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Cardiogenic Shock

Thea Wilkes Nursing English

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Cardiogenic Shock

The result of left, right, or both ventricle dysfunction that causes decreased cardiac output (Copstead & Banasik, 2013).
- (WebMD, 2019)
ETIOLOGY
- Myocardial Infarction
  - MOST COMMON CAUSE
- End-Stage Cardiomyopathy
- Papillary Muscle Dysfunction
- Free Wall Rupture
- Congenital Heart Defects
- (Copstead & Banasik, 2013)
  - (Cardiovascular Business, 2018)
CLINICAL MANIFESTATIONS
- Systolic BP <90 mmHg for >30 minutes
- (Thiele, Ohman, Desch, Eitel, & de Waha, 2015; Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
- Pulmonary Edema, Course Crackles, Wheezes, Tachypnea
- Elevated Left-Ventricular Filling Pressures; S3 Gallop
- Impaired Mental Status, Anxiety, Confusion, Agitation
- Oliguria
- Cool, Clammy Skin
- Signs of Impaired Organ Perfusion
- Increased Serum Lactate
- DIAGNOSTIC TESTING
  - Noninvasive Testing
    - Electrocardiogram
      - (VectorStock, 2019d)
    - Chest X-Ray
      - (NICEPNG, n.d.)
    - Echocardiogram
      - (CureSearch, 2019)
    - Computerized Tomography
      - (VectorStock, 2019b)
  - Laboratory Testing
    - Complete Blood Count
    - Electrolytes
    - Creatinine
    - Hepatic Function Tests
    - Arterial Blood Gas
    - Lactate
    - Cardiac Troponin
    - Ideally completed twice daily until results are within stable hemodynamic parameters (Mebazaa et al., 2018)
    - Within the first few hours, can indicate the level of organ damage and function (Mebazaa et al., 2018)
    - (Geeky Medics, n.d.)
  - Hemodynamic Monitoring
    - (Mebazaa et al., 2018)
    - Arterial Line
      - Allows for measurement of arterial blood pressure, regular blood gas analysis, and monitoring of arterial lactate
    - Central Venous Catheter
      - Visualizes elevated pressure/abnormal waveform of heart and lungs, oxygen supply and demand, and estimates extrathoracic organ congestion
    - Pulmonary Artery Catheter
      - Allows for measurement of cardiac performance (i.e., preload, afterload, and cardiac output) (Furer, Wessler, & Burkhoff, 2017)
    - Hemodynamic data guides clinical decision making and the therapeutic choices that are made regarding the proper "selection, timing, and settings of medical and mechanical support" (Furer, Wessler, & Burkhoff, 2017, p. 361)
    - Effects of Cardiogenic Shock on Hemodynamic Parameters
      - (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
        Heart Rate
        Pulse Pressure
        Blood Pressure
        Systemic Vascular Resistance
        Pulmonary Vascular Resistance
        Central Venous Pressure
        Pulmonary Artery Pressure
        Pulmonary Artery Occlusive Pressure
        Cardiac Output
        Central Venous Oxygen Saturation/Venous Oxygen Saturation
  - (Diepen et al., 2017)
- Slow Capillary Refill
- Pallor or Cyanosis
- Diminished Bowel Sounds
- Nausea, Vomiting
- DIAGNOSIS
  - (Thiele, Ohman, Desch, Eitel, & de Waha, 2015)
    - 1. Systolic Blood Pressure <90 mmHg for >30 minutes
    - 2. Pulmonary Congestion or Elevated Left-Ventricular Filling Pressures
    - 3. Indications of Impaired Organ Perfusion with at least one of the following:
    - a) Altered Mental Status
    - b) Cold, Clammy Skin
    - c) Oliguria
    - d) Increased Serum Lactate
    - (365PSD, 2019)
- (Ainuna, 2019)
PRECIPITATING FACTORS
- Systolic Dysfunction
  - The inability of the heart to pump and move blood forward
    - Myocardial Infarction
    - Cardiomyopathy
- Diastolic Dysfunction
  - The inability of the heart to fill during diastole
    - Pericardial Tamponade
- Structural Factors
  - Valvular Abnormality
    - Stenosis
    - Regurgitation
  - Ventricular Septal Rupture
  - Tension Pneumothorax
  - (WebMD, 2018)
- Dysrhythmias
  - (PedsRAP, n.d.)
- (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
  - (Sina Health Tour Inc., 2019)
- PATHOPHYSIOLOGY
  - (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014, p. 1961; Copstead & Banasik, 2013, p. 437)
    - (Mount Alvernia Hospital, 2017)
  - Diastolic Dysfunction
    - Left Ventricular Preload
      - Movement of fluid out of the Pulmonary Vascular Beds
        Build-up of Fluid in Pulmonary Interstitial Space
        Pulmonary Edema
        Oxygenation
        Tissue Perfusion
        Impaired Cellular Metabolism
      - Cardiac Output
        Cellular Oxygen Supply
  - Systolic Dysfunction
    - Stroke Volume
      - Cardiac Output
        Cellular Oxygen Supply
        Tissue Perfusion
        Impaired Cellular Metabolism
  - COMPLICATIONS
    - (National Heart, Lung, and Blood Institute, n.d.a)
    - Cardiogenic shock results in hypoperfusion of the body's vital organs which means that they are not receiving enough oxygen-rich blood. This results in organ damage - whether temporary or permanent.
      - Brain Injury
        (Bstigma-free, 2019)
      - Kidney Failure
        (Queensland Government, 2018)
      - Liver Damage
        (VectorStock, 2019a)
ASSESSMENT
- Patient History
  - Physical Examination
    - Laboratory Investigations
    - Vital Signs
    - Level of Consciousness
    - Peripheral Pulses
    - Capillary Refill
    - Skin
    - Urine Output
    - (Pediatric Dental Health, 2003)
- Although invasive hemodynamic monitoring is not required immediately upon initial assessment, it may be required if certain indicators are present. (Mebazaa et al., 2018)
  - For Example:
    - To differentiate the shock diagnosis, To guide pharmacologic therapy, and To guide fluid management
- TREATMENT
  - (Furer, Wessler, & Burkhoff, 2017)
    - 1. Address all of the reversible causes of cardiogenic shock based on the suspected condition's etiology
    - 2. Immediate intervention
      - Medications
        Persistent Hypotension
        Vasopressors
        Used in patients with low systemic vascular resistance and for those that don't respond to fluid therapy
        Increases contractility and heart rate by increasing cardiac output and systemic vascular resistance, as well as, induces vasoconstriction (VanValkinburgh & McGuigan, 2019)
        First Line of Treatment
        Epinephrine
        Sympathomimetic hormone/drug that increases cardiac output and peripheral vascular tone which increases mean arterial pressure
        Norepinephrine
        Vasopressin
        Dopamine
        Precursor for epinephrine and norepinephrine and has positive inotropic effects (i.e., increases heart contractility, automaticity, and atrioventricular conduction),
        First Drug of Choice
        Hormone that causes vasoconstriction
        Used to increase blood pressure
        Inotropes
        Increase myocardial contractility and cardiac output
        Dobutamine
        Milrinone
        Promotes the uptake of calcium which increases myocardial contractility and causes vasodilation
        Used to increase myocardial contractility, to cause vasodilation, and increase cardiac output
        (Amado, Gago, Santos, Mimoso, de Jesus, 2016; Mebazaa et al., 2018; Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
        (Shutterstock, 2019a)
        Diuretics
        Used for patients with pulmonary edema
        Aspirin
        Given to patients with acute myocardial infarction
        Nitroglycerin
        Used to dilate coronary arteries which decreases preload
        Amiodarone
        Used to treat arrhythmias
        Oxygen
        Dependent on cardiac output, oxygen saturation of arterial blood (SaO2), and available hemoglobin
      - Fluid Management
        (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
        Fluid Type
        Isotonic Crystalloids
        0.9% NaCl
        Lactated Ringer's Solution
        Used for initial fluid replacement
        Monitor patient for circulatory overload
        Blood/Blood Products
        Whole Blood/Packed RBCs
        Fresh/Frozen Plasma
        Used when hemoglobin levels are <120 g/L
        (Chief Fellow, 2015)
      - Early Revascularization
        (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
        Percutaneous Coronary Intervention
        (Heart and Stroke Foundation of Canada, 2018)
        (UT Southwestern Medical Center, 2019)
        Procedure that uses a small catheter to place a stent in a narrowed cardiac blood vessel to restore blood flow
        Coronary Artery Bypass Graft
        (National Heart, Lung, and Blood Institute, n.d.b)
        (Mayo Clinic, 2018)
        Procedure that utilizes blood vessels from different parts of the body and places them above or below narrowed coronary arteries in order to improve poor blood flow in the heart
      - Mechanical Intervention
        (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
        Intra-aortic Balloon Pump
        A circulatory assist device that is placed in the femoral artery and aorta in order to increase coronary blood flow and decrease the workload of the left ventricle
        (Anesthesia Key, 2016)
        Ventricular Assist Device
        Temporarily used in patients where the Intra-aortic balloon pump or fibrinolytic therapy is unsuccessful or for those awaiting transplantation
        (Wikipedia, 2019)
        Cardiac Transplantation
        Small select group of patients may require a cardiac transplant
        (Cartoon Collections, n.d.)
- (Mebazaa et al., 2018; Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
  - (ACE Nursing School, 2015)
Low cardiac output can result in "end-organ hypoperfusion and hypoxia" (Diepen et al., 2017, p. 232)
LIFE THREATENING
NURSING CARE
- Nutrition
  - Hypermetabolism
    - Common occurrence with shock
    - Must initiate enteral nutrition (or parenteral if contraindicated) within the first 24 hours
    - (IntechOpen, 2019)
  - Weight
    - Patients should be weighed daily on the same scale
      - Weight Loss - Must rule out dehydration
      - (Shutterstock, 2019b)
  - Laboratory Tests to Assess:
    - Serum Protein
    - Nitrogen Balance
    - Blood Urea Nitrogen
    - Serum Glucose Level
    - Serum Electrolytes
    - (Dreamstime, 2019)
- (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
- Planning
  - Main Goals:
    - 1) Ensure adequate tissue perfusion
      - 2) Restore/Maintain normal blood pressure
        3) Promote the return/recovery of organ function
        4) Prevent complications associated with prolonged hypoperfusion
  - (WikiHow, 2019)
- Health Promotion
  - Prevention:
    - Must identify those most at risk for developing shock:
      - Anyone that is at risk of impaired oxygen delivery is also at risk for shock
        Old Age
        Immunocompromised
        Debilitating Illness
        Surgical/Accidental Trauma
      - Once at risk individuals are established pre-planning can help to prevent shock
- Emotional Support
  - Nurse must address:
    - Pain
    - Fear
    - Anxiety
    - (YourCentre, 2017)
  - COMMUNICATION
    - Encourage family and friends to talk to patient even if they think the patient won't be able to hear (i.e., comatose, intubated, or sedated). Hearing is usually the last sense to go, so even though they cannot respond they likely can still hear.
      - (VectorStock, 2019c)
    - Must discuss and document advance directives
    - Compassionately answer patient and family questions
    - Use simple terms to explain various equipment that is in use
    - Ensure call bell is within reach
- Rehabilitation
  - Nurse must assess for complications that could affect the patient's rehabilitation process
    - For Example: Decreased range of motion or decreased physical endurace
    - The nurse must anticipate the services that will be required upon discharge in order to allow for a smooth and safe transition home from the hospital
      - For Example: Home health care or rehabilitation centre
      - (ASHE Health Facilities Management, 2016)
- Collaborative Care
  - Pharmacotherapy
    - Inotropes
    - Vasopressors
    - Diuretics
    - Aspirin
    - Oxygen
    - Nitroglycerin
    - Amiodarone
    - (Freepik, 2019)
  - Reperfusion and Mechanical Interventions
    - Percutaneous Coronary Intervention
      - Coronary Artery Bypass Graft
        Intra-aortic Balloon Pump
        Ventricular Assist Device
    - Surgery
      - Cardiac Transplantation
        (VectorStock, 2019e)
  - Collaboration with Other Healthcare Professionals
    - Physicians
      - Surgeons
        Nutritionist
        Physiotherapists
        Occupational Therapists
        Personal Support Workers
        Pharmacists
    - (PatientEngagementHIT, 2019)
  - Community Resources
    - Transitional Care Units
      - Rehabilitation Centres
        Home Health Care Agencies
    - (County of Los Angeles Public Health, n.d.)
Thea Wilkes (215501604); Ayla Ambrose (214717847); and Kevin Porcalla (215027048)
References
- Amado, J., Gago, P., Santos, W., Mimoso, J., & de Jesus, I. (2016). Cardiogenic shock: Inotropes and vasopressors. Portuguese Journal of Cardiology, 35(12), 681-695. doi:10.1016/j.repce.2016.08.004
- Copstead, L., & Banasik, J. (2013). Pathophysiology. St. Louis MO: Elsevier Mosby.
- Diepen, S., Katz, J., Albert, N., Henry, T., Jacobs, A., Kapur, N., … Cohen, M. (2017). Contemporary management of cardiogenic shock: A scientific statement from the American heart association. Circulation, 136, 232-268. doi:10.1161/CIR.0000000000000525
- Furer, A., Wessler, J., & Burkhoff, D. (2017). Hemodynamics of cardiogenic shock. Interventional Cardiology Clinics, 6(3), 359-371. doi:10.1016/j.iccl.2017.03.006
- Heart and Stroke Foundation of Canada. (2018). Percutaneous coronary intervention (PCI or angioplasty with stent). Retrieved from https://www.heartandstroke.ca/heart/treatments/surgery-and-other- procedures/percutaneous-coronary-intervention
- Lewis, S., Heitkemper. M., Dirksen, S., Bucher, L., & Camera, I. (2014). Medical-Surgical nursing in Canada: Assessment and management of clinical problems. Toronto ON: Elsevier Mosby.
- Mebazaa, A., Combes, A., Diepen, S., Hollinger, A., Katz, J., Landoni, G., … Thiele, H. (2018). Management of cardiogenic shock complicating myocardial infarction. Intensive Care Medicine, 44, 760-773. doi:10.1007/s00134-018-5214-9
- National Heart, Lung, and Blood Institute. (n.d.b). Coronary artery bypass grafting. Retrieved from https://www.nhlbi.nih.gov/health-topics/coronary-artery-bypass-grafting
- Thiele, H., Ohman, E., Desch, S., Eitel, I., & de Waha, S. (2015). Management of cardiogenic shock. European Heart Journal, 36, 1223-1230. doi:10.1093/eurheartj/ehv051
- VanValkinburgh, D., & McGuigan, J. (2019). Inotropes and vasopressors. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482411/
- National Heart, Lung, and Blood Institute. (n.d.a). Cardiogenic shock. Retrieved from https://www.nhlbi.nih.gov/health-topics/cardiogenic-shock

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Description: The result of left, right, or both ventricle dysfunction that causes decreased cardiac output
Created by: Thea Wilkes
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Cardiogenic Shock

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