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Blood Pressure



Cardiogenic Shock


<!--<h1>Cardiogenic Shock</h1>--> Cardiogenic shock is pump failure, usually caused by an acute myocardial infarction (involving about 40% of the myocardium), but occasionally from cardiomyopathies, drugs, toxins, pulmonary embolism, cardiac tamponade and some arrhythmias. <br><br> <strong>Cardiogenic Shock from Myocardial Infarction</strong><br><br> The patient may migrate into a shock state from a heart attack or present in shock. The main symptom is chest pain, although in the elderly, and occasionally in others it is absent. In shock, the skin is cool and moist. Neck veins are distended. Auscultation of the heart may reveal an S-3 gallop, a new murmur, tachycardia or bradycardia. The EKG usually shows a pattern of acute injury. Rales may be present. A chest x-ray may show pulmonary edema. Serum markers (i.e., CK-MB and troponin) are usually positive. <br><br> <strong>Treatment for myocardial infarction: </strong><br><br> 1. The ABCs of resuscitation are followed (i.e., high flow oxygen, pulse oximetry, intubation, IV access); <br> 2. Aspirin 160 mg is chewed and swallowed; <br> 3. Nitroglycerine 10 g/min is given for pain, and also reduces preload and afterload. If pain does not resolve, morphine sulfate 2-5 mg is used; <br> 4. For a systolic pressure less than 100 mmHg, a vasopressor is administered (however, if a right ventricular infarction is present, a fluid challenge of normal saline is used); <br> 5. Heparin 80 units/kg IV bolus and 18/kg/hr is administered; <br> 6. A beta-blocker such as metoprolol (Lopressor) 5 mg q for 5 min is given for three doses (assuming no bradycardia or hypotension) and<br> 7. A thrombolytic agent such as alteplase (t-PA) (Activase) 100 mg over 1.5 h or tenecteplase (TNKase) 40 mg over 5 seconds is administered. <br><br> <strong>Treatment for cardiogenic shock: </strong>the patient in shock (systolic BP<90 mmHg, pulmonary edema) should be transferred as soon as posible to a facility with the capability for intra-aortic balloon pump placement and percutaneous transluminal coronary angioplasty (PTCA). A balloon-tipped catheter is maneuvered into the blocked coronary artery; the balloon is inflated, dilating the narrowed artery and disrupting the atheromatous plaque. A stent may be placed. If that is not possible, thrombolytic therapy is begun. <br><br> <strong>Shock from Cardiac Tamponade/Tension Pneumothorax</strong><br><br> Other causes of cardiogenic shock are cardiac (pericardial) tamponade and tension pneumothorax. In these cases, the heart is compressed in tension pneumothorax by air in the pleural cavity pressing against the heart, and in cardiac tamponade by bleeding into the the pericardial sac. Commonly, cardiac tamponade is seen after a stab wound to the heart (which usually nicks a vessel), but occasionally after blunt trauma. The condition may also result from accumulated fluid secondary to metastatic disease (malignant pericardial effusion). Pulsus paradoxus may be present. <br><br> <strong>Treatment: </strong> treatment for tension pneumothorax is needle decompression, followed by chest tube placement. Treatment for cardiac tamponade is intravenous fluid infusion and immediate pericardiocentesis.


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