Cardiogenic Shock

Definition

• Shock is a syndrome characterized by decreased tissue perfusion and impaired

cellular metabolism. This result in an imbalance between the supply of and
demand for O2 and nutrients.

• Cardiogenic shock is an inadequate circulation of blood due to primary failure

of the ventricles of the heart to function effectively.

• Systolic or diastolic dysfunction of the pumping action of the heart results in

compromised cardiac output. The heart inability to pump the blood forward is
classified as systolic dysfunction and diastolic dysfunction.
Statistics and Incidences
Cardiogenic shock could be fatal if left untreated.

• Cardiogenic shock occurs as a serious complication in 5% to 10% of patients

hospitalized with acute myocardial infarction.

• Historically, mortality for cardiogenic shock had been 80% to 90%, but recent
studies indicate that the rate has dropped to 56% to 67% due to the advent of
thrombolytics, improved interventional procedures, and better therapies.

• Incidence of cardiogenic shock is more common in men than in women because of

their higher incidence of coronary artery disease.
Precipitating factors of shock

• Systolic dysfunction; inability of the heart to pump blood forward. E.g; MI

and cardiomyopathy.

• Diastolic dysfunction: inability of the heart to fill during diastole. E.g:

pericardial temponade.

• Dysarhythmias: bradydysrhythmias, tachyrhythmias.

• Structural factors: valvular abnormalities ( stenosis or regurgitation),

ventricular septal rupture, tension pneumothorax.
Causes
Cardiogenic shock can result from any condition that causes significant left ventricular
dysfunction with reduced cardiac output.

• Myocardial infarction (MI).Regardless of the underlying cause, left ventricular dysfunction

sets in motion a series of compensatory mechanisms that attempt to increase cardiac output,
but later on leads to deterioration.

• Myocardial ischemia. Compensatory mechanisms may initially stabilize the patient but later
on would cause deterioration with the rising demands of oxygen of the already compromised
myocardium.

• End-stage cardiomyopathy.The inability of the heart to pump enough blood for the systems
causes cardiogenic shock.
 Pathophysiology
This is what happens in cardiogenic shock:
• Inability to contract. When the myocardium can’t contract sufficiently to maintain adequate
cardiac output, stroke volume decreases and the heart can’t eject an adequate volume of blood
with each contraction.
• Pulmonary congestion. The blood backs up behind the weakened left ventricle, increasing
preload and causing pulmonary congestion.
• Compensation. In addition, to compensate for the drop in stroke volume, the heart rate
increases in an attempt to maintain cardiac output.
• Diminished stroke volume. As a result of the diminished stroke volume, coronary artery
perfusion and collateral blood flow is decreased.
• Increased workload. All of these mechanisms increase the heart’s workload and enhance left-
sided heart failure.
• End result. The result is myocardial hypoxia, further decreased cardiac output, and a triggering
of compensatory mechanisms to prevent decompensation and death.
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.
Classification

The causes of cardiogenic shock are known as either coronary or non-coronary.

• Coronary. Coronary cardiogenic shock is more common than noncoronary

cardiogenic shock and is seen most often in patients with acute myocardial
infarction.

• Noncoronary. Noncoronary cardiogenic shock is related to conditions that

stress the myocardium as well as conditions that result in an ineffective
myocardial function.
Stages of the shock:
• Compensatory stage – the body activates neural, hormonal and biochemical
compensatory mechanisms in an attempt to overcome the
increasingconsequences of anaerobic metabolism and to maintain
homeostasis.
• Progressive stage – continued decreased cellular perfusion and resulting
altered capillary permeability are the distinguishing features of this stage.
• Refractory stage – decreased perfusion from perioheral vasoconstriction and
decreased CO exacerbate anaerobic metabolism.
 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.
Pharmacologic Therapy
Drug therapy 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.
Surgical Management

When the drug therapy and medical procedures don’t work, then the last option
is for surgical procedure.

• Intra-aortic balloon pump (IABP).The IABP is a mechanical-assist device

that attempts to improve the coronary artery perfusion and decrease cardiac
workload through an inflatable balloon pump which is percutaneously or
surgically inserted through the femoral artery into the descending thoracic
aorta.
Nursing Management

Cardiogenic shock needs rapid, accurate nursing management.

Nursing Assessment

• The nurse should assess the following:

• Vital signs. Assess the patient’s vital signs, especially the blood
pressure.

• Fluid overload. The ventricles of the heart cannot fully eject the
volume of blood at systole, so fluid may accumulate in the lungs.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:
• Decreased cardiac output related to changes in myocardial contractility/inotropic
changes
• Impaired gas exchange related to changes in alveolar-capillary membrane.
• Excess fluid volume related to a decrease in renal organ perfusion,
increased sodium and water, hydrostatic pressure increase, or decrease plasma
protein.
• Ineffective tissue perfusion related to reduction/cessation of blood flow.
• Acute pain related to ischemic tissues secondary to blockage or narrowing of
coronary arteries.
• Activity intolerance related to imbalance between the oxygen supply and needs.
Nursing care planning & Goals

The major goals for the patient are:

• Prevent recurrence of cardiogenic shock.

• Monitor hemodynamic status.

• Administer medications and intravenous fluids.

• Maintain intra-aortic balloon counterpulsation.

Nursing Interventions
The appropriate nursing interventions for a patient with cardiogenic shock includes:
• Prevent recurrence. Identifying at-risk patients early, promoting adequate
oxygenation of the heart muscle, and decreasing cardiac workload can prevent
cardiogenic shock.
• Hemodynamic status. Arterial lines and ECG monitoring equipment must be
well maintained and functioning; changes in hemodynamic, cardiac, and
pulmonary status and laboratory values are documented and reported; and
adventitious breath sounds, changes in cardiac rhythm, and other abnormal
physical assessment findings are reported immediately.
• Fluids. IV infusions must be observed closely because tissue necrosis and
sloughing may occur if vasopressor medications infiltrate the tissues, and it is also
necessary to monitor the intake and output.
Contd.
• Intra-aortic balloon counterpulsation. The nurse makes ongoing timing
adjustments of the balloon pump to maximize its effectiveness by synchronizing it
with the cardiac cycle.
• Enhance safety and comfort. Administering of medication to relieve chest pain,
preventing infection at the multiple arterial and venous line insertion sites, protecting
the skin, and monitoring respiratory and renal functions help in safeguarding and
enhancing the comfort of the patient.
• Arterial blood gas.Monitor ABG values to measure oxygenation and detect acidosis
from poor tissue perfusion.
• Positioning. If the patient is on the IABP, reposition him often and perform passive
range of motion exercises to prevent skin breakdown, but don’t flex the patient’s
“ballooned” leg at the hip because this may displace or fracture the catheter.
Evaluation

Expected outcomes include:

• Prevented recurrence of cardiogenic shock.

• Monitored hemodynamic status.

• Administered medications and intravenous fluids.

• Maintained intra-aortic balloon counterpulsation.

Discharge and Home Care Guidelines

• Lifestyle changes must be made to avoid the recurrence of cardiogenic shock.

• Control hypertension. Exercise, manage stress, maintain a healthy weight,
and limit salt and alcohol intake.
• Avoid smoking. The risk of stroke is the same for smokers and nonsmokers
years after you stop smoking
• Maintain a healthy weight. Losing those extra pounds would be helpful in
lowering the cholesterol and blood pressure.
• Diet. Eat less saturated fat and cholesterol to reduce heart disease.
• Exercise. Exercise daily to lower blood pressure, increase high-density
lipoproteins, and improve the overall health of the blood vessels and the heart.