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{{Family tree/start}}
{{Family tree/start}}
{{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>
{{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>


❑&nbsp;&nbsp;Evidence of end-organ [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]
❑&nbsp;&nbsp;Evidence of end-organ [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]
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❑&nbsp;&nbsp;Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]</div>}}
❑&nbsp;&nbsp;Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]</div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%;| |,|-|-|-|^|-|-|-|.| |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%;| | | | |,|-|-|-|^|-|-|-|.| |}}
{{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>}}
{{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>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | |!| |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072; border-top: 0px;| | | | A04 | | | | | | A05 |A04=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic shock suspected</BIG></div>
{{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>
|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>}}
|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>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A06 | | | | | | | | |A06=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate management'''</BIG>
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | A06 | | | | | | | | |A06=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate management'''</BIG>


❑&nbsp;&nbsp;[[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
❑&nbsp;&nbsp;[[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
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❑&nbsp;&nbsp;Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</span>]]</div>}}
❑&nbsp;&nbsp;Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</span>]]</div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate workup'''</BIG>
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate workup'''</BIG>


❑&nbsp;&nbsp;[[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>]]
❑&nbsp;&nbsp;[[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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❑&nbsp;&nbsp;[[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]</div>}}
❑&nbsp;&nbsp;[[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]</div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
{{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 &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">(click for details on criteria)</span>]]''</div>}}
{{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 &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">(click for details on criteria)</span>]]''</div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| A09 | | | | | | | | |A09=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Hemodynamic Optimization &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Optimization of hemodynamic parameters</span>]]'''</BIG></div>}}
{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| | | | A09 | | | | | | | | |A09=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Hemodynamic Optimization &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Optimization of hemodynamic parameters</span>]]'''</BIG></div>}}
{{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>'''''[[{{PAGENAME}}#Preload &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Preload (click for details)</span>]]'''''</BIG>
{{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>'''''[[{{PAGENAME}}#Preload &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Preload (click for details)</span>]]'''''</BIG>


❑&nbsp;&nbsp;'''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 15–18 mm Hg, [[Central venous pressure|<span style="color: #FFFFFF;">CVP</span>]] 8–12 cm H<sub>2</sub>O'''
❑&nbsp;&nbsp;'''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 15–18 mm Hg, [[Central venous pressure|<span style="color: #FFFFFF;">CVP</span>]] 8–12 cm H<sub>2</sub>O'''
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: ❑&nbsp;&nbsp;± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg slow IV injection
: ❑&nbsp;&nbsp;± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg slow IV injection
</div>}}
</div>}}
{{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>'''''[[{{PAGENAME}}#Afterload &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Afterload (click for details)</span>]]'''''</BIG>
{{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>'''''[[{{PAGENAME}}#Afterload &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Afterload (click for details)</span>]]'''''</BIG>


❑&nbsp;&nbsp;'''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] &gt;65 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>'''
❑&nbsp;&nbsp;'''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] &gt;65 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>'''
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: ❑&nbsp;&nbsp;If ↓ MAP & ↓ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasopressin|<span style="color: #FFFFFF;">vasopressin</span>]]
: ❑&nbsp;&nbsp;If ↓ MAP & ↓ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasopressin|<span style="color: #FFFFFF;">vasopressin</span>]]
</div>}}
</div>}}
{{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>'''''[[{{PAGENAME}}#Cardiac Index &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Cardiac index (click for details)</span>]]'''''</BIG>
{{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>'''''[[{{PAGENAME}}#Cardiac Index &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Cardiac index (click for details)</span>]]'''''</BIG>


❑&nbsp;&nbsp;'''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] &gt;2.2 L/min/m<sup>2</sup>'''
❑&nbsp;&nbsp;'''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] &gt;2.2 L/min/m<sup>2</sup>'''
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: ❑&nbsp;&nbsp;± [[Milrinone|<span style="color: #FFFFFF;">Milrinone</span>]]</div>}}
: ❑&nbsp;&nbsp;± [[Milrinone|<span style="color: #FFFFFF;">Milrinone</span>]]</div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| A13 | | | | | | | | |A13=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Optimization of perfusion and oxygenation'''</BIG></div>}}
{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| | | | A13 | | | | | | | | |A13=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Optimization of perfusion and oxygenation'''</BIG></div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A14 | | | | | | | | |A14=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | A14 | | | | | | | | |A14=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;">


❑&nbsp;&nbsp;'''Endpoints'''
❑&nbsp;&nbsp;'''Endpoints:'''


: ❑&nbsp;&nbsp;[[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] &gt;92%
: ❑&nbsp;&nbsp;[[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] &gt;92%
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❑&nbsp;&nbsp;'''Consider [[IABP|<span style="color: #FFFFFF;">IABP</span>]], [[VAD|<span style="color: #FFFFFF;">VAD</span>]], or [[ECMO|<span style="color: #FFFFFF;">ECMO</span>]]'''
❑&nbsp;&nbsp;'''Consider [[IABP|<span style="color: #FFFFFF;">IABP</span>]], [[VAD|<span style="color: #FFFFFF;">VAD</span>]], or [[ECMO|<span style="color: #FFFFFF;">ECMO</span>]]'''


❑&nbsp;&nbsp;'''± Correct [[arrhythmia|<span style="color: #FFFFFF;">tachyarrhythmias</span>]] and [[arrhythmia|<span style="color: #FFFFFF;">bradyarrhythmias</span>]]'''
❑&nbsp;&nbsp;'''± Correct [[tachyarrhythmia|<span style="color: #FFFFFF;">tachyarrhythmias</span>]] and [[bradyarrhythmia|<span style="color: #FFFFFF;">bradyarrhythmias</span>]]'''


❑&nbsp;&nbsp;'''± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">acid-base and electrolyte disturbance</span>]]'''</div>}}
❑&nbsp;&nbsp;'''± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">acid-base and electrolyte disturbance</span>]]'''</div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072;| A15 |-| A16 | | | | | |A15=<div style="background: #FA8072; color: #F8F8FF; padding: 16px;"><BIG>'''[[{{PAGENAME}}#Criteria for Acute Myocardial Infarction &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Acute myocardial infarction likely?</span>]]'''</BIG>
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072;| | | | A15 |-| A16 | | | | | |A15=<div style="background: #FA8072; color: #F8F8FF; padding: 16px;"><BIG>'''[[{{PAGENAME}}#Criteria for Acute Myocardial Infarction &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Acute myocardial infarction likely?</span>]]'''</BIG>
 
❑&nbsp;&nbsp;[[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cTnT, cTnI, or CK-MB</span>]] '''''AND'''''
❑&nbsp;&nbsp;[[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cTnT, cTnI, or CK-MB</span>]] '''''AND'''''


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❑&nbsp;&nbsp;New significant ST–T changes or LBBB</div>
❑&nbsp;&nbsp;New significant ST–T changes or LBBB</div>
|A16=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 20px;"><BIG>'''YES, then proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></div>}}
|A16=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 20px;"><BIG>'''YES, then proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></div>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
 
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A17 | | | | | | | | |A17=<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>}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | ||!| | | | | | | | | |}}
{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | |A17 | | | | | | | | |A17=<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>}}
{{Family tree/end}}
{{Family tree/end}}



Revision as of 17:27, 29 April 2014

Cardiogenic Shock
Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, MBChB. [2]



FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[1]

Boxes in the red signify that an urgent management is needed.

Abbreviations: CBC, complete blood count; CI, cardiac index; CK-MB, creatine kinase MB isoform; CVP, central venous pressure; DC, differential count; ICU, intensive care unit; INR, international normalized ratio; LFT, liver function test; MAP, mean arterial pressure; PCWP, pulmonary capillary wedge pressure; PT, prothrombin time; PTT, partial prothrombin time; SaO2, arterial oxygen saturation; SBP, systolic blood pressure; ScvO2, central venous oxygen saturation; SvO2, mixed venous oxygen saturation; SMA-7, sequential multiple analysis-7.

 
 
 
 
 
 
 
Does the patient have cardinal findings that increase the pretest probability of cardiogenic shock?

❑  Evidence of end-organ hypoperfusion

❑  Altered mental status
❑  Cold extremities
❑  Cyanosis
❑  Oliguria (urine output <0.5 mL/kg/h)
❑  Sustained hypotension
❑  SBP <90 mm Hg for ≥30 min or
❑  MAP ↓ >30 mm Hg below baseline for ≥30 min
❑  Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
NO
 
 
 
Cardiogenic shock suspected
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate workup

❑  CBC/DC/SMA-7/LFT/PT/PTT/INR

❑  Cardiac troponins, CK-MB

❑  BNP, NT-proBNP

❑  Lactate

❑  12-Lead ECG

❑  Chest radiograph

❑  Echocardiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiogenic shock confirmed
(click for details on criteria)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preload (click for details)

❑  Goal: PCWP 15–18 mm Hg, CVP 8–12 cm H2O

❑  Fluid challenge protocol ("TROL")

❑  ± Correct pulmonary congestion

❑  ± Furosemide 40 mg slow IV injection
❑  ± Morphine 2–4 mg slow IV injection
 
 
 
 
 
 
 
 
 
 
 
Afterload (click for details)

❑  Goal: MAP >65 mm Hg, SVR 800–1200 dyn·s·cm−5

❑  If ↑ MAP & ↑ SVR: wean vasopressors ± vasodilators
❑  If ↓ MAP & ↑ SVR: vasopressors + inotropes
❑  If ↓ MAP & ↓ SVR: vasopressors ± vasopressin
 
 
 
 
 
 
 
 
 
 
 
Cardiac index (click for details)

❑  Goal: CI >2.2 L/min/m2

❑  ± Dobutamine
❑  ± Milrinone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Optimization of perfusion and oxygenation
 
 
 
 
 
 
 
 
 
 
 

❑  Endpoints:

❑  SaO2 >92%
❑  SvO2 >60%
❑  ScvO2 >70%
❑  Urine output >0.5 mL/kg/h
❑  Lactate <2.2 mM/L
❑  Hematocrit ≥30%

❑  Consider IABP, VAD, or ECMO

❑  ± Correct tachyarrhythmias and bradyarrhythmias

❑  ± Correct acid-base and electrolyte disturbance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute myocardial infarction likely?

❑  Positive cTnT, cTnI, or CK-MB AND

❑  Symptoms of myocaridal ischemia OR

❑  New significant ST–T changes or LBBB
 
YES, then proceed to
acute ischemia pathway
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No, then proceed to
complete diagnostic approach
 
 
 
 
 
 
 
 

Do's

Criteria for Cardiogenic Shock [Return to FIRE]

Hemodynamic Optimization [Return to FIRE]

Preload [Return to FIRE]

Fluid Challenge Protocol
  • Protocolized fluid administration titrated to hemodynamic and clinical endpoints secures the efficacy of tissue perfusion and oxygenation.[9]
  • Four elements of the fluid challenge protocol: type of fluid (T), rate of fluid administration (R), objective (O), and limits (L).[10]
  • 1. Type of fluid (T)
  • The choice of crystalloid or colloid solution should be made on the basis of the underlying disease, the nature of fluid deficit, the severity of circulatory failure, the serum albumin concentration, and the risk of bleeding.[11]
  • There were no significant differences in mortality between saline and albumin infusion for critically ill patients.[12]
  • Blood transfusion may be considered in the presence of profound anemia or massive hemorrhage.[9]
  • Hyperchloremic acidosis may be associated with the use of isotonic saline solution.[13]
  • 2. Rate of fluid administration (R)
Baseline PCWP (mm Hg) Baseline CVP (cm H2O) Rate of fluid administration
≥16 ≥14 50 mL over 10 minutes
<16 but ≥12 <14 but ≥8 100 mL over 10 minutes
<12 <8 200 mL over 10 minutes
  • 3. Objective (O)
  • Fluid administration should be titrated to reach predetermined clinical endpoints such as resolution of tachycardia or oliguria, improved skin perfusion or level of consciousness, normalization of lactate concentrations, and restoration of adequate blood pressure or ventricular filling pressure.[11]
  • 4. Limits (L)
  • Fluid administration should be stopped if the safety limits are violated to minimize the risk of developing pulmonary edema.
  • Inotropes, vasodilators, or mechanical circulatory device may be required if signs of hypoperfusion persist despite optimal fluid loading.
  • Hemodynamic safety limits based on PCWP (the 7–3 rule) or CVP (the 5–2 rule):[9]
↑ PCWP (mm Hg) ↑ CVP (cm H2O) Action
≥7 ≥5 Stop fluid administration
<7 but >3 <5 but >2 Wait and recheck pressure after 10 minutes
≤3 ≤2 Continue fluid administration
Pulmonary Congestion
  • Findings suggestive of cardiogenic pulmonary edema:[14]
  • History and clinical manifestations
  • Cough
  • Dyspnea
  • Expectoration of frothy sputum
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Signs and symptoms of heart failure
  • Signs and symptoms of hypoxemia
  • Signs and symptoms of myocardial ischemia
  • Signs and symptoms of valvular dysfunction
  • Tachypnea
  • Physical examination
  • Cool extremities
  • Heart murmurs
  • Hepatomegaly
  • Inspiratory crackles or rhonchi
  • Jugular venous distention
  • S3 gallop
  • Peripheral edema
  • Laboratory and hemodynamic findings
  • BNP > 500 pg/mL
  • PCWP >18 mm Hg
  • Radiologic findings
  • Central infiltrates with peripheral sparing
  • Cephalization of pulmonary vessels
  • Enlarged cardiac silhouette
  • Enlargement of peribronchovascular spaces
  • Increased opacity of acinar areas that coalesce into frank consolidations
  • Kerley B lines
  • Peribronchial cuffing
  • Pleural effusions
  • Vascular pedicle width >70 mm
PCWP (mm Hg) Phase of Pulmonary Congestion Findings on Chest Radiograph
18–20 Onset of pulmonary congestion Redistribution of pulmonary flow to the upper lobes ("cephalization") and Kerley lines
20–25 Moderate congestion Diminished clarity of the borders of medium-sized pulmonary vessels ("perihilar haze")
25–30 Severe congestion Radiolucent grapelike clusters surrounded by radiodense fluid ("periacinar rosette")
>30 Onset of pulmonary edema Coalescence of periacinar rosettes resulting in "Bat's wing" opacities
  • Dosage and Administration
  • For acute pulmonary edema, the initial dose is 40 mg injected slowly intravenously (over 1 to 2 minutes).
  • 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).
  • Contraindications
  • Dosage and Administration
  • Morphine may be used adjunctively in the treatment of acute pulmonary edema at a dose of 2–4 mg (slow IV injection over 1–5 minutes) every 5–30 minutes as needed.
  • Contraindications

Afterload [Return to FIRE]

Cardiac Index [Return to FIRE]

Criteria for Acute Myocardial Infarction [Return to FIRE]

  • 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:[19]
  • Recent episode of typical ischemic discomfort that either is of new onset or is severe or that exhibits an accelerating pattern of previous stable angina (especially if it has occurred at rest or is within 2 weeks of a previously documented MI)
  • Chest pain or severe epigastric pain, nontraumatic in origin, with components typical of myocardial ischemia or MI:
  • Central/substernal compression or crushing chest pain
  • Pressure, tightness, heaviness, cramping, burning, aching sensation
  • Unexplained indigestion, belching, epigastric pain
  • Radiating pain in neck, jaw, shoulders, back, or 1 or both arms



References

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  6. 6.0 6.1 Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts)". N Engl J Med. 295 (25): 1404–13. doi:10.1056/NEJM197612162952505. PMID 790194. Unknown parameter |month= ignored (help)
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