic Shock</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↑↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↓ — ↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">N — ↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #DCDCDC;" align="center">↑ — ↑↑
| |
| </td></tr>
| |
| <tr>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" rowspan="1" align="center"> <b>Hypovolemic</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> <b>Volume Depletion</b>
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↑
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;" align="center">↓
| |
| </td>
| |
| <td style="font-size: 100%; padding: 0 5px; background: #F5F5F5;"> Small cardiac chambers with normal or high contractility
| |
| </td></tr></table>
| |
| |}
| |
|
| |
| </div>
| |
|
| |
| ==Treatment==
| |
|
| |
| ==Do's==
| |
|
| |
| * ''Initial Management''
| |
| ::* [[Resuscitation]] should be initiated while investigation is ongoing. Correct the cause of [[shock]] immediately once it is identified.
| |
| ::* The VIP (Ventilate-Infuse-Pump) approach is useful for ensuring an orderly sequence of therapeutic-diagnostic maneuvers.<ref name="Weil-1969">{{Cite journal | last1 = Weil | first1 = MH. | last2 = Shubin | first2 = H. | title = The VIP approach to the bedside management of shock. | journal = JAMA | volume = 207 | issue = 2 | pages = 337-40 | month = Jan | year = 1969 | doi = | PMID = 5818156 }}</ref>
| |
|
| |
| :* ''Ventilate''
| |
| ::* [[Endotracheal intubation]] should be performed in patients with severe [[dyspnea]], [[hypoxemia]], or persistent or worsening [[acidemia]] (pH <7.30).
| |
|
| |
| :* ''Infuse''
| |
| ::* A [[intravenous therapy#Central IV lines|central venous catheter]] should be placed for the infusion of fluids and [[vasopressor|vasoactive agent]]s and to guide fluid therapy.
| |
| ::* A [[pulmonary artery catheter]] should be inserted for monitoring of [[blood pressure]] and [[sampling|blood sampling]] unless shock is rapidly reversed. '''''([[Right heart catheterization#Indications|Indications]])'''''
| |
| ::* An infusion of 300–500 ml of [[Intravenous fluid#Crystalloid Fluids|crystalloid fluid]] is usually administered during a period of 20–30 minutes.
| |
| ::* End point of fluid therapy can be defined as a [[central venous pressure|central venous pressure (CVP)]] of a few [[mmHg|millimeters of mercury (mmHg)]] above the baseline to prevent fluid overload.<ref name="Dellinger-2013">{{Cite journal | last1 = Dellinger | first1 = RP. | last2 = Levy | first2 = MM. | last3 = Rhodes | first3 = A. | last4 = Annane | first4 = D. | last5 = Gerlach | first5 = H. | last6 = Opal | first6 = SM. | last7 = Sevransky | first7 = JE. | last8 = Sprung | first8 = CL. | last9 = Douglas | first9 = IS. | title = Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. | journal = Crit Care Med | volume = 41 | issue = 2 | pages = 580-637 | month = Feb | year = 2013 | doi = 10.1097/CCM.0b013e31827e83af | PMID = 23353941 }}</ref>
| |
|
| |
| :* ''Pump''
| |
| ::* [[Vasopressor]]s are indicated in [[hypotension]] that is severe or refractory to fluid challenge.
| |
| ::* [[Norepinephrine]] (0.1–2.0 μg/kg/min IV) is the first choice of [[vasopressor]], while [[epinephrine]] (0.1–0.5 μg/kg/min IV) is reserved for severe [[hypotension]] as the second-line agent.
| |
| ::* [[Isoproterenol]] (0.5–5.0 μg/min IV) should be limited to the treatment of [[hypotensive]] patients with severe [[bradycardia]].
| |
| ::* Adjunctive [[vasopressin]] (0.01–0.04 U/min IV) to [[norepinephrine]] should be considered only in hyperdynamic phase of [[distributive shock]].
| |
|
| |
| ==Don'ts==
| |
|
| |
| * Do not test [[orthostatic hypotension]] in [[hypotension|hypotensive]] patients.
| |
| * 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]].
| |
| * Do not administer low-dose [[dopamine]] (<5 μg/kg/min) to preserve [[renal function]] in patients with [[shock]].
| |
|
| |
| ==References==
| |
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| {{reflist|2}}
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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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