CARDIOGENIC SHOCK
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.
