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Cardiogenic Shock

Ameer Kabour, M.D,. F.A.C.C.,

Toledo Cardiology Consultant, TCC

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Classification of Shock

Hypovolemic Shock

Cardiogenic Shock

results from blood and/or fluid loss, leading to decreased circulating blood volume, reduced preload or diastolic filling pressure, and decreased cardiac stroke volume. This results in reduced cardiac output, hypotension, and shock. Common etiologies of hypovolemic shock include blood loss from trauma, GI hemorrhage, and dehydration.

caused by a severe reduction in cardiac contractility and function, resulting from direct damage to myocardium or from an intracardiac mechanical abnormality

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Classification of Shock

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Classification of Shock
Extracardiac Obstructive Shock

Distributive Shock

results from obstruction to flow in the CV circulation, extrinsic to the heart. Conditions such as tension pneumothorax or cardiac tamponade cause decreased diastolic filling and reduced cardiac output, whereas acute massive pulmonary embolism or aortic dissection may cause a marked increase in ventricular afterload and impaired systolic function.

is caused by multiple and complex abnormalities of circulation. There is loss of vasomotor control, with dilation of both venous and arterial beds, leading to decreased preload, decreased afterload, and hypotension. Cardiac output is often normal or elevated

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Classification of Shock

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Cardiogenic Shock

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Cardiogenic Shock - Pathophysiology

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Cardiogenic Shock Infarct Location

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Cardiogenic Shock Infarct Location

STEMI vs NSTEMI

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Risk Factors for Cardiogenic Shock

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Cardiogenic Shock Statistics

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Cardiogenic Shock Statistics

Treatment Practices Total Samples 2001 - 2005

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Cardiogenic Shock Etiologies: Ischemic

Extensive MI: most common cause: 40% of myocardial impairment. Acute severe ischemia: could cause shock due to myocardial stunning.
Mechanical Complication: Papillary muscle rupture Severe MR Intraventricular septal rupture Free wall rupture with tamponade

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Cardiogenic Shock Etiologies-Non Ischemic

End stage Cardiomyopathy

Acute myocarditis

Myocardial Contusion (Blunt Trauma) Severe aortic stenosis

Hypertrophic Obstructive CM Acute stress cardiomyopathy

Infective endocarditis complicated with severe MR or AI

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Cardiogenic Shock Hemodynamic Profile

Systolic BP < 90 mm Hg or
Mean arterial pressure (MAP) < 60 mm Hg.

Crdiac Index (CI) < 2.2 L/Min/m2. Elevated Pulmonart artery occlusion pressure > 18 mm Hg. Elevated systemic vascular resistance(SVR)

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Cardiogenic Shock Hemodynamic Profile

RV Infarction:

CI: Low

Mean RAP: > 10 mm Hg Equalization of diastolic pressure, RA pressure > 80% of PAOP (Pulmonary artery occlusive pressure).
If septum ruptured a step up in O2 from RA to PA are noticed.

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Shocks Inter-Relationship

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Cardiogenic Shock Clinical Approach

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Cardiogenic Shock Organ Dysfunction

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Cardiogenic Shock Clinical Approach

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Cardiogenic Shock Clinical Approach

The pulmonary catheter provides essential hemodynamic information in patients with shock. Study results showing only questionable benefit of PA catheter use in patients with heart failure or ARDS should not be extrapolated to the population with shock. (Shock patients were excluded
from clinical studies evaluating pulmonary artery catheters). hemodynamic assessment utilizing the PA catheter in patients with shock helps to determine the type of shock as well as the etiology. It will help guide appropriate fluid resuscitation and the use of vasopressors and inotropic drugs. Importantly, serial measurements are invaluable in assessing the patients response to therapy.

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Cardiogenic Shock Clinical Approach

SvO2: mixed venous saturation (PA O2 saturation) Reflect the balance between systemic O2 supply and consumption. Normal SvO2: 65-75%. Low SvO2: can be seen in : Anemia Hypoxemia Low cardiac output:
Acute MI with minimal CHF, SvO2: < 60% Cardiogenic shock < 40% = Lactate level rise

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Cardiogenic Shock Treatments

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Cardiogenic Shock Treatments Guideline

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Cardiogenic Shock IABP

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Cardiogenic Shock IABP

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Cardiogenic Shock Drug Treatments

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Cardiogenic Shock What drug is better

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Cardiogenic Shock Revascularization

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Cardiogenic Shock Revasculrization SHOCK Trial

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Cardiogenic Shock SHOCK Trial

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Cardiogenic Shock Rescue Revascularization post fibrinolytic treatments

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Cardiogenic Shock B. Blockers

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Cardiogenic Shock Mechanical Complications

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Cardiogenic Shock LVAD Circularory Support

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Cardiogenic Shock LVAD Percutaneos

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Cardiogenic Shock LVAD vs IABP

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Cardiogenic Shock Impella

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Cardiogenic Shock IABP vs Perc LVAD (Impella and Tandemheart)

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Cardiogenic Shock Summary

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Cardiogenic Shock Impella vs IABP

ISAR - SHOCK

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Cardiogenic Shock Organ Dysfunction

Cardiogenic Shock

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Shock - Management

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Shock - Management

Obtain SvO2 > 70% in the first 6 hours

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Shock - Management

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Shock - Resuscitation
1.

Secure respiratory status

1.

2.
3.

PEEP could be necessary Pain management Bicarbonate: should be reserved for severe acidosis (pH < 7.10) Crystalloid fluid challenge No evidence of benefit from Albumine / Dextran)

2.

Hyptenstion (non cardiogeneic):

1.

2.

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Shock Resuscitation Septic Shock

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Shock Resuscitation Septic Shock

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Shock Resuscitation Vasopressors / Inotropes