Cardiogenic Shock

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

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	Created by Ervine-Nicole Rulloda over 6 years ago