Cardiogenic Shock
Basics
Description
Description
- Persistent hypotension and tissue hypoperfusion due to cardiac dysfunction in the presence of adequate intravascular volume and left ventricular (LV) filling pressure
- Most common cause of death in hospitalized patients with acute MI (AMI)
- Underlying mechanisms in AMI:
- Pump failure:
- ≥40% LV infarct
- Infarct with pre-existing LV dysfunction
- Reinfarction
- Mechanical complications:
- Acute mitral regurgitation
- Ventricular septal defect
- LV rupture
- Pericardial tamponade
- Right ventricular (RV) infarction
- Pump failure:
- 5–8% of patients with STEMI develop cardiogenic shock
Etiology
Etiology
- AMI
- Sepsis
- Myocarditis
- Myocardial contusion
- Valvular disease
- Cardiomyopathy
- Left atrial myxoma
- Drug toxicity:
- β-Blocker
- Calcium channel blocker
- Adriamycin
Diagnosis
Signs and Symptoms
Signs and Symptoms
- ABCs and vital signs:
- Patent airway (early)
- Labored breathing and tachypnea (early); respiratory failure (late)
- Diffuse crackles or wheezing
- Hypoxia
- Hypotension:
- Systolic BP <90 mm Hg for at least 30 min or decline by at least 30 mm Hg below baseline level
- Tachycardia
- Weak pulses
- General:
- Cyanosis
- Pallor
- Diaphoresis
- Dulled sensorium
- Decrease in body temperature
- Urine flow of <20 mL/hr
- Neck:
- Jugular venous distention
- Cardiac:
- Ischemic chest pain
- Systolic apical blowing murmur
- Gallop rhythm:
- S3 reflects severe myocardial dysfunction
- S4 is present in 80% patients in sinus rhythm with AMI
- Systolic click:
- Suggests rupture of the chordae tendineae
- Abdominal:
- Epigastric pain
- Nausea and vomiting
- Neurologic:
- Obtundation
History
- Obtain history from patient, family, or EMS for clues to possible etiology
- Medication history
Physical Exam
- Perform rapid survey and stabilize ABCs
- Distended neck veins and cool extremities distinguish cardiogenic shock from distributive and hypovolemic shock
- Careful heart and lung exam
Essential Workup
Essential Workup
Ancillary studies further define the type and degree of cardiac injury and determine the indications for emergent catheterization or surgical intervention
Diagnostic Tests and Interpretation
ECG:Diagnostic Tests and Interpretation
- Normal ECG does not rule out AMI
- Classically, findings of AMI (ST-elevations in 2 or more contiguous leads)
- Can also occur in non–ST-elevation acute coronary syndrome
- Dysrhythmias
- LV hypertrophy
Lab
- B-type natriuretic peptide (BNP):
- Diagnostic and prognostic value
- Creatine kinase (CK), CK-MB, troponin
- Electrolytes and renal function:
- Acute renal failure is a strong predictor of mortality
- CBC:
- Identify anemia or elevated WBC
- Lactate:
- Lack of clearance is associated with a higher risk of mortality
- Drug levels (e.g., digoxin)
Imaging
- CXR:
- Pulmonary congestion
- Pleural effusion
- Cardiomegaly
- Pneumonia
- Pneumothorax
- Pericardial effusion
- Emergent echocardiography:
- Transthoracic echocardiography (TTE) with color Doppler
- LV contractility looking for hypokinesis, akinesis, or dyskinesis
- Acute mitral regurgitation or septal defects
- RV dilatation, tricuspid insufficiency, high pulmonary artery, and RV pressures suggest pulmonary embolism
- RV hypokinesis or akinesis, RV dilatation, normal pulmonary pressures suggest RV infarction
- Pericardial effusion, right atrium, or RV diastolic collapse suggest cardiac tamponade
Differential Diagnosis
Differential Diagnosis
- Obstructive shock:
- Tension pneumothorax
- Cardiac tamponade
- Pulmonary embolism
- Spontaneous esophageal rupture
- Air embolus
- Distributive shock:
- Sepsis
- Anaphylaxis
- Addisonian crisis
- Neurogenic shock
- Hypovolemic shock:
- Hemorrhage
- GI losses
- Dehydration
- Burns
Treatment
Pre Hospital
Pre Hospital
- ABCs, IV access, O2, monitor
- Consider fluid bolus if no crackles
- Aspirin
- Nitroglycerin or morphine sulfate for chest pain in absence of hypotension. Should be avoided if suspicion of RV infarction
- Transport AMI patients to facility with 24-hr cardiac revascularization capability
Initial Stabilization/Therapy
Initial Stabilization/Therapy
- ABCs
- 2 large-bore peripheral IV lines
- Cardiac monitor
- Endotracheal intubation for airway compromise:
- Consider etomidate for induction (minimal effect on BP)
- Fluid challenge (100–250 mL normal saline) in absence of pulmonary congestion
- Foley catheter to monitor urine output
Ed Treatment/Procedures
Ed Treatment/Procedures
- AMI:
- Aspirin
- Heparin or bivalirudin
- Thrombolysis if percutaneous coronary intervention or bypass surgery not available
- GP IIb/IIIa inhibitors prior to percutaneous coronary intervention
- Clopidogrel – Often held until after revascularization attempt as may be contraindicated in patients requiring emergent bypass
- Hypotension:
- Norepinephrine is first-line vasopressor
- Consider dopamine in absence of NE
- Normotensive patient:
- Dobutamine may be used with NE or dopamine; combine with nitroprusside in acute mitral regurgitation
- Milrinone may be considered in conjunction with dobutamine or dopamine
- Pulmonary edema:
- Nitroglycerin drip or furosemide in the normotensive patient
- Prompt cardiology consultation is crucial for the initiation of the following therapies:
- IABP independently improves survival in experienced centers
- Evaluation for the role of VADs and ECMO in refractory cases of cardiogenic shock
- Early revascularization is the single most important life-saving measure
Medication
Medication
- Bivalirudin 0.75 mg/kg bolus then 1.75 mg/kg/hr IV
- Clopidogrel 600 mg PO
- Dobutamine: 3–5 mcg/kg/min, titrate to 20–50 mcg/kg/min as needed IV
- Dopamine: 3–5 mcg/kg/min, titrate to 20–50 mcg/kg/min as needed IV
- Furosemide: 40–80 mg/d (peds: 1 mg/kg IV or IM, not to exceed 6 mg/kg) IV or IM
- Milrinone: 50 mcg/kg loading dose, 0.375–0.75 mcg/kg/min continuous infusion IV
- Nitroglycerin: 10–20 mcg/min (peds: 0.1–1 mcg/kg/min) IV, USE NON-PVC tubing
- Nitroprusside: 0.3 mcg/kg/min, titrate to a max of 10 mcg/kg/min IV
- Norepinephrine: 2 mcg/min, titrate up as needed IV
Ongoing Care
Disposition
Disposition
Admission Criteria
All patients in cardiogenic shock require admission to a critical care unit
Pearls and Pitfalls
- Cardiogenic shock is the leading cause of death in inpatient AMI
- Early recognition of preshock states is essential
- Early revascularization offers better outcomes
Additional Reading
- Mebazaa A, Tolppanen H, Mueller C, et al. Acute heart failure and cardiogenic shock: A multidisclipinary practical guidance. Intensive Care Med. 2016;42:147–163.
- Reyentovich A, Barghash MH, Hochman JS. Management of refractory cardiogenic shock. Nat Rev Cardiol. 2016;13:481–492.
- Rui Q, Jiang Y, Chen M, et al. Dopamine versus norepinephrine in the treatment of cardiogenic shock: A PRISMA-compliant meta-analysis. Rosa SD, ed. Medicine. 2017;96(43):e8402.
- Van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: A scientific statement from the American Heart Association. Circulation. 2017;136:e232–e268.
- Vincent JL, Quintairos E Silva A, Couto L Jr, et al. The value of blood lactate kinetics in critically ill patients: a systematic review. Crit Care. 2016;20:257–271.
See Also
See Also
Authors
Rodolfo Loureiro
Shamai A. Grossman
© Wolters Kluwer Health Lippincott Williams & Wilkins
Citation
Schaider, Jeffrey J., et al., editors. "Cardiogenic Shock." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307026/all/Cardiogenic_Shock.
Cardiogenic Shock. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307026/all/Cardiogenic_Shock. Accessed December 5, 2024.
Cardiogenic Shock. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307026/all/Cardiogenic_Shock
Cardiogenic Shock [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 December 05]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307026/all/Cardiogenic_Shock.
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