|
|
| (138 intermediate revisions by 13 users not shown) |
| Line 1: |
Line 1: |
| {{DiseaseDisorder infobox | | | __NOTOC__ |
| Name = Cardiogenic shock |
| | {| class="infobox" style="float: right;" |
| ICD10 = {{ICD10|R|57|0|r|50}} |
| | | style="vertical-align: middle; padding: 5px;" align=center | [[File:Siren.gif|30px|link=Cardiogenic shock resident survival guide]] |
| ICD9 = {{ICD9|785.51}} |
| | | style="vertical-align: middle; padding: 5px;" align=center | [[Cardiogenic shock resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| }}
| | |} |
| | {{Cardiogenic shock}} |
| | '''For patient information, click [[Cardiogenic shock (patient information)|here]].''' |
|
| |
|
| {{Search infobox}} | | {{CMG}}; {{AE}} {{JS}} {{AEL}}, {{sali}} |
|
| |
|
| {{CMG}}
| | ==[[Cardiogenic shock overview|Overview]]== |
|
| |
|
| {{Editor Help}}
| | ==[[Cardiogenic shock historical perspective|Historical Perspective]]== |
|
| |
|
| ==Overview== | | ==[[Cardiogenic shock classification|Classification]]== |
| '''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 pathophysiology|Pathophysiology]]== |
|
| |
|
| 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. | | ==[[Cardiogenic shock causes|Causes]]== |
|
| |
|
| 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]].
| | ==[[Cardiogenic shock differential diagnosis|Differentiating Cardiogenic shock from other Diseases]]== |
|
| |
|
| In clinical trials, cardiogenic shock has been defined as follows by the SHOCK investigators: <ref>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.</ref>
| | ==[[Cardiogenic shock epidemiology and demographics|Epidemiology and Demographics]]== |
|
| |
|
| ===Clinical criteria=== | | ==[[Cardiogenic shock risk factors|Risk Factors]]== |
| # Systolic blood pressure <90 mm Hg
| |
| # Evidence of hypoperfusion
| |
| # Cool, clammy periphery
| |
| # Decreased urine output
| |
| # Decreased level of consciousness
| |
|
| |
|
| ===Hemodynamic criteria=== | | ==[[Cardiogenic shock natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| # Left ventricular end diastolic pressure or pulmonary capillary wedge pressure >15 mm Hg
| |
| # Cardiac index <2.2 L/min/m2
| |
|
| |
|
| == Pathophysiology of Cardiogenic Shock == | | ==Diagnosis== |
| Cardiogenic shock can be a complication of the follwoing conitions:
| |
|
| |
|
| *[[Acute MI]], more often [[ST elevation MI]]. Anterior MI with pronounced left ventricular dysfunction, posterior MI with acute mitral regurgitation, and inferior MI wiht [[right ventricular infarct]] physiology can be associated with cardiogenic shock.
| | [[Cardiogenic shock diagnostic evaluation|Diagnostic Evaluation]] | [[Cardiogenic shock history and symptoms|History and Symptoms]] | [[Cardiogenic shock physical examination|Physical Examination]] | [[Cardiogenic shock laboratory findings|Laboratory Findings]] | [[Cardiogenic shock electrocardiogram|Electrocardiogram]] | [[Cardiogenic shock chest x ray|Chest X Ray]] | [[Cardiogenic shock CT|CT]] | [[Cardiogenic shock MRI|MRI]] | |
| *[[Tachyarrhythmia]]s resulting in inadequate ventricular filling times and inadequate forward [[cardiac output]].
| | [[Cardiogenic shock echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Cardiogenic shock other imaging findings|Other Imaging Findings]] | [[Cardiogenic shock other diagnostic studies|Other Diagnostic Studies]] |
| *[[Congestive heart failure]]
| |
| *[[Cardiomyopathy]]
| |
| *[[Valvular heart disease]] including [[aortic stenosis]], [[mitral stenosis]] with [[tachycardia]] and inadequate diastolic filling time.
| |
| *[[Aortic dissection]]
| |
| *[[Hypertrophic obstructive cardiomyopathy]] with systolic anterior motion (SAM)
| |
| *[[Ventricular septal defect]]
| |
| *[[Cardiac tamponade]]
| |
| *Iatrogenic due to excess administration of vasodilators and venodilators
| |
|
| |
|
| == Diagnosis == | | ==Treatment== |
|
| |
|
| === Symptoms ===
| | [[Cardiogenic shock medical therapy|Medical Therapy]] | [[Cardiogenic shock surgery|Surgery]] | [[Cardiogenic shock primary prevention|Primary Prevention]] | [[Cardiogenic shock secondary prevention|Secondary Prevention]] | [[Cardiogenic shock cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Cardiogenic shock future or investigational therapies|Future or Investigational Therapies]] |
| * [[Anxiety]], restlessness, and an [[Glasgow Coma Scale|altered mental state]] may be present due to decreased cerebral perfusion and ensuing [[hypoxia (medical)|hypoxia]].
| |
| * [[Fatigue]] may be present due to the work of breathing and [[hypoxia]].
| |
|
| |
|
| ===Physical Examination=== | | ==Case Studies== |
| ====Vitals====
| |
| * [[Hypotension]] due to decrease in [[cardiac output]].
| |
| * A rapid, weak, thready pulse due to decreased circulation combined with tachycardia.
| |
|
| |
|
| ====Neck====
| | [[Cardiogenic shock case study one|Case #1]] |
| * Distended [[jugular vein]]s due to increased [[jugular venous pressure]].
| |
| ====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.
| | ==Related Chapters== |
| * [[Pulmonary Edema]] (fluid in the lungs) due to insufficient pumping of the heart, fluid backs up into the lungs.
| |
|
| |
|
| === Electrocardiogram ===
| |
| An [[ECG|Electrocardiogram]] helps establishing the exact diagnosis and guides treatment, it may reveal:
| |
| * [[Cardiac arrhythmia]]s
| |
| * Signs of [[cardiomyopathy]]
| |
|
| |
| === 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 [[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).
| |
|
| |
| == See also ==
| |
| * [[Intra-aortic balloon pump]] | | * [[Intra-aortic balloon pump]] |
| * [[Ventricular assist device]] | | * [[Ventricular assist device]] |
|
| |
| == 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==
| |
| {{reflist|2}}
| |
|
| |
| == External links ==
| |
| * [http://www.emedicine.com/med/topic285.htm Cardiogenic Shock] by [[eMedicine]]
| |
| {{Symptoms and signs}}
| |
| {{Intensive care medicine}}
| |
| {{SIB}}
| |
|
| |
|
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Cardiovascular diseases]] | | [[Category:Cardiovascular diseases]] |
| | [[Category:Emergency medicine]] |
| | [[Category:Intensive care medicine]] |
| [[Category:Medical emergencies]] | | [[Category:Medical emergencies]] |
| [[Category:Intensive care medicine]]
| |
| [[Category:Emergency medicine]]
| |
|
| |
| [[de:Kreislaufstillstand]]
| |
| [[es:Parada cardiorrespiratoria]]
| |
| [[fr:Arrêt cardio-circulatoire]]
| |
| [[id:Gagal jantung]]
| |
| [[he:דום לב]]
| |
| [[nl:Hartstilstand]]
| |
| [[ja:心停止]]
| |
| [[pl:Asystolia]]
| |
| [[pt:Choque cardiogênico]]
| |
| [[sr:Кардиогени шок]]
| |
| {{WikiDoc Help Menu}}
| |
| {{WikiDoc Sources}}
| |
