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| {| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0";
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| ! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align=center| {{fontcolor|#2B3B44|Cardiogenic Shock<BR>Resident Survival Guide}}
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Overview|Overview]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Causes|Causes]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Do's|Do's]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
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| |}
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| __NOTOC__
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| {{CMG}}; {{AE}} [[User:Ahmed Zaghw|Ahmed Zaghw, MBChB.]] [mailto:ahmedzaghw@wikidoc.org]
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| ==Overview==
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| The clinical definition of [[cardiogenic shock]] includes decreased [[cardiac output]] with evidence of tissue [[hypoxia]] in the presence of adequate intravascular volume.<ref name="Califf-1994">{{Cite journal | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref>
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| ==Causes==
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| ===Life Threatening Causes===
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| Cardiogenic shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.
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| ===Common Causes===
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| :* ''Arrhythmic''
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| ::* [[Atrioventricular block]]
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| ::* [[Sinoatrial block]]
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| ::* [[Supraventricular tachycardia]]
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| ::* [[Ventricular tachycardia]]
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| :* ''Mechanical''
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| ::* [[Mitral regurgitation|Acute mitral regurgitation]] ([[papillary muscle rupture]], [[chordae tendinae]] [[rupture]])
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| ::* [[Myocardial rupture|Free wall rupture]]
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| ::* [[Hypertrophic cardiomyopathy]]
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| ::* [[Left ventricle|Obstruction to left ventricular filling]] ([[mitral stenosis]], [[left atrial myxoma]])
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| ::* [[Left ventricular outflow tract obstruction|Obstruction to left ventricular outflow tract]] ([[aortic stenosis]], [[hypertrophic obstructive cardiomyopathy]])
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| ::* [[Ventricular septal defect]]
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| :* ''Myopathic''
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| ::* [[Cardiomyopathy]]
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| ::* [[Myocardial contusion]]
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| ::* [[Myocardial infarction]]
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| ::* [[Myocarditis]]
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| ::* [[Myxedema coma]]
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| ::* [[ischemia|Postischemic]] [[myocardial stunning]]
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| ::* [[Sepsis|Septic myocardial depression]]
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| :* ''Pharmacologic''
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| ::* [[Anthracycline]]s
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| ::* [[Calcium channel blockers]]
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|
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| ''Click '''[[Cardiogenic shock causes|here]]''' for the complete list of causes.''
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|
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| ==FIRE: Focused Initial Rapid Evaluation==
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="Robin-2006">{{Cite journal | last1 = Robin | first1 = E. | last2 = Costecalde | first2 = M. | last3 = Lebuffe | first3 = G. | last4 = Vallet | first4 = B. | title = Clinical relevance of data from the pulmonary artery catheter. | journal = Crit Care | volume = 10 Suppl 3 | issue = | pages = S3 | month = | year = 2006 | doi = 10.1186/cc4830 | PMID = 17164015 }}</ref>
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|
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| <span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span>
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| <span style="font-size: 85%;">
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| '''Abbreviations''':
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| CBC, complete blood count;
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| CI, cardiac index;
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| CK-MB, creatine kinase MB isoform;
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| CVP, central venous pressure;
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| DC, differential count;
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| ICU, intensive care unit;
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| INR, international normalized ratio;
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| LFT, liver function test;
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| MAP, mean arterial pressure;
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| PCWP, pulmonary capillary wedge pressure;
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| PT, prothrombin time;
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| PTT, partial prothrombin time;
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| SaO2, arterial oxygen saturation;
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| SBP, systolic blood pressure;
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| ScvO2, central venous oxygen saturation;
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| SvO2, mixed venous oxygen saturation;
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| SMA-7, sequential multiple analysis-7.
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| </span>
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| {{Family tree/start}}
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| {{Family tree|boxstyle=width: 400px; text-align: left; font-size: 90%; padding: 0px;| | | | | A01 | | | |A01=<div style="padding: 15px;"><BIG>'''Does the patient have cardinal findings that increase the pretest probability of [[cardiogenic shock|<span style="color: #000000;">cardiogenic shock</span>]]?'''</BIG>
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| ❑ Evidence of end-organ [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]
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| : ❑ [[Altered mental status|<span style="color: #000000;">Altered mental status</span>]]
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| : ❑ [[Cold extremities|<span style="color: #000000;">Cold extremities</span>]]
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| : ❑ [[Cyanosis|<span style="color: #000000;">Cyanosis</span>]]
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| : ❑ [[Oliguria|<span style="color: #000000;">Oliguria</span>]] ([[urine output|<span style="color: #000000;">urine output</span>]] <0.5 mL/kg/h)
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| : ❑ Sustained [[hypotension|<span style="color: #000000;">hypotension</span>]]
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| :: ❑ [[SBP|<span style="color: #000000;">SBP</span>]] <90 mm Hg for ≥30 min ''or''
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| :: ❑ [[MAP|<span style="color: #000000;">MAP</span>]] ↓ >30 mm Hg below baseline for ≥30 min
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|
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| ❑ Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%;| |,|-|-|-|^|-|-|-|.| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A02 | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>YES</BIG></div>|A03=<div style="text-align: center; background: #FA8072; color: #F8F8FF; font-weight: bold; padding: 15px;"><BIG>NO</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | |!| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072| A04 | | | | | | A05 |A04=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic shock suspected</BIG></div>
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| |A05=<div style="text-align: center; background: #FA8072; color: #FFFFFF; padding: 15px; font-weight: bold;"><BIG>'''Proceed to <br> [[shock resident survival guide|<span style="color: #FFFFFF;">shock resident survival guide</span>]]'''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A06 | | | | | | | | |A06=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate management'''</BIG>
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|
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| ❑ [[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
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| ❑ [[Pulse oximeter|<span style="color: #FFFFFF;">Pulse oximeter</span>]]
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| ❑ [[Arterial blood gas|<span style="color: #FFFFFF;">Arterial blood gas</span>]]
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|
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| ❑ [[Intubation|<span style="color: #FFFFFF;">Intubation</span>]] with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]
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|
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| ❑ [[Intravenous therapy#Peripheral IV lines|<span style="color: #FFFFFF;">Large-bore peripheral venous lines</span>]]
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| ❑ [[Arterial line|<span style="color: #FFFFFF;">Arterial line</span>]]
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| ❑ [[Central venous catheter|<span style="color: #FFFFFF;">Central venous catheter</span>]]
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| ❑ [[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]]
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| ❑ [[Foley catheter|<span style="color: #FFFFFF;">Foley catheter</span>]]
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| ❑ [[ICU|<span style="color: #FFFFFF;">ICU admission</span>]]
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| ❑ [[Cardiology|<span style="color: #FFFFFF;">Cardiology consultation</span>]]
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| ❑ Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate workup'''</BIG>
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| ❑ [[CBC|<span style="color: #FFFFFF;">CBC</span>]]/[[Differential blood count (patient information)|<span style="color: #FFFFFF;">DC</span>]]/[[Basic metabolic panel|<span style="color: #FFFFFF;">SMA-7</span>]]/[[LFT|<span style="color: #FFFFFF;">LFT</span>]]/[[PT|<span style="color: #FFFFFF;">PT</span>]]/[[PTT|<span style="color: #FFFFFF;">PTT</span>]]/[[INR|<span style="color: #FFFFFF;">INR</span>]]
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|
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| ❑ [[Troponin|<span style="color: #FFFFFF;">Cardiac troponins</span>]], [[CK-MB|<span style="color: #FFFFFF;">CK-MB</span>]]
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|
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| ❑ [[Brain natriuretic peptide|<span style="color: #FFFFFF;">BNP</span>]], [[Brain natriuretic peptide|<span style="color: #FFFFFF;">NT-proBNP</span>]]
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]]
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| ❑ [[ECG|<span style="color: #FFFFFF;">12-Lead ECG</span>]]
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| ❑ [[CXR|<span style="color: #FFFFFF;">Chest radiograph</span>]]
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| ❑ [[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A08 | | | | | | | | |A08=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic shock confirmed</BIG> <br> ''[[{{PAGENAME}}#Criteria for Cardiogenic Shock [Return to FIRE]|<span style="color: #FFFFFF;">(click for details on criteria)</span>]]''</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| A09 | | | | | | | | |A09=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Hemodynamic Optimization [Return to FIRE]|<span style="color: #FFFFFF;">Hemodynamic optimization</span>]]'''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A10 | | | | | | | | |A10=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Preload [Return to FIRE]|<span style="color: #FFFFFF;">Preload (click for details)</span>]]'''''</BIG>
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| ❑ '''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 15–18 mm Hg, [[Central venous pressure|<span style="color: #FFFFFF;">CVP</span>]] 8–12 cm H<sub>2</sub>O'''
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|
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| ❑ '''[[{{PAGENAME}}#Fluid Challenge Protocol|<span style="color: #FFFFFF;">Fluid challenge protocol ''("TROL")''</span>]]'''
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| ❑ '''± Correct [[pulmonary congestion|<span style="color: #FFFFFF;">pulmonary congestion</span>]]'''
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|
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| : ❑ ± [[Furosemide|<span style="color: #FFFFFF;">Furosemide</span>]] 40 mg slow IV injection
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|
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| : ❑ ± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg slow IV injection
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A11 | | | | | | | | |A11=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Afterload [Return to FIRE]|<span style="color: #FFFFFF;">Afterload (click for details)</span>]]'''''</BIG>
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|
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| ❑ '''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] >60 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>'''
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|
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| : ❑ If ↑ MAP & ↑ SVR: wean [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasodilator|<span style="color: #FFFFFF;">vasodilators</span>]]
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|
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| : ❑ If ↓ MAP & ↑ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] + [[inotrope|<span style="color: #FFFFFF;">inotropes</span>]]
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|
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| : ❑ If ↓ MAP & ↓ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasopressin|<span style="color: #FFFFFF;">vasopressin</span>]]
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A12 | | | | | | | | |A12=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Cardiac Index [Return to FIRE]|<span style="color: #FFFFFF;">Cardiac index (click for details)</span>]]'''''</BIG>
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| ❑ '''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] >2.2 L/min/m<sup>2</sup>'''
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|
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| : ❑ ± [[Dobutamine|<span style="color: #FFFFFF;">Dobutamine</span>]]
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|
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| : ❑ ± [[Milrinone|<span style="color: #FFFFFF;">Milrinone</span>]]
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|
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| : ❑ ± [[IABP|<span style="color: #FFFFFF;">IABP</span>]], [[VAD|<span style="color: #FFFFFF;">VAD</span>]], or [[ECMO|<span style="color: #FFFFFF;">ECMO</span>]] if refractory</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A13 | | | | | | | | |A13=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate goals'''</BIG>
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|
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| ❑ [[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] >90%–92%
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|
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| ❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">SvO2</span>]] >60%
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|
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| ❑ [[SCVO2|<span style="color: #FFFFFF;">ScvO2</span>]] >70%
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|
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| ❑ [[urine output|<span style="color: #FFFFFF;">Urine output</span>]] >0.5 mL/kg/h
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]] <2.2 mM/L
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| ❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin</span>]] >7–9 g/dL
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| ❑ ± Correct [[arrhythmia|<span style="color: #FFFFFF;">arrhythmia</span>]]
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| ❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072;| A14 |-| A15 | | | | | |A14=<div style="background: #FA8072; color: #F8F8FF; padding: 16px;">'''Acute myocardial infarction likely?''' [[{{PAGENAME}}#Criteria for Acute Myocardial Infarction [Return to FIRE]|<span style="color: #FFFFFF;">'''''(click for details)'''''</span>]]
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| ❑ [[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)</span>]]
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| ❑ Symptoms of myocaridal ischemia
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| ❑ New significant ECG findings of myocardial ischemia
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|
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| </div>
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| |A15=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 20px;"><BIG>'''YES, then manage as <br> UA/NSTEMI <br> and proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A14 | | | | | | | | |A14=<div style="text-align: center; background: #FA8072; color: #FFFFFF; font-weight: bold; padding: 15px;"><BIG>No, then proceed to <br> [[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]]</BIG></div>}}
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| {{Family tree/end}}
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| ==Acute Ischemia Pathway==
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| ==Complete Diagnostic Approach==
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| ==Treatment==
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| ==Do's==
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| ===Criteria for Cardiogenic Shock <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>===
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|
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| * ''Clinical Criteria''<ref name="Califf-1994">{{Cite journal | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref><ref name="Hollenberg-1999">{{Cite journal | last1 = Hollenberg | first1 = SM. | last2 = Kavinsky | first2 = CJ. | last3 = Parrillo | first3 = JE. | title = Cardiogenic shock. | journal = Ann Intern Med | volume = 131 | issue = 1 | pages = 47-59 | month = Jul | year = 1999 | doi = | PMID = 10391815 }}</ref><ref name="Goldberg-1991">{{Cite journal | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref>
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|
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| :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]] <90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
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| :* Evidence of [[hypoperfusion|tissue hypoperfusion]] (such as [[oliguria]], [[cyanosis]], [[cool extremities]], and [[Altered mental status|altered mental status]])
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| :* Presence of [[myocardial]] dysfunction after exclusion or correction of non-[[myocardial]] factors contributing to [[hypoperfusion|tissue hypoperfusion]] (such as [[hypovolemia]], [[hypoxia]], and [[acidosis]])
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|
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| * ''Hemodynamic Criteria''<ref name="Califf-1994">{{Cite journal | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref><ref name="Goldberg-1991">{{Cite journal | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref><ref name="Forrester-1976">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref>
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| :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]] <90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
| |
| :* Depressed [[cardiac index]] (<1.8 L/min/m<sup>2</sup> of [[body surface area|BSA]] without support or <2.0–2.2 L/min/m<sup>2</sup> of [[body surface area|BSA]] with support) in the presence of an elevated [[PCWP|wedge pressure]] (>15 mm Hg).
| |
| <!--
| |
| :* Adequate filling pressure (left ventricular end-diastolic pressure >18 mm Hg or right ventricular end-diastolic pressure >10–15 mm Hg)
| |
| :* Elevated [[arteriovenous oxygen difference]] (>5.5 mL/dL)
| |
| -->
| |
|
| |
| ===Hemodynamic Optimization <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>===
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|
| |
| ====Preload <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>====
| |
|
| |
| * Preload optimization involves manipulation of [[PCWP]] and/or [[central venous pressure|CVP]] levels and correction of [[pulmonary congestion]].<ref name="Forrester-1976">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref><ref name="Crexells-1973">{{Cite journal | last1 = Crexells | first1 = C. | last2 = Chatterjee | first2 = K. | last3 = Forrester | first3 = JS. | last4 = Dikshit | first4 = K. | last5 = Swan | first5 = HJ. | title = Optimal level of filling pressure in the left side of the heart in acute myocardial infarction. | journal = N Engl J Med | volume = 289 | issue = 24 | pages = 1263-6 | month = Dec | year = 1973 | doi = 10.1056/NEJM197312132892401 | PMID = 4749545 }}</ref>
| |
|
| |
| ======Fluid Challenge Protocol======
| |
|
| |
| * Protocolized fluid administration titrated to hemodynamic and clinical endpoints secures the efficacy of tissue perfusion and oxygenation.<ref name="Weil-fluid1">{{Cite journal | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month = | year = | doi = | PMID = 571235 }}</ref>
| |
|
| |
| * Four elements of the fluid challenge protocol: type of fluid (T), rate of fluid administration (R), objective (O), and limits (L).<ref name="Vincent-2011">{{Cite journal | last1 = Vincent | first1 = JL. | title = Let's give some fluid and see what happens versus the mini-fluid challenge. | journal = Anesthesiology | volume = 115 | issue = 3 | pages = 455-6 | month = Sep | year = 2011 | doi = 10.1097/ALN.0b013e318229a521 | PMID = 21792055 }}</ref>
| |
| :* 1. Type of fluid (T)
| |
| ::* The choice of crystalloid or colloid solution should be made on the basis of the underlying disease, the nature of fluid deficit, the severity of circulatory failure, the serum albumin concentration, and the risk of bleeding.<ref name="Weil-fluid2">{{Cite journal | last1 = Vincent | first1 = JL. | last2 = Weil | first2 = MH. | title = Fluid challenge revisited. | journal = Crit Care Med | volume = 34 | issue = 5 | pages = 1333-7 | month = May | year = 2006 | doi = 10.1097/01.CCM.0000214677.76535.A5 | PMID = 16557164 }}</ref>
| |
| ::* There were no significant differences in mortality between saline and albumin infusion for critically ill patients.<ref name="Finfer-2004">{{Cite journal | last1 = Finfer | first1 = S. | last2 = Bellomo | first2 = R. | last3 = Boyce | first3 = N. | last4 = French | first4 = J. | last5 = Myburgh | first5 = J. | last6 = Norton | first6 = R. | title = A comparison of albumin and saline for fluid resuscitation in the intensive care unit. | journal = N Engl J Med | volume = 350 | issue = 22 | pages = 2247-56 | month = May | year = 2004 | doi = 10.1056/NEJMoa040232 | PMID = 15163774 }}</ref>
| |
| ::* [[Hyperchloremic acidosis]] may be associated with the use of isotonic saline solution.<ref name="Scheingraber-1999">{{Cite journal | last1 = Scheingraber | first1 = S. | last2 = Rehm | first2 = M. | last3 = Sehmisch | first3 = C. | last4 = Finsterer | first4 = U. | title = Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. | journal = Anesthesiology | volume = 90 | issue = 5 | pages = 1265-70 | month = May | year = 1999 | doi = | PMID = 10319771 }}</ref>
| |
|
| |
| :* 2. Rate of fluid administration (R)
| |
| ::* Based on the level of [[pulmonary capillary wedge pressure]] or [[central venous pressure]], a volume of 50, 100, or 200 ml of fluid is administered over a 10-minute interval through a peripheral venous catheter.<ref name="Weil-fluid1">{{Cite journal | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month = | year = | doi = | PMID = 571235 }}</ref>
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|
| |
| {|
| |
| | style="width: 10%" |
| |
| | style="width: 90%" |
| |
| {| style="border: 2px solid #DCDCDC; font-size: 90%;"
| |
| | align="center" style="background: #DCDCDC; width: 150px;" | '''Baseline PCWP (mm Hg)'''
| |
| | align="center" style="background: #DCDCDC; width: 150px;" | '''Baseline CVP (cm H<sub>2</sub>O)'''
| |
| | align="center" style="background: #DCDCDC; width: 300px;" | '''Rate of fluid administration'''
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | ≥16
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | ≥14
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | 50 mL over 10 minutes
| |
| |-
| |
|
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | <16 but ≥12
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | <14 but ≥8
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | 100 mL over 10 minutes
| |
|
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | <12
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | <8
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | 200 mL over 10 minutes
| |
| |}
| |
| |}
| |
|
| |
| :* 3. Objective (O)
| |
| ::* Fluid administration should be titrated to reach predetermined clinical endpoints such as resolution of tachycardia or oliguria, improved skin perfusion or level of consciousness, normalization of lactate concentrations, and restoration of adequate blood pressure or ventricular filling pressure.<ref name="Weil-fluid2">{{Cite journal | last1 = Vincent | first1 = JL. | last2 = Weil | first2 = MH. | title = Fluid challenge revisited. | journal = Crit Care Med | volume = 34 | issue = 5 | pages = 1333-7 | month = May | year = 2006 | doi = 10.1097/01.CCM.0000214677.76535.A5 | PMID = 16557164 }}</ref>
| |
|
| |
| :* 4. Limits (L)
| |
| ::* Fluid administration should be stopped if the safety limits are violated to minimize the risk of developing [[pulmonary edema]].
| |
| ::* Inotropes, vasodilators, or mechanical circulatory device may be required if signs of hypoperfusion persist despite optimal fluid loading.
| |
| ::* Hemodynamic safety limits based on PCWP (the 7–3 rule) or CVP (the 5–2 rule):<ref name="Weil-fluid1">{{Cite journal | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month = | year = | doi = | PMID = 571235 }}</ref>
| |
|
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| {|
| |
| | style="width: 10%" |
| |
| | style="width: 90%" |
| |
| {| style="border: 2px solid #DCDCDC; font-size: 90%;"
| |
| | align="center" style="background: #DCDCDC; width: 150px;" | '''↑ PCWP (mm Hg)'''
| |
| | align="center" style="background: #DCDCDC; width: 150px;" | '''↑ CVP (cm H<sub>2</sub>O)'''
| |
| | align="center" style="background: #DCDCDC; width: 300px;" | '''Action'''
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | ≥7
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | ≥5
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | Stop fluid administration
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | <7 but >3
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | <5 but >2
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | Wait and recheck pressure after 10 minutes
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | ≤3
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | ≤2
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | Continue fluid administration
| |
| |}
| |
| |}
| |
|
| |
| ======Pulmonary Congestion======
| |
|
| |
| * Findings suggestive of cardiogenic pulmonary edema:<ref name="Ware-2005">{{Cite journal | last1 = Ware | first1 = LB. | last2 = Matthay | first2 = MA. | title = Clinical practice. Acute pulmonary edema. | journal = N Engl J Med | volume = 353 | issue = 26 | pages = 2788-96 | month = Dec | year = 2005 | doi = 10.1056/NEJMcp052699 | PMID = 16382065 }}</ref>
| |
| :* History and clinical manifestations
| |
| ::* Cough
| |
| ::* Dyspnea
| |
| ::* Expectoration of frothy sputum
| |
| ::* Orthopnea
| |
| ::* Paroxysmal nocturnal dyspnea
| |
| ::* Signs and symptoms of heart failure
| |
| ::* Signs and symptoms of hypoxemia
| |
| ::* Signs and symptoms of myocardial ischemia
| |
| ::* Signs and symptoms of valvular dysfunction
| |
| ::* Tachypnea
| |
| :* Physical examination
| |
| ::* Cool extremities
| |
| ::* Heart murmurs
| |
| ::* Hepatomegaly
| |
| ::* Inspiratory crackles or rhonchi
| |
| ::* Jugular venous distention
| |
| ::* S3 gallop
| |
| ::* Peripheral edema
| |
| :* Laboratory and hemodynamic findings
| |
| ::* BNP > 500 pg/mL
| |
| ::* PCWP >18 mm Hg
| |
| :* Radiologic findings
| |
| ::* Central infiltrates with peripheral sparing
| |
| ::* Cephalization of pulmonary vessels
| |
| ::* Enlarged cardiac silhouette
| |
| ::* Enlargement of peribronchovascular spaces
| |
| ::* Increased opacity of acinar areas that coalesce into frank consolidations
| |
| ::* Kerley B lines
| |
| ::* Peribronchial cuffing
| |
| ::* Pleural effusions
| |
| ::* Vascular pedicle width >70 mm
| |
|
| |
| * Radiologic manifestations of [[pulmonary congestion]] reflect the extent of elevation in [[PCWP|wedge pressure]]:<ref name="Forrester-1976">{{Cite journal | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref>
| |
|
| |
| {|
| |
| | style="width: 4%" |
| |
|
| |
| | style="width: 96%" |
| |
| {| style="border: 2px solid #DCDCDC; font-size: 90%;"
| |
| | align="center" style="background: #DCDCDC; width: 100px;"| '''PCWP (mm Hg)'''
| |
| | align="center" style="background: #DCDCDC; width: 200px;" | '''Phase of Pulmonary Congestion'''
| |
| | align="center" style="background: #DCDCDC; width: 500px;" | '''Findings on Chest Radiograph'''
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | 18–20
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | Onset of pulmonary congestion
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | Redistribution of pulmonary flow to the upper lobes ("cephalization") and Kerley lines
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | 20–25
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | Moderate congestion
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | Diminished clarity of the borders of medium-sized pulmonary vessels ("perihilar haze")
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | 25–30
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | Severe congestion
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | Radiolucent grapelike clusters surrounded by radiodense fluid ("periacinar rosette")
| |
| |-
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | >30
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=center | Onset of pulmonary edema
| |
| | style="padding: 0 5px; background: #F5F5F5;" align=left | Coalescence of periacinar rosettes resulting in "Bat's wing" opacities
| |
| |}
| |
| |}
| |
|
| |
| * [[Furosemide]]<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="FUROSEMIDE injection">{{Cite web | last = | first = | title = FUROSEMIDE INJECTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=2d6a6ff9-3f12-4a6e-bba3-3f85fd54ffac | publisher = | date = | accessdate = }}</ref>
| |
| :* ''Dosage and Administration''
| |
| ::* For [[pulmonary edema|acute pulmonary edema]], the initial dose is 40 mg injected slowly intravenously (over 1 to 2 minutes).
| |
| ::* If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).
| |
| :* ''Contraindications''
| |
| ::* [[Anuria]]
| |
| ::* [[Hypersensitivity]] to [[furosemide]]
| |
|
| |
| * [[Morphine]]<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="MORPHINE SULFATE INJECTION">{{Cite web | last = | first = | title = MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=cadc3fdb-8edc-44cd-aaea-89e68aaf9a04 | publisher = | date = | accessdate = }}</ref><ref name="O'Connor-2010">{{Cite journal | last1 = O'Connor | first1 = RE. | last2 = Brady | first2 = W. | last3 = Brooks | first3 = SC. | last4 = Diercks | first4 = D. | last5 = Egan | first5 = J. | last6 = Ghaemmaghami | first6 = C. | last7 = Menon | first7 = V. | last8 = O'Neil | first8 = BJ. | last9 = Travers | first9 = AH. | title = Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S787-817 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.971028 | PMID = 20956226 }}</ref>
| |
| :* ''Dosage and Administration''
| |
| ::* Morphine may be used adjunctively in the treatment of acute pulmonary edema at a dose of 2–4 mg (slow [[IV|IV injection]] over 1–5 minutes) every 5–30 minutes as needed.
| |
| <!--
| |
| :* ''Indications''
| |
| ::* Relief of severe [[pain]] as in severe [[injuries]] or in severe [[chronic pain]] associated with terminal [[cancer]] after all non-[[narcotic]] [[analgesic]]s have failed.
| |
| ::* Relief of [[chest discomfort]] that is unresponsive to [[nitrate]]s in [[STEMI]] [[ACC AHA guidelines classification scheme|(Class I, LOE C)]] and [[unstable angina]] or [[NSTEMI]] [[ACC AHA guidelines classification scheme|(Class IIa, LOE C)]].
| |
| ::* Management of [[dyspnea]] associated with [[heart failure|acute left ventricular failure]] and [[pulmonary edema]] to relieve [[anxiety]] and reduce [[preload]].
| |
| ::* Preoperative [[sedation]] to facilitate [[anesthesia]] induction and reduce [[anesthetic]] dosage.
| |
| -->
| |
| :* ''Contraindications''
| |
| ::* [[Hypersensitivity]] to [[morphine sulfate]] is one of the contraindications to its use.
| |
| ::* [[Morphine]] should not be used in [[convulsion|convulsive states]], such as those occurring in [[status epilepticus]], [[tetanus]], and [[strychnine]] poisoning.
| |
| ::* [[Morphine]] is also contraindicated in the following conditions: [[respiratory insufficiency|respiratory insufficiency or depression]]; [[bronchial asthma]]; [[heart failure]] secondary to [[COPD|chronic lung disease]]; [[cardiac arrhythmia]]s; increased [[ICP|intracranial or cerebrospinal pressure]]; [[head injury|head injuries]]; [[brain tumor]]; acute [[alcoholism]]; and [[delirium tremens]].
| |
| <!--
| |
| :* ''Precautions''
| |
| ::* May cause [[Hypoventilation|respiratory depression]]
| |
| ::* May exacerbate [[hypotension]] in [[hypovolemia|volume-depleted]] patients.
| |
| -->
| |
|
| |
| ====Afterload <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>====
| |
|
| |
|
| |
|
| |
|
| |
| ====Cardiac Index <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>====
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| <!--
| |
|
| |
| ======Vasopressor======
| |
|
| |
| * [[Norepinephrine]]<ref name="NOREPINEPHRINE BITARTRATE INJECTION">{{Cite web | last = | first = | title = NOREPINEPHRINE BITARTRATE INJECTION | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3352c7d0-e621-46ed-9a54-e4a9583cde10 | publisher = | date = | accessdate = }}</ref><ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref>
| |
| :* ''Dosage and Administration''
| |
| ::* Mix 1 ampule (4 mg) of [[norepinephrine]] in 250 mL of [[Intravenous sugar solution|D5W]] or [[Intravenous sugar solution|D5NS]]. Avoid dilution in [[normal saline]] alone.
| |
| ::* Initial dose: 0.5–1.0 μg/min [[IV|IV infusion]]; titrate to maintain [[SBP]] at above 90 mm Hg (up to 30–40 μg/min).
| |
| :* ''Indications''
| |
| ::* [[Blood pressure]] control in certain acute [[hypotensive]] states (e.g., [[pheochromocytoma|pheochromocytomectomy]], [[sympathectomy]], [[poliomyelitis]], [[spinal anesthesia]], [[myocardial infarction]], [[septicemia]], [[transfusion|blood transfusion]], and [[drug reaction]]s).
| |
| ::* Adjunct in the treatment of [[cardiac arrest]] and profound [[hypotension]].
| |
| :* ''Contraindications''
| |
| ::* [[Norepinephrine]] should not be given to patients who are [[hypotensive]] from [[hypovolemia|blood volume deficits]] except as an emergency measure to maintain [[coronary]] and [[cerebral]] artery [[perfusion]] until blood volume replacement therapy can be completed.
| |
| ::* [[Norepinephrine]] should also not be given to patients with [[mesentery|mesenteric]] or peripheral vascular [[thrombosis]] unless it is necessary as a life-saving procedure.
| |
|
| |
| -->
| |
|
| |
|
| |
|
| |
|
| |
| <!--
| |
|
| |
| ======Vasodilator======
| |
|
| |
| * [[Nitroprusside]]<ref name="Chatterjee-1973">{{Cite journal | last1 = Chatterjee | first1 = K. | last2 = Parmley | first2 = WW. | last3 = Ganz | first3 = W. | last4 = Forrester | first4 = J. | last5 = Walinsky | first5 = P. | last6 = Crexells | first6 = C. | last7 = Swan | first7 = HJ. | title = Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction. | journal = Circulation | volume = 48 | issue = 6 | pages = 1183-93 | month = Dec | year = 1973 | doi = | PMID = 4762476 }}</ref>
| |
| :* Initial dose: 16 μg/min
| |
| :* Adjust the infusion rate to maintain a [[PCWP]] of 15–18 mm Hg without causing a marked decrease in [[arterial pressure]].
| |
|
| |
| -->
| |
|
| |
|
| |
| ===''Criteria for Acute Myocardial Infarction'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|[Return to ''FIRE'']]]</SMALL></SMALL>===
| |
|
| |
| * Detection of a rise and/or fall of [[cardiac biomarker]] values (preferably [[cardiac troponin]]) with at least one value above the 99th percentile upper reference limit and '''with''' at least one of the following:<ref name="Thygesen-2012">{{Cite journal | last1 = Thygesen | first1 = K. | last2 = Alpert | first2 = JS. | last3 = Jaffe | first3 = AS. | last4 = Simoons | first4 = ML. | last5 = Chaitman | first5 = BR. | last6 = White | first6 = HD. | last7 = Thygesen | first7 = K. | last8 = Alpert | first8 = JS. | last9 = White | first9 = HD. | title = Third universal definition of myocardial infarction. | journal = J Am Coll Cardiol | volume = 60 | issue = 16 | pages = 1581-98 | month = Oct | year = 2012 | doi = 10.1016/j.jacc.2012.08.001 | PMID = 22958960 }}</ref>
| |
| :* Symptoms of [[ischemia]]
| |
| ::* Recent episode of typical ischemic discomfort that either is of new onset or is severe or that exhibits an accelerating pattern of previous stable angina (especially if it has occurred at rest or is within 2 weeks of a previously documented MI)
| |
| ::* Chest pain or severe epigastric pain, nontraumatic in origin, with components typical of myocardial ischemia or MI:
| |
| :::* Central/substernal compression or crushing chest pain
| |
| :::* Pressure, tightness, heaviness, cramping, burning, aching sensation
| |
| :::* Unexplained indigestion, belching, epigastric pain
| |
| :::* Radiating pain in neck, jaw, shoulders, back, or 1 or both arms
| |
| :* New or presumably new significant [[ST-segment]]–[[T wave]] (ST–T) changes or new [[LBBB|left bundle branch block (LBBB)]].
| |
| :* Development of [[Pathologic Q Waves|pathological Q waves]] in the [[ECG]].
| |
| :* Imaging evidence of new loss of viable [[myocardium]] or new region wall motion abnormality.
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| :* Identification of an intracoronary [[thrombus]] by [[angiography]] or [[autopsy]].
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| <!--
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| ❑ ± [[Norepinephrine|<span style="color: #FFFFFF;">Norepinephrine</span>]]
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| :❑ Initial dose: 0.5–1.0 μg/min [[IV|<span style="color: #FFFFFF;">IV infusion</span>]]
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| :❑ Titrate to maintain [[SBP|<span style="color: #FFFFFF;">SBP</span>]] at ≥90 mm Hg (up to 40 μg/min)
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| -->
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| ==Don'ts==
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| ==References==
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| {{reflist|2}}
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| [[Category:Disease]]
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| [[Category:Pulmonology]]
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| [[Category:Emergency medicine]]
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| [[Category:Medicine]]
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| [[Category:Resident survival guide]]
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