Cardiogenic shock: Difference between revisions
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! Pressor !! Initial Dose !! Max Dose !! Cardiac Effect !! BP Effect !! Arrhythmias !! Special Notes
! Header text !! Header text !! Header text !! Header text !! Header text !! Header text !! Header text
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| Dobutamine || 2.5mcg/kg/min || 10-40 mcg/kg/min || mainly inotrope (ß1) || alpha effect minimal || Some HR(ß1) increase. Also Increase SA and AV node fx || Debut Research 1979<ref>Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine</ref> Isoproterenol has most Β2 vasodilatory and Β1 HR effects
| Example || Example || Example || Example || Example || Example || Example
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| Dopamine || 2mcg/kg/min || 20-50 mcg/kg/min || β1 and NorEpi release || α effects if > 20mcg/kg/min || Arrhythmogenic from β1 effects || More adverse events when used in shock compared to Norepi<ref name="soap2">De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789</ref>
| Example || Example || Example || Example || Example || Example || Example
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| Norepinephrine || 8-12mcg/min || 30 mcg/min || β1 direct effect || β1 and α1,2 effects || Less arrhythmias than Dopamine<ref name="soap2"</ref>  || Increases MAP, coronary perfusion pressure, little β2 effects.
| Example || Example || Example || Example || Example || Example || Example
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*Transfusion
*Transfusion
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Tintinalli
Tintinalli
EMCrit Podcast 10
EMCrit Podcast 10
<references/>
<references />
[[Category:Cards]]
[[Category:Cards]]

Revision as of 03:34, 8 November 2013

Background

  • Leading cause of death in pts w/ MI who reach the hospital alive

Work-Up

  • Labs
    • Troponin
    • Lactate
    • CBC
    • Chem
    • BNP
      • <100 may rule-out cardiogenic shock
  • ECG
  • CXR
  • TTE

Etiology

  • Myocardial infarction
    • Pump failure
    • Mechanical complications
    • Acute MR (papillary muscle rupture)
    • VSD
    • Free-wall rupture
  • RV infarction
  • Decreased forward flow
    • Sepsis
    • Rate-related
      • Bradycardia
      • Tachycardia
    • Myocarditis
    • Myocardial contusion
    • Cardiomyopathy
  • Mechanical obstruction to forward flow
    • AS
    • HOCM
    • Mitral stenosis
    • Pericardial
  • LV regurgitation
    • Chordal rupture
    • Aortic insufficiency

DDX

  • MI
  • PE
  • COPD exacerbation
  • Peri/myocarditis
  • Aortic dissection
  • Pericardial tamponade
  • Acute valvular insufficiency
  • Sepsis
  • Hemorrhage
  • Toxins/drugs of abuse

Treatment

  • General
    • Intubation
      • Decreases O2 demand BUT may worsen preload
  • Coronary perfusion
  1. Small Fluid challenge
  2. Increase inotropy
      • Titrate to CO (e.g. warm extremities)
      • Dobutamine or Milrinone - if
        • Use milrinone if pt is on BB
      • CaCl 1gm
        • Give if pt is hypocalcemic
  1. Achieve MAP >65

Pressors

Header text Header text Header text Header text Header text Header text Header text
Example Example Example Example Example Example Example
Example Example Example Example Example Example Example
Example Example Example Example Example Example Example
Example Example Example Example Example Example Example
Example Example Example Example Example Example Example
Example Example Example Example Example Example Example
  • Transfusion
    • Consider if Hb < 10
  • Specific
    • Mitral Regurg
      • Need to increase forward flow
        • Dobutamine (contractility)
        • Nitroprusside (afterload reduction)
    • MI
      • PCI or thrombolysis
    • Tox
      • Reverse CCB, BB, or dig toxicity

See Also

Source

Tintinalli EMCrit Podcast 10

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