 A 62 years old male was brought to ED with history of

sudden onset of chest pain, excessive sweating, nausea

and dyspnoea.

 He is agitated upon presentation and is unable to give

any history.

 There was no past medical history as per his relatives.

ON ARRIVAL IN EMERGENCY:

 Airway: Patent no secreations.

 Breathing: Spontaneous, tachypneic & inadequate.
 SPO2 62% in RA
 RR >40/min.
 Circulation: All peripheral pulses are feeble
 HR 135/min
 BP 80/60mm of HG
 Drowsy obeying simple commands.
 Cold clammy skin, Cyanosed extremities.
 RS B/L AE +Bilateral Diffuse crackles
 CVS S1S2 + no murmurs
 P/A soft no organomegaly
 CNS NFND.
CHEST X-Ray
CARDIOGENIC SHOCK
DEFINITION

 Cardiogenic shock is a state of systemic hypotension persisting

>30minutes, with reduced end-organ perfusion due to low cardiac output
despite adequate filling pressures.

CRITERIA

 Persistent (>30 minutes) hypotension with systolic arterial pressure

<90mm Hg

 Reduction in cardiac index <2.2 litres/min/m2

 Presence of elevated left ventricle filling pressure

(PCWP>18 mm Hg)

 Signs and symptoms of end organ hypoperfusion (restlessness,

confusion,cold cyanotic extremeties, oliguria<30ml/hr)
 CAUSES:
 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.
 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.

Other possible causes of cardiogenic shock

include:
 Inflammation of the heart muscle
(myocarditis)
 Infection of the heart valves
(endocarditis)
 Weakened heart from any cause.
 Drug overdoses or poisoning with
substances that can affect your heart's
pumping ability.
CLASSIFICATION

Coronary Non-coronary

Coronary cardiogenic shock is more Non-coronary cardiogenic shock is

common than non-coronary related to conditions that stress the
cardiogenic shock and is seen most myocardium as well conditions that
often in patients with acute result in ineffective myocardial
myocardial infarction. function.
PATHOPHYSIOLOGY
DIAGNOSIS
MANAGEMENT
 Rapid correction of haemodynamic compromise is essential, to
avoid organ damage from hypoperfusion.
 Management of reversible cause: 5H's,5T's
 Hypoxia, hypovolemia, hypokalemia, hypothermia, hydrogenion,
tamponade, tension pneumothorax, toxins, thrombosis .
 Maintain SBP >90mm Hg and PCWP <20mm Hg.
 Correct hypoxia, acidosis- ventilatory support if required.
 Control arrhythmias- brady or tachyarrhythmias
 Control hyperglycemia by insulin.
 If condition persists despite optimal LV filling, inotropic
support is usually needed
 Vasodilators (These drugs acts
as blood vessel dilator):
Nitrates
 Beta-Blockers (Decrease work
load in heart): Propranolol
 Calcium channel blocker (They
improve coronary blood flow):
Nifedipine, Verapamil

Antiplatelet medication.

 These drugs similar to aspirin

to help prevent new clots
from forming.
MEDICAL PROCEDURES
 ANGIOPLASTY  CABG
 IABP

 Inflation occurs at
aortic dicrotic notch
and deflation occurs
immediately before
systole for maximum
augmentation in
diastole and
maximum systolic
unloading
 Timing is usually
adjusted as 1:2 (one
inflation in 2 beats)
POSITIONING

 The end of the balloon should be just distal (1-2 cm) to the
takeoff of the left subclavian artery
 Position should be confirmed by fluoroscopy or chest x-ray
Tandem Heart LVAD-Extracorporeal devices

 The Tandem Heart removes blood from the left atrium using a cannula
placed through the femoral vein and into the left atrium via transseptal
puncture.
 Blood is then returned to a systemic artery, usually the femoral artery with
retrograde perfusion of the abdominal and thoracic aorta.
Intracorporeal devices
 IMPELLA LP 2.5 & LP5.0
 Helical propellar - axial flow
 Minimally-invasive, percutaneous catheter LVADs
 Insertion similar to IABP but device rests across the aortic valve, with the
tip in the LV cavity.
 FDA approved for high risk PCI, post PCI, cardiogenic shock, myocarditis
&bridge to decision.
Ventricular assist device
 A mechanical device can be implanted into the abdomen and
attached to the heart to help it pump.
 This might extend and improve the lives of some people with
end-stage heart failure.
RECENT UPDATES
Medical Dialogues ...Daily Dose of Health & Medical News
Written By Dr Kartikeya K - Published On 25 Oct 2022 10:15 AM | Updated On 25 Oct 20221:16 PM

 Impella Use During High-

Risk PCI Leads To Better
Survival And Outcomes
Compared To IABP

 USA: The use of Impella during the high- risk percutaneous

coronary intervention (PCI) led to improved survival and less in-
hospital myocardial infarction (MI) and cardiogenic shock
compared with an intra- aortic balloon pump (IABP), researchers
state in a recent study in the American Journal of Cardiology.
Impella received approval from the US Food and Drug
Administration in 2015 for use.