LMH Emergency Rounds May 23, 2017 Prepared by Shane Barclay MD Cardiogenic Shock LMH Emergency Rounds May 23, 2017 Prepared by Shane Barclay MD

Objectives Review all categories of Shock. Define Cardiogenic Shock. Review causes of Cardiogenic Shock. Review an overall approach to Cardiogenic Shock.

Overview of Shock Categories of Shock Volume Depletion – hemorrhage, hypovolemia Inflow obstruction – tamponade, tension pneumothorax Vasodilation – anaphylaxis, sepsis, neurogenic Pump failure – cardiogenic shock, pulmonary embolus Other/mixed – toxigenic

Overview of Shock

Cardiogenic Shock Definition: A state of critical end-organ hypoperfusion due to reduced cardiac output. Prognosis: If not diagnosed and treated effectively immediately can result in over 50% mortality.

Cardiogenic Shock - Criteria Systolic BP less than 90 mmHg for 30 min. or MAP less than 65 mmHg for 30 min. or Use of inotrops/vasopressors required to achieve the above. 2. Evidence of pulmonary congestion/edema. 3. Signs of impaired end organ perfusion with one of the following: - altered mental status - cold, clammy skin - oliguria - increased serum lactate

Cardiogenic Shock - Symptoms Symptoms are the ones we usually associate with ‘shock’ from most causes: Rapid breathing Altered heart rate (brady or tachy) Weak pulse Sweating Pale skin Cold extremities (differentiate from sepsis, with warm extremities)

Cardiogenic Shock -Causes 5 Major Causes of Cardiogenic Shock: Ischemia (STEMI, NSTEMI, Rt. sided infarct) Rate Related Valve Related Cardiomyopathy Toxicologic

Cardiogenic Shock - Causes 1. Ischemia By far the most common cause of cardiogenic shock is acute infarction (over 70% of cases) In most cases cardiogenic shock develops within the first 48 hours. Therefore unless there is an obvious cause, all patients in cardiogenic shock should have acute MI ruled out first. Acute MI accompanied by Cardiogenic Shock has 40% mortality.

Cardiogenic Shock - Causes 1. Ischemia If Right Ventricular infarction is causing shock, treat with aggressive fluids to fill the left ventricle. If STEMI is causing cardiogenic shock, TNK is often ineffective as there is not enough perfusion for it to work. These patients either need their perfusion restored first, or ideally go for angiography.

Cardiogenic Shock -Causes 2. Rate – too fast, too slow These are usually easy to identify with Rhythm strips or ECG. Treatment is based on standard ACLS protocols. Rhythm – again, identified on ECG. Treatment as per ACLS protocols

Cardiogenic Shock -Causes 3. Valve Related: Acute valve regurgitation (rupture mitral valve cordae tendineae) These patients are difficult to manage medically, as they need surgery.

Cardiogenic Shock -Causes 4. Cardiomyopathy ER treatment is medical management to restore perfusion ie inotrops.

Cardiogenic Shock -Causes 5. Toxicology Treatment is dependent on the toxic agent, but that may initially not be apparent. Inotropic and/or vasopressor treatment is often the initial step while searching for a cause.

Initial Assessment History: Labs: ECG, CXR, EDE heart, CBC, Trop, LVT, GFR, D dimer, BNP

Initial Management For a very good review article: “Experts’ recommendations for the management of adult patients with cardiogenic shock” Bruno Levy, et al Annals of Intensive Care 2015 5:17

Initial Management Because these patients are so sick, you need to do simultaneous evaluation and management. The evaluation is as mentioned in previous slides. The initial management will depend on the underlying cause ie rate etc, but all these patients should be considered for early inotropic therapy.

Initial Management - Inotrops Dobutamine Sympathomimetic – primarily beta 1 agonist Makes the heart ‘beat harder’. Dose: Start 2 mcg/kg/min titrate 2 – 20 mcg/kg/min. 2. Calcium Can give Calcium Gluconate 2 -3 gm IV peripheral line (or Calcium Chloride 1 gm but through a central line)

Initial Management -Vasopressors If Dobutamine +/- Calcium has not achieved the MAP you want, then you should add a vasopressor. Norepinephrine: Dose: start 0.1 mcg/Kg/min While RN is mixing the Norepinephrine you can use Push Dose Phenylnephrine (50 – 100 mcg IV q 15 – 20 minutes)

Initial Management - Diuretics If there is evidence of pulmonary congestion, use diuretics. Furosimide 40 mg IV NIV with PEEP Avoid nitroglycerin as this will lower BP even more.

Initial Management –End Point Clinical endpoint is: MAP > 65 mmHg and good peripheral perfusion ie warm feet. A higher MAP endpoint may be indicated if the patient has a history of hypertension (there system is used to higher MAPs)

Initial Management – “Don’t Drugs” Epinephrine: Has been associated with increased risk of arrhythmia, tachycardia, more myocardial oxygen consumption and hyperlactatemia. Beta blockers: Should not be used in the setting of cardiogenic shock even with pulmonary edema. Nitroglycerin (or any nitrovasodilators): Not used in APE with shock. Must restore the MAP first.

Initial Management – Hg Hemoglobin: Most reviews suggest a lower threshold for transfusion if patient is anemic and in cardiogenic shock. Consensus suggests to maintain Hg level above 80.

Initial Management Monitor oxygen saturation, cardiac rhythm. Provide oxygen if SpO2 < 90% Consider early intubation. If patient has pulmonary edema, make sure they have PEEP. Can provide NIV with PEEP initially during Intubation set-up.

Initial Management Fluid Challenge: If there is no evidence of acute pulmonary edema, a fluid challenge of 500 cc N/S will not adversely affect outcome and can be beneficial.

Summary 1. Consider the 5 causes of Cardiogenic shock. 2. Evaluation and treatment must be done simultaneously. 3. Standard treatments: IV, oxygen, monitors, labs, CXR etc. 4. Consider early Inotropes – Dobutamine 2 mcg/kg/min, Calcium. 5. Consider adding Vasopressors if needed – Bridge with push dose Phenylnephrine while starting Norepinephrine.

Summary 6. Goal is MAP > 65 mmHg and ‘warm feet’. 7. Use Furosemide for pulmonary edema. 8. Consider early intubation. 9. Avoid Epinephrine, Beta blockers and Nitroglycerin. 10. Consider fluid challenge if no pulmonary edema.

Questions ?

Scenario

Scenario 56 year old is brought to the ER by his wife. He states he is having major shortness of breath and exhaustion. Normally healthy. When asked about chest pain, he states 2 days ago while driving back from Winnipeg he had ‘the worst’ indigestion he has ever had after eating at a “Joes Diner” in Swift Current. It lasted most of the night. No prior cardiac history. Medications include Amlodipine 5 mg daily for HTN, Citalopram 10 mg daily and Tecta 40 mg daily.

Scenario Nurse tells you his vitals are: BP 90/48, (MAP 62 mmHg) HR 110 /min Respiratory rate 35/min Oxygen Sats were 88% initially. Temp 37 He has an IV started and a NRB mask on at 10 liters/min Oxygen Sats are now 94%

Scenario

Scenario He looks unwell on the stretcher. In obvious respiratory distress. He can respond in 5 – 6 word sentences. His JVP appears to be near the angle of his jaw. He has no murmurs. Heart otherwise sounds normal. Chest has crepitations bilaterally to mid lung fields. Abdomen is benign. Extremities (feet) feel cool.

Scenario

Scenario

Scenario LABS: WBC 11.5 Hg 136 GFR 72 Lytes all within normal range Troponin 2.6

What are you going to do?