CARDIOGENIC SHOCK (Clinical Manifestations, Assessment and Diagnostic Findings, Medical Management and Drug Treatment)

Clinical Manifestations

Cardiogenic shock produces symptoms of poor tissue perfusion.

• Clammy skin. The patient experiences cool, clammy skin as the blood could not circulate properly to the peripheries.
• Decreased systolic blood pressure. The systolic blood pressure decreases to 30 mmHg below baseline.
• Tachycardia. Tachycardia occurs because the heart pumps faster than normal to compensate for the decreased output all over the body.
• Rapid respirations. The patient experiences rapid, shallow respirations because there is not enough oxygen circulating in the body.
• Oliguria. An output of less than 20ml/hour is indicative of oliguria.
• Mental confusion. Insufficient oxygenated blood in the brain could gradually cause mental confusion and obtundation.
• Cyanosis. Cyanosis occurs because there is insufficient oxygenated blood that is being distributed to all body systems.

Assessment and Diagnostic Findings

Diagnosis of cardiogenic shock may include the following diagnostic tests:

• Auscultation. Auscultation may detect gallop rhythm, faint heart sounds and, possibly, if the shock results from rupture of the ventricular septum or papillary muscles, a holosystolic murmur.
• Pulmonary artery pressure (PAP). PAP monitoring may show increase in PAP, reflecting a rise in left ventricular end-diastolic pressure and increased resistance to the afterload.
• Arterial pressure monitoring. Invasive arterial pressure monitoring may indicate hypotension due to impaired ventricular ejection.
• ABG analysis. Arterial blood gas analysis may show metabolic acidosis and hypoxia.
• Electrocardiography. Electrocardiography may show possible evidence of acute MI, ischemia, or ventricular aneurysm.
• Echocardiography. Echocardiography can determine left ventricular function and reveal valvular abnormalities.
• Enzyme levels. Enzyme levels such as lactic dehydrogenase, creatine kinase. Aspartate aminotransferase and alanine aminotransferase may confirm MI.

Medical Management

The aim of treatment is to enhance cardiovascular status by:

• Oxygen. Oxygen is prescribed to minimize damage to muscles and organs.
• Angioplasty and stenting. A catheter is inserted into the blocked artery to open it up.
• Balloon pump. A balloon pump is inserted into the aorta to help blood flow and reduce workload of the heart.
• Pain control. In a patient that experiences chest pain, IV morphine is administered for pain relief.
• Hemodynamic monitoring. An arterial line is inserted to enable accurate and continuous monitoring of BP and provides a port from which to obtain frequent arterial blood samples.
• Fluid therapy. Administration of fluids must be monitored closely to detect signs of fluid overload.

Drug Treatment

Drug used may include:

• IV dopamine. Dopamine, a vasopressor, increases cardiac output, blood pressure, and renal blood flow.
• IV dobutamine. Dobutamine is an inotropic agent that increase myocardial contractility.
• Norepinephrine. Norepinephrine is a more potent vasoconstrictor that is taken when necessary.
• IV nitroprusside. Nitroprusside is a vasodilator that may be used with a vasopressor to further improve cardiac output by decreasing peripheral vascular resistance and reducing preload.

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