Updated: 12/3/2021

Cardiogenic Shock

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  • 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
  • Differential
    • Different Types of Shock
      Shock TypeSkin

      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 ↑
  • Diagnosis
    • Making the diagnosis
      • most cases are clinically diagnosed
  • 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
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(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?

QID: 107376

Hypovolemia due to hemorrhage resulting in decreased preload

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(2/19)

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

5%

(1/19)

Impaired left ventricular filling resulting in decreased left ventricular stroke volume

79%

(15/19)

Increased peripheral vascular resistance, resulting in increased afterload

5%

(1/19)

Acute valvular dysfunction resulting in a hyperdynamic left ventrical

0%

(0/19)

M 6 B

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