CARDIOGENIC SHOCK

Synonyms
cardiogenic shock
cardiac shock
global hypo perfuse
cardiac gallop

Meaning
Cardiogenic shock is
characterized by a decreased
pumping ability of the heart that
causes a shock like state (i.e.,
global hypo perfusion). It most
commonly occurs in association
with, and as a direct result of,
acute myocardial infarction(AMI).

Incidence
Cardiogenic shock occurs in 8.6%
of patients with ST-segment
elevation
MI with 29% of those presenting to
the hospital already in shock.
It occurs only in 2% of nonSTsegment elevation MI.

Mortality/Morbidity
Leading cause of death in AMI.
The overall in-hospital mortality rate is
57%.
Persons older than 75 years, the
mortality rate is 64.1%.
Younger than 75 years, the mortality rate
is 39.5%.
Overall mortality when revascularization
occurs is 38%. If not attempted, mortality
rates approach 70%.

Race
Hispanics
- 74%
African Americans - 65%
Whites
-56%
Asians/others
- 41%.
Indians
- 43.7%
Sex
Women comprise 42% of all
cardiogenic shock patients.

Risk factors

Pre existing myocardial

damage
Diseases like diabetes
Advanced age
Previous AMI
AMI (Q-wave, large or anterior
wall AMIs) dysrhythmia.

Etiology
Acute myocardial ischemia

Others: Beta-blocker overdose,

calcium channel blocker overdose,
myocardial contusion, respiratory
acidosis, hypocalcaemia,
hypophosphatemia, and cardio
toxic drugs (e.g., doxorubicin
[Adriamycin])

Ventricular hypertrophy and restrictive

Cardiomyopathy
After load - Aortic stenosis, hypertrophic
Cardiomyopathy, dynamic outflow
obstruction, aortic coarctation, and
malignant hypertension
Valvular/structural - Mitral stenosis,
endocarditis, mitral or aortic
regurgitation, atrial myxoma or
thrombus, and tamponade

Pathophysiology
AMI

Dead myocardium does not

contract

Marked decrease in contractility

reduces the ejection fraction and
cardiac output.

Increased ventricular filling

pressures, cardiac chamber
dilatation

Univentricular or biventricular failure

Systemic hypotension and/or

pulmonary edema.

A systemic inflammatory
response syndrome
Myocardial infections

Elevated levels of white blood cells, body

temperature, interleukins, and C-reactive protein.
Similarly, inflammatory nitric oxide synthetase
(iNOS) is also released in high levels during
myocardial stress.

iNOS induces nitric oxide production, which may

uncouple calcium metabolism in the myocardium
resulting in a stunned myocardium. Additionally,
iNOS leads to the expression of interleukins, which
may themselves cause hypotension.

Myocardial ischemia

Decrease in contractile function

Left ventricular dysfunction and decreased

arterial pressure

Exacerbate the myocardial ischemia

Severe cardiovascular decompensation.

Other pathophysiological
mechanisms
papillary muscle rupture leading
to acute mitral regurgitation
(4.4%);
ventricular septal defect (1.5%)
wall rupture (4.1%) as a
consequence of AMI.

 Right ventricular (RV) infarct, by

itself, may lead to hypotension
and shock because of reduced
preload to the left ventricle.
Cardiac tamponade may result
as a consequence of
Pericarditis, uremic pericardial
effusion, or in rare cases
systemic lupus erythematosus.

Medications

Calcium channel blockers may cause

profound hypotension with a normal or
elevated heart rate.
Beta-blocking agents may also cause
hypotension with or without bradycardia, or
AV node block.
Nitroglycerin, Angiotensin-converting
enzyme inhibitors, opiate, and
barbiturates can all cause a shock state
and may be difficult to distinguish from
cardiogenic shock.

Clinical manifestations
The physical examination
findings are consistent with
shock.
Patients are in frank distress
profoundly diaphoretic with
mottled extremities
visibly dyspneic

 A- Airway usually is patent initially.

B- Breathing may be labored, with
audible coarse crackles or wheezing.
C-Circulation is markedly impaired.
Tachycardia, delayed capillary refill,
hypotension, diaphoresis, and poor
peripheral pulses are frequent
findings.
Signs of end-organ dysfunction (eg,
decreased mental function, urinary
output) may be present.

Diagnostic measures
History collection
General physical examination
Initial vital sign assessment
Neck examination may reveal jugular
venous distention
LV dysfunction, characterized by
pulmonary edema, can be
auscultated as crackles with or
without wheezing.

Careful cardiac examination may reveal mechanical

causes of cardiogenic shock.
Loud murmurs may indicate a valvular
dysfunction, whereas muffled heart tones with
jugular venous distention and pulsus paradoxus
may suggest tamponade (Beck triad).
A gallop may also be heard. The presence of
an S3 heart sound is pathognomonic of
congestive heart failure. The presence of
pulmonary edema increases the likelihood of
cardiogenic shock in the setting of hypotension.

Lab Studies
No one test is completely sensitive,
laboratory studies are directed at the
potential underlying cause.
Following are assessed in cases of
suspected cardiac ischemia:
Cardiac enzymes (eg, creatine kinase,
troponin, myoglobin)
CBC
Electrolytes
Coagulation profile (eg, prothrombin time,
activated partial thromboplastin time)

 An ABG may be useful to evaluate

acid-base balance because acidosis .
Elevated serum lactate level is an
indicator of shock.
Brain natriuretic peptide (BNP) may
be useful as an indicator of
congestive heart failure and as an
independent prognostic indicator of
survival.
A low BNP level may effectively
rule out cardiogenic shock in the
setting of hypotension.

Imaging Studies
Portable chest radiograph
Overall impression of the cardiac
size
Pulmonary vascularity
Coexistent pulmonary pathology
A rough estimate of Mediastinal
and aortic sizes

Other Tests
ECG
Helpful if it reveals an acute injury
pattern consistent with an AMI
Echocardiogram
*To reveal akinetic or dyskinetic
areas of ventricular wall motion.
*To reveal surgically correctable
causes, such as valvular dysfunction
and tamponade.

Differential Diagnosis

Acute coronary syndrome

Aortic Regurgitation
Cardio myopathy
Congestive cardiac failure
Mitral regurgitation
Hypovolemic or septic shock
Myocardial infarction

MANAGEMENT
Prehospital Care: aimed at minimizing
any further ischemia and shock.
All patients require intravenous access, highflow oxygen administered by mask, and
cardiac monitoring.
Twelve-lead electrocardiography, The ED
physician, can thus be alerted, and may
mobilize the appropriate resources.

 Emergency Department Care:

Aim: making the diagnosis, preventing
further ischemia, and treating the
underlying cause.
coronary artery bypass is the treatments
of choice within 90 minutes of
presentation; however, it remains helpful,
as an acute intervention, within 12 hours
of presentation.
If not immediately available,
thrombolytics should be considered which
is the second best.

Treatment begins with assessment and

management of the ABCs.
Airway should be assessed for patency.
Breathing evaluated for effectiveness and
increased work of breathing.
Endotracheal intubation and mechanical
ventilation is considered in patients with
excessive work of breathing.
Positive pressure ventilation may improve
oxygenation but may also compromise venous
return, preload, to the heart. In any event, the
patient should be treated with high-flow oxygen.

supporting myocardial perfusion and

maximizing cardiac output.
Intravenous fluids should be provided to
maintain adequate preload, guided by
central venous pressure or pulmonary
capillary wedge pressure monitoring .

Pharmacotherapy
Aim: To reduce morbidity and to prevent
complications.
Intravenous vasopressors provide
inotropic support increasing perfusion
of the ischemic myocardium and all
body tissues.
Extreme heart rates should be avoided
because they may increase myocardial
oxygen consumption

1. Dopamine may provide vasopressor

support. With higher doses, it has the
disadvantage of increasing the heart
rate and myocardial oxygen
consumption.
Dose:5-20 mcg/kg/min IV continuous
infusion.
Increase by 1-4 mcg/kg/min q10-30min
to optimal response
(>50% of patients have satisfactorily
responses with doses <20 mcg/kg/min)

2.Dobutamine, inamrinone
(formerly amrinone), or milrinone
may provide inotropic support. In
addition to their positive inotropic
effects, inamrinone and milrinone
have a beneficial vasodilator
effect, which reduces preload and
after load.
Dose: 5-20 mcg/kg/min IV
continuous infusion.

3. Phosphodiestrase enzyme inhibitors

-improve cardiac output in refractory
hypotension and shock. Milrinone and
inamrinone (formerly amrinone) may be
used.
Loading dose: 50 mcg/kg IV over 10
min
Continuous infusion: 0.375-0.75
mcg/kg/min IV

4.Natrecor (nesiritide)
Should be used with caution in the
setting of cardiogenic shock because
it has been shown to cause
hypotension.
5.Vasodilators
Smooth-muscle relaxants and
vasodilators that can reduce systemic
vascular resistance, allowing more
forward flow and improving cardiac
output.

6. Analgesics -- Pain control is essential

to quality patient care. It ensures
patient comfort and promotes
pulmonary toilet.
7. Natriuretic peptide
Nitrates and/or morphine excessive
use of either of these agents can
produce profound hypotension. Neither
of these options has been shown to
improve outcomes in cardiogenic
shock

8.Diuretics :cause diuresis to decrease

plasma volume and edema and thereby
decrease cardiac output BP.
The initial decrease in cardiac output
causes a compensatory increase in
peripheral vascular resistance. With
continuing diuretic therapy, extracellular
fluid and plasma volumes almost return to
pretreatment levels.
Peripheral vascular resistance decreases
below that of pretreatment baseline.
Lasix: 40-80 mg/d IV/IM

Intra-aortic balloon pump (IABP)

recommended for cardiogenic
shock not quickly reversed with
pharmacologic therapy.
It is also recommended as a
stabilizing measure combined
with thrombolytic therapy when
angiography and
revascularization are not readily
available.

o IABP reduces LV after load and

improves coronary artery blood flow.
o Although this procedure is generally
not performed in the ED, planning is
essential, and early consultation with a
cardiologist regarding this option is
recommended.
o Although complications may occur in
up to 30% of patients, extensive
retrospective data support its use.

Complications

Cardiopulmonary arrest
Dysrhythmia
Renal failure
Multisystem organ failure
Ventricular aneurysm
Thromboembolic sequelae
Stroke
Death

Prognosis
The prognosis is universally poor.
The mortality rate is more than
55% in patients treated medically.
At best, the rate is 38% in whom
surgical reperfusion is achieved.

NURSING MANAGEMENT
Assessment:

ABC,s,
tissue perfusion,
vital signs,
capillary refill ,
skin and urinary output.

Nursing Diagnosis
Decreased cardiac output related to shock
as manifested by increased diastolic BP,
tachycardia, dry mucous membrane,
pallor, cyanosis, cool and clammy skin.
Fear and anxiety related to severity of the
condition as manifested by verbalization of
anxiety about condition and fear of death
or withdrawal with no communication,
increase in heart and respiratory rate.
High risk for organ dysfunction related to
decreased tissue perfusion.

Nursing implementation
Health Promotion: Planning is
essential to help to prevent shock after
a susceptible individual has been
identified.
The primary goal for the patient with an
acute MI is to limit the size of the
infarction.
The nurse can modify the patients
environment to provide care at
intervals to increase patients oxygen
demand.

Acute Intervention:
The role of nurse in shock involves
monitoring the patients ongoing physical
and emotional status .
Planning and implementing the nursing
interventions and therapy
Evaluating the patients response to
therapy
Providing emotional support to patient and
family
Collaborating with other members of
health team.

 Neurologic status, including orientation

and level of consciousness should be
assessed at least every hour
Monitor BP, HR, CVP, PAWP at least
every 15 mts until patient is stable.
Respiratory status of the patient in
shock must be frequently assessed to
ensure adequate oxygenation, detect
complication early and provide data
regarding the patients acid-base status.

 Hourly monitoring of urinary output is essential

to assess adequacy of renal perfusion.
Monitoring body temperature and skin for any
change in colour indicates adequacy of
perfusion
Assessment of personal hygiene is important in
shock because impaired tissue perfusion
predisposes the client to skin breakdown and
infection.
Monitoring the patients anxiety and providing
emotional support and comfort to the patient and
family is an integral part of nursing care.

 Ambulatory and Home care:

The nurse should continue to monitor the
patient for indications of complications
throughout the recovery period.
Patient Education:
Early warning signs of AMI and how to
access the emergency medical system
Cardiac risk factors, particularly those that
are reversible and subject to change (eg,
smoking, diet, exercise).

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