Cardiogenic shock: Difference between revisions

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==Overview==
==Overview==
'''Cardiogenic shock''' is based upon an inadequate circulation of [[blood]] due to primary failure of the [[ventricle (heart)|ventricle]]s of the [[heart]] to function effectively.<ref name="IrwinRippe"> [http://www.lww.com/product/?0-7817-3548-3 Irwin and Rippe's Intensive Care Medicine] by Irwin and Rippe, Fifth Edition (2003), Lippincott Williams & Wilkins, ISBN 0-7817-3548-3</ref>
'''Cardiogenic shock''' is defined as an inadequate [[cardiac output]] to maintain perfusion of vital organs to meet ongoing demans for oxygenation. Cardiogenic shock is due to inadequate left ventricular function. Cardiogenic shock should be distinguisehd from [[septic shock]] and [[neurogenic shock]].
<ref name="Marino">
[http://www.lww.com/product/?0-683-05565-8 The ICU Book] by Paul Marino MD, PhD, Second Edition (1997), Lippincott Williams & Wilkins, ISBN 0-683-05565-8 </ref>
<ref name="FCCS">
[http://www.sccm.org/education/fccs_courses/course_textbook/index.asp Fundamental Critical Care Support, A standardized curriculum of Critical Care] by the Society of Critical Care Medicine</ref>
<ref name="InternalMedicine"> Textbooks of Internal Medicine
* [http://books.mcgraw-hill.com/medical/harrisons/ Harrison's Principles of Internal Medicine] 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7
* [http://www.cecilmedicine.com/buy.cfm?book=goldman Cecil Textbook of Medicine] by Lee Goldman, Dennis Ausiello, 22nd Edition (2003), W.B. Saunders Company, ISBN 0-7216-9652-X
* [http://www.oup.com/us/catalog/general/subject/Medicine/PrimaryCare/?ci=0192629220&view=usa The Oxford Textbook of Medicine] Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press, ISBN 0-19-262922-0</ref>
<ref name="Overview">
[http://www.surgicalcriticalcare.net/Lectures/shock_overview.pdf Shock: An Overview] PDF by Michael L. Cheatham, MD, Ernest F.J. Block, MD, Howard G. Smith, MD, John T. Promes, MD, Surgical Critical Care Service, Department of Surgical Education, [[Orlando Regional Medical Center]] Orlando, Florida</ref>
 
Since this is a category of [[Shock (medical)|shock]] there is insufficient [[perfusion]] of [[Biological tissue|tissue]] (i.e. the [[heart]]) to meet the required demand for [[oxygen]] and [[nutrients]]. This leads to [[cell (biology)|cell]] death from [[oxygen]] starvation, [[hypoxia (medical)|hypoxia]]. Because of this it may lead to [[cardiac arrest]] (or circulatory arrest) which is an acute cessation of cardiac pump function.<ref name="InternalMedicine"/>


== Definition ==
== Definition ==
Line 32: Line 20:
Cardiogenic shock is defined by sustained hypotension with tissue hypoperfusion despite adequate left ventricular filling pressure.  Signs of tissue hypoperfusion include oliguria (<30 mL/h), cool extremities, and altered mentation.
Cardiogenic shock is defined by sustained hypotension with tissue hypoperfusion despite adequate left ventricular filling pressure.  Signs of tissue hypoperfusion include oliguria (<30 mL/h), cool extremities, and altered mentation.


== Etiology ==
== Pathophysiology of Cardiogenic Shock ==
Cardiogenic shock is caused by the failure of the heart to pump effectively.  It can be due to damage to the [[heart]] muscle, most often from a large [[myocardial infarction]]. Other causes include [[cardiac arrhythmia|arrhythmia]], [[cardiomyopathy]], [[cardiac valve]] problems, ventricular outflow obstruction (i.e. [[aortic valve stenosis]], [[aortic dissection]], systolic anterior motion (SAM) in [[hypertrophic cardiomyopathy]]), ventriculoseptal defects or medical error.
Cardiogenic shock can be a complication of the follwoing conitions:
<ref name="IrwinRippe"/>
 
<ref name="Marino"/>
*[[Acute MI]], more often [[ST elevation MI]]. Anterior MI with pronounced left ventricular dysfunction, posterior MI with acute mitral regurgitation, and inferior MI wiht [[right ventricular infarct]] physiology can be associated with cardiogenic shock.
<ref name="InternalMedicine"/>
*[[Tachyarrhythmia]]s resulting in inadequate ventricular filling times and inadequate forward [[cardiac output]].
<ref name="FCCS"/>
*[[Congestive heart failure]]
<ref name="Overview"/>
*[[Cardiomyopathy]]
<ref name="HongKongCS">
*[[Valvular heart disease]] including [[aortic stenosis]], [[mitral stenosis]] with [[tachycardia]] and inadequate diastolic filling time.
[http://www.aic.cuhk.edu.hk/web8/cardiogenic_shock.htm Cardiogenic shock] Department of Anaesthesia and Intensive Care of The Chinese University of Hong Kong</ref>
*[[Aortic dissection]]
<ref name="HongKong">
*[[Hypertrophic obstructive cardiomyopathy]] with systolic anterior motion (SAM)
[http://www.aic.cuhk.edu.hk/web8/shock.htm Introduction to management of shock for junior ICU trainees and medical students] Department of Anaesthesia and Intensive Care of The Chinese University of Hong Kong</ref>
*[[Ventricular septal defect]]
*[[Cardiac tamponade]]
*Iatrogenic due to excess administration of vasodilators and venodilators
 


== Signs and symptoms ==
== Signs and symptoms ==

Revision as of 13:41, 17 May 2009

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Overview

Cardiogenic shock is defined as an inadequate cardiac output to maintain perfusion of vital organs to meet ongoing demans for oxygenation. Cardiogenic shock is due to inadequate left ventricular function. Cardiogenic shock should be distinguisehd from septic shock and neurogenic shock.

Definition

Cardiogenic shock is defined by sustained hypotension with tissue hypoperfusion despite adequate left ventricular filling pressure. Signs of tissue hypoperfusion include oliguria (<30 mL/h), cool extremities, and altered mentation.

Pathophysiology of Cardiogenic Shock

Cardiogenic shock can be a complication of the follwoing conitions:


Signs and symptoms

  • Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia.
  • Hypotension due to decrease in cardiac output.
  • A rapid, weak, thready pulse due to decreased circulation combined with tachycardia.
  • Cool, clammy, and mottled skin (cutis marmorata), due to vasoconstriction and subsequent hypoperfusion of the skin.
  • Distended jugular veins due to increased jugular venous pressure.
  • Oliguria (low urine output) due insufficient renal perfusion if condition persists.
  • Rapid and deep respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis.
  • Fatigue due to hyperventilation and hypoxia.
  • Absent pulse in tachyarrhythmia.
  • Pulmonary Edema (fluid in the lungs) due to insufficient pumping of the heart, fluid backs up into the lungs.

Diagnosis

Electrocardiogram

An Electrocardiogram helps establishing the exact diagnosis and guides treatment, it may reveal:

Radiology

Echocardiography may show arrhythmia, signs of PED, ventricular septal rupture (VSR), an obstructed outflow tract or cardiomyopathy.

Swan-ganz catheter

The Swan-ganz catheter or Pulmonary artery catheter may assist in the diagnosis by providing information on the hemodynamics.

Biopsy

In case of suspected cardiomyopathy a biopsy of heart muscle may be needed to make a definite diagnosis.

Diagnostic criteria of cardiogenic shock

A. Clinical criteria

  1. Systolic blood pressure <90 mm Hg
  2. Evidence of hypoperfusion
  3. Cool, clammy periphery
  4. Decreased urine output
  5. Decreased level of consciousness

B. Hemodynamic criteria

  1. Left ventricular end diastolic pressure or pulmonary capillary wedge pressure >15 mm Hg
  2. Cardiac index <2.2 L/min/m2

Reference:

  1. Data from Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med 1999; 341 (9) : 625–34.

Treatment

In cardiogenic shock: depending on the type of myocardal infarction one can infuse fluids or in shock refractory to infusing fluids, inotropes should be administered. Positive inotropic agents, which enhance the heart's pumping capabilities, are used to improve the contractility and correct the hypotension. Should that not suffice an intra-aortic balloon pump (which reduces workload for the heart, and improves perfusion of the coronary arteries) can be considered or a left ventricular assist device (which augments the pump-function of the heart). [1] [2] [3]

See also

Notes

  1. ↑
  2. ↑
  3. ↑

References

  • Irwin, R.S., Rippe, J.M., Curley, F.J., Heard, S.O. (1997) Procedures and Techniques in Intensive Care Medicine (3rd edition). Boston: Lippincott, Williams and Wilkins.
  • Marino, P. (1997) The ICU Book. (2nd edition). Philadelphia: Lippincott, Williams and Wilkins.

External links

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