Diferencia entre revisiones de «Cardiogenic shock»

Revisión del 21:30 14 may 2011

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. Fluid challenge
- 2. Increase inotropy
  - Titrate to CO (e.g. warm extremities)
  - Dobutamine or Milrinone
    - Use milrinone if pt is on BB
  - CaCl 1gm
    - Give if pt is hypocalcemic
- 3. Achieve MAP >65
  - Pressors
    - Norepi or dopamine
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

Source

Tintinalli

EMCrit Podcast 10

Authors:

@@ Línea 3: / Línea 3: @@
 ==Work-Up==
-*What is the etiology
-**Is this is a rate-cause?
-***Bradycardia - give atropine/pace
-***Tachycardia - Meds/cardioversion
-**Is this a valve problem?
-***Needs surgery
-**Is pt ischemic?
-***Cath
-***Is there RV infarction?
-****Increase preload
-**Is there a cardiomyopathy
-***Medical management
-**Is there tox issue
-***CCB, BB, dig overdose
 *Labs
 **Troponin
@@ Línea 37: / Línea 22: @@
 **Free-wall rupture
 *RV infarction
-*Decreased contractility
+*Decreased forward flow
 **Sepsis
+**Rate-related
+***Bradycardia
+***Tachycardia
 **Myocarditis
 **Myocardial contusion
@@ Línea 65: / Línea 53: @@
 ==Treatment==
 *General
-**Airway
+**Intubation
-***Caution - PPV may worsen preload and CO
+***Decreases O2 demand BUT
-**Blood Pressure
+***May worsen preload
-***Fluid challenge
+*Coronary perfusion
+**1. Fluid challenge
+**2. Increase inotropy
+***Titrate to CO (e.g. warm extremities)
+***Dobutamine or Milrinone
+****Use milrinone if pt is on BB
+***CaCl 1gm
+****Give if pt is hypocalcemic
+**3. Achieve MAP >65
 ***Pressors
-****Sys BP < 70: Dopamine or dopamine + dobutamine
+****Norepi or dopamine
-****Sys BP > 70: Dobutamine or dobutamine + dopamine
+*Transfusion
-*****Dobutamine: 2–5 mcg/kg/min, up to 20mcg/kg/min
+**Consider if Hb < 10
-******Has potential vasodilation effect
-*****Dopamine: 3–5 mcg/kg/min, up to 50mcg/kg/min
 *Specific
 **Mitral Regurg
@@ Línea 82: / Línea 76: @@
 **MI
 ***PCI or thrombolysis
+**Tox
+***Reverse CCB, BB, or dig toxicity
 ==Source==
 Tintinalli
+EMCrit Podcast 10
 [[Category:Cards]]