Shock

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Shock

• Shawn Dowling, PGY-5

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Objectives

• Briefly discuss general pathophysiology
• Classification of shock
• Review of vasopressors
• Lots of cases
• We will not talk about septic shock - this will
  be discussed in a future set of rounds

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Intro

• 35M. Pulled from an industrial fire.
• Brought in by EMS.
• Pt is awake, but clearly altered. Only complaint
  is a HA. Prev well.
• T37, HR 110, BP 160/70, RR 20/100 c/s 7
• The nurses have already drawn a venous gas
• CO is 18, lactate is 13
• Is this patient in shock?

4

• What do you think is going on?
• Lactate gt 10 is highly predictive of cyanide
  toxicity with inhalational exposure regardless of
  CO level
• Baud FJ, et al Elevated blood cyanide
  concentrations in victims of smoke inhalation. N
  Engl J Med 2001 32517611766.
• How do you want to treat this patient other than
  with O2 /- hyperbarics? Why?
• Only give the sodium thiosulfate portion of the
  Cyanide Antidote Kit if you give them the
  nitrite component you induce more of a functional
  anemia which they will not tolerate because of
  the other functional anemia the CO

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Definition of shock

• Rude unhinging of the machinery of life
• Or
• The inability of the circulatory system to
  adequately supply tissues with 02 nutrients and
  remove cellular waste

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• Diagnosis of Shock Rosens
• Need 4 of 6
• Ill appearance or decreased LOC (as a general
  rule MAPlt 50 before AMS)
• HR gt 100
• RR gt 22 or PC02 lt 32
• Base deficit lt-5 or lactate gt4
• Urine output lt 0.5 ml/kg/hr
• Hypotension gt 20 minute duration
• NOTE - ?BP not required for Dx

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Diagnosing Shock

• The more advanced the shock state, the easier
  the Dx, but
• Significant tissue hypoxia appears to exist prior
  to development of significant signs symptoms
• THE BETTER WE CAN RECOGNIZE SHOCK, THE EARLIER WE
  CAN INSTITUTE Tx
• TIME IS TISSUE (see RIVERS STUDY)
• Can be is shock with normal vitals
• Normal BP in face of hypovolemia means some
  organs are hypoperfused to maintain systemic BP

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• Shock is the transition between life and death

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Shock unifying features

• Imbalance between cellular O2 demand and supply
• Disrupted cellular homeostasis
• Failed aerobic metabolism gt anaerobic metabolism
  gt lactic acidosis
• Calcium shifts - impairs cardiac contractility
• Failed ion gradients and cellular pumps
• Cell edema and death

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How does our body compensate?

• Counter-regulatory mediators
• Catecholamines, glucocorticoids, angiotensin,
  vasopressin, insulin
• Increased substrates
• glucose, TG and FFA
• Anaerobic metabolism
• incr CO202 ratio

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Pertinent Critical Care formulas

• CO
• HR x SV
• BP
• CO x SVR
• O2 content
• 1.34 x hgb x O2 saturation 0.003 x Po2
• (02 bound to hgb) (02 in plasma)
• Oxygen delivery is the CO x O2 content
• Why is this equation so important to a shock
  talk?
• In which shock scenario do we target the O2 in
  plasma for treatment?
• CO poisoning

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• What are some different shock classifications?

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Classification of Shock

• Many different ways
• Mnemonics
• Physiologic
• Clinical
• It doesnt matter which you use as long as
• You know it cold
• Its exhaustive

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Shock
BP ?CO x ?SVR
Hypovolemic Cardiogenic Obstructive
Distributive
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Shock
Shock
Hypovolemic
Cardiogenic
Obstructive
Distributive

• Bleeding or
• Fluid Loss
• Overt
• Occult
• Excessive
• Losses

• Vessels
• Rhythm
• Valvular
• Myocardium
• Pericardium

• Intravascular
• Extravascular

• NASTE
• Neurogenic
• Anaphylactic
• Septic
• Toxicologic
• Endocrine

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Hypovolemic

• Overt/Occult losses of blood
• 5 sources of life threatening hemorrhage in
  trauma?
• Chest, Abdo, Pelvis, Long bones, Street (from
  skin)
• Excessive Fluid loss
• 3rd spacing (burns, pancreatitis, dermatologic,
  ascites)
• Excessive sweating/vomiting/diarrhea/urine
  output(diuretics, DI)

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Cardiogenic

• Vessels
• AMI or acute or chronic usually need to infarct
  40 to cause shock
• AoD
• Rhythm
• Brady
• Tachydysthrythmias
• Valvular
• Stenosis
• Regurgitation

• Myocardium
• Rupture (FW or VSD)
• Myocarditis
• Cardiomyopathy
• RV involvement
• Pericardium
• Tamponade

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Obstructive

• Intravascular
• PE
• Amniotic Fluid Embolism
• Air embolism
• Fat embolism
• Extravascular
• Tension PTX
• Cardiac tamponade
• SVC syndrome

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Distributive

• Neurogenic
• Anaphylactic
• Septic
• Toxicologic
• (CaCB, BB), CO, cyanide, iron, ASA, etc
• Endocrine
• Adrenal insufficiency, thyroid storm,
  electrolytes (hyperK)

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• Top three causes of shock in infants
• Sepsis
• Hypovolemic
• Cardiac
• SHOCK in a neonate
• Sepsis
• Cardiac
• non-Accidental Trauma
• Metabolic
• Surgical

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Physical Exam

• Two purposes
• Try to determine if the patients is in shock
• Look for evidence of end organ damage
• Determine the cause of the shock
• JVP perfusion status is VERY helpful

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Thanks to ICU Crash Course
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Match the shock with the appropriate vasopressor
and why

• Sepsis
• Neurogenic Shock
• Anaphylactic Shock

• Epinephrine
• Ephedrine
• Phenylephrine
• Norepinephrine
• Dopamine
• Milrinone

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Direct vs indirect vasopressors

• Direct agents stimulate the receptor directly
• Indirect agents have their effect by stimulating
  the adrenals to release catecholamines
• . If stressor has been ongoing for a period of
  time -gt bodys catecholamine reserve is likely
  deplete and the indirect agents will have less
  effect

• Direct
• Norepi
• Epi
• Phenylephrine
• Indirect
• Dopamine
• Dobutamine
• Ephedrine

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Receptor
Primary location
Primary fx
a
ß1
ß2
D
DDopaminergic
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Receptor
Primary location
Primary fx
a Vessel walls Peripheral Arterial Constriction
ß1 Heart Inotropy/Chronotropy
ß2 Lungs/Skeletal muscle Dilatation of smooth muscle (skeletal and bronchial)
D Kidneys Increase renal blood flow
DDopaminergic
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Cochrane Review(updated) Feb. 11, 2005.

• For all kinds of shock
• RCTs
• Levo vs Dop (3 studies, N62)
• RR death 0.88 (0.57,1.36)
• Levo dob vs epi (2 studies, N52)
• RR death 0.98 (0.57,1.67)
• Unfortunately, these studies are too small to
  definitively answer the question but better data
  to support that norepi achieves HD endpoints
  better and since its a direct agent likely
  better for septic patients

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Case 1

• PP 8yo F with known allergy to wasps
• PMHx Healthy and no meds
• HPI
• At day camp and forgot her epi-pen
• Stung by 2 hornets after accidentally running
  into a nest
• Presents by personal vehicle to ED
• Given PO Benadryl by family member

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Case 1

• Generally
• Appears unwell and flushed
• HR128, RR38, T37.8, BP85/40, Sat 89 RA
• CVS
• Tachy, warm extremities
• Resp
• Significant indrawing
• Audible wheeze throughout
• No stridor noted
• Derm
• Urticarial rash and diffuse flushing
• ENT
• Lip swelling noted and uvula swollen on exam

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Case 1

1. Name the general category of shock
2. Describe the pathophysiology
3. Name the management goals
4. Define the best interventions to obtain the above
   goals
5. Name potential pitfalls

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Case 1

• The pediatric nurse is panicked..
• He wants to know how much Epinephrine you want to
  give this child and by what route..

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Case 1

• The patient is not responding to your IM
  epinephrine
• The pressure is 60 systolic and the patient has
  become obtunded..

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Case 2

• PP
• 58yo Male with known shrimp allergy
• PMHX
• MI 2 years ago
• NIDDM
• HTN
• HPI
• Ate the egg roll special at a Thai restaurant
• Immediate throat swelling
• EMS called and IM epinephrine given on route

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Case 2

• Generally
• Appears flushed and unwell with marked work of
  breathing and distress
• HR 62, RR 28, BP 80/46, Sat 89 on mask, T37.4
• CVS
• Normal heart sounds, normal cap refill
• Resp
• Diffuse wheeze throughout
• Abdomen
• Soft but mildly tender
• Neuro
• Starting to appear somnolent

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Case 2

• You repeat another IM injection of 0.3cc of
  11000 epi and give H1 and H2 blockers
  intravenously
• There is no improvement and the patient remains
  hypotensive and relatively bradycardic..

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Case 2

• Name the general category of shock
• Describe the pathophysiology
• Difference between anaphylaxis and anaphylactoid?
• Name the management goals
• Define the best interventions to obtain the above
  goals
• Name potential pitfalls

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Management

• Fluids
• Meds
• Epi is the first line Tx for anaphylaxis
• IV (110,000)
• 1 mL (100ug) aliquot repeat q60sec until
  desired effect
• Infusion - 1ug/min-4ug/min
• If pt not in shock IM (why not SC?)
• Ventolin nebs
• Benadryl 50mg IV
• Zantac 50mg IV
• Solu-medrol 125mg IV

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• Glucagon (for pts on ßß, ?ACE-I)
• 1-2mg IV
• Then 5-15mcg/min infusion
• Inotropic/chronotropic/vasoactive properties
  beyond the b-receptor

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Case 3

• 80M. Hx of COPD.
• Presents with productive cough and feels unwell.
• T-40, RR28, sats 85 on NRB, HR-120, BP 90/50
• Working Dx Pneumonia Sepsis
• You decide you going to intubate this patient
  because of failure to oxygenate
• Any concerns? How are you going to prepare?
  Induction agent? Other meds?

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Sepsis and airway management

• Sepsis significantly increases you O2
  requirements therefore these patients can
  desaturate quite rapidly . Optimize the
  conditions (i.e. positioning, pre-oxygenate,
  best-intubator, etc)
• Use of accessory muscles can ?O2 consumption by
  50-100!
• Another reason to manage their airway early or if
  you are not meeting your physiologic end points
• Any other concerns

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Post-intubation hypotension

• Septic patients are very catecholamine driven
  intubating can remove that stimuli and they can
  drop their pressures precipitously
• Also, the agents we give for intubation may play
  a role
• ? intra-thoracic pressure (from mechanical
  ventilation) can drop the preload . causing
  hypotension)

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Intubating a septic patient

• Pre-oxygenate as much as possible
• Pretreat with fluids /- bicarb if you thing they
  are really acidotic (no evidence)
• Careful choice of induction agent
• Ketamine or ½ dose etomidate (0.15mg/kg) are
  likely best options, AVOID propofol
• Have some pressors drawn up (phenyl/norepi)
• Why not dopamine or ephedrine?
• phenylephrine
• How do you mix this?
• 10mg in 100mL bag draw up 10cc and give
  1cc(100Ug)/dose
• RSI if no CI (gives you the best look)

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• http//ca.youtube.com/watch?vpY8jaGs7xJ0

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Case 3

• PP 38yo Male transfer by STARS
• PmHx Asthma but otherwise healthy
• Meds Ventolin and Flovent PRN
• HPI
• Patient riding QUAD in kananaskis country and
  flipped
• Helmet and no LOC
• Trapped under bike for 10 minutes extrication by
  friends
• STARS scene call
• No major blood loss noted on scene

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Case 3

• Generally
• GCS 12/15 patient confused and aggitated
• HR 120, BP 81/40, RR 15, Temp 37.2, Sats 92
• CVS
• Tachycardic, normal HS, Cap refill 4 seconds,
  weak thready pulse
• Resp
• Clear bilaterally but poor inspiratory effort
• Abdomen
• Diffusely tender to palpation
• Soft and not distended
• MSK
• Pelvis is grossly unstable to palpation
• Perineal hematoma noted
• Femurs and hips normal to exam
• Neuro
• PEARL, No signs of depressed skull or basal skull
  injury
• No signs of head trauma

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Case 3

1. Name the general category of shock
2. Describe the pathophysiology
3. Name the management goals
4. Define the best interventions to obtain the above
   goals
5. Name potential pitfalls

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Case 3

• You do a ED FAST and it is negative for free
  fluid in the abdomen
• What do you want to do now?

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Case 4

• 68yo Male with known small cell lung Ca
• Meds
• Undergoing outpatient chemotherapy and
  radiotherapy at TBCC for last 2 months
• HPI
• 3 day history of dyspnea, apprehension and mild
  chest pain
• Presents today feeling very unwell, presyncopal
  and markedly short of breath on minimal exertion

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Case 4

• Generally
• Appears unwell and dyspneic, markedly diphoretic
• HR 119, RR 24, BP 90/55, Sat 98 RA, Temp 36.9
• CVS
• Faint HS appreciated, normal S1S2 and no EHS
• Extremities cool and cap refill 3-4 seconds,
  mottled
• Peripheral edema is noted
• JVP 6cm above sternal angle and pulsus
  paradoxus 22mmHg
• Resp
• Chest clear throughout but shallow breaths
• Abd
• Soft but tender to palpation diffusely
• Neuro
• Alert but confused and disorientated

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DDX of pulsus paradoxus

• Cardiac
• pericardial effusion
• Tamponade
• PE
• Cardiogenic shock
• Pulmonary
• Asthma
• COPD
• Tension pneumothorax

• Other
• Anaphylaxis
• SVC syndrome

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EKG
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EDUS
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Case 4

1. Name the general category of shock
2. Describe the pathophysiology
3. Name the management goals
4. Define the best interventions to obtain the above
   goals
5. Name potential pitfalls

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Management of Tamponade

• Maximize preload
• Fluids to ? filling pressure
• Pressors
• (dialysis)
• Uremic pce is an indication
• Pericardiocentesis
• See remergs.com for how to
• (thoracotomy)
• If post-traumatic

Temporizing Measures
Definitive Measures
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Case 5

• PP 26yo Female
• PMHx Healthy
• HPI
• Involved in motorcycle accident at highway speeds
  Helmet
• LOC on scene and now GCS 9
• STARS transfer and advised hypotensive on route
  unresponsive to fluids

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Case 5

• Generally
• GCS 6, collared, not responding to pain
• No obvious sites of external bleeding
• HR 57, RR 16, BP 79/40, Sats 98 3L NP, T37.8
• CVS
• Heart sounds normal, no pedal edema, JVP normal
• Warm and dry skin
• Resp
• Normal
• Abdomen
• Soft and non-distended
• MSK
• Pelvis stable
• Neuro
• PEARL, no signs of depressed or basal skull
  fracture
• Reflexes absent
• Poor rectal tone

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C-spine xray
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Case 5

• What is the difference between spinal shock and
  neurogenic shock?

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Spinal Shock

• Concussive injury to the spinal cord
• Causes total neurological dysfunction distal to
  the site of injury
• Usually lasts lt24hrs
• May persist for several days
• The end of spinal shock is heralded by the return
  of..
• Bulbocavernousus reflex

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Neurogenic Shock

• Disruption of sympathetic autonomic ganglia
  resulting in loss of vasomotor tone and lack of
  reflex tachycardia
• Results in hypotension (low SVR)
• Bradycardia can be absolute or relative
• Due to unopposed vagal tone to heart
• Usually only occurs is lesion is at/above T4

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• DDx for hypotension bradycardia
• Medications (CaCB, BB, digoxin)
• Neurogenic Shock
• Adrenal insufficiency
• vagal tone (yng, intra-abdominal issue)

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Case 5

1. Name the general category of shock
2. Describe the pathophysiology
3. Name the management goals
4. Define the best interventions to obtain the above
   goals
5. Name potential pitfalls

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Management of neurogenic shock

• Fluids they have relative hypovolemia
• Atropine 0.5 mg 1.0 mg iv
• Can try to help with their pressure transiently
• Have ready for intubation as they may brady down
  2ndary to the vagal response
• Pressors
• Phenylephrine 100mcg aliquots is a good
  temporizer
• Ephedrine is an alternative

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Case 6

• 53yo M
• 1400 golfing and severe central CP radiating to R
  shoulder and SOB
• Within minutes was unresponsive and EMS called
• Nitro given and BP ??
• Palpable pressure on route

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Case 6

• Generally
• Appears very unwell, pale diaphoretic and cool
  periphery. Minimally responsive
• HR 108, BP 88/65, Sats 84 non-rebreather, RR 30
• CVS
• Tachy with no obvious murmur
• Cool peripheries and thready pulse
• Resp
• Diffuse crackles throughout
• Pink froth at the mouth
• Significant respiratory distress

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EKG
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Case 6

1. Name the general category of shock
2. Describe the pathophysiology
3. Name the management goals
4. Define the best interventions to obtain the above
   goals
5. Name potential pitfall

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Shock Post-MI

• DDx
• Myocardium pump failure,VSD, FWR, RV infarct
• Valvular acute MR
• Rhythm brady/tachycardia
• Other (later) PE, pericardial effusion, stroke,
  bleed (from a/c)

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Cardiogenic shock approach

• AMI shock?
• RV infarct?
• YES NO
• Volume resuscitate Pulmonary congestion
  present?
• NO YES
• Response adequate Pressor
• Revascularize Response adequate
• YES
• IABP and PTCA

NO
YES
NO
Thanks Phil
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• How does a IABP work?

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Cardiogenic ShockApproach

• Stabilize the ABCs
• Identify etiology of cardiogenic shock
• Small fluid bolus (250cc)
• Dont be shy on fluids if RV infarct
• Ionotropic/vasopressor support
• Manage infarct (avoid ßß nitrates)
• Cath vs lytics

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MI Cardiogenic shockHow to manage the MI?

• Options
• Thrombolysis
• Get BP up with ionotropes then thrombolyse
• Stabilize with IABP then thrombolyse
• Early Revascularization (PTCA or CABG)
• What does the literature tell us?

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MI Cardiogenic shockHow to manage the MI?

• Thrombolysis in cardiogenic shock
• GISSI (N280) 30 day MR
• streptokinase 70.1
• medical mx 69.6
• NO trial has shown reduction mortality with
  cardiogenic shock with thrombolysis

Thanks Rob
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• SHOCK trial
• RCT of AMI cardiogenic shock
• 152 early revascularization (PTCA or CABG) or 150
  initial medical mx only (lysis initially, some
  had PTCA/CABG after 52hrs)
• End Point early revasc. Med Mx stats
• 30d MR 46.7 56 p.11
• 6mth MR 50.3 63.1 p.027

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Cardiogenic Shockthe SHOCK trial

• Hochman JS. One year survival following early
  revascularization for cardiogenic shock. JAMA
  2001.
• End Point
• early revasc. Med Mx stats
• 1yr survival 46.7 33.6 p.03

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MI Cardiogenic shockHow to manage the MI?

• Conclusions .
• Patients with AMI complicated by cardiogenic
  shock, especially those lt 75yo, should undergo
  emergent revascularization (PTCA or CABG)

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Bonus Case

• 78F.
• Presents with SOB, hypoxia hypotension
• PMHX CAD, CHF
• VSHR 110 BP 80/50, RR28, sats 88RA
• JVP up, lungs are clear, no peripheral edema
  poorly perfused
• You order a portable CXR

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N CXR
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• What do you think?
• What do you want to do?

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• Which can help you make the Dx?
• STAT ECHO
• CT
• but this patient is not stable enough for CT

Empiric heparin while investigating (if no CI)
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• As the pCXR is being done the patient finally
  stops pestering you with questions about what you
  think is going on.
• Youre enjoying the silence until you see the
  monitor

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• What do you want to do know?

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Jerjes-Sanchez C. et al. Streptokinase and
Heparin versus Heparin Alone in Massive Pulmonary
Embolism A Randomised Controlled Trial. Journal
of Thrombosis and Thrombolysis. 1995.

• Prospective and randomised trial, N8
• all had massive PE and in cardiogenic shock
• high prob. V/Q, with abnormal RH on echo or gt9
  obstructed segments on V/Q
• 100 survival in streptokinase plus heparin group
  
• 100 mortality in heparin group
• Small study, lots of limitations BUT one of the
  few studies on this

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tPA in PE

• The role for tPA in submassive PE is debatable
  not a decision for us to make
• If the patient is in shock they have a PE
  give tPA (likely in consultation with ICU)
• In the mean time intubate, heparinize fluids
  PRN /- pressors
• If the patient has a cardiac arrest give it
• tPA dosing
• 1mg/kg over 2-5 mins if in CA
• Over 30mins if perfusing
• If stable 100mg over 2 H ask yourself why
  youre giving it in emerg

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