Updated: 3/10/2021

Cardiogenic Shock

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
4
0
0
0%
0%
Evidence
4
0
0
Topic
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 19 Ratings

Questions (4)
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

(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
1

Hypovolemia due to hemorrhage resulting in decreased preload

20%

(2/10)

2

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

10%

(1/10)

3

Impaired left ventricular filling resulting in decreased left ventricular stroke volume

60%

(6/10)

4

Increased peripheral vascular resistance, resulting in increased afterload

10%

(1/10)

5

Acute valvular dysfunction resulting in a hyperdynamic left ventrical

0%

(0/10)

M 6 B

Select Answer to see Preferred Response

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