View source for Cardiogenic shock

==Background==
*Leading cause of death in patients with [[ACS]] who reach the hospital alive

===Etiologies===
*[[Myocardial infarction]]
**Pump failure
**Mechanical complications
**Acute MR (papillary muscle rupture)
**VSD
**Free-wall rupture
*RV infarction
*Decreased forward flow
**[[Sepsis]]
**Rate-related
***Bradycardia
***Tachycardia
**[[Myocarditis]]
**[[Myocardial contusion]]
**Cardiomyopathy
*Mechanical obstruction to forward flow
**[[Aortic stenosis]]
**[[HOCM]]
**[[Mitral stenosis]]
**Pericardial 
*LV regurgitation
**Chordal rupture
**Aortic insufficiency

==Clinical Features==
===Physical Exam===
*Assess for signs of [[CHF]]
**elevated JVD, pulmonary edema, S3
*Assess for [[valvular disease]] ([[mitral regurgitation]], critical [[aortic stenosis]], or [[aortic regurgitation]])
*Assess for end-organ hypoperfusion
**cool/mottled extremities, weak pulses, [[altered mental status]], decreased UOP
*Assess for [[pulsus paradoxus]] ([[cardiac tamponade]])

==Differential Diagnosis==
{{Shock DDX}}

==Evaluation==
===Workup===
*Labs
**[[Troponin]]
**Lactate
**CBC
**Chem
**[[BNP]]
*[[ECG]]
*[[CXR]]
*TTE

{{BNP value}}

==Management==
===General===
''Aim for MAP >65''
#Consider etiologies (see above) and treat specific one, if present
#Consider small fluid challenge (250-500cc normal saline IV) or fluid removal, depending on estimation of patient's point on Starling curve
#Increase inotropy 
#*[[Dobutamine]] +/- [[levophed]] OR [[dopamine]]
#**[[Dobutamine]] may initially drop pressures, so may need to use second agent to maintain BP
#**Consider [[milrinone]] or [[beta-blocker toxicity|beta-blocker reversal]] if patient is on a [[beta-blocker]]
#*Consider [[calcium chloride]] 1 g if hypocalcemic or normocalcemic through good PIV or central line
#Consider [[transfusion]] if hemoglobin < 10 (be aware of added fluid)
#Consider [[intubation]]
#*Decreases O2 demand BUT may worsen preload

===Specific Situations===
====[[Mitral Regurgitation]]====
''Increase forward flow''
*[[Dobutamine]] (contractility) + [[nitroprusside]] (afterload reduction)

====[[ACS]]====
*PCI or [[thrombolysis]]

====[[Aortic stenosis]]====
''Decrease afterload (with extreme caution in very small, carefully-titrated doses)''
*Agents:
**[[Nitroprusside]]
**[[Dobutamine]]
**[[Hydralazine]]
*Do not give preload reducers such as [[nitro]]
*Patients are flow dependent over stenotic value.  Flow proportional to degree of stenosis and afterload.

====[[Toxins]]====
*[[Beta-Blocker Toxicity]]
*[[Calcium Channel Blocker Toxicity|Calcium Channel Blocker]]
*[[Digoxin Toxicity | Digoxin]]

{{Vasopressor table}}

==Disposition==
*Admission, frequently to intensive or higher-level of care

==See Also==
*[[Shock]]
*[[Ultrasound in Shock and Hypotension]]

==External Links==
*[http://emcrit.org/podcasts/cardiogenic-shock/ EMCrit Podcast – Cardiogenic Shock]

==Video==
{{#widget:YouTube|id=GTZ8Zh8jPxA}}

==References==
<references />

[[Category:Cardiology]]
[[Category:Critical Care]]