Cardiogenic shock

Ultrasound showing cardiogenic shock due to myocarditis[1]
Specialty| Cardiology
Symptoms| Altered mental status, clammy, bluish, or mottled skin.[2]
Complications| Kidney failure, respiratory failure, stroke[2]
Causes| Heart attack, valvular heart disease, aortic dissection, cardiomyopathy, myocarditis, arrhythmia, beta blocker or calcium channel blocker overdose[2]
Risk factors| Diabetes, old age, females[2]
Diagnostic method| SBP < 90 mmHg, urine output < 30 mL/hr, cool extremities[2]
Differential diagnosis| Septic shock, neurogenic shock, hemorrhagic shock, obstructive shock[2][3]
Treatment| Raise blood pressure, support breathing, reverse any underlying causes[2]
Deaths| 30 to 80% risk[2]

Cardiogenic shock (CS) is a disorder of the heart that results in prolonged inadequate blood flow to the tissues of the body.[2] The most common symptoms are altered mental status and clammy, bluish, or mottled skin.[2] Swelling may be present in the legs.[2] Complications may include kidney failure, respiratory failure, and stroke.[2]

The most common cause is a heart attack.[2] Other causes include valvular heart disease, aortic dissection, cardiomyopathy, myocarditis, arrhythmia, and beta blocker or calcium channel blocker overdose.[2] Diagnosis involves a systolic blood pressure less than 90 mmHg and a urine output of less than 30 mL/hr or cool arms and legs.[2] This occurs despite sufficient volume in the blood vessels.[4] Cardiac tamponade and pulmonary embolism are generally deemed to be causes of obstructive shock.[3]

The initial goal of treatment is to raise the blood pressure, support breathing, and reverse any underlying causes.[2] This may include intravenous fluids and vasopressors such as norepinephrine or dobutamine.[2] A central line and arterial line may be useful for giving medications and monitoring the condition.[2] If the underlying cause is a heart attack, primary percutaneous coronary intervention (PCI) is recommended.[2] Other efforts may include extracorporeal membrane oxygenation (ECMO), ventricular assist device (VAD), or heart transplant.[2] Mechanical ventilation or dialysis may also be required.[5] Palliative care may be useful in certain cases.[2]

Cardiogenic shock affects about 7% of STEMIs and 3% of NSTEMIs.[2] It is becoming less common with the greater use of primary percutaneous coronary intervention (PCI) for heart attacks.[2] Poor outcomes are common, with a 30% to 80% risk of death.[2] The condition was first described in 1912 by Herrick; however, the current name for the condition did not come into use until 1942.[4]

Video explanation of shock

## Contents

* 1 Signs and symptoms
* 2 Causes
* 3 Diagnosis
* 3.1 Electrocardiogram
* 3.2 Ultrasound
* 3.3 Swan-Ganz catheter
* 3.4 Biopsy
* 3.5 Cardiac index
* 4 Treatment
* 5 References
* 6 External links

## Signs and symptoms[edit | edit source]

* Anxiety, restlessness, altered mental state due to decreased blood flow to the brain and subsequent hypoxia.
* Low blood pressure 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 to inadequate blood flow to the kidneys if the condition persists.
* Rapid and deeper respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis.
* Fatigue due to hyperventilation and hypoxia.
* Absent pulse in fast and abnormal heart rhythms.
* Pulmonary edema, involving fluid back-up in the lungs due to insufficient pumping of the heart.

## Causes[edit | edit source]

Cardiogenic shock is caused by the failure of the heart to pump effectively. It is due to damage to the heart muscle, most often from a heart attack or myocardial contusion.[6] Other causes include abnormal heart rhythms, cardiomyopathy, heart valve problems, ventricular outflow obstruction (i.e. systolic anterior motion (SAM) in hypertrophic cardiomyopathy), or ventriculoseptal defects. It can also be caused by a sudden decompressurization (e.g. in an aircraft), where air bubbles are released into the bloodstream (Henry's law), causing heart failure.[7][8][9][10][8][11][12]

## Diagnosis[edit | edit source]

### Electrocardiogram[edit | edit source]

An electrocardiogram helps to establish the exact diagnosis and guides treatment, it may reveal:

* Abnormal heart rhythms, such as bradycardia (slowed heart rate)
* myocardial infarction (ST-elevation MI, STEMI, is usually more dangerous than non-STEMIs; MIs that affect the ventricles are usually more dangerous than those that affect the atria; those affecting the left side of the heart, especially the left ventricle, are usually more dangerous than those affecting the right side, unless that side is severely compromised)
* Signs of cardiomyopathy

### Ultrasound[edit | edit source]

Echocardiography may show poor ventricular function, signs of PED, rupture of the interventricular septum, an obstructed outflow tract or cardiomyopathy.

* Ultrasound showing cardiogenic shock due to myocarditis[1]

* Ultrasound showing cardiogenic shock due to myocarditis[1]

### Swan-Ganz catheter[edit | edit source]

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

### Biopsy[edit | edit source]

When cardiomyopathy is suspected as the cause of cardiogenic shock, a biopsy of heart muscle may be needed to make a definite diagnosis.

### Cardiac index[edit | edit source]

If the cardiac index falls acutely below 2.2 L/min/m2, the person may be in cardiogenic shock.

## Treatment[edit | edit source]

Depending on the type of cardiogenic shock, treatment involves infusion of fluids, or in shock refractory to fluids, inotropic medications. In case of an abnormal heart rhythm immediate synchronized cardioversion or anti-arrhythmic agents may be administered, e.g. adenosine.

Positive inotropic agents (such as dobutamine or milrinone), which enhance the heart's pumping capabilities, are used to improve the contractility and correct the low blood pressure. Medications that improve the heart's ability to contract (positive inotropes) may help; however, it is unclear which is best.[13] Cardiogenic shock may be treated with intravenous dobutamine, which acts on β1 receptors of the heart leading to increased contractility and heart rate.[14]

Should that not suffice an intra-aortic balloon pump (which reduces workload for the heart, and improves perfusion of the coronary arteries) or a left ventricular assist device (which augments the pump-function of the heart) can be considered. Mechanical ventilation or ECMO may be used to help stabilize people with severe or refractory cardiogenic shock until they can be given some type of definitive treatment, such as a ventricular assist device.[7][8][9] Finally, as a last resort, if the person is stable enough and otherwise qualifies, heart transplantation, or if not eligible an artificial heart, can be placed. These invasive measures are important tools—more than 50% of patients who do not die immediately due to cardiac arrest from a lethal abnormal heart rhythm and live to reach the hospital (who have usually suffered a severe acute myocardial infarction, which in itself still has a relatively high mortality rate), die within the first 24 hours. The mortality rate for those still living at time of admission who suffer complications (among others, cardiac arrest or further abnormal heart rhythms, heart failure, cardiac tamponade, a ruptured or dissecting aneurysm, or another heart attack) from cardiogenic shock is even worse around 85%, especially without drastic measures such as ventricular assist devices or transplantation.

## References[edit | edit source]

1. ↑ 1.0 1.1 1.2 "UOTW #7 - Ultrasound of the Week". Ultrasound of the Week. 30 June 2014. Archived from the original on 8 May 2017. Retrieved 27 May 2017.
2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 Kosaraju, A; Pendela, VS; Hai, O (January 2020). "Cardiogenic Shock". PMID 29489148. `{{cite journal}}`: Cite journal requires `|journal=` (help)
3. ↑ 3.0 3.1 "Shock - Critical Care Medicine". Merck Manuals Professional Edition. Archived from the original on 27 November 2020. Retrieved 31 December 2020.
4. ↑ 4.0 4.1 Hochman, Judith S.; MD, E. Magnus Ohman (2009). Cardiogenic Shock. John Wiley & Sons. p. 1\. ISBN 978-1-4443-1693-3. Archived from the original on 2021-08-28. Retrieved 2020-12-31.
5. ↑ Simko, Lynn Coletta; Culleiton, Alicia L. (July 2019). "Cardiogenic shock with resultant multiple organ dysfunction syndrome". Nursing Critical Care. 14 (4): 26–33. doi:10.1097/01.CCN.0000565132.49413.54.
6. ↑ International Trauma Life Support for Emergency Care Providers (8 ed.). Pearson Education Limited. 2018. pp. 172–173. ISBN 978-1292-17084-8.
7. ↑ 7.0 7.1 Rippe, James M.; Irwin, Richard S. (2003). Irwin and Rippe's intensive care medicine. Philadelphia: Lippincott Williams & Wilkins. ISBN 978-0-7817-3548-3. OCLC 53868338.[page needed]
8. ↑ 8.0 8.1 8.2 Marino, Paul L. (1998). The ICU book. Baltimore: Williams & Wilkins. ISBN 978-0-683-05565-8. OCLC 300112092.[page needed]
9. ↑ 9.0 9.1 Society of Critical Care Medicine. (2001). Fundamental Critical Care Support. Society of Critical Care Medicine. ISBN 978-0-936145-02-0. OCLC 48632566.[page needed]
10. ↑ Textbooks of Internal Medicine Harrison's Principles of Internal Medicine Archived 2012-08-04 at the Wayback Machine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7Cecil Textbook of Medicine Archived 2010-06-16 at the Wayback Machine by Lee Goldman, Dennis Ausiello, 22nd Edition (2003), W. B. Saunders Company, ISBN 0-7216-9652-XThe Oxford Textbook of Medicine Archived 2006-09-23 at the Wayback Machine 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
11. ↑ Cardiogenic shock Archived 2017-07-23 at the Wayback Machine Department of Anaesthesia and Intensive Care of The Chinese University of Hong Kong
12. ↑ Introduction to management of shock for junior ICU trainees and medical students Archived 2017-07-27 at the Wayback Machine Department of Anaesthesia and Intensive Care of The Chinese University of Hong Kong
13. ↑ Schumann, J; Henrich, EC; Strobl, H; Prondzinsky, R; Weiche, S; Thiele, H; Werdan, K; Frantz, S; Unverzagt, S (29 January 2018). "Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome". The Cochrane Database of Systematic Reviews. 1: CD009669. doi:10.1002/14651858.CD009669.pub3. PMC 6491099. PMID 29376560.
14. ↑ Rang and Dale's Pharmacology, H. P. Rang, M. M. Dale, J. M. Ritter, R. J. Flower, Churchhill Livingstone, Elsevier, 6th Edition[page needed]

## External links[edit | edit source]

Classification|

* ICD-10: R57.0
* ICD-9-CM: 785.51
* MeSH: D012770
* DiseasesDB: 29216

|

External resources|

* MedlinePlus: 000185
* eMedicine: med/285

* Cardiogenic Shock Archived 2006-03-15 at the Wayback Machine by eMedicine

* v
* t
* e

Shock

Distributive|

* Septic shock
* Neurogenic shock
* Anaphylactic shock
* Toxic shock syndrome

Obstructive|

* Abdominal compartment syndrome

Low volume|

* Hemorrhage
* Hypovolemia
* Osmotic shock

Other|

* Cardiogenic
* Spinal shock
* Cryptic shock
* Vasodilatory shock

* v
* t
* e

Intensive care medicine

* Health science
* Medicine
* Medical specialities
* Respiratory therapy

General terms|

* Intensive care unit (ICU)
* Neonatal intensive care unit (NICU)
* Pediatric intensive care unit (PICU)
* Coronary care unit (CCU)
* Critical illness insurance

Conditions|

| Organ system failure|

Shock sequence
SIRS
Sepsis
Severe sepsis
Septic shock
Multiple organ dysfunction syndrome

Other shock
Cardiogenic shock
Distributive shock
Anaphylaxis
Obstructive shock
Neurogenic shock
Spinal shock
Vasodilatory shock

Organ failure
Acute renal failure
Acute respiratory distress syndrome
Acute liver failure
Respiratory failure
Multiple organ dysfunction syndrome

* Neonatal infection
* Polytrauma
* Coma

|

Complications|

* Critical illness polyneuropathy / myopathy
* Critical illness–related corticosteroid insufficiency
* Decubitus ulcers
* Fungemia
* Stress hyperglycemia
* Stress ulcer

Iatrogenesis|

* Methicillin-resistant Staphylococcus aureus
* Oxygen toxicity
* Refeeding syndrome
* Ventilator-associated lung injury
* Ventilator-associated pneumonia
* Dialytrauma

Diagnosis|

* Arterial blood gas
* Catheter
* Arterial line
* Central venous catheter
* Pulmonary artery catheter
* Blood cultures
* Screening cultures

Life-supporting treatments|

* Airway management
* Chest tube
* Dialysis
* Enteral feeding
* Goal-directed therapy
* Induced coma
* Mechanical ventilation
* Therapeutic hypothermia
* Total parenteral nutrition
* Tracheal intubation

Drugs|

* Analgesics
* Antibiotics
* Antithrombotics
* Inotropes
* Intravenous fluids
* Neuromuscular-blocking drugs
* Recombinant activated protein C
* Sedatives
* Stress ulcer prevention drugs
* Vasopressors

ICU scoring systems|

* APACHE II
* Glasgow Coma Scale
* PIM2
* SAPS II
* SAPS III
* SOFA

Physiology|

* Hemodynamics
* Hypotension
* Level of consciousness
* Acid–base imbalance
* Water-electrolyte imbalance

Organisations|

* Society of Critical Care Medicine
* Surviving Sepsis Campaign
* European Society of Paediatric and Neonatal Intensive Care

Related specialties|

* Anesthesiology
* Cardiology
* Internal medicine
* Neurology
* Pediatrics
* Pulmonology
* Surgery
* Traumatology

* v
* t
* e

Signs and symptoms relating to the circulatory system

Chest pain|

* Referred pain
* Angina
* Levine's sign

Auscultation|

* Heart sounds
* Split S2
* S3
* S4
* Gallop rhythm
* Heart murmur
* Systolic
* Functional murmur
* Still's murmur
* Diastolic
* Pulmonary insufficiency
* Graham Steell murmur
* Continuous
* Carey Coombs murmur
* Mitral insufficiency
* Presystolic murmur
* Pericardial friction rub
* Heart click
* Bruit
* carotid

Pulse|

* Tachycardia
* Bradycardia
* Pulsus paradoxus
* doubled
* Pulsus bisferiens
* Pulsus bigeminus
* Pulsus alternans

Other|

* Palpitations
* Apex beat
* Cœur en sabot
* Jugular venous pressure
* Cannon A waves
* Hyperaemia

Shock|

* Cardiogenic
* Obstructive
* Hypovolemic
* Distributive
* See further Template:Shock

Cardiovascular disease|

| Aortic insufficiency|

* Collapsing pulse
* De Musset's sign
* Duroziez's sign
* Müller's sign
* Austin Flint murmur
* Mayne's sign

|

Other endocardium|

* endocarditis: Roth's spot
* Janeway lesion/Osler's node
* Bracht–Wachter bodies

Pericardium|

* Cardiac tamponade/Pericardial effusion: Beck's triad
* Ewart's sign

Other|

* rheumatic fever:
* Anitschkow cell
* Aschoff body
* EKG
* J wave
* Gallavardin phenomenon

Vascular disease|

| Arterial|

* aortic aneurysm
* Cardarelli's sign
* Oliver's sign
* pulmonary embolism
* Right heart strain
* radial artery sufficiency
* Allen's test
* pseudohypertension
* thrombus
* Lines of Zahn
* Adson's sign
* arteriovenous fistula
* Nicoladoni sign

|

Venous|

* Friedreich's sign
* Caput medusae
* Kussmaul's sign
* Trendelenburg test
* superior vena cava syndrome
* Pemberton's sign

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