Updated: 12/21/2019

Cardiogenic Shock

0%
Topic
Review Topic
0
0
0%
0%
Questions
4 4
0
0
0%
0%
Evidence
4 4
0
0
Snapshot
  • A 65-year-old man is brought into the emergency room after being found at home unconscious. His family did not witness the event but report that his past medical history includes hypercholesterolemia, diabetes, and hypertension. Vital signs are significant for a blood pressure of 86/50 mmHg. On physical exam, he has jugular venous distension and cool extremities. An electrocardiogram reveals ST elevations in leads II, III, and aVF. (Myocardial infarction)
Introduction
  • Clinical definition
    • shock secondary to dysfunction of the heart and pump failure
      • the heart is unable to generate sufficient cardiac output to maintain tissue perfusion
  • Epidemiology
    • risk factors
      • coronary artery disease
  • Etiology
    • cardiomyopic
      • myocardial infarction (MI) (most common cause)
      • cardiomyopathy
      • myocarditis
      • drug-induced
    • arrhythmias
    • mechanical
      • septal defect or ruptured valve
      • blunt cardiac trauma
  • Pathogenesis
    • an underlying event (such as MI) results in ↓ cardiac output, which causes ↓ perfusion to tissue
    • ↓ cardiac output and blood pressure causes
      • ↑ catecholamines, which ↑ vasoconstriction and ↑ myocardial oxygen demand
      • ↑ renin-angiotensin-aldosterone system, which ↑ vasoconstriction and retention of sodium and water
    • ↑ shunting of blood to the brain and vital organs, which causes ↓ perfusion to peripheral organs
Presentation
  • Symptoms
    • symptoms depend on etiology
    • myocardial infarction
      • chest pain
      • dyspnea
    • arrhythmias
      • palpitations
      • syncope
  • Physical exam
    • mental status change
    • hypotension
    • tachycardia
    • pulmonary edema
      • diffuse lung crackles
      • distended jugular veins
    • cool extremities
    • ↓ urine output
Imaging
  • Echocardiography
    • indication
      • identify etiology of cardiogenic shock
    • findings
      • dilated ventricles
      • decreased ejection fraction
      • any anatomic abnormalities
Studies
  • Electrocardiography (ECG)
    • indication
      • identify etiology of cardiogenic shock
    • findings
      • any arrhythmias or myocardial infarction
  • Pulmonary artery catheterization
    • findings
      • ↑ pulmonary capillary wedge pressure (PCWP >15 mmHg)
      • ↑ systemic vascular resistance
      • ↓ cardiac output
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
 
Different Types of Shock
Shock Type Skin 

Wedge Pressure (PCWP) (Preload)

Systemic Vascular Resistance (SVR) (Afterload)
Cardiac Output
Hypovolemic Cold and clammy skin  ↓↓ 
Cardiogenic 
Obstructive ↑ or ↓ ↔ or ↓↓
Distributive Warm or dry skin ↔ or ↓  ↓↓ ↓ or ↑
 
Treatment
  • Management approach
    • always assess the ABCs – airway, breathing, and circulation
    • identify and treat the underlying cause (e.g., revascularization in the case of myocardial infarction-induced cardiogenic shock)
  • Conservative
    • supportive
      • indications
        • hypotension
        • PCWP < 15 mmHg
      • modalities
        • fluid bolus
        • oxygen
  • Medical
    • intravenous inotropic drugs
      • indication
        • maintain perfusion
      • drugs
        • dopamine (first line)
        • dobutamine
        • norepinephrine
Complications
  • Pulmonary edema
  • Acute renal failure
 
 
 

Please rate topic.

Average 4.7 of 14 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.CV.17.4686) A 53-year-old man is brought in by EMS to the emergency room. He was an unrestrained driver in a motor vehicle crash. Upon arrival to the trauma bay, the patient's Glasgow Coma Scale (GCS) is 13. He appears disoriented and is unable to follow commands. Vital signs are: temperature 98.9 F, heart rate 142 bpm, blood pressure 90/45 mmHg, respirations 20 per minute, shallow with breath sounds bilaterally and SpO2 98% on room air. Physical exam is notable for a midline trachea, prominent jugular venous distention, and distant heart sounds on cardiac auscultation. A large ecchymosis is found overlying the sternum. Which of the following best explains the underlying physiology of this patient's hypotension? Review Topic | Tested Concept

QID: 107376
1

Hypovolemia due to hemorrhage resulting in decreased preload

0%

(0/5)

2

Hypovolemia due to distributive shock and pooling of intravascular volume in capacitance vessels

0%

(0/5)

3

Impaired left ventricular filling resulting in decreased left ventricular stroke volume

100%

(5/5)

4

Increased peripheral vascular resistance, resulting in increased afterload

0%

(0/5)

5

Acute valvular dysfunction resulting in a hyperdynamic left ventrical

0%

(0/5)

L 2 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidences (4)
Topic COMMENTS (14)
Private Note