Cardiogenic Shock Complicating Acute Myocardial

Infarction :
Review on Hemodynamic Monitoring and Support
FIKRI
Supervisor : Dr. Daniel P.L. Tobing Sp.JP (K)

DIVISION OF INTENSIVE CARE AND CARDIOVASCULAR EMERGENCY

DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE
FACULTY OF MEDICINE UNIVERSITAS INDONESIA
OUTLINE

INTRODUCTION

CASE ILLUSTRATION

DISCUSSION

SUMMARY
 INTRODUCTION
• CS following AMI : 3-13%
• CS = most leading cause of death in AMI (40-50%)
• Incidence in US : 40.000-50.000/year, Europe : 60.000-70.000/year
• Despite recent advances in revascularization, mortality is still high
• Lack of schema or algorithm of management based of severity
• Review the management of CS following AMI
OUTLINE

INTRODUCTION

CASE ILLUSTRATION

DISCUSSION

SUMMARY
CASE ILLUSTRATION
• 31 year old male came to NCCHK ED with chief
complaint of SOB and typical chest pain 7 hours prior
• Prior history : active smoker and type 2 diabetes
mellitus
 PHYSICAL EXAMINATION
Compos mentis Conjungtiva anemis -/-,
BP: 103/59 mmHg; HR 112x/min, Sclera icteric -/-
regular; RR: 38 x/min, peripheral oxygen
saturation 75% (on nasal canule)

Cor : S1S2 normal,

murmur (-), gallop (-)
Pulmo : rales ++/++, no
wheezing

Extremity examination
were warm, and there was
no edema
ECG

sinus tachycardia 118x per minute, right axis deviation, normal p wave, interval PR 0,16
sec, duration of QRS 0,09 sec, pathological Q wave in V2-V3, ST elevation on V2-V5
 WORKING DIAGNOSIS

STEMI ANTERIOR ONSET 7 HOURS KILLIP 3 TIMI 6/14

 TREATMENT IN ED
• Semi Fowler Position
• NRM 15 LPM
• NTG drip start 10mcg/min
• Furosemide 40mg IV
CXR

CTR 56%, dilated aortic segment, normal pulmonary

segment, Cardiac waist was convex, downward apex, there
was congestion and infiltrate
 LABORATORIUM & ECHOCARDIOGRAPHY
HB 13, HT : 40, Leu : 15.910, Trom : 235.000,
Ur : 29,6 , Cr : 1,4 , GFR 59 , NT-pro BNP :
1932 , hsTropT : 102, Na 132 K 4.0, Blood
sugar 238
Blood gas analysis pH 7.41 , pCO2 36,4, pO2
43 , HCO3 23 BE – 0,6 SpO2 78% Laktat 2,8
LABORATORIUM
Leu : 15.910, Ur : 29,6 , Cr : 1,4 , GFR 59 ,
NT-pro BNP : 1932 , hsTropT : 102 Blood
sugar 238
EDD 41mm, ESD 31mm, EF 35%, TAPSE 1.8cm,
RWMA of akinetic of apical segment,
hypokinetic of basal-mid anteroseptal. LVOT
VTI 9, IVC 21/16, SV 28.26, CO 3.1 L, SVR 1703,
PCWP 17. There was no pericardial or pleural
effusion.
• BEDSIDE ECHO
EF 35%, TAPSE 1.8cm, RWMA(+). LVOT VTI 9, IVC
21/16, SV 28.26, CO 3.1 L, SVR 1703, PCWP 17.
 DIAGNOSIS
STEMI ANTERIOR ONSET 7 HOURS KILLIP 3 TIMI 6/14

TYPE 2 DIABETES MELLITUS

COMMUNITY ACQUIRED PNEUMONIA

 After 60 minutes observation in ED
• Symptoms subsided
• BP 98/63
• HR 101 bpm
• RR 24x/min
• SaO2 98%
• Rales was reduced to minimally in basal bilaterally

Improved acute lung oedema Primary PCI

 Corangiography
• LAD : 80% stenosis in mid,
• LCX : diffuse stenosis in proximal-distal with subtotal
occlusion in distal OM1
• RCA : diffuse lesion in mid-distal with maximal stenosis of
90% in mid and 80% in distal

PCI to LAD
 Events during PCI
BP dropped to 65/40, HR
Increasing SOB, 40bpm Rhythm changed
Wire crossing agitate, RR • Fluid challenge to junctional then
LAD 40x/min • SA 2 ampules
• Norepinephrine 0,02
PEA
• Intubation mcg/kg/min • CPR for 5 minutes, sodium
• Dobutamin 3 mcg/kg/min bicarbonate 50 mEq IV

ROSC Predilatation 12 atm Electrical Rhythm back to

with 2,5x20 SC cardioversion 100 J
• Put patient on ballon • Rhythm back to sinus
VT
ventilator • Second predilatation • Second 100 J
• BP dropped to 58/30 +
• Continue PCI ventricular tachycardia cardioversion

Asystole Successful Patient

implantation of DES
• CPR 15 minutes + ROSC in mid LAD with TIMI admitted to
3 ampules flow 2 CVCU
epinephrine
 FOLLOW UP
Day 1
BRAIN COOLING
HR 125x/m, BP 81/45 (52),
RR 14 on
dobu 7mcg, SO2 88%.
LVOT VTI 10,2 cm, TAPSE
1,7 cm, EF 25%
(Simpson), IVC 24/21. SV 32/
CO 4,0 / SVR 800. B line (++)
AGDA jam 15.28: pH 7,41 /
pCO2 44,6 / pO2 53,1 /
HCO3 23,3 / BE -3,3 / SO2
87% / GDS 292 / Laktat 6,5
Dobutamin 7mcg/kg/min
Vascon 0.01mcg/kg/min
Day 2 Day 3
BP 104/66 (72) HR 99
BP 103/75 (81) HR 107
on dobutamine I : 2499 O1650 BC
7mcg/kg/mnt +849cc/25 jam
Intake : 2510 Output (on lasix drip 5 mg/jam) -->
2150 BC +360 UO 1,01 cc/kg/jam
AGDA : pH 7.5 pO2 111 AGD
pCO2 30 HCO3 24 pH 7,43 // pCO2 42,1 // pO2
BE 2.2 SpO2 99.1%,
90 // HCO3 28 // BE 4,0 //
Laktat 2.3
SpO2 97,4 // GDS 225 //
laktat 2,6 //
Echo : on dobu 7mcg, EF
Echo hemodinamik : on dobu
30%, LVOT 8 mcg, MAP 72 HR
VTI 9.7 IVC 19/17 SV
125x/min // EF 35%, TAPSE
30.4 CO 3.1 SVR 1548
1,9 cm // LVOT
VTI 10,6 IVC 23/20 // SV
Dobutamin 8mcg/kg/min 33,2 CO 4,1 SVR 1112
Vascon stop
Lasix drip 5mg/Hr Dobutamin 8mcg/kg/min
Initiated captopryl 3x6.25mg
Day 4
TD 96/64 (70) HR 112 on
support
dobutamine 8 mcg/kg/mnt
Intake : 3010 Output 3200 BC -
190cc/24 jam
(on lasix drip 5 mg/jam) --> UO
1,9
cc/kg/jam
AGD
pH 7,47 // pCO2 41,3 // pO2
125,6 // HCO3 30.3 // BE 6,6 //
SpO2 99,1 //
Asam laktat 1,6
Echo hemodinamik : // EF 35%,
TAPSE 1,9 cm // LVOT
VTI 13 IVC 23/20 // SV
40.82 CO 4,5 SVR 1102
Dobutamine 7mcg/kg/min
Captopryl 3x12.5mg
18
Patient plan to disch
Day 5
TD 97/63 (70) HR 122 on
support
dobutamine 5 mcg/kg/mnt
Intake : 2292 Output 3300 BC
-1008cc/24 jam
(on lasix drip 5 mg/jam) -->
UO 2.0
cc/kg/jam
AGD
pH 7,5 // pCO2 44,7 // pO2
107,4 // HCO3 34.9 // BE
11,1 // SpO2 98,8 // GDS
168 //Asam laktat 1,2
Echo hemodinamik : EF 36%,
TAPSE 1,9 cm // LVOT
VTI 13 Variasi VTI < 10% IVC
19/17 // SV
40.82 CO 4,8 SVR 1033
Dobutamine 5mcg/kg/min
Lasix 3x20mg
Captopryl 3x25mg
 Day 6 Day 7

Follow Up EXTUBATION

TD 97/63 (70) HR 122 on support

Dobutamin 5 mcg/kg/min
Intake : 2044 Output 2050 BC -
6cc/24 jam CM TD 122/53(71) HR
(on lasix 3x20mg IV) --> UO 1.2 110 on
cc/kg/jam support
AGD dobutamine 5 mcg/kg/mnt
Hb 12,2 // Ht 37 // pH 7,49 // RR 23 kali/menit
pCO2 42.6 // pO2 Saturasi 100%
132,1 // HCO3 32.6 // BE 8,9 //
SpO2 99,3 // GDS
167 //Asam laktat 1,0 // Na 133 // Echo hemodinamik : EF
K 4,4 // Ca 42% IVC 20/18 VTI 17 SV
2,5 53.38 CO
5.8 SVR 868.96
Echo hemodinamik : on dobu 5
mcg, MAP 70 HR AGDA : (pH 7.5 pO2 154
118x/min // EF 36%, TAPSE 1,9 pCO2 35.5 HCO3
cm // LVOT
VTI 13.3 Variasi VTI < 10% IVC 31.1 BE 8.9 laktat 1.7
20/18 // SV saturasi 97.2%
41.76 CO 4,8 SVR 983 dyne
sec.cm-5
Dobutamine 3mcg/kg/min
Dobutamin 5mcg/kg/min
Dobutamine
45
Brain cooling
40 40.82 40.82

35 35 35 36
32.6 33.2
30 30 30
29.2
25
23 23
20 20 20 20 19
18 18 17
15 15
13 13
10 10.3 10.6
9.3
5 4.4 4.1 4.5 4.8
2.7
0
1 2 3 4 5

EF LVOT VTI IVC IVC2 SV CO

Dobutamine
On dobutamine 10 Dobutamine Dobutamine Dobutamine
downtitrated to 8
mcg/kg/min and uptitrated to 8 downtitrated downtitrated
mcg/kg/min,
norepinephrine0,01 mcg/kg/min to 7 to 5
norepinephrine
mcg/kg Initiated ACE I mcg/kg/min mcg/kg/min
stop
CVCU Follow Up (blood gas analysis)
Laktat

2.6
2.3
2

1.6

1.2
Brain cooling

1 2 3 4 5

On dobutamine Dobutamine Dobutamine Dobutamine Dobutamine

7 mcg/kg/min downtitrated to uptitrated to 8 downtitrated downtitrated
and 8 mcg/kg/min, mcg/kg/min to 7 to 5
norepinephrine norepinephrine Initiated ACE I mcg/kg/min mcg/kg/min
0,01 mcg/kg stop
OUTLINE

INTRODUCTION

CASE ILLUSTRATION

DISCUSSION

SUMMARY
Cardiogenic Shock Definition

In this patient : hypotension + no response on

fluid challenge + signs of decressed cardiac
output + clinical hypoperfusion
Cardiogenic Shock Classification

Hypotension + hypoperfusion but

responded to the treatment = type C
Cardiogenic Shock Management

In this patient, we done :

• Revascularization
• Fluid challenge
• Ventilatory support
• Intravonus inotropes
• Vasopressors
THANK YOU
Treatment in ED
• total fluid intake 1400 cc/24 hour
• nitroglycerin infusion of 10 mcg/min up to 50 mcg/min
• furosemide 40 mg IV extra
• ceftriaxone 2 gr IV OD
• aspilet 80 mg OD
• clopidogrel 75 mg OD
• captopril 6,25 mg TID
• Oxygen NRM 15 lpm