Cardiogenic shock: Difference between revisions
Ostermayer (talk | contribs) |
Ostermayer (talk | contribs) |
||
| Line 68: | Line 68: | ||
{| class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
! | ! Pressor!! Initial Dose !! Max Dose !! Cardiac Effect !! BP Effect !! Arrhythmias !! Special Notes | ||
|- | |- | ||
| | | Dobutamine || 2.5mcg/kg/min || 10-40 mcg/kg/min || mainly inotrope (ß1) || alpha effect minimal || Some HR(ß1) increase. Also Increase SA and AV node fx || Debut Research 1979<ref>Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine</ref> Isoproterenol has most Β2 vasodilatory and Β1 HR effects | ||
|- | |- | ||
| | | Dopamine || 2mcg/kg/min || 20-50 mcg/kg/min || β1 and NorEpi release || α effects if > 20mcg/kg/min || Arrhythmogenic from β1 effects || More adverse events when used in shock compared to Norepi<ref name="soap2">De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789</ref> | ||
|- | |- | ||
| | | Norepinephrine || 8-12mcg/min || 30 mcg/min || β1 direct effect || β1 and α1,2 effects || Less arrhythmias than Dopamine|| Increases MAP, coronary perfusion pressure, little β2 effects. | ||
|- | |- | ||
| Example || Example || Example || Example || Example || Example || Example | | Example || Example || Example || Example || Example || Example || Example | ||
Revision as of 03:38, 8 November 2013
Background
- Leading cause of death in pts w/ MI who reach the hospital alive
Work-Up
- Labs
- Troponin
- Lactate
- CBC
- Chem
- BNP
- <100 may rule-out cardiogenic shock
- ECG
- CXR
- TTE
Etiology
- 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
- AS
- HOCM
- Mitral stenosis
- Pericardial
- LV regurgitation
- Chordal rupture
- Aortic insufficiency
DDX
- MI
- PE
- COPD exacerbation
- Peri/myocarditis
- Aortic dissection
- Pericardial tamponade
- Acute valvular insufficiency
- Sepsis
- Hemorrhage
- Toxins/drugs of abuse
Treatment
- General
- Intubation
- Decreases O2 demand BUT may worsen preload
- Intubation
- Coronary perfusion
- Small Fluid challenge
- Increase inotropy
- Titrate to CO (e.g. warm extremities)
- Dobutamine or Milrinone - if
- Use milrinone if pt is on BB
- CaCl 1gm
- Give if pt is hypocalcemic
- Achieve MAP >65
Pressors
| Pressor | Initial Dose | Max Dose | Cardiac Effect | BP Effect | Arrhythmias | Special Notes |
|---|---|---|---|---|---|---|
| Dobutamine | 2.5mcg/kg/min | 10-40 mcg/kg/min | mainly inotrope (ß1) | alpha effect minimal | Some HR(ß1) increase. Also Increase SA and AV node fx | Debut Research 1979[1] Isoproterenol has most Β2 vasodilatory and Β1 HR effects |
| Dopamine | 2mcg/kg/min | 20-50 mcg/kg/min | β1 and NorEpi release | α effects if > 20mcg/kg/min | Arrhythmogenic from β1 effects | More adverse events when used in shock compared to Norepi[2] |
| Norepinephrine | 8-12mcg/min | 30 mcg/min | β1 direct effect | β1 and α1,2 effects | Less arrhythmias than Dopamine | Increases MAP, coronary perfusion pressure, little β2 effects. |
| Example | Example | Example | Example | Example | Example | Example |
| Example | Example | Example | Example | Example | Example | Example |
| Example | Example | Example | Example | Example | Example | Example |
- Transfusion
- Consider if Hb < 10
- Specific
- Mitral Regurg
- Need to increase forward flow
- Dobutamine (contractility)
- Nitroprusside (afterload reduction)
- Need to increase forward flow
- MI
- PCI or thrombolysis
- Tox
- Reverse CCB, BB, or dig toxicity
- Mitral Regurg
See Also
Source
Tintinalli EMCrit Podcast 10