Cardiogenic shock

Presentation of cardiogenic shock,useful for Nursing students

1. CARDIOGENIC SHOCK Ms. Jinumol Jacob First year M.sc Nsg NUINS

2. Cardiogenic shock occurs when the heart has been damaged so much, that it is unable to supply enough blood to the vital organs of the body. As a result of the failure of the heart to pump enough nutrients to the body, blood pressure falls and organs may begin to fail . Cardiogenic shock is uncommon, but when it does occur, it’s a serious medical emergency .  INTRODUCTION

3. Cardiogenic shock is the failure of heart to pump blood adequately to meet the oxygenation needs of body. ( Cardiovascular Medicine) Cardiogenic Shock is defined as the hearts inability to contract and pump the blood effectively due to inadequate supply of oxygen and nutrients to the body. (Red cross Society) DEFINITION

4. Incidence rate of cardiogenic shock is 43.7%. 40 to 70 % cardiogenic shock is with Acute MI INCIDENCE

5. Acute MI Severe Hypoxia Cardiomyopathy Pericardial tamponade Acidosis Dysrhythmia Trauma Structural Abnormalities. ETIOLOGY

6. Classification based on . Coronary cardiogenic shock Non coronary Cardiogenic shock CORONARY CARDIOGENIC SHOCK Coronary cardiogenic shock occurs when the significant amount of the left ventricular myocardium has been damaged. Eg Myocardial infraction. More common .

7. NON CORONARY CARDIOGENIC SHOCK Occur mainly due to stress to myocardium. Examples severe hypoxemia Acidosis Hypoglycaemia Tension pneumothorax .

8. Older age History of heart disease Hypertension Diabetes mellitus Obesity Atherosclerosis RISK FACTORS

9. PATHOPHYSIOLOGY Structural problem Dysrhythmias Systolic Dysfunction : Ineffective Forward movement of blood Stroke volume Diastolic dysfunction: Ineffective Filling Primary ventricular ischemia

10. . Cardiac output ( amount of blood the heart pump from each ventricle per minute ) Pulse pressure Pulmonary edema Oxygenation Cellular oxygen Tissue perfusion Impaired Cellular Metabolism

11. The classic signs and symptoms of cardiogenic shock are the heart muscle loses it’s contractle power, resulting in a marked reduction of SV and CO . Confusion, restlessness, mental lethargy ( due to poor perfusion of brain) Low Systolic Blood pressure Oliguria ( urine output less than 30ml/hr( due to decrease perfusion of kidneys) Chest pain( due to lack of oxygen and blood to heart muscle ). CLINICAL FEATURES

12. Cold ,clammy skin. Thready peripheral pulses . Distended neck vein. Tachypnea, with respiratory crackles. cyanosis. sweating, cold hand and feet .

13. History Collection Physical Examination ( Hypotension, Tachycardia, cyanosis, S3 Gallop sound) ECG ( ST Segment elevation) Echocardiogram Chest x-ray ( reveal pulmonary congestion) Cardiac enzyme test ( CPK-MB ,) Coronary angiography Pulmonary artery catheterization ABG, LFT & Renal function test DIAGNOSTIC MEASURES

14. Management measures include MANAGEMENT MEDICAL MANAGEMENT SURGICAL MANAGEMENT NURSING MANAGEMENT

15. MEDICAL MANAGEMENT

16. The goal of medical management in cardiogenic shock are . To limit further myocardial damage and preserve the healthy myocardium. ( To improve blood f low to myocardium) To improve the cardiac function by increasing cardiac contractility, decreasing ventricular after load or both . In general this goals are achieved by increasing oxygen supply to the heart muscle while reducing oxygen demands. GOAL

17. First line treatment of cardiogenic shock involves the following actions. Supplying supplemental oxygen Controlling chest pain Providing selected fluid support Administrating vasoactive medications First-line treatment

18. Oxygen is administrated at a rate 2 to 6 L/Min to achieve oxygen saturation above 90 %. Monitoring of ABG Value and pulse oximetry help to determine if patient require more oxygen therapy. Pain Control Morphine sulphate ( IV) Oxygen therapy

19. Vasopressors Maintain mean arterial pressure Eg Dopamine , Norepinephrine Inotropic Agents Increase myocardial contractility Eg Milrinone, Levosimendan, dobutamine Vasodilator Relax vascular smooth muscles, reduce systemic vascular resistance and cardiac output. Eg Nitro-glycerine, Sodium Nitro prusside Drug therapy

20. Other medications include antiarrhythmic medications and fluid therapy. Diuretics Furosemide

21. SURGICAL MANAGEMENT

22. Percutaneous coronary intervention Coronary Artery bypass graft Intra – aortic Balloon Pump ( IABP) Transvenous pacing Percutaneous Ventricular Assist Device. Extracorporeal Membrane oxygenation Left ventricular assist Device. SURGICAL PROCEDURES

23. coronary artery bypass graft (CABG) surgeries are among the most commonly performed major operations . CABG surgery is advised for selected groups of patients with significant narrowing and blockages of the heart arteries (coronary artery disease , cardiogenic shock). CABG surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle .(saphenous vein, mammary or radial artery) CORONARY ARTERY BYPASS GRAFT

24. PCI is recommended for client with acute MI followed by cardiogenic shock.  Percutaneous coronary intervention is performed by inserting a catheter through the skin in the groin or arm into an artery. At the leading tip of this catheter, several different devices such as a balloon,  stent , or cutting device (artherectomy device) can be deployed . The catheter and its devices are threaded through the inside of the artery back into an area of coronary artery narrowing or blockage. PERCUTANEOUS CORONARY INTERVENTION ( PCI)

25. IABP Is a device used for mechanical circulatory assistance in case of LV dysfunction on the principle of counter pulsation The goals of IABP include the following.. Increased SV Improved coronary artery perfusion Decreased preload Decreased cardiac work load INTRAAROTIC BALLON PUMP

26. IABP Consist of intra aortic balloon about 1o inches long placed over the distal end of catheter. Catheter is inserted surgically or percutaneously over femoral artery. When it reaches in aorta ,tip of balloon is positioned just below the tip of the origin of left subclavian artery. PROCEDURE

27. Pump console monitor the patient’s heartbeat R Wave in the ECG trigger pumps inflating mechanism As balloon inflates it displaces the blood, increase aortic pressure, which increase coronary blood flow . During left ventricular ejection balloon deflates, thus reducing aortic pressure, help in ejection of blood from left ventricle, reducing workload of left ventricle. .

28. IABP

29. when IABP become insufficient percutaneous ventricular assist device is used. Shock persist after coronary revascularization. Eg TANDEM HEART DEVICE, IMPELLA PERCUTANEOUS VENTRICULAR ASSIST DEVICE

30. Provides hemodynamic support and oxygenation if lung function is compromised. EXTRACORPOREAL MEMBRANE LEFT VENTRICULAR ASSIST DEVICE Used in patients with acute myocardial infraction complicated by cardiogenic shock

31. NURSING MANAGEMENT

32. NURSING ASSESSMENT. Administer safe and accurate IV fluids and medications. Documents and records medications and treatment that are administered as well as the patient response to treatment . Patients receiving thrombolytic therapy must be monitored for bleeding. Arterial and venous puncture sites must be observed for bleeding, and pressure must be applied at the sites if bleeding occurs . . Nursing management

33. Neurologic assessment is essential after the administration of thrombolytic therapy to assess for the potential complications of cerebral haemorrhage associated with the therapy. Urine output ,BUN ,creatinine levels should be monitored . Maintain mechanical assistive devices function Prevent complications associated with cardiogenic shock. Enhancing safety and comfort. .

34. Decreased cardiac output related to impaired contractility due to extensive heart muscle damage. GOAL Improving cardiac output INTERENTION Establish continuous ECG monitoring Hemodynamic monitoring Closely monitor adverse response to drug therapy Monitor BP with intra-arterial line continuously. Measure and record intake and urine out put NURSING DIAGNOSIS

35. GOAL :Improving oxygenation INTERVENTION Monitor rate and rhythm of respiratory every hour. * Auscultation lung fields for abnormal sounds * ABG evaluation * Administer oxygen * Invasive oxygen therapies (ET & MV) Impaired gas exchange related to pulmonary congestion due to elevated left ventricular pressure

36. GOAL : Maintaining adequate Tissue perfusion INTERVENTION Perform neurologic assessment every hour using with “Glasgow coma scale” ( GCS) Report changes immediately Obtain BUN & creatinine blood levels & monitor output to evaluate renal function. Ineffective tissue perfusion ( renal, cerebral, cardiopulmonary GI and peripheral) related to decreased blood flow

37. Goal : To Relive anxiety Assess the anxiety level Provide adequate information regarding physical condition Encourage to ask questions Provide diverational therapy Anxiety related to intensive care environment and invasive procedures.

38. COMPLICATIONS COMA BRAINDAMAGE MULTIPLE ORGAN FAILURE KIDNEY DAMAGE LIVER DAMAGE DEATH .

39. Cardiogenic shock is a treatable illness with a reasonable chance for full recovery. The Cardiogenic shock literature has traditionally focused on the very high mortality associated with this diagnosis. It is important to recognize that although patients with Cardiogenic shock are at very high risk for early death, great potential exists for salvage . CONCLUSION

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