CARDIOGENIC SHOCK




CARDIOGENIC SHOCK


1 Give supplemental oxygen to achieve SpO2 ≥ 90%.

2 Intubate if SpO2 not maintained or altered mental state.

3 Get a 12-lead ECG and screen for STEMI equivalents using right side and posterior leads as appropriate.

4 Give aspirin and start heparin if ECG shows ischemia.

5 Request blood chemistry, CBC, coagulation panel, type and

screen, troponin, lactate, ABG and CXR.

6 Review the differential diagnosis.

7 Perform focused echocardiography and RUSH exam for hemodynamic status and possible causes 09 .

8 Monitor cardiac output if equipment available.

9 Start peripheral norepinephrine to obtain MAP ≥ 65 mmHg.

10 If poor cardiac function after MAP corrected, begin inopressor or inotrope.

11 Insert CVC, arterial line and urinary catheter for infusions and monitoring.

12 Request interventional cardiology review for diagnostic catheterization and placement of mechanical support device.

13 Consider ECMO team consultation




Drug Doses:

Norepinephrine start at 5 mcg/min and titrate to 1 mcg/kg/min

Epinephrine (inotropic) 0.01-0.08 mcg/kg/min

Dobutamine 2-20 mcg/kg/min

Levosimendan 0.05-0.2 mcg/kg/min (no loading dose)


Methods of measuring cardiac output:

TTE - Transthoracic Echocardiography

PiCCO - Pulse Contour Cardiac Output

LiDCO - Lithium Dilution Cardiac Output

NICOM - Non Invaive Cardiac Output Monitoring

FloTrac - Arterial Pulse Waveform Analysis


Differential Diagnosis of Cardiogenic Shock:

Myocardial infarction

Valvular dysfunction

Cardiomyopathy (including peripartum and Takotsubo)

Myocarditis

Pericarditis

Cardiac tamponade

Pulmonary embolus (PE)

Papillary muscle rupture

Ventricular wall disruption

Dysrhythmia

Toxicologic

Metabolic disturbance

Thyrotoxic crisis

Pneumothorax


Cardiogenic shock masqueraders include sepsis and aspirin toxicity.

The internal jugular vein is preferred for the CVC and the femoral artery for the arterial line. Aim to leave the right femoral and radial arteries available for interventionists. Use ultrasound to guarantee location in the common (rather than superficial) femoral artery.


Echocardiography and RUSH

These allow visualisation of the myocardium and valvular structures, as well as realtime hemodynamic assessment.


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