Cardiogenic Shock

Case Presentation
Mrs. Settles, a 50-year-old woman, came to the emergency department at 6:30AM with
a 2-hour history of crushing substernal chest pain radiating to the jaw, back, and subxiphoid
area. She was mildly diaphoretic and slightly short of breath, and she complained of nausea.
Her lungs had bibasilar crackles on auscultation. Heart sounds revealed the presence of a S3
heart sound without murmurs. The initial chest x-ray film showed no abnormalities. Her initial
vital signs were as follows:

BP 156/98 mm Hg Respirations 30 breaths/min

HR 124 bpm Temperature 37° C (98.6° F)

Mrs. Settles had a history of stable angina for an undetermined period. However, she
revealed that for the past 3 weeks, she has experienced substernal pain radiating to the back

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every hour. Chest pain was relieved with sublingual nitroglycerin (NTG). There was a family
history of a brother dying from a myocardial infarction (MI) and a sister with a history of three

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MIs. Mrs. Settles has a 30-year history of cigarette smoking and continues to smoke one pack
of cigarettes a day. She has been taking the following medications:

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 Aspirin 81 mg po qd
 Propranolol hydrochloride (Inderal LA) 80 mg po qd
 Isosorbide mononitrate (Imdur SR) 30 mg po qd
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 Lisinopril (Zestril) 10 mg po qd
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Upon arrival at the emergency department, intravenous (IV) NTG 50 mg in 250 ml of

dextrose
5% in water (D5W) was started and titrated to Mrs. Settles’s pain level and blood pressure. Mrs.
Settles was also given morphine sulfate 2 mg via slow IV push, and oxygen at 6 L through a
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nasal cannula was started. The initial 12-lead electrocardiogram (ECG) revealed early Q waves
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and massive ST-segment elevation in leads V1 through V 4 . Initial baseline laboratory data
results were as follows:
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WBCs 13.9 mm3 Myoglobin 120 ng/L

Glucose 117 mg/dl K* 4 mmol/L
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Hgb 14 g/dl Troponin T 0.0 µg/L

BUN 6 mmol/L CI 103 mmol/L
Hct 41.8% CK-MB 1.8%
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Creatinine 0.9 mg/dl CO2 24 mmol/L

Na* 141 mmol/L Troponin I 0.0 µg/L

Mrs. Settles was assessed and confirmed to be a candidate for thrombolytic therapy. A
tissue plasminogen activator (tPA) bolus and infusion were given, and a weight-based heparin

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 drip of 25,000 U/250 ml of D5W was started at 1200 U/hr. She was then transferred to the
cardiac intensive care unit (CICU) at 8:30AM.
Once the tPA infusion was complete, Mrs. Settles experienced pain relief and occasional
premature ventricular contractions (PVCs). An echocardiogram revealed dyskinesia with the
entire septum, apex, and anterior wall. The ejection fraction (EF) was 20%.
At 12:30PM (4 hours later), enzyme and arterial blood gas levels were determined:

Myoglobin 150 ng/L PCO2 52.1 mm Hg

pH 7.261 Troponin I 5.2 µg/L
Na* 141 mmol/L HCO3 22.4 mmol/L

Mrs. Settles was then given 60% oxygen via face mask, and her vital sign were as
follows:

BP 140/100 mm Hg

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HR 130 bpm

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Respirations 34 breaths/min

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Day 1

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The next morning Mrs. Settles continued to complain of shortness of breath and
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restlessness with level 2 chest pain. Rales were auscultated throughout all lung fields. A chest
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x-ray film revealed increasing congestive heart failure (CHF) with pulmonary edema. Vital signs
were as follows:
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BP 100/60 mm Hg Respirations 36 breaths/min

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HR 128 bpm Urine Output 20 ml/hr for past 2 hr

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Mrs. Settles was given dopamine (Intropin) at 5µg/kg/min and dobutamine (Dobutrex) at
5µ/kg/min. She was also given 40 mg of furosemide (Lasix) intravenously. The NTG drip was
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continued at the same rate as that when she was admitted to the CICU. Morning enzyme levels
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were as follows:

Myoglobin 63 ng/L Troponin I 5.0 µg/L

CK-MB 24% Troponin T 0.2 µg/L
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A morning 12-lead ECG revealed resolution of the ST-segment elevation but

development of a new left bundle branch block (LBBB). Mrs. Settles was given another 40 mg of
furosemide intravenously. The dopamine drip was continued with the order to titrate to maintain
systolic blood pressure of 100 mm Hg, and the dobutamine drip was continued at 5 µg/kg/min.
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Because Mrs. Settles continued to complain of chest pain despite the NTG drip, placement of
an intraaortic balloon pump catheter (IABP) and a pulmonary artery catheter was done in the
catheterization laboratory.
After her return to the CICU, Mrs. Settles’s vital signs and hemodynamic values were as
follows:

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 BP 90/60 mm Hg CO 2.5 L/min
PCWP 22 mm Hg Respirations 30 breaths/min
SVR 1800 dynes/sec/cm CI 1.5 L/min/m2
HR 130 bpm

The IABP was timed at 1 to 1. Mrs. Settles continued to receive dopamine 6 µg/kg/min
(to maintain blood pressure) and dobutamine 5 µg/kg/min. The NTG drip was decreased to 1
µg/kg/min to reduce afterload. The urine output had increased to 150 ml/hr, and the patient was
breathing easier and was less restless and more alert.

Day 2
The morning of the second day of her hospital stay, Mrs. Settles’s vital signs and
hemodynamic values were as follows:

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BP 100/60 mm Hg CO 3 L/min

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PCWP 18 mm Hg Respirations 28 breaths/min

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SVR 1420 dynes/sec/cm CI 2 L/min/m2

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HR 110 bpm

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Her cardiac enzyme levels continued to return to normal, and the transient LBBB was
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gone. Urine output was 100 ml/hr, and the drips remained unchanged.

Day 3
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The morning of the third day, Mrs. Settles was free of pain and had unlabored
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respirations. Oxygen was decreased to 4 L/min through a nasal cannula. Vital signs and
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hemodynamic values were as follows:

BP 100/60 mm Hg CO 4 L/min
PCWP 14 mm Hg Respiration 24 breaths/min
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SVR 1250 dynes/sec/cm CI 2.1 L/min/m2

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HR 110 bpm

The IABP settings were reduced to 2 to 1. The dopamine drip was decreased to 3
µg/kg/min, the dobutamine drip was reduced to 2 µg/kg/min, and the NTG drip was
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discontinued.
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Day 5
By the morning of the fifth day, the vasoactive drips and the IABP were discontinued.
Hemodynamic values were within normal range for Mrs. Settles, and her vital signs were as
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follows:

BP 110/60 mm Hg
HP 83 bpm
Respirations 22 breaths/min

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 Mrs. Settles was scheduled for an afternoon cardiac catheterization for follow-up after
thrombolysis and her brief episode of cardiogenic shock.

Cardiogenic Shock Questions

1. What is the clinical presentation of a patient having an acute myocardial infarction (AMI)?
Identify Mrs. Settles’s clinical presentation to the emergency department.

2. How is a diagnosis of AMI determined? Identify the results for Mrs. Settles that confirmed the
diagnosis of AMI.

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3. What are the treatment goals for a patient with an AMI?

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4. Discuss the role of thrombolytic therapy in a patient with an AMI. Include indications and
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contraindications for use of thrombolytics.

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5. Discuss the role nitrates, β-blockers, and angiotensin-converting enzyme (ACE) inhibitors in
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the patient with an AMI.

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6. What complication are commonly seen after an MI? What are the most common
complications seen with an anterior wall MI?
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7. What significant 12-lead ECG changes are sometimes seen following an anterior wall AMI?
What 12-lead ECG changes occurred with Mrs. Settles?

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 8. Define cardiogenic shock and why it occurs after an anterior wall MI. What is the prognosis
for the patient with cardiogenic shock?

9. What are the hemodynamic parameters seen in the patient with cardiogenic shock in
comparison with normal hemodynamic parameters?

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10. Discuss the goals of pharmacologic management in cardiogentic shock. Which medication

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were used for Mrs. Settles?

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11. What types of mechanical support devices can be used for patients in cardiogenic shock
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and why? Which type was used for Mrs. Settles? Identify any specific nursing responsibilities for
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the device chosen for Mrs. Settles.

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12. What are the nursing diagnoses for the patient in cardiogenic shock after an anterior AMI?
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