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Cardiogenic Shock

Ervine-Nicole Rulloda Nursing English

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Cardiogenic Shock

Diagnosis
- Pathophysiology
  - Myocardial Dysfunction, Structural Abnormalities, or Dysrhythmias
    - Decreased Stroke Volume
      - Decreased cardiac output
        Decreased cellular oxygen supply
        Decreased tissue perfusion
        Impaired cellular metabolism
    - Diastolic Dysfunction: ineffective filling
      - increased pulmonary pressure
        Pulmonary edema
        Decreased Oxygenation
  - Occurs most often after an acute myocardial infarction
- Diagnostic Studies
  - Echocardiography - determine left ventricular function and reveal valvular abnormalities
  - Physical Examination
  - Health and Medical History
    - History of heart attack or heart failure?
  - Elevated lactate levels (>4 mmol/L)
  - Chest X-Ray
  - Electrocardiography - show possible evidence of acute MI, ischemia, or ventricular aneurysm
  - ABG analysis - may show metabolic acidosis and hypoxia
  - ↑ Cardiac markers
  - ↑ Blood glucose
  - ↑ Blood Urea Nitrogen (BUN)
Assessment
- Risk Factors
  - Older age
  - Hx of myocardial infarction or heart failure
  - Diabetes
  - Coronary heart disease
  - High blood pressure
- Clinical Presentation
  - Neurological
    - Altered mental status/ cerebral hypoxia
    - Cerebral infarction
    - Lethargy
    - Stupor
    - Coma
  - Respiratory
    - Dyspnea
    - Accessory respiratory muscle use
    - Air hunger
    - Tachypnea
    - Hypoxia
    - Low O2 saturation <90%
  - Cardiovascular
    - Tachycardia
    - Hypotension
    - Arrhythmias
    - Conduction disturbances
    - Delayed capillary refill
    - Extra heart sound S3 or murmur suggesting mechanical complication
  - Renal
    - Oliguria (<o.5 ml/kg/hour)
    - Excretion of low solute urine
    - Acute tubular necrosis
    - Acute renal failure
  - Skin
    - Pallor
    - Cool, Clammy
  - Gastrointestinal
    - Decreased bowel sounds
    - Nausea and vomiting
Treatment
- Nursing Interventions
  - Monitor hemodynamic status
    - Assess vitals regularly
      - HR
      - BP
      - RR
      - Pulse
      - SpO2
      - Skin status
      - Level of consciousness
      - Temperature
    - ECG monitoring
      - Arrhythmia
      - Changes in cardiac rhythm
    - Maintain arterial line, if applicable
    - Monitor lab values
      - Electrolyte abnormality
      - Acid/Base balance
    - Monitor pulmonary status
      - Respiratory distress
      - Auscultate for adventitious sounds
  - Administer medications & IV fluids
    - Monitor input & output
      - Urine output
        Note concentration & amount
      - If fluid overload
        Administer diuretic, if prescribed
      - If hypovolemic
        Fluid resuscitation
        Only if no presence of pulmonary edema
    - Maintain IV infusion sites
      - Signs of infection
      - Bleeding
    - Assess vitals before & after administration
  - Limit myocardial oxygen demand
    - Administer analgesics/sedatives, if necessary
    - Comfortable positioning
      - Careful not to displace/fracture catheter
      - Implement measures to prevent skin breakdown
    - Limit activities
      - When bedrest, monitor signs for impaired skin integrity
      - Adequate protein & calories in diet
  - Provide emotional support
    - Calm & peaceful environment
    - Reduce anxiety
      - Patient education
    - pain management
    - Family & significant others invovlement
  - Enhance myocardial oxygen supply
    - Administer O2
    - Monitor respiratory status
      - ABGs
- Oxygenation
  - Supplemental oxygen (via nasal prong or venti mask
  - Initiate intubation and mechanical ventilation if necessary
- Pharmacological Therapy
  - Thrombolytics
    - Reduces frequency of cardiogenic shock
  - Nitrates
    - Nitroglycerin
      - Dilates coronary arteries
      - Decreases systemic vascular resistance and blood pressure
  - Inotropes
    - Increase myocadial contractility
    - Eg. Dobutamine
    - Decrease ventricular filling pressures
  - Vasopressors
    - Dopamine
      - Increase myorcardial contractility Increase automacity
      - In low doses: increase blood flow to renal, mesenteric, and cerebral circulation
    - Norepinephrine
  - Diuretics
    - Eg. Furosemide
    - If patient has pulmonary edema
  - Antiarrhytmic
    - Amiodarone
- Circulatory Assist Devices
  - Ventricular Assist Device (VAD)
    - Used of refractory to the IABP
    - A temporary measure for patients who are in cardiogenic shock or awaiting cardiac transplantation
  - Intra-Aortic Balloon Pump (IABP)
    - Reduces afterload via deflation Coronary perfusion via inflation
    - Balloon catheter inserted into the femoral artery and placed in the descending thoracic aorta
      - Increased myocardial oxygen supply and reduced left-ventricular workload
- Early recognition and rapid treatment are key!
Evaluation
- Patient Education
  - Heart healthy lifestyle
    - Control hypertension & diabetes
    - Heart healthy diet
    - Maintain healthy weight
    - Regular physical activity
    - Avoid smoking
    - Limit alcohol intake
    - Stress management
  - Warning signs of heart attack
    - Chest pain/discomfort
    - Upper body discomfort
    - Shortness of breath
    - If symptoms not relieved by rest/nitroglycerin, call 911
  - Restrict fluid intake to 2-2.5L/day
    - Report if
      - Weight gain of >4lbs in 2 days
      - Increased difficulty breathing
      - Presence of edema
  - If history of heart disease
    - Adhere to the treatment regime
    - Regular check-ups
- Prevention
  - Early identification of patients at risk
  - Prevent recurrence of cariogenic shock
    - Adequate oxygenation
    - Decrease cardiac workload
  - Treatment of underlying conditions
- Complications
  - Cardiopulmonary arrest
    - Sudden loss of heart function resulting in loss of blood flow
    - Symptoms
      - Loss of consciousness
      - Abnormal/absent breathing
    - Life-threatening emergency
      - Assess ABCD's
      - Call 9-1-1
      - Defibrillate & perform CPR
  - Multiple organ dysfunction syndrome
    - Acute sequential failure of several organ systems
      - Renal damage
      - Brain damage
      - Liver damage
    - Require external interventions to maintain hemostasis
      - Supportive care
      - Safeguarding hemodynamics
      - Respiration
  - Thromboembolic sequelae
    - Symtoms
      - SOB/dysnpea
      - Chest pain
      - Syncope
      - Tachycardia
      - Fever
    - Anticoagulant/thrombolytic therapy required
  - Ventricular aneurysm
    - Abnormal dilation of the ventricular wall
    - May cause
      - Angina pectoris
      - Heart failure
      - Thrombus formation
      - Ventricular tachycardia
  - Arrhythmia
  - Coma
  - Death
By: Min Jee Bae and Ervine Nicole Rulloda