Cardiogenic shock: Difference between revisions

Line 74: Line 74:
| 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>
| 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>
|-
|-
| 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.
| 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
Milrinone || 50mcg/kg x 10 min || 0.375-75mcg/kg/min || Direct influx of Ca<sup>2+</sup> channels|| Smooth muscle vasodilator ||   || PDE Inhibitor which increases Ca<sup>2+</sup> uptake by sarcolemma.  No venodilatory activity
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| Phenylephrine || 100-180mcg/min then 40-60mcg/min || 0.4-9 mcg/kg/min  || || Alpha agonist  ||   || Long half life
|-
|-
| Example || Example || Example || Example || Example || Example || Example
| Vasopressin || Fixed Dose || 0.4 U/min || unknown || increases via ADH peptide ||   || should not be titrated due to ischemic effects ||
|}
|}



Revision as of 03:40, 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

Milrinone || 50mcg/kg x 10 min || 0.375-75mcg/kg/min || Direct influx of Ca2+ channels|| Smooth muscle vasodilator || || PDE Inhibitor which increases Ca2+ uptake by sarcolemma. No venodilatory activity
Pressor Initial Dose Max Dose Cardiac Effect BP Effect Arrhythmias Special Notes
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[1] Isoproterenol has most Β2 vasodilatory and Β1 HR effects
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[2]
Norepinephrine 8-12mcg/min 30 mcg/min β1 direct effect β1 and α1,2 effects Less arrhythmias than Dopamine[2] Increases MAP, coronary perfusion pressure, little β2 effects.
Phenylephrine 100-180mcg/min then 40-60mcg/min 0.4-9 mcg/kg/min Alpha agonist Long half life
Vasopressin Fixed Dose 0.4 U/min unknown increases via ADH peptide should not be titrated due to ischemic effects
  • 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

  1. Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
  2. 2.0 2.1 De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789