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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Tuesday, November 10, 2015

Shock cardiogénico

emDocs - August 4, 2014 - By Anad Swaminathan 
"Some Background… 
Cardiogenic shock develops when there is tissue hypoperfusion that is primarily attributable to damage to the heart. The cardiology literature focuses diagnostic criteria on a low systolic blood pressure (SBP) < 90 mm Hg or a decrease in the mean arterial pressure (MAP) by > 30 mm Hg (Gowda 2008). It is more important, however, to look for evidence of hypoperfusion. In the acute setting, this will typically manifest as a change in mental status (lethargy, decreased responsiveness, agitation etc.). 
Although cardiogenic shock is not common, it does complicate 7-10% of patients with STEMI and 3% of NSTEMIs. Additionally, the mortality is greater than 50% (Goldberg 1999). While acute myocardial infarction (AMI) is the major cause of cardiogenic shock, other diagnostic considerations should always be entertained. These include valvular heart disease (particularly flail leaflet), myocarditis, myocardial contusion, and cardiomyopathies. 
In AMI-induced cardiogenic shock, the pathophysiology is straightforward. An AMI leads to LV dysfunction leading to hypoperfusion. Hypoperfusion subsequently causes neurohormonal activation (just as in ADHF) leading to increased preload and afterload. As the stress on the left ventricle mounts, it is unable to overcome the heightened afterload and cardiac output drops leading to worsening hypoperfusion and acidosis. This process creates a vicious cycle (see image below). We will focus on discussing the management of AMI-induced cardiogenic shock. 

Take Home Points 
  1. Start with what you know: ABCs, IV/IO, O2, Monitor, 12-lead ECG, and Ultrasound. 
  2. Look for a STEMI and activate the cath lab as quickly as possible. 
  3. Address hypotension and hypoxia prior to RSI if possible 
  4. Initiate vasopressor (norepinephrine or epinephrine) and titrate to a MAP of 65 mm Hg. Then consider adding an inotrope (dobutamine)."