Cardiogenic shock: Difference between revisions

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== Treatment ==
== Treatment ==
In cardiogenic shock: depending on the type of myocardal infarction one can infuse fluids or in shock refractory to infusing fluids, inotropes should be administeredPositive [[inotrope|inotropic agents]], which enhance the heart's pumping capabilities, are used to improve the contractility and correct the hypotension.  Should that not suffice an [[intra-aortic balloon pump]] (which reduces [[afterload|workload]] for the heart, and improves perfusion of the [[coronary arteries]]) can be considered or a left [[ventricular assist device]] (which augments the pump-function of the heart).
The goal of managing the patient with cardiogenic shock is to optimize the filling of the left ventricle so that the Starling relationship is optimized.  In the stting of acute MI, a pulmonary capillary wedge pressure of 18 to 20 mm Hg may optimize left ventricular filling.  Filling pressures higher than this may lead to LV dialtion, poorer left ventricular functionIf hypotension persists in the presence of adequate left ventricular filling pressures, then the addition of positive [[inotrope|inotropic agents]] to imporve contractility may be required.  Should that not suffice an [[intra-aortic balloon pump]] (which reduces [[afterload|workload]] for the heart, and improves perfusion of the [[coronary arteries]]) can be considered or a left [[ventricular assist device]] (which augments the pump-function of the heart).
<ref name="IrwinRippe"/>
<ref name="Marino"/>
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== See also ==
== See also ==

Revision as of 14:31, 17 May 2009

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Overview

Cardiogenic shock is defined as an inadequate cardiac output to maintain adequate perfusion of vital organs to meet ongoing demands for oxygenation. Cardiogenic shock is due to either inadequate left ventricular pump function (such as in congestive heart failure) or inadequate left ventricular filling (such as in cardiac tamponade or mitral stenosis with tachycardia). In so far as the course of treatment differs substantially, cardiogenic shock should be distinguished from other forms of shock such as septic shock and neurogenic shock.

Definition

Cardiogenic shock is defined by sustained hypotension with tissue hypoperfusion despite adequate left ventricular filling pressure. Signs of tissue hypoperfusion include oliguria (<30 mL/h), cool extremities, and altered mentation.

The pathophysiology of cardiogenic shock is complex and multifaceted, and as a result, diagnostic criteria for cardiogenic shock have been debated. Some clinicians argue that hypotension alone should not be the key criteria in so far as compensatory tachycardia and vasoconstriction may compensate for the reduced cardiac output to yield a mildly depressed systolic blood pressure. These clinicians advocate a hemodynamic definition with greater reliance placed on hemodynamic measures and interpretation of the cardiac output in the context of left ventricular filling pressure as often gauged by the pulmonary capillary wedge pressure. For instance, a patient who has a history of hypertension who now has a blood pressure of 100 mm Hg with a markedly elevated systemic vascular resistance (SVR) and pronounced tachycardia with a markedly reduced cardiac output, would be in cardiogenic shock in the judgement of some clinicians despite the absence of hypotension.

In clinical trials, cardiogenic shock has been defined as follows by the SHOCK investigators: [1]

Clinical criteria

  1. Systolic blood pressure <90 mm Hg
  2. Evidence of hypoperfusion
  3. Cool, clammy periphery
  4. Decreased urine output
  5. Decreased level of consciousness

Hemodynamic criteria

  1. Left ventricular end diastolic pressure or pulmonary capillary wedge pressure >15 mm Hg
  2. Cardiac index <2.2 L/min/m2

Pathophysiology of Cardiogenic Shock

Cardiogenic shock can be a complication of the follwoing conitions:

Diagnosis

Symptoms

Physical Examination

Vitals

  • Hypotension due to decrease in cardiac output.
  • A rapid, weak, thready pulse due to decreased circulation combined with tachycardia.

Neck

Skin

  • Cool, clammy, and mottled skin (cutis marmorata), due to vasoconstriction and subsequent hypoperfusion of the skin.

Lungs

  • Rapid and deep respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis.
  • Oliguria (low urine output) due insufficient renal perfusion if condition persists.
  • Absent pulse in tachyarrhythmia.
  • Pulmonary Edema (fluid in the lungs) due to insufficient pumping of the heart, fluid backs up into the lungs.

Electrocardiogram

An Electrocardiogram helps establishing the exact diagnosis and guides treatment, it may reveal:

Radiology

Echocardiography may show arrhythmia, signs of PED, ventricular septal rupture (VSR), an obstructed outflow tract or cardiomyopathy.

Swan-ganz catheter

The Swan-ganz catheter or Pulmonary artery catheter may assist in the diagnosis by providing information on the hemodynamics.

Biopsy

In case of suspected cardiomyopathy a biopsy of heart muscle may be needed to make a definite diagnosis.

Treatment

The goal of managing the patient with cardiogenic shock is to optimize the filling of the left ventricle so that the Starling relationship is optimized. In the stting of acute MI, a pulmonary capillary wedge pressure of 18 to 20 mm Hg may optimize left ventricular filling. Filling pressures higher than this may lead to LV dialtion, poorer left ventricular function. If hypotension persists in the presence of adequate left ventricular filling pressures, then the addition of positive inotropic agents to imporve contractility may be required. Should that not suffice an intra-aortic balloon pump (which reduces workload for the heart, and improves perfusion of the coronary arteries) can be considered or a left ventricular assist device (which augments the pump-function of the heart).

See also

Sources

  • Irwin, R.S., Rippe, J.M., Curley, F.J., Heard, S.O. (1997) Procedures and Techniques in Intensive Care Medicine (3rd edition). Boston: Lippincott, Williams and Wilkins.
  • Marino, P. (1997) The ICU Book. (2nd edition). Philadelphia: Lippincott, Williams and Wilkins.

References

  1. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med 1999; 341 (9) : 625–34.

External links

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