Cardiogenic shock

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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 contractility
    • Sepsis
    • 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
    • Airway
      • Caution - PPV may worsen preload and CO
    • Blood Pressure
      • Fluid challenge
      • Pressors
        • Sys BP < 70: Dopamine or dopamine + dobutamine
        • Sys BP > 70: Dobutamine or dobutamine + dopamine
          • Dobutamine: 2–5 mcg/kg/min, up to 20mcg/kg/min
            • Has potential vasodilation effect
          • Dopamine: 3–5 mcg/kg/min, up to 50mcg/kg/min
  • Specific
    • Mitral Regurg
      • Need to increase forward flow
        • Dobutamine (contractility)
        • Nitroprusside (afterload reduction)
    • MI
      • PCI or thrombolysis

Source

Tintinalli